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Martin Charles Bricknell is Professor of Conflict, Health, and Military Medicine at King’s College London. Derek Licina is an Adjunct Professor in the Milken Institute School of Public Health at George Washington University.
The last decade has seen a progressive breakdown in global acceptance of a rules-based international system. This has led to the reemergence of tension, confrontation, and conflict between the major power blocs. The annexation of eastern Ukraine by Russia in 2014, and the escalation to a full-scale invasion in 2022, has increased the risk of actual combat between the North Atlantic Treaty Organization (NATO) and Russia in Europe. China’s extraterritorial ambitions have become more public, with Hong Kong fully incorporated into the Chinese Communist Party system and explicit threats being made toward Taiwan. The nuclear ambitions of Iran and North Korea remain unchecked.
Beyond these interstate security threats, the COVID crisis demonstrated the effect of a pandemic on global health and economic activity. Climate change is already threatening water supplies, food security, and littoral habitation.
Across many recent national security policies, these collective threats have been recognized as substantially increasing the risks to security and the likelihood of a significant conflict between a U.S.-led coalition and a competitor state. Unfortunately, there is one unifying consequence of these different risks: a substantial, and potentially catastrophic, impact on human health through the direct and indirect impact of war or the unmitigated consequence of war on food security, water security, or population movement.
This article discusses how these global trends have significant implications for the military component of national health systems, both regarding health care provided to armed forces personnel and wider beneficiaries (family members, retirees, and veterans) within countries and concerning the potential demands on the field medical system during combat or other military operations. It particularly considers the U.S. military health system not only as the lead member in any coalition military operation but also in respect to its characteristics in comparison to its global competitor nations. The article concludes by identifying how these implicit risks have implications for civil-military relations within the U.S. national health economy and wider national security policy. The key argument herein is that the design, capabilities, and capacity of the national health systems enterprise should be considered as the strategic equivalent of the defense–industrial complex for weapons production.
The Health Implications of Strategic Insecurity
Unfortunately, this risk of a local or global catastrophe affecting human health is concurrent with tensions across the global health system. At a time when biomedical science can offer so much to improve human health, most of the world’s population has limited access to universal health care, with inequity for citizens within countries and across the globe despite health being the primary theme within the United Nations (UN) Sustainable Development Goals. Advances in global public health have shifted the population structure in many countries with a “demographic timebomb” of growing demand for health and social care, placing increasing strain on the economically active members of societies. There is insufficient capacity and workforce to meet the future needs for health and social care in high- and middle-income countries, with the added consequence of healthcare worker migration reducing health system capacity in low-income countries. The COVID pandemic and its subsequent impact on economic development are already reversing many measures of progress in global health in low-income, fragile, and conflict-affected states. Thus, while health systems are an important contributor to national resilience, both the capability and the capacity of health systems to absorb strategic shocks need strategic investment to ensure that they are better prepared for the next health emergency. 1
The conflicts in Iraq and Afghanistan provided a reminder of the realities of war and the damage caused by weapons to the human body and mind. Unfortunately, the war in Ukraine has demonstrated the true casualty rates arising from near-peer combat on both the armed forces and civilians. The war has also shown the consequences of a disregard of the laws of armed conflict on wider civilian infrastructure, with evidence of direct targeting of health facilities and the secondary impact of cyberattacks and attacks on power and water systems on the functioning of health services.2 Moreover, the false and misleading Russian information operation that has targeted military and civilian personnel has obstructed efforts by health ministries and other health organizations to mitigate disease threats and provide healthcare services to Ukrainian society. This further undermines trust in national institutions and leadership. These are indicators of the human cost of potential large-scale contingency operations for the United States and its allies.
