Health Support to Complex Warfighting: More than just ‘Deploy the Level Three’
Abstract
As the contemporary battlespace evolves, consideration needs to be given to the requirements for Army Health. This article critiques the existing structure and use of health capabilities in the Army and suggests future developments to improve how Army cares for the medical needs of its members against the backdrop of complex warfighting.
I went over to Brizzo, who was still alive at this time. He was laying down and he had no wounds from his knackers up, but every square inch of his legs was just hole. He kept on trying to sit up, but I had to keep him down because I didn’t want him to see his legs.
- Jeff Sculley, Platoon Medic, Vietnam War 1
Time for Change
When Jeff Sculley was deployed to Vietnam, complex warfighting was not taught—it was practised. Jump forward forty years and despite advances in combat body armour, a large number of the catastrophic wounds that Coalition forces are experiencing in Iraq and Afghanistan are remarkably similar to those suffered by Sculley’s Vietnam casualties. The Australian Army is once again practising complex warfighting, teaching warfighting theory and restructuring the combat arms of Army to fight more effectively. What improvements, however, have been made or suggested to the way Army Health fights its battles?
Army Health underwent revolutionary change as part of the overall restructuring of the Army in the mid-1990’s which was termed ‘Army for the 21st Century’ (A21). This introduced the formation of standardised health capability structures to generate health support effects within the battlespace. Building upon the lessons of Rwanda, the Field Ambulances, Preventive Medicine Companies and Field Hospitals were removed from Army’s order of battle. In their place arose new team-based structures to provide health support to deployed forces. At the same time, command and control of Army’s deployable health assets was wrested from the hands of health professionals and passed to logisticians, and Health was excised as a function from Army Headquarters. These changes, in an era of change, have had a fundamental impact on the ability of Army Health to fight.
The health challenges of today’s complex warfighting are different from those that generated the A21 structural changes. These challenges require a rethink of the way Army Health is organised and does business. It is time to move on.
This paper provides a glimpse of the health challenges for Army that it must overcome in order to maximise casualty survivability rates in the complex warfighting environment of the future. The lesson from Army’s past is that it must prepare and adapt for the future. The ideas in this paper are a mile wide and an inch deep, but the intent is to generate interest in the deployed health system Army requires to support complex warfighting activities.
Defining Complex Warfighting
Army’s capstone doctrine states that winning future battles will depend on skilled personnel, flexible organisations, robust support infrastructure, excellent training, the right equipment and sound doctrine.2 The future battlespace is shaping to be one in which many factors are at play. Diverse urbanised terrain, a variety of state and non-state players, and a wide range of conventional and non-conventional threats increase the vulnerability of logistic and health support nodes, routes and assets. It is within this battlespace that the Australian Army is posturing itself to undertake complex warfighting.
For the purposes of this paper, complex warfighting is defined as multidimensional conflict—that is a conflict not just in space and time, but also in context. This context is created by the physical, political, cultural and informational environments where conflicts are fought.3 ‘Complex warfighting operations demand the application of precise and discriminating force, in a whole of government framework, to influence and control populations and perceptions’.4
Such warfighting occurs in a complex environment. This environment is characterised by physical, human and informational factors that interact in a mutually reinforcing fashion. A complex environment limits the utility of technological intelligence, surveillance and reconnaissance and reduces opportunities for long-range engagement with a consequent increased emphasis on close combat.5 Significantly for Army, close combat results in casualties and increased risk to any responding health system.
Of all the characteristics of the complex environment, asymmetry and the battlespace’s non-contiguous nature provide the biggest obstacles to the provision of health support. Military asymmetry may be reflected by differences in composition of forces, intent, culture, technology or size.6 The non-contiguous battlespace means that activities conducted in what were traditionally perceived as relatively secure areas now take place wherever contact with the enemy is possible.7 In complex warfighting, the ‘front line’ is gone and a robust, fleeting enemy will maximise targets of opportunity using a variety of conventional and unconventional weapons and techniques.
