Medical strategy to medical diplomacy by Stéphane Gaudin

MEDICAL STRATEGY TO MEDICAL DIPLOMACY : The Role of the Military Medical Domain in Military and Political Thinking Médecin en chef Valérie DENUX

THEATRUM BELLI Éditions

Editorial Manager : StĂŠphane Gaudin Website : www.theatrum-belli.org Contact : stephane.gaudin@theatrum-belli.org Published by TB in June 2013, all rights reserved. Photo (top) : French field hospital during Desert Storm between 1990-1991. Credit: Yves Cudennec. Photo taken into the website devoted to french Daguet Division: www.site-daguet.fr

MEDICAL STRATEGY TO MEDICAL DIPLOMACY The Role of the Military Medical Domain in Military and Political Thinking

Médecin en chef Valérie DENUX

MEDICAL STRATEGY TO MEDICAL DIPLOMACY The role of the military medical domain in military and political thinking

PART ONE: Medical Support: a real strategic player A source of power A tool for freedom of action Protective Security

PART TWO: The limitations on the use of the medical domain as a strategic player Cultural environment Command decisions The medical domainâ&#x20AC;&#x2122;s own limitations

PART THREE: The part played by the medical domain in modern military thinking Direct Strategy Indirect Strategy Political Tool

Table of Contents

PREAMBLE ..........................................................................................................................3 INTRODUCTION .................................................................................................................5 PART ONE: .........................................................................................................................12 Medical Support: a Real Strategic Player ............................................................................12 I- Source of Power ...........................................................................................................14 A. Conserving Human Lives.................................................................................14 B. Keeping Up Morale ..........................................................................................24 C. The Preservation of Military Animals .............................................................28 II A Tool for Freedom of Action......................................................................................32 A. Controlling the Environment ...........................................................................32 B. Population Management...................................................................................37 C. Freedom of Manoeuvre ....................................................................................40 D. Technical Innovations ......................................................................................45 III Protective Security ......................................................................................................48 A. Assessing the Threat ........................................................................................48 B. Medical Countermeasures ................................................................................50 PART TWO: The Limitations on the Use of the Medical Domain as a Strategic Player ....53 I. The Cultural Environment .......................................................................................54 A. Man as an Asset ...............................................................................................54 B. Man as a Servant of God or Ideology ..............................................................56 C. When Man Serves Machines ............................................................................58 D. Man as an End in Himself ................................................................................60 II. Command Decisions ................................................................................................63 A. A Domain First Ignored then Held in Contempt..............................................63 B. The Constraints of the Medical Domain ..........................................................67 C. The Need for Mutual Understanding ...............................................................69 D. Strategic Choices ..............................................................................................71 III. The Medical Domainâ&#x20AC;&#x2122;s Own Limitations ................................................................73 A. Technical Failings ............................................................................................73 B. Organizational Issues. ......................................................................................77 C. Medical Ethics ..................................................................................................83 PART THREE : The Part Played by the Medical Domain in Modern Military Thinking...88 I. Action Strategy .............................................................................................................91 A- Space ................................................................................................................92 B- Time .................................................................................................................95 C- Force.................................................................................................................97 D- Environment ...................................................................................................101 II. Indirect Strategy ........................................................................................................105 A- Medical Aid to Populations............................................................................106 B. Rebuilding the Health Network .....................................................................108 III. Political Tool ............................................................................................................111 A. Participating in Disaster Relief ......................................................................111 B. Managing Public Opinion ..............................................................................114 C. Medical Diplomacy ........................................................................................117 CONCLUSION ..................................................................................................................120 BIBLIOGRAPHIE .............................................................................................................123 2

PREAMBLE The French Military Health Service celebrated its 300th anniversary in 2008. It is one of the oldest in the world, a royal decree in 1708 establishing « inspectors general of medicine and surgery, surgeon-majors of barracks and armies, doctors and surgeon-majors of city and fortress hospitals, and armies1 ». This act is considered the founding act of the Service, marking the official recognition of the state’s duty of care. Since Antiquity, the development of medical support for armed forces was slow and erratic. The millennia which preceded the formal constitution of a military health service provide valuable lessons for military players involved in modern conflicts. Much research has been devoted to the history of medical support of armies in general and of the French Military Health Service in particular. These historical surveys have reviewed the technical2 or organizational aspects of the support provided, in particular during major battles, providing readers with a useful source of lessons learnt. These two approaches are very important and they guided the gradual improvement of the efficiency and efficacy of the world’s military medical services. However, one aspect has not been explored much: the place that the medical domain held and holds in the thinking of military leaders. One may wonder about the reason for this absence. Was it due to an oversight or to a lack of interest in the medical/military partnership? History shows that war and medicine have always coexisted, albeit often within an ambiguous and cyclical relationship. With the appearance of “civilized” warfare, all the conditions were in place for the warfare – medicine relationship to develop and grow. As Médecin Général des Armées Bernard Lafont pointed out 3: “the permanence of war in human history has created a special link between nations and their soldiers. The importance a community attaches to their protection and support, to the quality of healthcare afforded them, and to their return serves as proof of the nation’s gratitude for their sacrifices4”. In this context, the influence of the medical domain in the art of war and of command was strongly influenced by the techniques used in each era and the price

Royal Edict, Versailles January 1708, recorded by Parliament 22 March 1708. Technical aspects cover all elements related to medical practice. 3 Surgeon General of the French MHS from 1 October 2005 to 1 October 2009. 4 Bernard Lafont, Editorial : Hier, aujourd’hui, demain…, Médecine et armées, 2008, 36,5, quoted p 389. 2

attached to the life of others, that is to say the part played by man in the society he defended. We will therefore attempt to understand why there is such variation in the military/medical relationship and to show how they can mutually reinforce one another. The new typology of conflict requires that military strategy constantly evolve, including in relation to the human factor. Which is why the part played by the medical domain in military thinking, which we are calling medical strategy, must be defined. We chose the term by analogy with the concepts of ‘geostrategy’, and to a lesser extent the terms ‘topostrategy’, ‘morphostrategy’, ‘physiostrategy’, or ‘meteostrategy’ - even if these are static concepts where medicine is not - used by Hervé Coutau-Bégarie in his Treatise on Strategy. By ‘medical strategy’ we mean that the military medical domain has always had a strategic dimension throughout history, although it was not exploited to the fullest extent until modern times. The object of this study is to encourage military decision-makers to integrate ‘medical strategy’ in their theorization of military thinking and for the heads of medical services to provide the medical domain with the military dimension required for its exploitation within the overall strategy. This partnership is now mature and it therefore seemed necessary to study its past in order to get a better understanding of its future.

INTRODUCTION The French ‘White Book on Defence and National Security’ published in June 2008 specified that “the primacy of the human factor must be reaffirmed5”. This was a relatively recent trend; Marshal Foch was still saying in 1914 that “when you are commander in chief, you do not have time to think about the men, if you do, you lose the war”. But the value attached to human life has gradually increased since the First World War. The study of man and the human factor has developed considerably and populations are now central, as confirmed by the strong influence perceptible in European Defence since 2004 of a “strategy of human security6». This new emphasis clearly has an impact on the care taken to protect the life of combatants. Military medical services therefore have an important part to play since this implies their participation in all major strategic functions such as, in the case of France, “knowledge and anticipation” by contributing to the assessment of threats, such as deliberate biological risks; “prevention” by contributing to the monitoring and early warning system for natural risks; “protection” by developing medical preservation measures and countermeasures; “intervention” by favouring operational preparation, the support of forces and the participation in civil-military actions. The range covered by the medical domain has therefore considerably increased since its creation since it is no longer confined to the treatment of the wounded. It is now a full operational capability considered by the commander as a force multiplier. As proof one can simply look at the place given to medical advisors in France but also in other members nations of the North Atlantic Treaty Organization (NATO) and European Union (EU); they are usually placed close to the commander in chief, alongside political or legal advisers at a strategic level, but also via the medical advisor (MEDAD) at the operational and tactical levels. This situation resulted from a long progression, which saw significant changes to the relationship between the medical domain and military command, consecrated by the recognition of a “very advanced technical medical capability7”. Many aspects can still be improved, such as mutual understanding and the optimisation of the medical tool by its improved integration within military thinking. In order to understand this process of integration, one must begin by analysing the historical relationship between the medical and war domains. This covers several millennia 5

Livre Blanc, défense et sécurité nationale, 2008, quoted page 203. The European Security Strategy (ESS) includes the new concept of ‘Human Security’. 7 Livre Blanc, défense et sécurité nationale, 2008, quoted page 217. 6

which witnessed both the birth of medicine and of the first large organized armies. But it is worth noting that their coexistence did not lead to the immediate creation of a permanent structure for the medical support of troops. This study covers the period from Antiquity to today, concentrating in particular on the great historical periods and significant battles. During this “extensive analysis”, “a definite impression grew stronger8”: that the importance of the medical domain in warfare bears a strong correlation with the price that men of succeeding generations attached to the lives of those who were defending them. For a long time, men were more concerned with their afterlife than with death itself. Their life, affected by illness, famine, infantile mortality and violence, was considered a passage to be accomplished with dignity before ascending to eternal life after death. This sense of fatality tended to diminish the human factor. Furthermore, the parallel development of defensive and offensive technologies occurred at different tempos, the second usually preceding the first. The slow progression of medical techniques was also delayed by a combination of superstition - applied to illnesses which went beyond human understanding - and religion which was not inclined to question, relying instead on divine explanations.

However, despite these limitations on the harmonious development of a partnership between doctors and soldiers, physicians were already present on the battlefield of Antiquity. Their service was initially reserved for key leaders. This approach was logical at a time when armies were relatively small and their efficiency was based essentially on the individual qualities of war chiefs. The medical assistance offered by Egyptian and Mesopotamian doctors was reserved for the king and his main subordinates. In the Iliad, Machaon, believed to be the most competent healer, was called to tend the wounded King Menelaus.

The Greek vision of democracy encouraged the extension of healthcare to soldiers, who were now perceived as citizens entitled to the city’s care. The state’s conscience awoke to its duty towards those who sacrificed everything for its protection. The appearance of large organized armies in ancient civilisations, initially made up of Greek mercenaries, then Roman legionaries, further encouraged the medical support of soldiers. This was not born of a concern for the sanctity of human life, but rather from the need for the efficient preservation of experienced troops. Medical considerations were included in Roman strategy, not only with regard to the care of the wounded, but also the legionaries’ rations and physical preparation, which contributed in no small part to their warrior spirit. Which 8

Jomini praising, as did Lindell Hart, the pedagogical virtues of history.

is why, in spite of the presence of physicians in the legions and the establishment of military hospitals (valetudinarium), the absence of a structured medical service is an oddity. While the commanders appeared interested in sparing the blood of their soldiers in order to accomplish their missions, they did not seem ready to give military medicine a significant role. We find the same attitude prevalent within Byzantine armies.

During the Middle Ages, the relationship between man and God reached its apogee. In this context, any event was considered the result of divine will and it was therefore useless to object: man was expected to accept his fate. This vision was most clearly expressed in the ideal of knighthood where glory required suffering and sacrifice in the service of God. To counter weapons’ technological progress, only passive protection measures were developed. When a soldier was hurt, it had to be God’s will. The stagnation and limited efficiency of medical care (medical progress being limited by religious prescriptions which forbade dissection for instance) also contributed to the limited role of military medical support. Nevertheless, it was during this period that military leaders became concerned with medical issues, especially during the Crusades which required large armies which could not easily be replenished. The availability of trained combatants had to be preserved, so the development of a medical organization became essential. Religious military orders thus appeared, a case of military necessity overcoming religious reluctance. The Christian world adapted by taking over these establishments, the Catholic Church could thus control these orders’ medical practices while demonstrating its goodwill towards combatants.

Science gradually grew in importance during the centuries that followed. Gaining its clearest expression during the Renaissance, it allowed medicine to achieve significant advances. The sophistication of weaponry also improved, allowing man to free himself from individual combat and injure his opponent from a distance and thus multiply the number of casualties. Man’s conscience awoke to his power of destruction, leading to the creation of an increasingly structured medical support. Kings expressed a true desire to provide medical help to the wounded. This gradual development of medical support structures culminating in France with the 1708 Royal Edict.

But the recognition of a need for a state-run support system for military casualties merely marked the beginning of a long process which would face numerous obstacles before it fully matured.

The Napoleonic wars revealed the ambivalence of military leaders towards medical support. Napoleon, very aware of the heavy toll of campaigning on his army - both as a result of combat, but also from diseases and infections – paid close attention to the billeting and hygiene of his troops. On the other hand, in spite of his personal respect for Desgenettes9, he stated that due to the lack of medical efficiency, “the military physician in an army corps is an absurd and useless thing’ and further noted that they would no longer be required, an illustration of the ambiguous relationship between the command and medical realms. The situation did not improve after Napoleon’s departure; physicians (Percy10, Larrey11 and Coste12) were left to organize, without real means, emergency healthcare and casualty evacuation.