The health response to the COVID pandemic provides us with insights into the issues and choices that face health systems during a strategic crisis. Potential and actual demand forced governments to make implicit and explicit decisions about prioritization and entitlement to health care. Implicit decisions using mass-casualty triage resulted in rationing of emergency COVID care for those with low likelihood of benefit. Demand was reduced by delaying access to care for all “non-emergency” conditions, and urgent care for heart disease, cancer, and joint re- placement surgery was stopped. Hospital infrastructure was expanded, and the healthcare workforce was bolstered by reassigning duties across professions and calling up retirees, but at the same time quality was diluted by reducing clinician-to-patient ratios. Governments took unprecedented control over the “healthcare market” by controlling patient regulation between hospitals and even moved patients across international borders. Finally, entire national health economies were mobilized, including the assignment of military medical services as a national strategic reserve for redeployment within countries and internationally to reinforce local health systems under pressure.3 The health system response to the COVID crisis provides some insights into the types of strategic choices needed to provide care for casualties from a large-scale conflict.
Military Health Systems as a Strategic Capability
The resurgence of the war in Ukraine has provided a tragic reminder of the “meat grinder” reality of the casualty rates to be expected from a near-peer conflict. The war injuries and mental damage caused to large numbers of military personnel challenge both the physical and the moral components of fighting power that need mitigation to meet public expectations of survival, casualty care, and recovery of the injured. The lethality of the close combat zone and the lack of discrimination in the employment of weapons mean that health services support in war is a tactical military task. This requires a medical service that is fully integrated and equipped to operate alongside combat forces and that seamlessly transfers patients between military and civilian health services as a unified national health system.4 The replacement of the Ukrainian surgeon general in November 2023 is an indication of the strategic pressure faced by a military health system during war.5 The tactical lessons from the war in Ukraine for military health systems are becoming widely recognized.6
Peacetime military health systems in Western countries have already been reduced to the minimum needed for training with an explicit expectation of mobilizing part-time medical personnel from the reserve and other auxiliary forces (for example, the U.S. Army National Guard) in times of war. As seen in previous wars, these augmentees will need military and medical induction training prior to assignment to operational medical units. Concurrently, capacity in the garrison health system will need to be expanded to provide definitive care, rehabilitation, and recovery pathways for injured service personnel who have been evacuated from the combat zone. As the war in Ukraine and previous wars have shown, managing the capacity of a national health economy during war is a strategic civil-military endeavor that requires explicit and implicit decisions that mirror the difficult choices faced during the COVID crisis. Conceptually, we need to consider the military health system as much a national cross-government strategic asset as the defense–industrial complex that supplies the materiel for war. It is so much more than a combat service support constraint that upsets peacetime training by taking soldiers away from more important duties.
The Meaning of Scale in Military Health Systems
The U.S. military health system is experiencing one of the greatest transformations in its history with the transfer of garrison hospital care from the Services to the Defense Health Agency.7 The primary driver seems to be to reduce the cost of health benefits to Armed Forces personnel and beneficiaries as Department of Defense (DOD) employees. However, policy decisions taken within the DOD budget have significant implications for the capacity of the overall Federal health system to respond to strategic shocks. Most analyses that inform such decisions use U.S. health maintenance organizations (HMOs) or NATO Allies as comparative cases examples.8 There is little open-source evidence of any comparative analyses with the military health systems of global competitors such as China, Russia, Iran, or North Korea, or comparisons with militaries of equivalent size such as India, Pakistan, South Korea, or Brazil. This is quite different than the approach taken for comparative analyses of other components of military power such as armies, navies, or air, space, or cyber forces.9
A commercial HMO manages insurance-based income to meet contractual health benefit obligations through providing access to health care for beneficiaries from directly employed health providers or commercial hospitals. There is a tension among expectations of insurance policyholders, breadth and cost of benefits, and return on shareholder capital. Thus, the system must operate at maximum efficiency with minimal spare capacity. The TRICARE, or purchased care benefit, and the Veterans Health Administration components of the overall military health benefit most closely match this model (and are the most expensive element of the military health system). Controlling these costs explicitly creates pressure to reduce DOD and Veterans Affairs health infrastructure and uses Federal funding to influence the organization and capacity of commercial health services to provide care. This pressure must be balanced against the requirement for DOD to maintain an operationally focused uniformed medical service that has the strategic reserve to expand for war.