Army’s approach to succeeding in complex warfighting is shaped by the Chief of Army’s development intent for a Hardened and Networked Army (HNA). The HNA is to be capable of complex warfighting, using the combined-arms effect at the small team level to generate a capability for close combat in complex terrain.8
Supporting this intent demands a rethink of the way Army Health is currently commanded, employed and deployed. With complex warfighting comes complex health challenges—and Army Health must evolve to meet these challenges.
The Complex Warfighting Health Challenges
Complex warfighting requires a specific approach to close combat—an approach which acknowledges that while combat does not itself guarantee victory, close combat remains an essential prerequisite for mission success. To be effective, forces must be organised and consciously optimised for close combat under conditions of complex warfighting.9 This raises a number of unique challenges for Army Health.
A failure to understand the health threats faced by any deploying force will result in both an inadequate force protection posture and an unsuitable health system being deployed. Most casualties suffered by any deployed force will be disease and non-hostile injuries. Health participation in mission reconnaissance significantly reduces the non-battlefield casualties suffered by the deploying force. Reconnaissance missions use active or passive methods to obtain information about the activities and resources of an enemy or potential enemy, or about specific environmental data sets.10 Army Health already adheres to this doctrinal guidance. Such reconnaissance achieves a number of outcomes. Firstly it validates the Strategic Health Intelligence assessment of the deployment area and provides an initial chance to scope the environmental and occupational threats that may impact on the deploying force. Secondly, it provides a chance for the on-the-ground Health Commander to ensure that the disposition of the deploying Health force conforms to the operational commander’s in-theatre concept of operations. Finally, it performs the important corporate shaping task of ensuring that Health is visible to the operational commander as a separate and essential part of the overall force. Health is not logistics and logisticians cannot undertake this vital health reconnaissance task. Army’s existing Health Threat Assessment Sections within each of the Health Support Battalions are ideally postured to undertake these missions—but they need tasking, restructuring and re-equipping to be effective.
Prior to deployment, Mission Rehearsal Exercises (MRE) are vital to the force preparation of Australian soldiers deploying into any operational environment. The active participation by Army Health Services in scheduled MRE must be considered as essential. All deploying soldiers need to be exposed to the full spectrum of operational realities—and that includes traumatic injuries and mass casualty situations. Further, health personnel must be adequately force prepared and assessed. Statements such as ‘you don’t need access to that type of vehicle as it won’t be your ambulance’11 miss the point that, unless Army Health Services personnel train realistically and practice extracting and treating casualties from all dependency vehicle types, then they will not be able to operate effectively. Simple things like knowing where vehicle hatches are located, how to open doors and what type of casualty extraction equipment will be required will save lives. To validate the success of force preparation activities, Army must implement procedures for the formal assessment of collective health capabilities before deployment. Australia’s major coalition partners already conduct assessments of this nature12 and the reduction in their mortality and morbidity rates during current conflicts is testament to the success of this approach.
There is already abundant data on wound profiles being generated out of the Middle East. The adoption of an ever increasing range of combat body armour has seen a move in the pattern of fatal wounds away from the torso to the extremities and limbs. Unfortunately, due to the unclassified nature of this article, it is not possible to expand on this point, but what can be stated is that wound profiling of US and UK casualties reveals potential for improvements in combat body armour.13 Capitalising on these lessons, the already highly significant reduction in mortality and morbidity rates vis-à-vis the Vietnam War can be further improved upon. The key lesson for Army Health from changing wound profiles is the need for specialist surgical support to be available to respond rapidly to the escalating number of extremity and head wounds. This requires development work on the skill set components of Army’s Role Three surgical support capabilities and investment in securing an adequate pool of specialists for Army from the limited number available within the Australian community.