The battle of Solferino, on 24 June 1859, marked a turning point. It brought out into the open the hitherto hidden relationship between medical support and command by drawing the attention of public opinion to the issue of medical support of soldiers. The Crimean War (1853-1855) had already encouraged British opinion, alerted by the new mass media, to object to the massive casualties due to a lack of adequate care. Henri Dunant13, a Swiss businessman, witnessed the horrific spectacle of wounded soldiers dying on the battlefield without help, because of a lack of assets or poor organization. In 1863, he created what later became the International Committee of the Red Cross, which a year later initiated the first Geneva Convention whose primary objective was the protection of wounded soldiers. Populations were no longer willing to accept the sacrifices of their family members without adequate care, and were no longer willing to accept the military medical services’ inability to provide a decent level of support, since it had become necessary to call upon private care organizations.

René-Nicolas Dufriche, Baron Desgenettes, was appointed in 1793 by Napoléon Bonaparte as Chief Medical Officer for the expedition to Egypt and in 1807 as the Grande Armée’s Physician. He took part in the major Napoleonic campaigns. 10 Percy (1754-1813) was a military physician and noted organizer who was concerned with soldiers’ welfare and spent his entire career trying to improve the medical support and situation of soldiers. 11 Larrey (1766-1842) was a war surgeon nicknamed ‘the soldier’s salvation’ on the battlefield. Napoleon called him “the worthiest man I ever met”. Wellington at Waterloo ordered fire away from him and saluted in him the “courage and devotion of another age”. 12 Coste (1741-1819) was a physician and hygienist who fought scurvy, dysentery and smallpox. He began the variolation of troops as early as 1803. 13 During a business trip in June 1859, Henri Dunant found himself near Solferino in Italy and noted the human aftermath of the battle. He published a book in 1862 based on his experiences “Un souvenir de Solferino”. A year later, he took part in the creation in Geneva of the International Committee for Relief to the Wounded, later renamed the Red Cross in 1876. The First Geneva Convention is dated 1864 and is largely based on his proposals. He was awarded the Nobel Peace Prize in 1901.

This inability to answer the growing medical needs of military forces was in part due to the lack of interest on the part of military leaders, who considered medical officers and surgeons much as they did the simple soldiers: unwilling to listen to their advice and only partially responsive to their requests. This resulted in France with the subordination of the medical service to the Commissariat, whose total incompetence, improvidence and occasional dishonesty in medical matters did not allow initiatives intended to alleviate the sufferings of soldiers or victims of war to develop. The French military medical service was eventually able to gain its autonomy in 188914, although its autonomy continued to be limited. One has to wait for the First World War before it was finally able to organize the medical support of forces.

The Great War bore brutal witness to the inadequacy of medical support, on both the French and German sides, resulting from the lack of dialogue and consideration for the medical function from the military command, which continued to deny it a real operational function. In France, the Decree of 11 May 1917 constituted the first step towards “direct contact with the high command, as well as a more complete control over its personnel and equipment, thus placing it directly behind the combatant arms15”. This approach was further reinforced in 1922, but the successive draft laws16 related to the organization of the army’s military health service were never voted.

The medical support of the military was reorganized between the two wars, but as was the case for the army in general, the medical service was unable to adapt to the war of movement. The Second World War, in large part because of the atrocities and crimes against humanity that characterized it, was a turning point for the health domain because it made the world conscious of the importance of the human factor in warfare. This was formalized through the Nuremberg jurisprudence, the United Nations’ Universal Declaration of Human Rights in 1948, and the formalisation of international humanitarian law in armed conflicts with the four Geneva Conventions of 194917. After 1945, armies could no longer consider medical support merely a tool for the preservation of manpower or a normal duty of the state, it had become humanitarian obligation.

The colonial wars of conquest and decolonisation allowed military medical services to extend their activities to the medical aid to local populations. Commanders, such as 14

Law of 1882 modified in 1889. Draft legislation on the Army’s Medical Service (SSA°, 1922. Temporary classification 9NN631, DAT, SHD. 16 Three draft laws followed in 1922, 1927 and 1928. 17 Geneva Conventions, 12 August 1949 and additional protocols PI, PII,1977 and PIII, 2005. 15

Lyautey, considered it might contribute to “the pacification of the countries under France rule18 ». Medical considerations began to be seen as a real strategic asset and were integrated in military thinking, in concert with the growing popularity of the “indirect strategy”.

The medical domain has matured technically and organizationally. Commanders now consider the medical function a force multiplier, but much remains to be done to ensure it is systematically taken into account by military thinkers, to further the intellectualisation of military practices, encourage studies and facilitate the instruction of future generations. It is evidently expressed through strategy, which is both “art, as the practice, and science (in the wide sense), as the knowledge acquired by the strategist19 ». Through the theorization of the art of war, which in the West essentially began in the nineteenth century, strategy went from instinctive20 to scientific. Each area of military endeavour had to find its place in order to tie theory to the corresponding operational practice. A survey of the writings of theoreticians such as Sun Tzu (the seventh century BC Chinese strategist), Clausewitz, Jomini, Lindell Hart, Foch and our contemporaries reveals that ‘medical’ aspects are often only mentioned in passing, or not at all. Whether this was because they believed this domain to be unnecessary or because military leaders, in the absence of the demonstrable proof of its efficiency, were reluctant to include medical data in their analysis of warfare, is unclear. The second appears somewhat more plausible when one reviews, through “universal experience21”, the attitudes of past military leaders; the relationship was tumultuous, cyclical and occasionally conflictual, but the requirement ever-present. We must now integrate ‘medical’ aspects in the theorization of the military art, in the form of ‘medical strategy’. Strategy has also evolved in keeping with the times. “The art of war cannot be reduced to a catalogue set in stone, it must adapt continuously to technological or cultural changes22”. There is now a real opportunity for the integration of the medical domain within strategic thinking and to make it a real factor with an impact on all the main strategic principles.

R. Forissier, Crise du soutien sanitaire du corps de bataille français au cours de la retraite de mai-juin 1940 (Crisis of the medical support of French Armed Forces during the May-June 1940 retreat), Médecine et armées, 1999, 27, 8 cité p 609. 19 Hervé Coutau-Bégarie, Traité de stratégie (Strategy Treatise), 6ème édition, Economica, 2008, cité p 27. 20 Herbert Rosinski, La structure de la stratégie (Structure of Strategy), Paris, ISC-Economica, Bibliothèque stratégique, 2009. 21 B.H. Lindell Hart, Strategy, Perrin, quoted p 53 22 Hervé Coutau-Bégarie, Bréviaire stratégique (Compendium of Strategy), ISC, cité p 33.

This study is intended to show, using historical examples, how ‘medical’ contributions can be integrated in the overall strategic vision. It will then attempt to identify the limitations which may explain the past lack of interest in this potentially very useful strategic resource. Finally, the study will lead to the implementation of the medical domain, as medical strategy, that is to say its integration by the command level within strategic theory and on the ground. This would allow the optimization of theory and practice for operations carried out under the new typology of 21st century conflicts. As Sun Tzu put it in the first chapter of his treatise23 : “The art of war is of vital importance to the State. It is a matter of life and death”. The medical domain clearly has a role to play; it simply requires the appropriate framework.

Sun Tzu, The Art of War.

PART ONE: Medical Support: a Real Strategic Player

Strategy (from stratos- army and agein- to lead) «originally designated the art of manoeuvring an army in theatre until it is in contact with the enemy24 ». This somewhat basic definition was later expanded to include the overall conduct of war and the organization of a nation’s defences.

The formalization of warfare practices is very ancient, Sun Tzu wrote his « Art of War » in the seventh century BC while Vegetius was the first in Antiquity to record the principles of warfare in his « De Re Militari ». But the search for military principles greatly expanded during the seventeenth century.

These principles, initially laid out at the tactical level, were later transposed to the strategic level. Nowadays we conceive of three levels of military action. The strategic level: “sets, through a series of iterations, the main stages, the tempo of main actions, the organization of the large systems of forces and thus fixes the overall “physiognomy of the fight25 » »; the operational level relates to operations or the manoeuvre of large units over the entire theatre of operations; the tactical or combat level deals with combat at the level of basic units.

The level of study is of limited importance, as are the principles upheld, the crux of the matter resides in the identification of the keys to success which demonstrate the level of maturity of military thinking. Various lists of principles exist, of varying lengths. Marshal Foch believed there were three such guiding principles: economy of forces, freedom of action and concentration of efforts; Fuller put forward a much longer list in an attempt to be exhaustive. At any rate, although strategy may be universal, it must constantly adapt to societal changes. Any action intended to attain superiority over an enemy “at the decisive place and time26” may be considered as essential to the development of the principles governing the art of war. In particular since history has shown that this action exerts a constant influence on strategy. Castex wrote that “the principles of strategy bring together

André Collet, History of Military Strategy since 1945, Presses universitaires de France, 1994, quoted p 3. Sun Tzu, The Art of War. 26 Hervé Coutau-Bégarie, Bréviaire stratégique, (Compendium of Strategy), ISC, cité p 33. 25

realities, which may occasionally be seen as evident and drawn from past experiences”. History has since shown that the medical domain has a strategic role to play due to the influence it has over strategic factors such as time, environment, power or psychology, etc.

Studying past conflicts reveals the strong potential influence of the ‘health’ domain over the strategic process, centred on three strategic axes (and their corresponding repercussions at the operational and tactical levels). The medical domain is first of all a source of power by maintaining manpower levels, preserving assets and protecting troop morale. It also contributes to freedom of action through the command of the environment and casualty evacuation. Finally it is a strong contributor to dynamic security by assessing potential health threats and preparing health countermeasures.

The “health” domain therefore contributes more or less directly to the standard requirements of concentration, initiative, activity, direction, freedom, economy of forces, security, manoeuvre... but also the principles drawn from current operations such as adaptability, legitimacy (which will be dealt with in the last chapter).

I- Source of Power Power can be defined as the ability to command, dominate, and impose one’s authority27. This requires tools in order to convince others of one’s overwhelming strength. The object of strategy is to transform force into power. “There is no power without force, but power adds intelligence and authority to material and measurable assets28 ». Furthermore, the loss of power is one of the strategist’s main concerns, Clausewitz considered that among seven factors that might lead to a loss of power, the third was related to “combat losses and diseases29”.

The medical domain supplies power by preserving human and animal assets, but also by acting on troop morale, through psychological support, anticipating issues and providing remedial action. Clausewitz believed that “the morale factor can acquire such importance that it will carry all before it with irresistible force30”.

A powerful force is a healthy force and “a healthy force is a force that is being taken care of31 ». The favourable ‘medical bulletin’ it receives is recognition of the efforts expended and of those, at all levels, who have contributed to its physical and psychological health.

A. Conserving Human Lives

The strategist’s notion of conserving assets is intended to avoid wasting available assets in order to reach set objectives. Although this is a pragmatic vision based on a search for greater efficiency with little avowed humanitarian intention, the end result – preserving lives as assets - is beneficial. The military medical services may in this instance find a balance by responding to the commander’s concerns and by simultaneously taking account of humanitarian principles. Bringing these two desires together constitutes a major strategic asset.

French definition drawn from Le petit Larousse (French Dictionary), 2003. Julien Freund, Qu’est-ce que la politique? (What are Politics), Paris, Seuil, Politique, 1967, quoted p 117. 29 Clausewitz, On War. 30 Clausewitz, On War. 31 Colonel Costedoat, ‘Direction du service de santé au ministère de la Défense Nationale’ (Medical Service Directorate of the Defence Ministry), CHEDN, La défense sanitaire, 1917. Provisional classification 9NN656, DAT, SHD. 28

Marshal Foch considered the principle of economy of forces a “higher level principle”32. Nowadays, the quest for economy has moved beyond forces to include assets in general in order to rein in costs. In the health domain, the first concern is with the conservation of manpower in order to maintain operational efficiency. General Desportes wrote « We have seen how essential firepower has become, but it cannot compensate for the lack of men33 ». Beyond manpower numbers, the object today is not only to save lives but also guarantee the effective presence of combatants on the battlefield. The Health Service, by making adapted assets available to the commander therefore satisfies Moltke’s definition of strategy: “the practical use of assets made available to the general in order to reach a specific objective”. This concern with conservation remains but is now completed by a humanitarian concern with the avoidance whenever possible of medical after-effects.

While it has become much more complex in our times, this concern with avoiding waste is hardly new. The raising of large armies was an issue for Egyptian and Mesopotamian rulers. Although not particularly concerned with human life, they did see the number of combatants as a decisive factor and this encouraged them to seek their preservation. This was later reinforced by the appearance of armies composed of Greek mercenaries and later Roman legionaries.

The intent was not only to maintain a numerical advantage, but also preserve the qualitative strength of the army by using experienced soldiers. The Peloponnesian War is a good illustration of the impact of significant losses on the war’s outcome. The Athenian army, intent on devastating Megara, included sixteen thousand men, but was half that size seven years later at the battle of Delium. This was important since for Athens to defeat the Peloponnesian or Theban armies, it needed the numerical superiority required for the handto-hand combat characteristic of the time. The battle of Mantinea also ended in defeat in 418 BC when Athens was only able to muster one thousand hoplites, as opposed to the several thousand arrayed at the battle of Marathon in 490 BC. Similarly, six or seven thousand oarsmen died, out of an initial number of twenty thousand, roughly enough to man thirty or thirty five triremes. It is thought that this high mortality rate significantly impacted Athens’ military capabilities for a decade.