Since the collapse of the Soviet Union, the size of military health systems as a proportion of the armed forces of NATO Allies has been disproportionately reduced. Most European countries have an inclusive healthcare system that provides universal services to all citizens that is funded either directly through taxation or through a government-mandated social insurance system. Thus, ministries of defense have closed military hospitals, and most health care for armed forces personnel has shifted into the civilian sector while remaining government funded. While operations in Afghanistan have shown that field military health services are one of the most interoperable of NATO military capabilities, the sum of the capacity of all Alliance military medical services is unlikely to be sufficient to meet the casualty demands of a near-peer conflict.10 The COVID crisis has shown that countries on the European border with Russia already take a total defense approach to the civil-military control of the national health system during crises in a similar manner to that taken by Ukraine.11
The HMO and NATO models contrast with the role of the military health system within the health economies of countries with armed forces of similar size to the U.S. military. There is insufficient space in this article to undertake a detailed comparison, but the COVID crisis can provide some insight into the strategic control and capacity of these military health systems and their status relative to civilian health services. The Chinese military medical services have a national network of large hospitals that serve armed forces personnel, other entitled beneficiaries, and civilians. They are a central element of China’s response to health emergencies and have a significant global presence across UN peacekeeping operations.12 The People’s Liberation Army publicly messaged the strategic deployment of armed forces medical personnel from across the country to expand the medical infrastructure of Wuhan in the early phases of the COVID pandemic in 2020.13 The Russian Federation’s military health system is the most respected element of the Russian health system, though it has been subject to similar reductions in structure and manpower as the U.S. military health system.14 Several Russian military field hospitals were used to reinforce the civilian health system during the COVID crisis.15 Though the war in Ukraine has put pressure on the Russian military health system and the wider civilian health system, it has shown that it has the strategic capacity to absorb large numbers of military casualties.16 The armed forces medical services in other countries with large militaries also have a significant role within national health economies, such as India, Pakistan, South Korea, and Brazil. They are likewise often the most respected element of the national health system and have a significant caseload from military families, beneficiaries, and the wider civilian population. The military health services of these countries also made a substantial contribution to the civilian response to COVID and are globally deployed in support of UN peacekeeping operations (except for the Republic of Korea).
This short case comparison suggests that the military health system can be an integral component of the whole national health economy, with substantial “political” power due to size, relative resources, status, and reputation. They are embedded in the civil-military response to national crises, and they maintain and deepen their deployed experience through supporting UN peacekeeping missions. While some of these factors might be explained by the role of the armed forces in society as part of their national civil-military relations culture, there might also be factors that are unique to a military health system of such scale that should inform comparisons of capability and capacity of the whole national health systems enterprise in support of large-scale military operations.
Implications of Health Threats for U.S. Civil-Military Relations Within the National Health Economy
The COVID pandemic can provide a lens to consider the U.S. military health system as a strategic national resource and its potential roles in a future national health emergency. The primary role of the military health system continues to be that of maintaining the health of warfighters and meeting the needs of their primary beneficiaries. While military hospitals did not specifically expand to treat non-beneficiary civilians, military medical personnel (Active duty, Reserve, and National Guard) were employed to augment the capacity of the civilian health system across testing, clinical care, and vaccinations. Military medical personnel reinforced the crisis management system at national and local levels, the military procurement system assisted in purchasing medical equipment and materials, and the military health research system complemented wider national bio-medical science research. These U.S. activities during the COVID pandemic almost exactly mirror the activities of those countries with health systems of equivalent size previously cited, but many U.S. military medical treatment facilities reported significant personnel shortages during the crisis.17
The global position of the United States and how it perceives its strategic threats mean that the U.S. Armed Forces are framed for military alliances with key allies and partners away from the continental United States (CONUS). In the event of conflict, U.S. military forces will be sustaining casualties on other continents within countries that are suffering their own military and civilian casualties. Concurrently, U.S. adversaries may have the capacity to create casualties or disrupt health systems among civilian and military populations in CONUS (with chemical, biological, radiological, nuclear, or cyber weapons). Although such attacks could provoke a strategic response, it would still be necessary for the Federal Government to have the resilience within the whole health systems enterprise to recover from such an event.