The civilian Airway, Breathing and Circulation (ABC) approach to the provision of first aid is redundant for military operations. The battlefield killer is, and has always been, the ‘C’. This revelation is nothing new. Obsolete Army doctrine states that:
the most common cause of death on the battlefield is haemorrhage. A large number of casualties bleed to death on the battlefield because of inadequate first aid. Research has shown that in cases of severe trauma, survival is improved if first aid can be provided within the first five minutes of the injury.14
Therefore, both history and our current experiences indicate that military battlefield trauma should be managed using a CAB approach, rather than the civilian-specific ABC model. Complex warfighting—and the greater use of individual force protection measures such as combat body armour—changes wound profiles and places a greater emphasis on the first responder to stop the inevitable extremity haemorrhage. Besides a change in our first response methodology, the HNA also requires both a greater percentage of Combat First Aiders in each combat team and a greater emphasis on individual soldier first aid skills. The Army standard must be for every soldier who is deploying to be a qualified Combat First Aider. The Canadian Army experience with this approach has seen a demonstrable improvement in their post-incident morbidity and mortality rates in Afghanistan.15 Further, in order to ensure Army maintains a solid base line of basic medical skills, annual re-qualification in basic first aid must become mandatory and this must be recorded on PMKeys.
‘Deploying the Level Three’ is not the solution to every health problem. Sadly, too many non-Army Health planners (and a large number of Army’s ‘Operational’ planners) can only see one solution to every health-related problem they encounter. The current mind-set on deploying health support has come about as a result of the demise of Army Health as a corporate entity and the inclusion of Army Health into logistic organisations. Not only does this impact on the command and control of Army Health assets, it is the prime determinant of what health capability assets are deployed. Health and logistics do not have the same aim or outcomes. Logistics is about sustainment, Health is about force protection and force preservation. Health support to deployed forces is a system of elements and responses. Early threat assessment during the reconnaissance phase must be supported by a comprehensive evacuation continuum, ongoing environmental health support, timely and world-class casualty treatment, wounded soldier rehabilitation and finally hand-off back into the personnel management world. Continued reliance on a single element of that system to meet all requirements will result in institutional failure.
Whether in the jungles of Vietnam or in the urban sprawl of the Middle East, locating casualties has always been a difficult task. In this area technology may come to Army’s assistance. Combat identification will be made simpler in the future through the use of emerging technology that will allow commanders to track and locate their subordinates at all times. Link these technologies with individual soldier system monitors16 and the possibilities are endless. Importantly for Army Health, monitoring an individual’s location and combat status facilitates a rapid treatment and evacuation response should that individual become combat ineffective due to injury or illness. At the Theatre Level and above, global visibility of casualty movements through the health system, and visibility of each treatment asset’s capability, must become a feature of the broader Army and ADF health system. Web-based casualty regulation and facility management tools will become a standard feature of future warfighting and are already in use by our coalition partners. There is now potential for the Australian Army to achieve real-time casualty visibility through the acquisition of the United States’ TRANSCOM Regulating and Command and Control Evacuation System (TRAC2ES). TRAC2ES is currently the subject of an ABCA study for more widespread coalition use. Australia is intimately involved in this study and it is anticipated Australian access to the system could be granted from mid-2008.
Casualty evacuation is the critical link between life and death. The reduction in the time between wounding and treatment is directly related to lower mortality and morbidity rates.17 The challenges of evacuating a casualty are complicated by the asymmetric and non-contiguous nature of the future complex battlespace—in complex warfighting, the casualty evacuation platforms themselves become prime targets of opportunity; soft-skinned B-vehicles become immediately obsolete. Aeromedical evacuation is not always an option due to time, space, platform availability and, more importantly, the growing vulnerability of the aerial platforms to increasingly sophisticated weapons and tactics. Army Health requires two response options for surface evacuation of casualties. Firstly, a fleet of ‘conventional’ hardened ambulance vehicles are required that have the same mobility, communications suite and self protection as the force they are supporting. These vehicles will be essential to undertake evacuations in an environment of threat to platforms, their occupants and to the very routes on which they travel. To demonstrate the importance of this point, the US Army now employs only up-armoured HUMVEE Ambulances in support of ground operations. Secondly, Army Health requires lightweight and robust uninhabited vehicles that are an integral part of the Combat Team organisation and whose role is to ‘swoop and scoop’ casualties back to a primary aid facility. The US Army is already exploring this idea and has termed its concept demonstrators ‘Mules’.18 Couple the uninhabited evacuation vehicle with developing suspended animation technology and an effective solution to casualty evacuation under fire emerges.