The importance of numerical strength also appeared clearly during the Byzantine wars. Goth losses during their assault on Rome in 546 were of such a magnitude that they lost 32 33

Ferdinand Foch, Des principes de la guerre, Economica, 2007. General Vincent Desportes, La guerre probable, 2nd edition, Economica, 2008, quoted p 5.

confidence and in the course of their next assault were routed by Belisarius’s counterattack, although they still enjoyed numerical superiority. The siege was lifted the next day and they retreated towards Tivoli. Similar examples abound throughout history. In 1760, following a strong advance against their Russian opponents, the troops of Frederick the Great were paralysed by the magnitude of their losses and the surviving sixty thousand troops were unable to risk another battle. Frederick was saved by the death of the Russian Tsarina and he was able to enter peace negotiations with her successor. During the Franco-Prussian War, the numerical imbalance was such that it carried the day: “against the two hundred ten thousand men of our Army of the Rhine, the disparity is horrific, since the Germans have arrayed along their frontline four hundred and sixty thousand soldiers from Prussia, Bavaria, Saxony, Württemberg and Baden in three armies, with a further reserve army gathering in Mainz. Their total numbers were an incredible one million two hundred thousand men”.

Paradoxically, military manpower was not considered a preponderant factor by theoreticians until the seventeenth century. Clausewitz however stated that: “the first rule, therefore, should be: put the largest possible army into the field34 ». There are of course exceptions to this rule such as the young king of Sweden’s stunning victory in 1700 against a much larger Russian army. For this reason, Clausewitz added that victory was possible without numerical superiority, since many other factors were involved. Nevertheless numerical superiority remained an important advantage which made it easier to overcome the absence of other factors. He considered that numerical superiority “had to be considered a fundamental issue, to be sought as a matter of priority and in all cases”.

Military medical services made it their primary function. Medical officer first class Coudray wrote in 192335 that “throughout its long and impressive history, military medicine has played an important role in the never-ending effort to protect the manpower it has been entrusted with». Military doctors established, when confronted with large numbers of casualties, a classification and triage system for the wounded according to the seriousness of their injuries which allows the treatment of light casualties as quickly as possible. This allowed the treatment of the largest number and the return of as many combatants as possible. This system may at first glance appear contrary to the Hippocratic Oath, which specifies that each patient should receive the same attention and care, free of 34

Clausewitz, On War, edited and abridged by Gérard Chaliand, Pérrin, translated by Laurent Murawiec, quoted p 160. 35 Correspondence, temporary filing reference 9NN670, DAT, SHD.

discrimination. However, when faced with a massive influx of casualties, it is the only way of ensuring efficient care for the greatest number and has been adopted by contemporary disaster medicine.

Commanders considered this the principal mission of health services. Some staff manuals (in Europe and the United States) specify that “the mission of military medical services is the preservation of military manpower or the force’s potential36 ». Military leaders realized, even if they did not recognize it in their strategic manuals, that medical support was a significant source of power. Pétain put it this way “it is clear that any measure that reduces our losses will improve the preservation of our military power37”. During the French colonial wars, Lyautey sent the following telegram to Gallieni: “if you can send me four additional doctors, I will return four companies to you38”.

The First World War further reinforced the concept of preservation of manpower as the primary role of the health domain. “The background Survey” made in 192239, in preparation for new legislation dealing with the organization of the military health service, demonstrated that “during the last war, the service had to solve increasingly complex issues which might have had a serious impact on the country and on military operations, in particular in relation to the preservation of manpower”. During the war medical issues had become particularly important since the military high command had become aware of the importance of preserving manpower after a real crisis arose in 191640. On 20 August 1916, Marshal Joffre had announced that the French army would lose at least four hundred thousand men in 1917. It had been necessary in the autumn of 1916, because of the losses suffered during the Battle of the Somme, to reduce the size of divisions from twelve to nine battalions, in order to maintain the level of flexibility required for establishing reserves and organizing the relief of units. The Great War had been one of the most lethal in history and general de Gaulle commented that “it now seems amazing that such catastrophic losses did not lead to the disintegration of the army41 ». A report published on 1 April 191942 by the French Army Staff gave the final number of casualties on 11 November 1918 as 1 365 735 dead or missing43. The French military health service might 36

G. Gillyboeuf, Le service de santé des armées en guerre: ses règles d’or (Military Health Services in Wartime), médecine et armées, 1972,1,6. 37 CQG, EM, 1er bureau, n°24025. 38 P.Doury, Lyautey et la médecine, Médecine et armées, 27, 8, 1999. 39 Draft law on the organization of Military Health Services «Background Survey », 1922. Provisional classification 9NN631, DAT, SHD. 40 Guy Pedroncini, Pétain : le soldat (Petain : the Soldier) 1914-1940, Perrin, p 125. 41 Guy Pedroncini, Pétain : le soldat (Petain : the Soldier) 1914-1940, Perrin, p 299. 42 Army General Staff Report, 1919. Provisional classification 9NN670, DAT, SHD. 43 1 355 00 for the Army, 16,2% of the mobilized total, and 10 735 for the Navy, 4,9%.

have saved a small number, but its efficiency was limited by a number of factors. The death rate remained high up to 1917, when out of the 357 729 casualties entering medical care, some 18 335 died, or 5.12%44.

The efficiency of medical support rapidly improved during the twentieth century. Military medicine progressed rapidly in two areas: the treatment of combat wounds and diseases. Technical and organizational advances led to the continuous improvement of the survival rate.

The military medical service, through its undeniable and increasingly efficient impact on the preservation of human lives, brought real strategic power to forces by treating combat casualties and caring for the sick. While the need for the first had appeared natural to chieftains since Antiquity, if only to repair damages they themselves had caused, the second was long ignored. Acknowledging illness was perceived as a sign of weakness: a true warrior should not be worrying about his health.

Combat casualties

The main concern of warlords was the preservation of their manpower by returning wounded warriors to combat. Treating combat casualties appeared noble and legitimate, whereas illness was ignored and seen as the direct result of fate. In his day, Caesar displayed his concern for his wounded legionnaires, noting during a review of a legion “that even every tenth soldier had not escaped without wounds45”. He also valued their bravery, since despite their wounds they had toiled day and night to build crucial fortifications. This was far from the current notion of intensive care for casualties but in its time the concern for these diminished combatants was symptomatic of the strong relationship between a chief and his men so typical of the Roman legions.

During the Middle Ages, the religious military orders were created in part out of compassion for war invalids. Surgical advances made in spite of religious prohibitions (such as those against dissection for instance) were motivated by a sense of duty for the wounded, although the preservation of manpower remained the primary concern. The concept of caring for the wounded appeared as armies, in the full sense of the term, replaced “hordes of dishevelled warriors”.

44 45

Survey of the Health Service, Provisional classification 9NN670, DAT, SHD. Caesar, The Gallic War.

Saving as many lives as possible became one of the guiding principles of military medical services. Although its huge potential may have been recognized throughout history, it only became realistic from the seventeenth century onwards with the technical advances achieved by combat surgery and medicine in general. Larrey was able, for instance, to impose infirmaries on warships. Because the wounded should not hinder operations, they were treated on the orlop deck. Despite the terrible conditions there, this constituted a huge improvement allowing intervention and the saving of lives to take place much earlier than it did on the battlefield.

During the Franco-Prussian War, 28 596 German soldiers died of their wounds, out of a total of 913 967 men mobilized. This represented a large number of potential manpower that might be saved. French data is insufficient to assess the number of those who died from their wounds but we do know that 131 000 wounded casualties were cared for by the medical services46. Once again this represented a huge potential for the health services.

During the First World War, 73% (996 986 men) of French losses were due to combat. The management of casualties was for the first time in history more of a challenge that of the sick.

Closer to our times, during the Yom Kippur War in 1973, Israeli army casualties were 2522 dead and 7000 wounded after 18 days of combat. Although data on those who died from their wounds has not been published, it is understood that the efficiency of their medical service was remarkable47.

Finally, during the Falklands War in 1982, not a single soldier wounded and evacuated alive from the theatre died. The lessons learnt from previous wars, in particular the First World War, had encouraged the British military medical service to institute a number of efficient surgical measures. The Falklands were confirmation that it was essential to have surgical units as close as possible to the frontline. The command could have no clearer evidence of the efficiency of modern military medical services. In the 1990s, this had a pernicious effect on American commanders who promoted the concept of “zero killed”.

46 47

Edited by Pierre Lefebvre, ‘Histoire de la médecine aux armées’, Lavauzelle, 1982. R. Forissier, M. Damandieu, ‘La guerre du Grand Pardon’, Médecine et armées, 4, 7, 1976, quoted p 636.

The Sick « The bullet is a thousand times less lethal than the microbe, and many examples taken from military history illustrate this painful truth (remember Sebastopol, Egypt, Madagascar)48 ». Diseases have through the centuries caused more casualties than all combat casualties combined. However, they had long been neglected, in part because of medicine’s limited efficiency in dealing with epidemics and in part because it would have been an admission of weakness to deal with diseases, whose origins were a mystery. Bravery required the occultation of pain and other symptoms. Sun Tzu had nevertheless already identified the importance of dealing with diseases: “An army that does not suffer from countless diseases is said to be certain of victory49 ».

The current situation has obviously changed, the ‘combat versus disease deaths’ ratio has continuously improved since pasteurisation. There are two main reasons behind this trend: prophylactic and therapeutic advances have tended to reduce medical morbidity while the increase in lethality of modern weaponry has increased surgical morbidity. We must however remain vigilant since diseases may reappear in the wake of the relaxation of prevention measures and new pathologies may surface. Epidemics constitute a health disaster, but also have a paralysing effect on armed forces. We must take account of lessons drawn from history to maintain military operational capability. Fighting epidemics is clearly a strategic issue.

During the Peloponnesian War, the plague (or so-called by the Greeks) broke out in 426427. Thucydides concluded that “to the power of Athens certainly nothing was more ruinous50 ». The epidemic led the Spartans away from Attica to concentrate their efforts on Plataea in 429. It also significantly reduced the number of available Athenians warriors during the following years. Although the real consequences remain unknown, had Athens not lost tens of thousands of citizens (including many potential soldiers), its tactics would presumably have been different. Thucydides listed military losses from the plague (without specifying wider losses): four thousand four hundred Athenian hoplites from the rolls and three hundred horsemen. The Athenians perceived a ‘before’ and ‘after’ the plague in the history of their army and fleet. 48

Colonel Costedoat, ‘Direction du service de santé au ministère de la Défense Nationale’ (Medical Service Directorate of the Defence Ministry), CHEDN, La défense sanitaire, 1917. Provisional classification 9NN656, DAT, SHD 49 Sun Tzu, The Art of War. 50 Victor Davis Hanson, A War Like No Other: How the Athenians and Spartans Fought The Peloponnesian War.

During the Middle Ages in London, the Black Plague killed a smaller proportion of the population than it did in Athens. In the later, the city was at war, the spread of the disease being encouraged by the privations of garrison life. There is a close relationship between war and sickness, with the proximity between humans and animals, bivouac conditions, the poor quality of food and water supplies, and exhaustion and psychological pressures as contributing factors.

One strategic principle, the concentration of forces, may be

imperilled by the threat of an epidemic. The hygienic and prevention actions of health services thereby contribute to this principle, which Marshal Foch considered fundamental.

There are many examples in history of health disasters during great battles. After taking Damietta in June 1249, Louis IX of France laid siege to Mansourah where an outbreak of scurvy, due to a lack of fresh supplies, reduced his army from 30000 to 12000 in the space of a few months.

The Hundred Yearsâ&#x20AC;&#x2122; War saw an outbreak of bacillary dysentery in the English army which landed at Honfleur in 1415, which was rapidly reduced to a quarter of its initial strength. Following the battle of Azincourt, the disease compelled the English Army to return across the Channel, although the French were also affected by disease, in their case the plague and smallpox.

In 1478, an outbreak of the plague occurred during the siege of Malaga; in 1489, exanthematic typhus decimated the force besieging Baza; in 1552, during the siege of Metz, typhus compelled Charles V to lift his siege of the city.

These unfortunate events led to the first element of a health service: the field hospital. Commanders were no longer willing to see their military operations hobbled by diseases which decimated their troops. Siege warfare which deprived assailants of medical help for their injuries and epidemics were therefore the spark which led to the deployment of the first field hospitals.

Navies were particularly affected during distant expeditions which involved overcrowding and poor hygiene. Vasco de Gama experienced scurvy during his trip to India in 1497. Pigafetta, who sailed with Magellan in 1520, gave the first precise description of the

disease during the expedition when: “few were those whom by the Grace of God were left unscathed51”.

Crews forced to winter over during northern expeditions, were unfortunately able to observe the harsh effects first-hand. In 1535, Jacques Cartier, during his second expedition to Canada, had to winter his ships at the mouth of the Sainte-Croix River. His crew was severely affected by scurvy until indigenous people were able to show him a recipe of bark and white spruce which proved beneficial in combating the disease.

Large scale campaigns have throughout the centuries suffered from devastating epidemics. Napoleon’s Egyptian Campaign (1798-1801) lost 1 700 men to plague and 2 410 to dysentery. During his Russian Campaign (1812-1814), 23 000 out of 30 000 Russian prisoners dyed from Typhus; during the siege of Danzig, 13 000 died of Typhus out of a total of 36 000. The American Civil War (1861-1865), with an average of 430 000 men in uniform, saw a million cases of malaria, 137 000 of typhoid fever and 234 000 of dysentery. There are many other examples and one occasionally wonders how armies were able to operate at all. The soldiers of the time really had an “appointment” with death. Health disasters reached their high point with the Crimean War (1853-1855). The French contingent (309 000 strong) suffered 75 000 deaths from disease against 20 000 from enemy fire. This comparatively high death rate was a direct result of the absence of a concerted prevention policy. While the British force was more careful about collective hygiene and its experience was slightly better, the number of deaths due to disease continued to dwarf combat losses (17 500 dead from disease versus 4 700 from combat wounds). The Russian experience was infinitely worse with 600 000 dying from disease compared with 30 000 combat losses.