In the Euro-Atlantic region, NATO is actively interpreting the implications of the war in Ukraine on the interoperability of military and civilian health systems in case of wider escalation of this crisis. This has shown the importance of civil-military planning across the health system and the importance of the European Union as the regional “civil” institution. This regeneration of interest was also reflected within NATO in December 2023 by the first joint meeting of the Committee of Chiefs of Military Medical Services and the Joint Health Group of senior civilian health officials of member nations. The Asia-Pacific theater poses similar challenges compounded by distance and the dispersion of forces across multiple locations separated by sea. The nature of alliances and coalitions in this theater is much more fluid, creating more challenges in framing discussions regarding interoperability and civil-military coordination, even if NATO engagement within the region provides a useful reference point to the evolving role of regional defense partners within the Shangri-La Dialogue.
Deployed military health services will need to care for civilians caught up in conflict, and military casualties may pass through civilian hospitals as part of their evacuation. Air and maritime threats are likely to constrain medical evacuation to ambulances and trains within the land environment with the need for national and regional coordination mechanisms for strategic patient movement and regulation by sea or air (either within country or between countries). The United States will need to have sufficient deployed medical forces to meet the needs of national patients, including the placement of U.S. national liaison officers in all the centers and headquarters that are coordinating medical services. Thus, considerable effort will need to be invested in “medically enabling the theater” from the perspective of both the western and eastern borders of CONUS.
All U.S. military (and potentially civilian) casualties that cannot be re- turned to duty within the theater will be evacuated to the United States. While the footprint of U.S. military hospitals in CONUS is likely to provide the initial reception centers, experience from major wars has shown the importance of the civilian sector (especially the Veterans Administration) in the onward dispersal and care of military patients. The arrangement for civil-military coordination of health services that was established during COVID may need to be maintained to provide a framework for other health emergencies. This will require an unprecedented level of civil-military cooperation through the U.S. National Disaster Medical System in the regulation and dispersal of combat casualties.18 The realities of planning for large-scale contingency operations have reinforced the importance of such civil-military cooperation at the strategic level with significant enhancements requested by the Department of Health and Human Services’ Administration for Strategic Preparedness and Response for fiscal year 2024.19 Overall, these examples show how the whole national health systems enterprise is equivalent to the strategic defense–industrial complex for weapons production. This strategic perspective is often missing from the analysis of the operational and tactical roles of the military health system.
Conclusions
Readers of this journal are acutely aware of the rapid review of national strategic security policies because of lessons from the COVID pandemic, the war in Ukraine, and increasing tensions in the Asia-Pacific region. It is important to remember that casualties are the one certainty in war and that the enemy has a vote. The scale of human suffering in the event of a large-scale contingency operation, both military and civilian, could exceed the capacity of military health systems to manage and care for such casualties.
Current approaches to changes in military health systems do not place sufficient emphasis on their strategic role within a national health systems enterprise. The use of HMOs or NATO Allies as a reference point ignores the importance of case studies based on strategic competitors of equivalent scale. This is counter to most other appraisals of comparative national military power. Using case examples of large-scale military health systems might provide some insights into the strategic choices in resource allocation across the health services provided by different government ministries in countries of comparable scale to the United States. Thus, a country’s military health system plays a similar strategic role in the whole national health economy to that of the defense–industrial complex within the technology and manufacturing sectors. Such an analysis might inform the balance of investment across the civil-military elements of the U.S. national health systems enterprise to mitigate potential strategic shocks to the health of the population of the United States. JFQ