Treating the casualty is actually the easiest and best understood part of the evacuation and treatment continuum. Army Health has long held the view that ‘it is fundamental that developments in civilian medical practice are translated without delay into the military environment’.19 The one enduring asset of Army Health is the high quality and training of its personnel. To bolster specialist numbers, the creation of a Specialist Reserve within Army will provide a greater and more responsive pool of critical medical specialists to support short-notice and long-standing Army activities. Treating a casualty becomes not so much a matter of how, but where. In an asymmetric non-contiguous battlespace, forward surgery becomes the only option. Supporting the forward surgical work, the importance of tactical and strategic aeromedical evacuation then becomes even more pronounced. The RAAF now has a role in complex warfighting on the ground—not by providing boots on the ground with underprepared and inappropriately equipped personnel, but by adhering to core business.
The reduction in mortality rates for severely injured soldiers comes at a cost. Where once the rehabilitation services for Australian veterans were the envy of the world, as the numbers of aging veterans decline, the range and depth of services and corporate experience has also declined. Already in contemporary operations the United States has suffered tens of thousands of casualties including nearly 600 personnel with a minimum one limb amputation.20 On top of this figure are the thousands of other US soldiers with severe long-term physical and psychological injuries. Complex warfighting produces complex casualties and increased survivability rates produce larger numbers of system-dependent individuals. The lesson from this overseas experience for the Australian Army is that veteran’s health support services post-separation from Army must include services to cater for the long term system-dependent injured soldier. As the vast majority of complex warfighting casualties will be Army personnel, Army must engage with this issue and not leave it to the joint world to seek solutions on its behalf.
Liaison is essential to establishing an internal-to-force presence and, when operating within a coalition, an external-to-force credibility. With the current ADF reliance on coalition assets for the provision of all in-theatre health support above that organic to units and Combat Teams, liaison becomes an essential force multiplier. Force Level Senior Health Officers performing a planning and liaison role must be selected on skills, knowledge, attitude and ability and not on just being a member of one particular health services craft group. This interfacing gap is not only at the tactical and operational levels, it is also at the strategic level. Army appears to be at an increasing disadvantage when senior non-Army Health Officers plan land-based warfighting health support without a full understanding of the range of effects Army Health can deliver. Army Health needs a strong advocate to champion its cause, and that strong advocate needs to be at Army Headquarters.
The critical component of any effective military organisation is command and control. Why then are Army’s deployable health assets part of Logistics organisations and commanded by logisticians? Logisticians know as much about health as most medics do about ammunition stacking. Grouping health with logistics has not been successful. It is time to cut the losses of the A21 period and recognise that some ill-informed command and control organisational changes have not worked. It is time to optimise Army Health for the future by excising Health out of the logistic environment, centralising Army Health assets into one formation and addressing the Army Health command and control gap.
The Health Structures Army Needs
The key to generating the right health effects for complex warfighting lies in the organisation and command and control of Army’s deployable health assets. The centralisation of all Army’s deployable health capabilities into one formation provides the only realistic solution if Army Health is to effectively contribute to combat viability. This concept is supported by Army doctrine that already states ‘there are some forces or assets that require treatment as significant resources because of their wide utility but limited availability, or limited expert control cells.21 In short, the Australian Army needs a Health Brigade.