Unfortunately, this slaughter was to last until the First World War. Partly a result of lack of technical knowledge, it was also due in no small part to a refusal to acknowledge the importance of microbes, in particular at the command level. It may seem incomprehensible since military leaders were by then well aware of the huge impact disease had on their armies. Back in the seventeenth century, general Montecuccoli had already highlighted the importance of disease, declaring that the commander “understood that only efficient logistics can ensure the support of an army, for although few die in battles, many die of

Pigafetta, ‘Il viaggio fatto da gli Spagnivoli a torno a’l mondo’.

sickness, exhaustion and hunger52 ». So why did later commanders, such as Napoleon, not establish an effective policy of prevention? What explains this lack of interest on the part of great strategic thinkers?

Especially since in the meantime, medicine science was progressing, with achievements such as the vaccination against smallpox. It became mandatory after the decree of 29 March 1811 for the French army53, some ninety years before the law of 15 February 1902 extended it to the wider population. In the United States, the smallpox vaccine was established in 1818. However in practice, vaccination was not applied with any rigour within armies for many years and commanders rarely showed any real commitment to this part of operational preparation. In France, vaccination only became widespread with the law of 1 April 1897. The War of 1870 constituted a clear example of the impact of this lack of commitment with 125 000 cases of smallpox in the French army and 23 000 deaths.

Health disasters continued into the nineteenth century. The Indian Wars against the Seminoles (1835-1842) left 1200 American dead, 75% due to disease. The French Tunisian expedition in 1881 was made up of 20 000 soldiers and experienced 4 200 cases of typhoid fever and 4000 cases of bacillary dysentery. The expedition to Madagascar lost a quarter of its force (6 000 men) to malaria. During the Russo-Turkish War of 1877 the ratio of combat losses to deaths due to disease was 1 to 5.

The First World War continued to experience significant mortality as a result of disease, 135 000 died of Typhus and 30 000 of influenza in Serbia between April and December 1918. However, health services were able to avoid a complete catastrophe. Losses during the Great War were obviously terrible, but for the first time the actions of health services resulted in considerably fewer deaths from disease than from combat.

Hyacinthe

Vincent54, who had imposed typhoid fever vaccination efforts, virtually insured the disease’s disappearance among French troops. Marshals Joffre and Foch paid homage to his role, considering him one of the main contributors to victory. The armies’ health situation might have been considerably worse as a result of the influenza’s onslaught on a global scale which left 20 million dead between 1918 and 1919. Like its larger counterpart on the Western Front, the French Army of the Orient was equally successful in fighting

Sous la direction de Bruno Colson et Hervé Coutau-Bégarie, Pensée stratégique et humanisme, Economica. 53 Decree dated 29 March 1811. Provisional classification 9NN631, DAT, SHD. 54 Hyacinthe Vincent (1862-1950), French military doctor, known mainly for his work on typhoid fever and gas gangrene.

disease, even though it operated in areas with a large number of exotic afflictions, with malaria a constant foe.

Military medical services thus led a constant fight to save human lives. Considerable progress was made over time and nowadays human losses in operations are limited. But while the battle for physical health was barely over, a new challenge appeared: the preservation of soldiers’ morale. Although its collective dimension was recognized from Antiquity, recognition of the importance of the soldier’s individual psychology is a more recent phenomenon.

B. Keeping Up Morale Clausewitz linked manpower and troop morale. He believed that numerical superiority would offer psychological superiority, as long as the balance of power was known. He considered morale a prerequisite for victory, since a battle was “intended to destroy the enemy’s courage rather the enemy himself”. He calculated the loss of moral force by measuring the depletion rate of reserves. Morale had become a central tenet of strategy. Before him, Sun Tzu had defined the importance of demoralizing the enemy which he considered as one of two essential pillars, alongside “freedom of action and indirect strategy executed prior to a victorious direct strategy”.

Sun Tzu explained that in order to impose one’s will on an enemy, it was possible to consider a direct assault on their collective and individual morale using appropriate methods. Anything connected to the enemy’s morale was therefore useful. This is where the health domain has a part to play, since it can unhinge the enemy’s morale by promoting the morale of friendly forces. By maintaining manpower through caring for the wounded or the sick, it contributes to psychological superiority and through it to numerical superiority. Direct action against the enemy is impossible since medical personnel cannot, for ethical reasons, have direct contact with him, except to provide medical care. Their action is therefore of an indirect nature, by encouraging the development of friendly power, keeping war chiefs in good health and providing psychological support to his troops, all of which make the health service an important strategic player in the field of morale.

Throughout history, enemies have sought to strike at their opponent’s leader. The removal of a charismatic leader has a powerful negative effect on troop morale, in particular during periods when victory often rested on the shoulders of a single leader. From the dawn of 24

history, doctors were attached to great political or military leaders for the protection of their person and image. Renowned military doctors were all attached to famous patrons: Henri de Mondeville55 to Phillip the Fair, Ambroise Paré to three different Kings of France56, Desgenettes and Larrey to Napoleon Bonaparte.

The position of physicians was strategic since there are numerous examples in history of an enemy concentrating his efforts against the opposing leader. In the spring of 334 BC, the Persians were swept away by Macedonian cavalry, but they had hoped to strike at Alexander himself, believing that a single blow might have halted the invasion in its tracks.

During the Middle Ages, the involvement of the king was essential to motivate his troops and his capture or death spelt disaster. It often meant the end of the war and crushing defeat as it did in Poitiers in 1356. But the king’s involvement was often limited to providing moral support and leading a few actions while real command was exercised by a general, as was the case in Bouvines with Philip II of France or at Marignano with Francis I. But the king’s symbolic value remained essential. The same applied to charismatic military leaders whose death had such an impact on morale that defeat ensued. During the battle of Auerstedt in 1806, the Prussian army, although it enjoyed numerical superiority collapsed after the Duke of Brunswick was killed.

Leaders have an essential role to play in maintaining troop morale and motivating their men. Lawrence57 explained that « the command of the Arab army had to arrange their men’s minds in order of battle, just as carefully and as formally as other officers arranged their bodies58 ». Strategy reference works on the art of war have dealt with this topic. The “Rosier des guerres”, a collective effort requested by Louis XI in 1482 discusses the issues of morale and cohesion. Naval forces were particularly concerned because crews were often poorly nourished, clothed or housed and some exhibited mental illnesses such as depression, referred to as “melancholia” born of long absences and the uncertainties related to their eventual return. Benoît de la Grandière prepared a dissertation on the topic for which he was awarded a prize by the Medical Academy in 1873.

Henri de Mondeville was a famous French surgeon celebrated in particular between the 12th and 14th centuries. 56 Ambroise Paré (1510-1590) served Duke René of Montjean, René of Rohan, Antoine de Bourbon, King of Navarre, Henri II of France, Charles IX then Henri III of France. 57 T. E. Lawrence (1888-1935), known as Lawrence of Arabia developed the concept of an Arab empire under British influence and backed the Arab revolt against the Turks (1917-1918). 58 T. E. Lawrence, Guerrilla, Encyclopedia Britannica, Vol. X, London, 14th edition, 1926.

For these reasons, commanders long aware of the importance of morale, have often expressed their interest in the subject and in the health services. In 1917, Marshal Pétain considered that morale had become “one of war’s essential factors59”. From the First World War onwards, commanders paid attention not only to morale on a collective level, but also for the first time at the individual level.

The armed forces were analysed as a specific social environment with its own particular mechanism and psychiatric pathologies with particular clinical manifestations.

Henri

Barbusse, described the ‘poilus’ as: “These are men, regular guys ripped away from their regular lives. […] Simple men who have been made even simpler and who have had their primordial instincts reinforced: survival instinct, selfishness, a tenacious desire for survival, enjoyment of food, drink and sleep. They occasionally let loose cries of humanity, deep shivers emerge from their great dark and silent human souls60 ».

In 1936, Doctor Martin-Sisteron sent the War Ministry an article entitled “Individual mental and nervous hygiene”: “this title should interest army doctors, since they have frequent occasion to encounter the problems resulting from the need for a brutal adaptation to military life by our youth who begin their military service at a vital stage in their intellectual and emotional development61”.

Commanders integrated this dimension and called upon the health services for help in understanding psychological or psychiatric disorders. General Huntziger, Commander-inchief of the Troops of the Levant wrote to the Health Service in 1936 to share his concerns: “it is important that officers and NCOs not stay too long out of France. The measures we have taken this year have imposed a cap on these postings and I believe they are entirely appropriate62”. Certain behaviours which had previously been called ‘drunkenness’ or ‘cowardice’, were now identified as a psychological reaction possibly linked to a high level of stress. There were peacetime pathologies and wartime pathologies. During military conflicts, Army Health Services now deal with the phenomenon of shell shock.

Provost, between 1938 and 1939, and de Quero launched the first ‘selection-orientation’ services and led the way towards the use of applied psychology for the optimal selection of 59

Letter to General Pershing dated 27 December 1917. Henri Barbusse, ‘Le feu’, in ; ‘The Great Novels of WWI, Paris, Ed. Armand Colin, 1983. 61 Letter from Dr Martin-Sisteron to the War Ministry, dated, 24 January 1936. Provisional classification 9NN621, DAT, SHD. 62 General Huntziger, Commander-in-chief of the Troops of the Levant, Letter to the Army Health Service in 1936. Provisional classification 9NN621, DAT, SHD. 60

professional or military personnel. The development of psychological profiles gradually grew.

The prevalence of combat-related stress disorders in Vietnam veterans has been assessed at 15.2%, and up to 30% for wounded soldiers63. The 1973 Yom Kippur War saw up to 30% psychological casualties. Surveys of the conflicts during the 1980s and 1990s, the Falklands War, the two Gulf Wars, the conflicts in Somalia and Former Yugoslavia confirmed that psychiatric casualties represented a significant threat to operational capabilities, since they were the single largest cause for medical repatriation to the country of origin. During the First Gulf War, two studies made between six months and one year after the end of hostilities reported that between 8 and 9% of American troops suffered from posttraumatic stress disorders64. In Rwanda, Raingeard65 reported that 60% of the soldiers involved in burial duties in Goma suffered from psychological difficulties at the end of their mission or shortly after their return.

The causes of these psychiatric problems have evolved over time, but it would seem that our contemporary society has tended to exacerbate them. The mostly urban modern citizen has become accustomed to comfort and finds it harder to adapt to the difficult conditions of campaign life. Furthermore, modern combat formations include a much larger than before proportion of fully mechanised units and are therefore exposed, when destroyed, to immediate and collective injuries. In 1960, K. Schimd described how patriotism had been weakened by the disappearance of the concept of ‘national war’. He believed66 that “man may soon find himself fighting not for his own country but for a coalition ... the rational and prosaic beliefs of modern western society make it more difficult to accept sacrifice ... Morale, given concrete expression by an individual’s psychological strength, will become the primary factor in conflict”. History has shown that “morale potential often plays the most decisive role67”. To maintain a durable army, one must have experimented soldiers, selected for their reliable psychological profile, who have received a psychological preparation and are given quick 63

D.Esquivié, P.Arvers, D.Leifflen, soutien médico- psychologique des personnels en opérations, Médecine et armées, 2006, 34,1 64 D.Esquivié, P.Arvers, D.Leifflen, soutien médico- psychologique des personnels en opérations, Médecine et armées, 2006, 34,1 65 Raingeard, Regard d’un médecin d’unité sur sa fonction d’hygiéniste mental, médecine et armées, 25,5,1997. 66 P.Juillet, P.Moutin, Psychiatrie militaire, Masson et cie, 1969. 67 A.Corvisier, Hervé Coutau-Bégarie, La guerre, Perrin, 2005, cité p 200.

support when they suffer from posttraumatic stress disorder. Military medical services have a vital part to play in reinforcing the psychological superiority of their troops. The psychological part of the medical support of troops has considerably developed over the last twenty years, encouraged both by psychiatrists and commanders. This is a significant advance, not only for the integration of troop morale as a strategic stake, but also in the relationship between health and army. Complementary structures have been developed, psychiatric activities undertaken by health services in the field and at home are based on psychosocial interventions structures developed within each service. The efficiency of care has significantly improved and advice from health services is now received with interest by commanders who had long ignored them.

Finally, the preservation of human assets covers two aspects: the preservation of physical and of mental health. The medical function also served to preserve other assets, such as animal assets. Paradoxically, the health/army couple developed rapidly when it came to caring for animals, the care of animals was long more elaborate than the care of combatants. The strategic importance of their use as means of transport (horses in particular) was recognized early on. C. The Preservation of Military Animals Animals were of considerable importance for armies and horses in particular were strategic assets which played decisive roles in victory. The introduction of mechanization in the twentieth century saw their importance decrease, but they continue to play a part in military manoeuvre. Courier pigeons were used during the First World War; mules were used in the Rif and during the War of Algeria, while dogs took on an important counterguerrilla role during colonial wars. Nowadays, the use of dogs in warfare has proved particularly useful in asymmetric and antiterrorist warfare.

Military medical services now play an important part in this domain, since in most countries they include the military veterinary services. In France the Army’s Corps of Veterinarians was only integrated within the Military Health Service on 1 January 197868. The 1949 Geneva Conventions do not consider veterinarians as medical personnel to which their protection applies. Article 22, related to the conditions which do not deprive a medical unit of protection, states: “shall not be considered as depriving a medical unit or establishment of the protection guaranteed by Article 19 […] that personnel and material of the veterinary service are found in the unit or establishment, without forming an integral 68

E.Dumas, M.Freulon, D.Davis, J-Y.Kervella, Le rôle des vétérinaires des armées dans l’évolution de la médecine vétérinaire, Médecine et armées, 2008, 36,2.

part thereof69”. This implies that veterinarian services do not enjoy protection, although their presence does not negate it. Those who cared for animals have not always been veterinarians, let alone military veterinarians. They were long considered ‘mechanics’ tasked with repairing “locomotion assets”. In France, the care of horses was provided by the most competent blacksmith who bore the title of “maréchal expert”. The appearance of French military veterinarians followed the creation of veterinarian schools by Claude Bourgelat in Lyon in 1761 and Alfort in 1765. The military corps was established in 1769.

Concern with the wellbeing of horses is attested in Antiquity, due to the important role of cavalry. Their care was in many ways more elaborate than that afforded men. A Phoenician tablet from the middle of the second millennium BC found at Ras-Shamra, the site of ancient Ugarit, lists a series of therapeutic remedies: “when [the horse] has swelling of the head and nostrils, a blend of figs and raisins and wheaten flour should be applied together in the nostrils70”. Treatises written by Hyginus and Vegetius attest to the presence of a Roman military veterinarian service. The Romans distinguished between those who cared for horses and those who cared for other animals, such as cattle using different titles such as “medicus veterinaries”, “medicus pecuorus” or “miles pecuorus”.

During the Middle Ages, despite a gradual decline of the role of cavalry, Juan Alvarez wrote a treatise in answer to a request from the Seneschal of Bigorre which summed up the current state of knowledge in the fifteenth century. His manual of equestrian science was significantly influenced by Arab practices and detailed the care provided by a specialist corps71. During the nineteenth century, the advances made in veterinary science gave remarkable results in preserving equine assets. Commanders like Marshal de Saint-Arnaud72, acknowledged the services provided, in particular during the conquest of Algeria and veterinarians were made officers in 1852.

Veterinarian services played a strategic role during French colonial conquests (Algeria 1830, Western and Equatorial Africa, Tunisia 1881, Madagascar 1896, Morocco 1907). 69

CG I, art 22, 4. Tablet translated by C.Virolleaud. 71 Spanish manuscrit n°214, Fol.31r° et v°- French Bibliothèque Nationale. 72 E. Dumas, M. Freulon, D. Davis, J-Y. Kervella, Le rôle des vétérinaires des armées dans l’évolution de la médecine vétérinaire (the Role of Military Veterinarians in the Evolution of Veterinary Medicine), Médecine et armées, 2008, 36,2. 70

They not only encouraged the acceptance of the French presence by rural populations whose livelihood depended on agriculture and cattle breeding, but also ensured that transport means were prepared adequately â&#x20AC;&#x201C; namely the horses and mules which accompanied the columns. They were even involved in caring for wounded soldiers; Veterinarian Assistant Hue, for instance, saved the life of second lieutenant Marchand, the future hero of Fashoda during the fighting at Koundian in 1889.

Early in the twentieth century, the establishment of horse stud farms and other equine establishments where military veterinarians served led to the improvement and adjustment to military requirements of the barb horse, a hardy and rustic breed. Barb horses carried Moroccan Spahis and African Chasseurs across the Jakupica Mountains in four days and four nights in very difficult conditions over narrow trails. This achievement allowed the North African cavalry to surprise, take and occupy Uskub (now Skopje) on 29 September 1918, cutting off the German 11th Army and its 77 000 men who had no choice but to surrender. Horses accustomed by breeding and training to extreme conditions were an important factor in the final collapse of central European empires in the Balkans.

The First World War also saw the first significant use of dogs by armed forces. They served as first aid dogs, searching for the injured, and also as carriers, couriers or sentries. But the use of dogs fell out of favour between the two wars and the 1940 defeat precluded further development in France. Colonial wars demonstrated the usefulness of dogs against guerrillas. Military veterinarians were entrusted, starting in 1948, with the selection, training and use of war dogs. In 1951, they were tasked with training operational dog commandos, made up of 9 men armed with submachine guns (one officer and 8 men with their dogs). These commando units (there were 10 in January 1954), were used in Indochina to support infantry companies. They were successful in detecting ambushes during the clearing of trails, searching and pursuing enemies and in searching houses. However the results were mixed when it came to clearing landmines. The excessive length of trails to be cleared and the low density of mines and traps, along with a difficult climate proved difficult for the dogs. The war in Algeria saw a significant development of the use of military dogs. Dog numbers went from 160 in 1955 to 900 in 1957 and reached 2000 in 1958. They were deployed within 90 to 100 dog platoons with 15 to 20 dogs each. They carried out several functions: reconnaissance dogs for patrols, clearing and sealing off actions; tracking dogs which served to detect sabotage, escapees, ambushes, and infiltrations; cave dogs which

uncovered enemies in caves; mine clearance dogs who achieved better results than in Indochina, in particular on railways.

Veterinarians, who traditionally had cared for horses, turned towards the veterinarian care of dogs. Since their incorporation into the French Military Health Service, they ceased to provide the care of dog groups. The French Army 132rd Dog Group has assumed that responsibility. They do however continue to provide care, expertise and advice to commanders concerning their preservation and efficiency as well as the development of new military techniques. Contemporary veterinarians have also extended the scope of their activities to include dietary hygiene, water and biological environment control.

An analysis of lessons learned demonstrates that the health function can be a significant force multiplier. Clearly our history would have been very different if physicians had been able to cure the sick, heal the wounded, and deal more appropriately with what was then described as mental weakness. Defeat might have been snatched from the jaws of victory in some instances. Nowadays military medicine is in a position to contribute to the avoidance of unnecessary losses and to ensure the efficient preservation of human and animal assets. Superiority belongs to the most powerful player; it is therefore no longer wise to ignore the health domain.

II A Tool for Freedom of Action Freedom is the emancipation from constraints. These may be human, social, political, technical, geographic, climatic, etc. The object is to make them disappear, or at least reduce their impact on one’s ability to act. Any action which can encourage the free choice of manoeuvre and eliminate strategic constraints therefore contributes to freedom of action.

Traditionally, theoreticians of military strategy have concentrated on the enemy’s freedom of action, believing that “the principle of freedom of action requires that we are not subject to the enemy’s dictates73”. Marshal Foch considered it an “absolute principle”, as important as the preservation of assets. He believed it related to offensive operations, while during defensive operations one is subject to the attacker’s will. Debate continues on this issue, but is not the subject of this review. At issue here is the assessment of all assets which allow free action against the enemy. The intention is therefore to go further in offering commanders the ability to overcome all constraints, in order to make available the entire range of strategies to choose from against their enemies.

We can thus extend the definition of freedom of action, applying it not only to the enemy but also to freedom from any element which might contribute to the enemy’s victory. This means not being limited by terrain, environment, population or space/time constraints and achieving increased power.

If we accept that the principle can be extended, as defined previously, the role of the health domain is related to the support it can provide the commander in relation to the control of the biological environment, the preparation of combatants, winning over local populations (giving commanders access to potential sources of intelligence, aid and support), while not hindering manoeuvre or by favouring through technological or physiological innovation, the development of increasingly effective military techniques. The object is to give the friendly force a head start, so that freed from external constraints; the commander can concentrate on the enemy.

A. Controlling the Environment

Hervé Coutau-Bégarie, Traité de stratégie, 6ème édition, Economica, 2008, quoted p 331.

The environment must not be allowed to become an operational obstacle. This requires minimizing its impact as much as possible by understanding and managing it. This should apply to knowledge of the terrain, topography, vegetation, climate, but also of the local population, its pathologies and culture. By fully understanding the specific risks present, the commander’s choice of manoeuvre is facilitated, the use of terrain can become an advantage and the force is better protected. This is particularly the case when force protection has become an essential requirement of efficiency. General Desportes considers that “paradoxically, when war was understood as a fight to the finish between blocks, force protection was not considered that important for two reasons. First because our vision of war was based on the notion of absolute war for vital interests which were felt, under the influence of Clausewitz, to justify and accept unavoidably huge losses. Secondly because lack of protection did not impact what was then considered the least important aspect of military action, its operational efficiency74”. Military efficiency has now taken centre stage, because of a concern for human lives and budgetary considerations. The health domain is one of the main players in this area for several reasons: biological risks, hygiene, water and food quality.

Hygiene Sun Tzu had already highlighted the importance of choosing the correct site for a camp: “one must choose the right site to preserve the health [of troops]75”. Quartering conditions have often had a significant impact on epidemics, even today with malaria when armies are based near swamps or other bodies of stagnant water. Hygiene in barracks is also vital, in particular with regards to typhus fever in connection with the proliferation of lice. There have been many instances in history of health disasters striking during great battles. The ancient Hebrews already recommended the purification of camps. Those afflicted with contagious diseases, leprosy or dysentery were to be excluded and their excrements buried76. These were both religious requirements related to the need for purity of the chosen, but also customary preventive measures learnt from nomadic camp life. One of the particular achievements of the Roman army was its organization, in particular in camps, which allowed its men to arrive ready and fit for combat. The French Royal Navy, because its crews had to operate in confined spaces during long crossings, was also quick to note the importance of hygiene.

General Vincent Desportes, La guerre probable, 2nd edition, Ed. Economica, 2008, quoted p 194. Sun ZI, The Art of War. 76 Deuteronomy, XXIII. 75

Modern military medical services advise the commander on issues of hygiene and operational security, and the protection of the environment. By adapting barracks, controlling behaviours, managing waste or by instituting medical countermeasures, the object is to reduce as much as possible the risks of accidents, intoxication or sickness associated with military life. It requires a combination of technical recommendations, health and safety considerations and the operational mission in order to reduce to the greatest extent possible any obstacle to manoeuvre. Through their knowledge of the military environment, their direct involvement in operations and their medical, chemical, biological and environmental knowledge, military health practitioners have a special role to play with regard to hygiene and operational safety. Their expertise is particularly important with regard to water and food safety since it has a direct impact on the health of combatants.

Food and Water

Water safety is essential, especially since it often serves as a vector for many pathologies, in particular bacillary dysentery and cholera. Where latrines are placed should not be left to chance; General Sherman77 for instance, was always particularly careful about where they were built, knowing that an entire army might be laid low by diarrhoea. For this reason, it rapidly became clear that preserving the environment of battlefields was essential in order to drawn from it life-sustaining water and food. Armies long survived by living off the land they conquered and used a scorched earth policy to deny supplies to other armies. The lack of supplies available to ancient armies often had severe consequences such as physical exhaustion or diseases like scurvy. Deuteronomy advises that: “When you besiege a city a long time, to make war against it in order to capture it, you shall not destroy its trees by swinging an axe against them; for you may eat from them, and you shall not cut them down78” in an echo of today’s concern for the protection of the environment. Furthermore, knowledge of local vegetation and fauna was indispensable. During its Russian Campaign, Napoleon’s army used oleander wood to roast their food, poisoning many soldiers.

Food quality is equally important. During the American Civil War, American military doctors insisted on the importance of food rations for combat troops for the prevention of

77 78

William Sherman (1820-1891) Union general who captured Atlanta and led the famous ‘March to the Sea. Deuteronomy, XX, 10-20.

disease, but the army staff was unconvinced by the results and chose to favour troop mobility rather than burden them with varied and sufficient rations. At the end of the nineteenth century, several incidents affecting troops attributed to the use of canned food led the French War Ministry to establish a commission on 1 February 1899, to review quality standards for military contracts. During the First World War, soldiers’ diet was exceedingly poor and based essentially on salted pork and alcohol. Surgeon General Joseph Lovell had earlier tried to lower the ratio of meat in rations in favour of an increase of bread and vegetables but was ignored. He was the precursor of modern dietetics which when applied to military personnel reinforces their performance and resistance. Parmentier, a French army pharmacist and famous promoter of the use of potatoes, was convinced that the best defence against disease was “good food and good hygiene79”. Veterinarians and pharmacists within the French health service are currently responsible for controlling water and food quality. The complementarity between the health service and command levels is in this instance less pronounced than it is for hygiene and security which have legal implications. While commanders understand the advantages of a healthy diet, they are often tempted to economize on the quality of rations since the effects are hard to detect in the short term. It is easier to convince them of the imperative nature of efforts against epidemics since these can have rapid and spectacular effects when left untreated.

Prevention

Epidemics appear and spread only when they encounter conditions which favour them and receptive individuals. Receptivity is determined by a number of factors, both external, such as promiscuity, overcrowding, temperature, barometric pressure, and humidity as well as internal such as exhaustion, physical decline, poor personal hygiene.

During the Middle Ages, commanders believed that their soldiers could only be used for a short lapse of time because the wearing of heavy armour tended to exhaust them rapidly – in an hour or so including pauses. Rest was considered essential.