Health Brigades are a reality for our major coalition partners, which grapple with the same health support problems as our forces. Health Brigades (or Medical Brigades) reside in both the US and UK armies and are viewed as essential combat multipliers. They are a specialised formation in which a limited, but essential, asset can be managed across a Corps or larger organisation. In the context of the Australian Army, centralising all Army’s Role Two and Three Combat Health Support (CHS) units into one formation and forming a CHS Brigade will realise significant force preparation and mobilisation benefits almost immediately.22 It will be far more capable than current organisations of generating and managing Army’s limited health specialist rosters because all specialists will reside within the one organisation. Further, Army’s force health protection capability development would significantly benefit from having a single formation where capability development and management can be achieved with a minimum superfluous or repetitious staff effort. The examples of Special Operations Command (SOCOMD) and 16 Brigade (Aviation) are highly noteworthy examples of centralising a limited asset to generate sustainable and highly successful outcomes. Army’s deployable CHS capabilities are another limited asset that could be far better commanded and managed in a single effects-focussed formation.
On the equipment front, if Army is looking to an existing project for new equipment solutions to health capability gaps, then it is time to widen its horizons. In the past few years Joint Project 2060 (JP2060) has been viewed by many as the saviour for Army Health of the future. The reality is that JP2060 has become an almost irrelevant project and certainly not one aligned to producing an Army Health system capable of operating in tomorrow’s complex warfare environment. The whole process of having to rely on watered-down joint concurrence to land warfighting support requirements delays the introduction of evolutionary equipment as a result of unnecessary and uneducated23 joint and materiel staff floundering while trying to work out what is best for Army. Army Health equipment solutions must be compatible with Army’s complex warfighting outcomes and methodology, not selected on the basis of political correctness or achieving non-Army program organisational efficiencies.
One of the realities of complex warfighting is the blurring in distinction between combat and support forces.24 Casualty evacuation becomes a challenge when the evacuation platforms and personnel are softer targets than those they are supporting—indeed, they then become the prime target. In order to maximise survivability rates, Army requires a standardised protected casualty evacuation platform at Role One and Two CHS units.25 This fleet of platforms must have mobility, protection and communications commensurate with the force it is supporting. Statements in Land Warfare Doctrine 1 such as ‘force protection will be difficult in the non-contiguous battlespace but must be kept in balance with mission needs’26 become merely words in a risk averse, casualty averse society. The Australian public and the soldiers of the Australian Army will not accept casualties that occur as a result of not hardening or networking the support elements of our new HNA. New protected casualty evacuation platforms and uninhabited casualty extraction vehicles are not a luxury—they are a political and operational necessity.
Lastly, to make Army Health really work, there is a requirement for a strong advocate at Army Headquarters. Army is now the only Service that has not re-raised a Health Directorate within its service headquarters. The impacts of this are threefold. Firstly there is no central coordination or oversight of the Army Health systems operating within the three functional commands.27 Implementing health policy is already difficult and there is virtually no extant Army Health policy. Secondly, there is no single Army Health voice in joint health forums and Army continually loses out due to the ability of other Services to ‘divide and conquer’. Finally, there is no informed interaction at the strategic level with force structure designers and concepts staff to ensure Army Health is an integral part of the force, not just some add on to logistics as an afterthought. Despite doctrinal rhetoric to the contrary, Army Health is not logistics. The reality is simple. For Army Health to avoid failure in the complex warfighting battles, a Health Directorate must be established at Army Headquarters, Army’s CHS assets must be removed from their current logistic locations and centralised into a single formation, and a complete rethink must be conducted at the strategic level into the way Army Health does business.
Conclusion
The restructure of Army Health under the banner of A21 was necessary to counter the perceived strategic threats of the time. Despite the changing strategic environment, it could be argued that the HNA of 2015 looks just like the soft un-networked Army of 2007—with a few more toys for the warfighters. Structures don’t change, combat groupings don’t really change, and even terminology doesn’t change.28 Yet, most disturbingly for Army Health, there are no planned changes from HNA initiatives. Something must be done before the reality of modern combat finds Army suffering as a result of its neglect of its own organic health services.