Receptivity is to a large extent dictated by the level of specific immunity resulting from either prior exposure and recovery or vaccination.

D. Vidal, R. Deloince, Trois siècles de recherche et de découvertes au sein du service de santé des armées, Médecine et Armées, 2008, 36, 5.

Already in the eleventh century, the Chinese practiced variolisation, by inoculating troops with a low virulence dose of smallpox. The efficacy of the procedure was limited and the death rate relatively high, around 1 or 2%. Nevertheless the practice gradually spread along the Silk Road. Voltaire wrote about inoculation80 : “the Bishop of Worcester recently preached in London about inoculation, demonstrating how the practice had saved the lives of subjects”. Daniel Bernoulli in 1760 demonstrated that the generalisation of the practice would add just over three years to life expectancy. In the army, Jean-François Coste, introduced variolisation81 for the troops sent to help the American revolutionaries. It became mandatory in the United States in 1818.

The great leap forward for vaccination and hygiene came with Pasteur in the nineteenth century. His explanation and publication of the principles of bacteriology, the aetiology of infectious diseases and the role of prevention had a profound impact on the relation of man with his environment. The army considered this a huge opportunity or as Professor Jacob put it: “presenting the work of Pasteur is to hear as many victory bulletins”. The Military Health Service now worked closely with the Pasteur Institute, in particular in its overseas institutes. There is a long list of famous military doctors, such as Yersin and Calmette, who took part in spreading Pasteur’s technique overseas. “The fight against epidemic and contagious diseases has always been the sacred duty of the military medical service82”, this new era totally modified the provision of healthcare but also prevention within the army. The object was no longer to fight off unknown threats but real enemies however small: microbes83. Many military doctors were seconded to the Pasteur institutes, especially overseas. Camille Pesas, Yersin’s first military veterinarian collaborator, worked on bovine and human plague in the Nhatrang Institute in 1896. Edmond Plantureux, who headed the Microbiology Service of the Alger Pasteur Institute, was also a military veterinarian who worked on rabies. Lucien Balozet was a military practitioner who headed the Tunis Pasteur Institute.

Other prevention measures were developed such as secondary chemoprophylaxis. In 1830, Maillot achieved a satisfactory level of protection against malaria in the Algerian Expeditionary Corps using quinine sulphate. In 1892, the army’s veterinarian service advocated the use of mallein to diagnose latent glanders. The disease was wiped out in 80

Voltaire, XIème lettre philosophique, 1734. The word « vaccination » comes from the Latin vacca ‘cow’ because of the early use of the cowpox virus against smallpox. 82 Doctor (Major) Coudray, 1923. Provisional classification 9NN670, DAT, SHD. 83 The word « microbe » was first used by Sédillot in 1878. 81

military and subsequently civilian horses. In 1914-1916, Carle Guessard, an army pharmacist, established measures to combat trench lice.

These technical advances and the increased efficacy of prevention convinced command of the importance of medical action. The First World War saw the development of the “health defence84”. Its objective was the implementation of measures most likely to prevent or stop the spread of diseases, especially contagious ones. In 1924 a decree established “health teams tasked with applying technical measures for hygiene and disinfection and which could be guided especially by the appearance of barrack epidemics85”. “Protecting one’s own forces must be the main motivation86” which Sun Tzu believed was an indirect way of destroying enemy forces. Our military leaders, having taken note of the preventive efficiency of medical science, instituted several systems for the protection of their force’s health. In France, the Joint Staff increased the part played by the health domain in operational planning. In 2003, it added the “Prevention, Security, Environment” Section (PSE) which was tasked with issues related to military hygiene and security (known under the French acronym HSO)87, and the Radiological, Biological and Chemical Decision Support Cell (CARBC), tasked with gathering and analysing information in order to provide support to decision-making at the strategic or operational levels. NATO has adopted a similar approach by creating the “Force Health Protection” branch and the European Union is following in its footsteps. Controlling the environment has become a serious concern because it can aid in overcoming physical constraints acting limiting freedom of action. Being able to use and manoeuvre one’s entire force while minimizing risks and threats offers the largest possible range of manoeuvre. Striving for this freedom of movement is echoed by efforts made to control the environment in which operations are taking place.

B. Population Management “Who will enjoy the advantage of elements and terrain?88 », today we might add: who will win over local populations? This is an essential aspect today: to enjoy freedom of action, gaining the trust of local populations makes it more likely they will accept the presence of 84

Colonel Costedoat, ‘Direction du service de santé au ministère de la Défense Nationale’ (Medical Service Directorate of the Defence Ministry), CHEDN, La défense sanitaire, 1917. Provisional classification 9NN656, DAT, SHD. 85 Decree n°1921 B dated 20 March 1924. Provisional classification 9NN624, DAT, SHD. 86 Sun Tzu The Art of War. 87 Instruction n°1826/DEF/EMA/SLI/PSE du 13 septembre 2005. 88 Sun Tzu, The Art of War.

a foreign force. “We have realized that societies and men are the new site of action89”. This is a recent development, until the nineteenth century armies normally chose to operate through terror, requisitioning supplies, local labour or even women by force.

Colonial wars were a turning point for military attitudes towards populations. The initial phase of exploration and conquest was not overly concerned with “the inhabitant who is at the heart of the conflict90”. However the pacification phase did appreciate the importance of medical assistance to local populations. Fixed medical installations were reinforced by mobile medical support which served as the basis for the fight against major tropical diseases. Lyautey considered “…that if he understands his role, [the physician] is the first and most efficient agent of penetration and pacification91”. He might be able to gradually spread mutual knowledge and confidence. In Morocco for instance army doctors had an important influence on policy through their medical support of indigenous populations and their actions against trypanosomiasis, leprosy and tuberculosis. During the conquest of Algeria, the efficiency of the doctor serving with Bugeaud’s flying column was a significant contributor to the operation’s success. Army doctors were well regarded by local populations as was evidenced by the word “toubib92” used to describe them which had a friendly connotation. The French93 and British health services also played an important role in extending their respective empires as was recognized in 1924: “the outstanding role played by the officers of the Colonial Troops Medical Corps in running and developing the indigenous medical support services in colonies, by stressing that medical monitoring, the preservation and improvement of indigenous human capital alone will compensate for the staggering drop of the French birth rate and ensure that should the need arise for a future war, France will have sufficient manpower to defend the national territory94”.

After the Second World War, during the wars of decolonisation or of national independence, the objective of medical support to local populations was radically different. The objective was to win over the locals and discourage them from siding with the enemy. In Vietnam for instance, American doctors serving in the special operations hospitals

General Vincent Desportes, La guerre probable, 2nd edition, Economica, 2008. R.Trinquier, La guerre moderne, Economica, 2008. 91 J.L.Rey, Service de santé des armées et actions civilo-militaires au Kosovo : de la théorie à la pratique, Médecine et armées, 2001, 29,2. 92 Skilful learned man in Arabic. 93 The French Colonial Medical Service managed over 3000 bodies including 41 hospitals, 593 medical centres, 2000 dispensaries and 600 maternities, throughout France’s overseas territories. 94 Direction des troupes coloniales, 1er bureau, bureau technique, n°2.354-1/8-1 October 1924. Provisional classification 9NN637, DAT, SHD. 90

provided medical care to men of the local indigenous defence forces, their families and many civilians. This medical support formed an integral part of the operations carried by American Special Forces flown in for counter-insurrection missions for the South Vietnamese.

With the end of the Cold War, “the goal of modern war became the conquest of population95”. Experiences acquired in Former Yugoslavia led to today’s civil-military cooperation (CIMIC). “By CIMIC we mean any action undertaken by forces in theatre to take account of the interaction between these forces and their civilian environment and thus facilitate the achievement of civilian and military objectives96”.

In France, the Military Health Service follows this directive in the following way: the first priority goes to the medical support of the force (providing medical support to populations cannot compromise the primary mission, in particular the rapidity or support capability for forces. The objective is to preserve at all times the health service’s capability for an operational force), the level of medical aid for populations must be controlled (that is to say remain acceptable and bearable for the forces), it must be also be reversible (as was the case in Bouake in November 2004). This reversibility must be possible on very short notice and complement the action of the force. “Real war is among the people and not among the mountains97”. One should not forget that part of what is required for survival and intelligence comes from local populations. For this reason the “medical aid to populations” function (which plays a major part in the army’s CIMIC actions) has assumed such a high level of importance in modern warfare. Although this function was not considered a real strategic factor by Clausewitz and his contemporaries or included by Marshal Foch in his list of principles, it represents an essential tool for armies. It has become a principle of modern strategy as we will see. Actions affecting population provide command with increased operational freedom by decreasing the support available to the enemy, but also at the political level by legitimizing the presence of armed forces. Controlling the environment, in both its physical and human dimensions, increases the commander’s freedom of action and manoeuvre. The health domain is able to support freedom of manoeuvre, including for instance the evacuations of casualties. This history of these evacuations has been long and chaotic, mirroring that of the general history of 95

R. Trinquier, La guerre moderne, Economica, 2008. 1997 Directive on CIMIC in Kosovo. 97 General (USMC) Victor Krulak. 96

medical support. Its study reveals a great deal about the evolution of the relationship between armies and health and all its ambiguities.

C. Freedom of Manoeuvre Medical evacuations are strategically important, not only because they save lives and thus improve troop morale, but also because they clear the battlefield. Technical progress has freed the commander, allowing him to fight knowing that his men will be cared for, with improved mobility and in occasionally extreme circumstances. The efficient evacuation of the wounded offers a form of reassurance which increases freedom of manoeuvre. When combatants are concerned about victims, this constitutes a constraint. General de La Motte noted that during the War in Indochina98 “any medical evacuation required a general withdrawal. Were I to send one section back on its own, it might be lost completely. One day one of my scouts was hit by a low velocity hit to the stomach. […] We built an improvised stretcher with two poles and two combat jackets and we returned, much to my regret: we had lost an intelligence opportunity. It took us 10 hours to return him to hospital 415. His peritoneum was exposed but he will make a complete recovery with a large scar”. But commanders have or do not always perceive the significant advantage that evacuation assets can bring. In the short term, this can be seen as cumbersome, but over an entire operation, sufficient and efficient assets can make the difference.

The Beginnings of Medical Evacuation

“Bringing the wounded and the doctor together in the shortest time possible is at the root of war medicine99”. The Byzantines used “ depotats” and Roman Gaul “army valets” to gather casualties from the field using improvised stretchers. Pliny the Younger described how Gnaeus Pompeius died for the lack of a stretcher. European royal armies did not have specialised stretcher-bearers. The concept of medical evacuation appeared for the first time in France in 1694100. It was not applied immediately for even in the 1708 Edict, the bandaged wounded had to make his own way to the mobile hospital with the help of a companion or local. A few rickety requisitioned carts were sometimes used for their transport. Jourdan Le Cointe101 denounced the barbaric nature of 98

Dominique de La Motte, De l’autre côté de l’eau – Indochine 1950-1952, Tallandier, 2009, quoted p 144. J-N.Giroux, Evacuations sanitaires héliportées au cours du conflit vietnamien, médecine et armées, 2001, 29, 3. 100 Catinat, ‘Mémoire contenant les moyens de faire la guerre offensivement dans le piémont en 1694 adressé au roi’. ‘Dissertation on the means of offensive warfare in Piedmont in 1694 addressed to the King’. 101 Eighteenth century Parisian physician who wrote the famous ‘Traité de cuisine’ under the Ancien Regime which dealt with food hygiene as an essential aspect of health and the medical care of combatants. 99

these “transport carts where wounded men were piled, bumping along without help for a painful transport102”.

The Convention reacted in 1792 by inviting coach-makers and artists to work together and design “light and well-sprung vehicles to carry the wounded”. Although the invitation did not produce tangible results, it did lead to the implementation of new methods (such as immobilising fractures) to lessen the suffering of the wounded. Larrey, during the First Empire, set up the “flying ambulances” which were well-suited to the transport of combat casualties. But near the frontline, casualties were carried using improvised implements such as tree limbs, muskets, canvas, ladders, etc. Percy suggested in 1813 the creation of units of specialized stretcher bearers equipped with stretcher kits. This proposal was not taken up.

The First World War was the turning point for the use of real stretchers born by “regimental stretcher-bearers”. This period also saw the growing use of stretcher carrying wheelbarrows, of stretchers fixed on sleds or skis, cacolets mounted on mules. But “the influx of casualties was too much for the insufficient number of regimental stretcherbearers who were unable to organize their transport to the rear. Doctors could then call upon battalion band members to reinforce the stretcher-bearers103”. Louis Maufrais, a doctor in the trenches described how: “in these trenches where I gave first aid to the wounded dumped among the dead, before they were transported, often too late, to the field hospital in Bois Vauban by the overwhelmed stretcher-bearers”. The shortage of stretcherbearers was partly compensated in 1915 by the arrival of American volunteer ambulance drivers104. Medical trains also appeared during the war on both sides. Some trains were in effect mobile hospitals travelling up to 15 or 20 kilometres from the frontline105. Stretchers and medical vehicles were improved between the two wars, becoming lighter and equipped with better handling. They were used during the 1939-1940 campaign. During this period, ships were also used for medical evacuations106.

102

Jourdan Le Cointe, La santé de Mars, 1790. Louis Maufrais, presented by Martine Veillet, ‘J’étais médecin dans les tranchée’, Robert Laffont, 2008, note 1 quoted p 74-75. 104 France had 450 medical vehicles in September 1914 and 5 427 by the end of the war. The German War Ministry had industry build a pool of real tactical medical vehicles whose capabilities were reinforced by trailers. By the end of 1914, the German Army had 226 new medical vehicles, with 239 other vehicles. By 1916, the numbers were 1 815, and 2 961 by early 1918. 105 At the beginning of the war, the Germans were believed to have 40 medical trains and to have used 232 different types for the transport of casualties. In France a directive from the General Headquarters specified the use of trains for medical evacuations - EM Général / direction de l’arrière 1663 DA. Provisional classification 9NN670, DAT, SHD. 103

The use of hospital ships continued to develop, the Americans, for instance used the USS Colleton and USS Nueces for river operations in 1967 in Vietnam.

Significant progress came with the use of air assets which significantly reduced the time required, demonstrated the possibility of picking up casualties where they fell and reduced the burden of evacuation.

Evacuation by Aircraft The first air medical evacuations were carried out by the French in 1877 using hot air balloons to evacuate the wounded from a besieged Paris. In 1912, French Senator Reymon, a flying surgeon, predicted that “in the future we will build aircrafts to carry the wounded”. Lieutenant Paulhan and Captain Dangelzer flew out of Serbia in this fashion in 1915. Doctor Chassaing in 1917 carried a few casualties in his fuselage from Moulin de Laffaux to safety some 80 kilometres away107. Medical aviation saw significant development in Morocco between 1921 and 1923. In October 1921, Army doctors major Epaulard and major Pennes evacuated 18 serious casualties from the Mekhnes subdivision using 6 aircraft travelling in a squadron. They covered 80 kilometres in 35 minutes, a journey which would have taken 3 days by land. In 1922, in Morocco and the Levant, some 1 200 casualties were evacuated. During the Rif War (1921-1926), 1 000 casualties were airlifted, but 4 409 were carried out in “cacolets” carried by mules, because of the poor terrain which made landings hazardous. Between 1918 and 1936, 6 981 sick or wounded patients were airlifted from North Africa and the Near East. In France, Army doctor Robert Picqué became a strong proponent of medical aviation but unfortunately died flying a patient requiring an emergency operation from Cazaux to Bordeaux on 1 June 1927. This mode of evacuation really took off during the Second World War, the Americans in particular made intense use of aircrafts for the time108.

Planes do however require an appropriate landing area and weather conditions, which had to be overcome to improve the patients’ survival rate. It was often a race against time, 106 Between 21 and 29 May 1940, 789 wounded were carried by French ships. The Royal Navy used 3 hospital ships to evacuate the British and French military wounded from the Zuydcoote hospital. 107 In 1918, he had 60 Breguet 14 A-2s refitted by replacing the machine guns in the fuselage with 2 stretchers. In 1920, 80 Breguets were built leading to the Breguet « limousine » 14 T-Bis type. 108 173 500 wounded were evacuated in 1943, 545 000 in 1944 and 454 000 in 1945. The direct consequence of the massive use of aircrafts led to a drop of the mortality rate from 6 for 100 000 in 1942 to 1.5 for 100 000 in 1945.

survival depending in large part on the rapidity of the intervention. Army doctor Mellies commented in June 1917: “do medical evacuations not lose in a few moments the good reputation the Medical Service has acquired over months of hard work and devotion? 109”. He meant that the Medical Service had to do all it could to carry out its mission: saving as many lives as possible, but unfortunately lacked the necessary tools for medical evacuations. A lack of transport assets led to a loss of time which could not be reversed. There is a requirement for mutual support between command and the medical domain at this level to ensure the full efficiency of evacuations.

The Medical Helicopter Revolution

The helicopter brought about the second revolution with its far greater landing ability. It opened a new era for military medicine, and emergency care in general, with every minute saved helping make a difference between life and death. The use of helicopters was studied in France in 1946 but effective and specialized use came in Indochina in 1950 where Valérie André, a pilot and doctor gave sterling service. The use of these aircrafts for collecting casualties near the combat zone and their evacuation to nearby field hospitals saved an incalculable number of lives and led to many innovations for airborne medical equipment and techniques. The lessons learnt by the Americans in Korea, the British in Malaysia and the French in Indochina all demonstrated the usefulness of helicopters for the caring of the wounded110.

In Vietnam, between the end of 1961 and 1973, the Americans, confronted with the difficulties of the terrain and Vietcong guerrilla techniques made great use of this method of evacuation. The helicopter proved invaluable in the mountains, jungles and swamps of Vietnam which further had few rail links or roads. Major Kelly became the symbol of airborne medical support. He became in a few months the incarnation of the devotion and sacrifices made by medical detachment pilots in Vietnam. In 1964, 16 000 American soldiers were deployed in Vietnam, requests were evacuation were significant with pilots flying over 100 flying hours per month. The medical transport helicopter concept was validated during the war.

109

Médecin Principal de 2ème classe Mellies, juin 1917. Provisional classification 9NN670, DAT, SHD. The French had 18 aircraft and 5 000 wounded were carried by helicopters between 1950 and 1954. In two months, 1 400 medical evacuation missions were flown for 4 200 patients in Laos. The Americans flew 17 700 casualties by helicopter in Korea. 110

The efficiency of this mode of evacuation is evidenced by the reduction of the time between injury and effective treatment which went from ten hours during the Second World War, to five hours in Korea to a little over one hour in Vietnam. These numbers are also confirmed by the study of mortality rates correlated by evacuation time, irrespective of the mode of transport used111.

The helicopter has now become the ideal tool for tactical in-theatre evacuations, while fixed wing aircraft are favoured for long distances (strategic). The French Military Health Service has made early medical evacuations one of the three pillars of medical support for operational forces. However due to the insufficient number of aircraft, this kind of evacuation remains underutilized. A dialogue is required between the medical services of various nations and command in order to assess the requirement and attempt to provide as much capability as possible.

The management of medical evacuation assets varies from nation to nation. The French Army does not have a fleet of aircraft dedicated exclusively to medical transport while the American Medical Service is equipped with medical helicopter units. The French aviation regulations do however specify that: “medical aircraft should not be employed for other uses other than medical evacuations so that they can be maintained and available at all times”. But the principle remains unchanged: provide assets to medical support so that evacuations can take place in the best circumstances possible and free the commander from associated constraints. Medical evacuations provide greater freedom of action by clearing terrain, lightening manoeuvre by freeing combatants and providing psychological support since their chance of survival is considerably improved. The medical domain’s strategic role is reinforced by its ability to integrate new technologies which allow military commanders to concentrate on purely operational concerns.

Medical evacuations, whether by land, sea or air, deserve attention since they save so many lives. They have in fact become part of the casualty care chain.

111

In WW I, it took between 9 and 18 hours to reach a surgery unit and the mortality rate was 8%; during WW II it was 8 to 12 hours and 4.5%; in Korea, 2 to 4 hours and 2.5% ; in Vietnam, 1.5 to 2 hours, 2.5% ; during the Yum Kippur War, between 1 and 10 hours and 1.3% on the Israeli side compared with 24 to 48 hours and 3.1% on the Arab side; for the Russians in Afghanistan, it was 1 to 6 hours and 3.5%; during the Falklands War, 2 to 12 hours and 1.3% and finally for the Former Yugoslavia 1 to 6 hours and 1.75% - Dejan Bajcetic, Stojan jovelic, Danilo Krstic, Nebojsa Jovic and Milovan Novovic, Experience in evacuation wounded and sick on the territory of the former Yugoslavia in the war time 1991-1995, F.Y.R.O.Macedonia, revue internationale des services de santé des forces armées.

D. Technical Innovations Through research and innovation, military medical services have sought to improve the medical support of forces and help combatants survive extreme conditions. They offer commanders the possibility of overcoming human and psychological barriers which impact military capabilities and therefore strategic objectives.

Overcoming Human Limits This aspect is particularly striking in the aeronautical domain, which could not have developed as it has without the results of medical research on aeronautical physiology. Aircraft, whose performances continue to increase, would not have been possible without protecting the aviator subjected to extreme pressures. Hypobaria and hyperbaria were the first challenges to be met. Physicians first studied the issue over 200 years ago when dealing with altitude sickness which had already been described in Antiquity by Aristotle in relation with the ascent of Mount Olympus. In 1590, a Spanish missionary, Joseph dâ&#x20AC;&#x2122;Acosta provided a scientific description during his stay in the Andes. Physiological research in this area led to specific training for mountain troops and the development of flight. Medicine made significant contributions to the development of flight, from the first hot-air balloons to space flight and microgravity. Several disciplines are involved in the creation of better and faster combat vehicles: physiology, climate medicine, psychology, cockpit habitability, ergonomics and pilot selection. By pushing human limits, the medical domain allows the commander to take part in the performance race and ultimately gain a strategic advantage.

Chemical warfare appeared during the First World War and chemical gas was used although neither army was prepared for this kind of assault. Following the attack on Ypres on 22 April 1915, the General Staff asked the French Health Service to gather information on gases, believing that â&#x20AC;&#x153;close collaboration between [Health Service and Chemical Material directorates] appears indispensable112 Âť. Pharmacists, who were experts in chemistry and toxicology, were called upon. The first French gas masks in 1915 used gauze dipped in castor oil and were produced by pharmacists. Instructions concerning therapy for gas intoxications were published on 4 March 1916. Filters were subsequently developed for gas masks by, among others, Paul Lebeau, a professor in chemical

112

Letter from the cabinet of the Deputy Secretary for Artillery and Munitions to the Military Health Service, dated 21 August 1915. Provisional classification 9NN691, DAT, SHD.

pharmacology and toxicology at the Pharmacy Faculty of Paris. He served in the Defence Staff against Gases during the Second World War. Survivors of the 1915 gas wars from the French 155th Infantry Regiment described how: “when the Germans used gas for the first time the frontline collapsed. But it was a technical trial and there were no troops ready to follow-up. It was different for the second trial. Our troops had been warned and were wearing protective gear, however primitive. When the warning was given, our soldiers put on their masks and rifles and the enemy was in for a choc113”.

However, and this brings up an issue of ethics, military pharmacists also assisted in the fabrication of toxins. Gabriel Bertrand, proposed the use of chloroacetone as tear gas in a grenade of his design in 1915. Pharmacists, working within the Chemical Service during the First World War played a role in developing offensive weapons, but also in designing protective gear for the army.

Improving the Medical Support of Forces The medical domain is continuously seeking to improve its service so that it can provide support to armed forces in all circumstances, by adapting to the various types of manoeuvre. The object being to reduce constraints on command and offer increased freedom of action by enabling medical support to logistically complicated military operations. Mobile parachute surgeries are a concrete example. They have allowed health support to be extended to long range airborne operations. The first unit was created in Indochina in 1947 in answer to the need for airborne operations. Operation ‘Castor’, launched at the end of November 1953 to capture Dien Bien Phu was a model for the efficiency of this type of medical support. Eighty soldiers wounded during the initial assault and skirmishes were saved during the first few days by the mobile surgery. Mobile surgery units were used in November 1956 in Cyprus, on the Suez Canal, and in Port Fouad opposite Port Saïd. Two hours after it landed, the unit was ready to provide support to the 2 ème RPC114 and 11ème choc115. The Parachute Surgery Unit also accompanied forces during the operation led by the 2ème R.E.P116 in Kolwezi (Zaire) in 1978.

113

History of the 155th Infantry Regiment of Commercy during WWI by survivors in memory of the 115 officers and 3985 NCOs and enlisted soldiers killed or missing, La Sainte Biffe, Ecole Don Bosco, 1976, quoting the testimony of Médecin major Benoît. 114 RPC : Colonial Parachutist Regiment. 115 11ème choc : 11th Shock Parachutist Regiment. 116 REP : Foreign Parachute Regiment.

Additional capabilities were developed in order to respond to the different situations confronting forces. Modular technical elements were used during the 1990s to provide medical structures irrespective of terrain while maintaining the same standards and quality of healthcare, including in a CBRN environment. Further development work is related to the miniaturisation of equipment in order to improve mobility by reducing load requirements. Special Forces have expressed their interest in this type of technology which would prove particularly useful for long range infiltration missions in enemy territory.

By eliminating constraints, encouraging technological progress and the continual improvement of the quality of medical support, health services provide commanders with an appreciable level of serenity, increased power and the ability to keep the initiative. Hervé Coutau-Bégarie considered that “seizing the initiative requires creativity for the design, speed and flexibility of execution117”. The medical function contributes to these three areas by its ability to design new systems for optimizing the support of forces, its ability to increase the speed of military action, including by the use of medical evacuations, and by the opportunities which allow commanders to overcome constraints on his manoeuvre. The last is particularly encouraged by the control of the environment, identification of risks, force protection and population management. These strategic advantages were long misunderstood or ignored.

117

Hervé Coutau-Bégarie, Traité de stratégie, 6th edition, Economica, 2008, quoted p 330.

III Protective Security Security is a prerequisite for warfare. The issue is no longer prevention of environmental risks but the anticipation of threats the enemy may direct at friendly forces. The objective in this instance is to avoid surprises and maintain control of the situation. As Marshal Foch put it: â&#x20AC;&#x153;where there is no strategic security, there is strategic surprise that is to say that the enemy can attack where we are not prepared to respond118â&#x20AC;?.