If Army Health is to operate in contemporary and future complex warfighting environments and ensure that the traumatic effects of battlefield wounds are minimised, then a full-function review of Army Health is required. This review must address the establishment of a Health Directorate at Army Headquarters, the reformation of Army’s deployable Role Two and Three CHS assets into a single effects-focussed formation and the introduction of new fleets of equipment to generate a CHS effect capable of supporting the HNA in complex warfighting.
Brigadier George Mansford once wrote that ‘the most tragic and disruptive impact on morale will be the unnecessary loss of life from friendly action’.29
He is wrong: the most tragic impact is the unnecessary loss of life from friendly inaction.
Endnotes
1 S. Rintoul, Ashes of Vietnam: Australian Voices, William Heinemann, Richmond, 1987, p. 133.
2 Commonwealth of Australia, LWD 1 The Fundamentals of Land Warfare, Department of Defence Puckapunyal, 2006, p. 30.
3 Complex Warfighting Paper, submitted to Chief of Staff Committee 31 March 2006, p. 2.
4 Ibid, p. 14.
5 The Fundamentals of Land Warfare, p. 84.
6 Ibid, p. 14.
7 Ibid, p. 28.
8 Lieutenant Colonel D. Kilcullen, ‘Future Land Operating Concept’, Complex Warfighting, Army Headquarters, Department of Defence, Canberra, 2004, p. 22.
9 Ibid, p. 18.
10 Commonwealth of Australia, LWD 3.1 Intelligence Surveillance, Target Acquisition and Reconnaissance, Department of Defence, Puckapunyal, 2006, pp. 1-2.
11 Made to the author when he attempted to shape an AMTG MRE casualty extraction activity.
12 Both the United States and United Kingdom have extensive pre-deployment assessment and certification regimes for their collective health capabilities.
13 From classified documents held in the LHQ Secure Registry.
14 Commonwealth of Australia, LWD 1.2 Combat Health Support, Department of Defence, Puckapunyal, 2004, p. 2.
15 Canadian Army observations made at the ABCA Annual Meeting 2007, noting that the vast majority of fatalities occur immediately at the point of incident.
16 I define the soldier system as the individual, their uniform and body armour and their equipment.
17 Commonwealth of Australia, MLW 2.1.1 Medical and Dental Training: The Employment of the Health Services, Headquarters Training Command, Department of Defence, 1984, pp. 1-2.
18 United States Army, Army Transformation 2020: Experience the Future Force (DVD), released 06 Oct 2003
19 Medical and Dental Training, pp. 1-2.
20 Correct as at 21 April 2007.
21 Commonwealth of Australia, 2003, LWD 0-0, Command Leadership and Management, Headquarters Training Command – Army, pp. 2-18.
22 CHS is to HSS as CSS is to Logistics. By definition Combat Health Support (CHS) is that health support provided to deployed forces within the area of operations. I therefore contend that we need a CHS not a HSS BDE.
23 ‘Uneducated’ in that they lack an understanding or appreciation of Army and what Army requires. As Army Health makes up an overwhelming majority of the deployable personnel asset and health capability available to the ADF, a ‘purple triumvirate’ approach is not in Army’s best interest.
24 United States Joint Forces Command Pamphlet 2007, Joint Urban Operations, p. 2.
25 NATO has adopted the use of Roles over Levels in its descriptive terminology for Health Support. ABCA publications are being amended to align with NATO and Australia will therefore need to start deleting the use of Levels and using Roles.
26 The Fundamentals of Land Warfare, p. 28.
27 Land Command, Special Operations Command and Training Command.
28 The 1995 pre-A21 RSG based upon 2 Cav Regt looks remarkably like the current BG Eagle.
29 G. Mansford, Junior Leadership on the Battlefield, Training Command Army Georges Heights, 1994, p. 9.