One issue in particular requires the optimal preparation of armed forces, the possibility of a nuclear, bacteriological or chemical attack. The health domain is a role to play for each of these threats, but its role is particularly important in the biological domain (where it is involved in the prevention, detection and treatment). Armed forces have developed a whole range of stratagems or substances which may be used as weapons of mass destruction. These weapons, of varying degree of sophistication, may entirely negate the effects of conventional weapons or the principle of numerical superiority. Their use can inspire terror because of their unparalleled destructive capabilities.

The biological threat is the oldest of the three since it use predates modern armies. There are throughout history many examples of the use of this type of weapon. However if we find them in Antiquity, it was only during the twentieth century that consensus developed over banning the use of biological agents for war purposes119. The technical means of delivery for the spreading of diseases have evolved to such an extent that they may have disastrous global effects. Therefore, although the use of this type of weapon is theoretically forbidden, it is imperative that vigilance and prevention be maintained. Health services have their role to play by assessing aggressive biological threats and preparing preventive and curative countermeasures.

A. Assessing the Threat The health assessment of threats is one element of strategic decision-making. Military medical services are involved in the assessment of environmental risks, the results of which are then supplied to the joint intelligence function. Medical intelligence is thus produced to determine the likelihood of potential health threats. In concrete terms, the health domain gathers medical information using an epidemiological monitoring and

118 119

Ferdinand Foch, Des principes de la guerre, Economica, 2007, quoted p 216. First in 1925 then 1972.

public health system. A technical analysis is carried out to feed the databases which command may use to establish its prevention policy and develop a strategic anticipation. Health services contribute to the assessment of the impact of chemical toxins on the human organism, whether industrial (such as lead poisoning from the Mitrovica factory in Kosovo in 1999) or actual used as weapons. The health domain is a vital element of biological defence with the detection of epidemics, natural or man-made.

We have numerous historical examples of the use of biological weapons and attempts to make them more efficient. During the Peloponnesian War, many Athenians did not consider the plague accidental, believing instead that the Spartans were attempting to contaminate their enemies. The Assyrians poisoned wells using ergot in the sixth century BC and Hannibal launching barrels of snakes on enemy ships in 184 BC are a few examples among many. These improvised forms of biological warfare continued until the twentieth century, creative war chiefs using the sick as weapons. Besieging Kaffa defended by the Genoese, the Tartars catapulted dead plague victims into the town, which won them the day but resulted in the spread of disease throughout Europe. The same practice was used in 1710 by the Russians to capture Tallinn from the Swedes.

The smallpox virus was also used, for example during the seventeenth century genocide of South American natives using contaminated clothing, and the same strategy was used by the British against North American Indians and by American colonists during the War of Independence. In 1763, General Amherst, the Governor of Nova Scotia wrote to British Colonel Bouquet: “could we not spread smallpox to rebellious Indian tribes? We should at this time use any means to defeat them” who responded: “I will attempt to ensure the spread of smallpox, using blankets which we make sure they receive120 ».

The First World War was the theatre of more sophisticated methods. Germans were accused of attempting to spread ganders to allied horses. A German agent was found carrying a vial of fluid, a paintbrush attached to a wire and instructions on how to spread the fluid by pouring it over fodder or on the horses’ nostrils121. They were also accused of sending cattle contaminated with anthrax to the United States, trying to spread cholera to Italy or plague to Russia. These accusations were however never proven.

120

Chemical gases were however used in 1915. Soldiers in the trenches described how: “the stench of gas started by irritating our eyes” and then they found themselves under attack from asphyxiating gases. These perfidious and terrifying attacks that “we did not hear arrive, their shells do not make noise” had an immediate paralysing effect on soldier’s war fighting capability: “we were submerged. I felt nauseous, faint, teary eyed and started sneezing. I felt knocked out and to sit on a pile of shells stored by the Harazée church. My medical staff was spread all over the ruins, most were incapacitated by vomiting122 ».

On 17 June 1925, the Geneva Convention was signed banning the use of chemical and biological weapons in war and was later completed by the 1972 Biological Weapons Convention and in 1993 by the Chemical Weapons Convention. But the race for ever more advanced weapons continued. In 1937, the Japanese established “Unit 731” in Manchuria for biological warfare research. Outbreaks of plague in China and Manchuria in 1940 were attributed to the deliberate release of infected fleas over these regions. In 1945, 400 kilos of anthrax spores were produced intended to be spread using fragmentation bombs. The 1948 Baldwin report recommended that the American military develop detection and identification tools; decontamination, protection, prophylactic and treatment procedures; and assess techniques for the distribution of biological agents.

The health domain naturally played an important role in implementing these recommendations. Medical techniques had previously been insufficiently effective to protect forces against these threats, but they are now able to develop, through research, real-time monitoring systems which allow armies to react and establish effective countermeasures. On the other hand, military medical services, bound by medical ethics, cannot take part in the development of these weapons.

B. Medical Countermeasures A Commission of the Society of Nations in 1924 concluded that: “the real threat, a deadly threat, would be for a nation to go to sleep while trusting international conventions and to awake helpless to a new threat”. This conclusion leads to the recognition for greater vigilance and the development of protection technologies. The health domain once again can provide a valuable strategic advantage to commanders by providing them with the tools they need to counter enemy intentions.

122

Louis Maufrais, présenté par Martine Veillet, J’étais médecin dans les tranchée, Robert Laffont, 2008, cité p 127-128.

In this way, “just like armour is opposed to canon, vaccines or serums are opposed to microbes123”.

Most diseases, which may serve as a potential arsenal, can in fact be

avoided. Medicine (and in many cases military medicine) has developed real countermeasures, such as vaccines (against typhoid fever, cholera, bubonic plague, smallpox, typhus, yellow fever, tetanus, diphtheria, etc), therapeutic serums (cholera, plague, diphtheria, tetanus, venoms, etc), chemical drugs (antibiotics, anti-malaria drugs, antiviral, etc). During the First Gulf War in 1991, because of a lack of knowledge about the real capabilities of the Iraqi army, the French Command acting on the advice of the French Military Medical Service, ordered the extension of vaccine protection for French soldiers and the reinforcement of environmental monitoring around Rhafa.

Concerning chemical weapons, close collaboration between command and the Military Medical Service began during the First World War when the Deputy Secretary of State of the Army for ‘Artillery and Munitions’ wrote to the Deputy Secretary of State for ‘Military Service’ suggesting they work together on “the search for protection devices against gases and other dangerous products which they enemy may use is currently being carried out by the War Chemical Studies Commission alongside the Chemical Equipment Service (3rd Directorate) [in relation] with the work carried out by laboratories, both for the identification of products collected on the battlefield and research on offensive products we might use”. He further added:” The Medical Service, which will distribute protective equipment, cannot ignore the issue. It alone will be able to gather and provide necessary information: observations and clinical trials made by frontline doctors, how the equipment is used, etc.124” One should note in passing that the letter reveals a certain ambiguity concerning the involvement of the health domain in the development of toxic products. There is little evidence to corroborate this implication, although we do know that delegates from the Medical Service were sent to the Permanent Commission for Further Studies in Chemistry and others were posted to the Technical and Industrial Section for War Chemical Equipment. It is clear however that the Medical Service was involved in the development of protective measures, the design and construction of gas masks and of specific treatments for victims of gas attacks. Doctors were involved in the drawing up of the treatment notice for gas intoxications distributed by the Armaments Ministry on 4 March 1916. Furthermore the period saw the growth of laboratories within the French 123

Colonel Costedoat, ‘Direction du service de santé au ministère de la Défense Nationale’ (Medical Service Directorate of the Defence Ministry), CHEDN, La défense sanitaire, 1917. Provisional classification 9NN656, DAT, SHD. 124 Letter from the Under Secretary of State for War « Artillery & Munitions » to the Under Secretary of State for the Medical Service dated 21 August 1915. Provisional classification 9NN691, DAT, SHD.

Medical Service, so that in 1917 there were 230 laboratories for the analysis of water and foodstuffs125, capable of detecting toxins. In France, this collaboration in the field of force protection continues today via the relationship between the Armyâ&#x20AC;&#x2122;s Medical Service Research Centre and the General Directorate for Armaments. Treatments and innovative systems patented by the Military Medical Service have been developed for chemical toxins, such as the auto-injector or HI6126. In France, the Medical Service is responsible for the strategic reserve of doses intended to treat, in case of a radiological accident or terrorist attack or chemical or biological attack, the military forces, but also part of the civilian population.

Avoiding an enemy surprise, in particular through the use of non-conventional weapons is a prerequisite for victory. Todayâ&#x20AC;&#x2122;s medical services have acquired a level of technical expertise sufficient to anticipate and counter these types of chemical, and especially biological attacks. In this way, the health domain plays an important strategic role, now able (even if this potential always existed, it could previously not be utilised), to take part fully in the execution of the strategic principle of security.

125

Provisional Classification 9NN691, DAT, SHD. HI6 : a new generation antidote for oxime neurotoxins which inhibits the action of human erythrocyte acetylcholine to block organophosphates. 126

PART TWO: The Limitations on the Use of the Medical Domain as a Strategic Player

A limitation is an obstacle which hinders action, it is either established or the result of the choices we make. The idea here is to apply this definition to elements which have throughout history hindered the medical domainâ&#x20AC;&#x2122;s potential strategic role. We have seen in the previous chapter how medical issues could present considerable advantages for commanders.

However, its use was in the past limited by three main reasons: societal dictates, command decisions and medical limitations. Attitudes to war have evolved over time. Behaviours condoned by society held a strong influence over how combatants were considered, on warrior practices or their interactions with civilian populations. The style of command was also considerably impacted by its time and beyond these changes the priorities set by military leaders were sometimes made at the expense of the health domain. Strategic principles were sometimes incompatible, such as concentration versus safety for instance127, requiring choices in favour or one or the other. These choices were also often provoked by the lack of technical efficiency of the medical domain. Medicine had to await the nineteenth century and the Pasteur revolution to advance sufficiently to allow significant advances for armed forces.

The three broad categories of limitations will be assessed to see whether they continue to be an issue in modern times. Strategy, although governed by a series of universal principles, continues to vary in accordance with the typology of conflicts. Contemporary strategy has had a profound effect on military theories, creating new scientific and technical forces in which the medical domain in particular finds a more welcoming soil. The range and nature of limitations acting on the potential role of the medical domain and its consideration by command have evolved along with these trends and have tended to diminish.

The objective is therefore to understand these obstacles, to see which have disappeared and which remain.

127

1914 Schlieffen plan.

I. The Cultural Environment The times, societies and their cultural environment have obviously had an impact on the relation of men with war and therefore live. Some civilizations value the individual, others favour the collective. Attitudes to death have also considerably evolved, glorified by some, denied by some and accepted as fate by others. Man has always sought answers, but they have varied and must be studied to understand the different methods of war and attitudes towards warriors. “The place of warriors is obviously different depending on period and society128”. The care of soldiers is therefore directly related to the vision his society has of him.

The army’s organization is itself a reflection of the mentality and combat methods of its society. This clearly has an effect on how forces are used and how they are supported. Clausewitz suggested that “each period strives to create its own strategic doctrine and wars are the reflection of their societies129”.

A thematic rather than linear approach was chosen since history has shown that societies and military thinking have not progressed in a linear fashion, but rather followed a cyclical evolution. While each period has its own specificities and technological discoveries, behaviours may echo through the centuries, be abandoned and rediscovered. Thus the attitude of society vis-à-vis the human factor is one of its characteristics, often correlated to the role of its warriors and the attention they warrant, in particular in the medical domain. This place is useful in explaining the relationship between command and the medical domain. It is the expression of the interest the State has in its soldiers. Four main tendencies have been identified, although there is some overlap. The first sees man as an asset, to be protected only to obtain the required level of performance; the second considers man to be entirely a servant of God or a specific ideology, which alone determine who lives and who dies; the third uses man to serve machines, leading to a cult of mechanical power; the fourth considers man an end in itself which should be protected.

A. Man as an Asset In Antiquity, physical strength was highly prized and considerations of morality were considered secondary. Only the strong deserved to survive. Man was considered from a purely practical point of view, he served to reinforce the hordes of warriors and defend the 128 129

Claude Nières, Faire la guerre (The Conduct of War), 2001, Privat, quoted p173. Clausewitz, On War

clan. Death was seen purely as the result of fate, at a time when there were so many calamities to cope with.

The Romans, attempting to hold off barbarian assaults brought the military system to a level of perfection that was unprecedented. But the legionnaire was also considered a mere tool for the grandeur of Rome. Roman soldiers were prized individually, since their experience, acquired from long training and combat was precious. Those who benefited from their protection were grateful to their soldiers in relation to the value of the service he provided. Collectively, the need to preserve manpower, faced with the growing barbarian threat and the demands of an army increasingly aware of its importance, led to the provision of care for wounded soldiers. It was therefore a strict need for military efficiency which favoured the introduction of physicians in the legions; the real motivation was not with human suffering but with the need to preserve veteran troops. This notion of yield (getting a return on investments) first appeared with mercenaries, mostly Greek at first, soldiers for hire were later inserted into the legions used to defend the Empireâ&#x20AC;&#x2122;s borders during the 1st and 2nd centuries AD. The value attached to a combatant was obviously related to his physical condition. Roman legionnaires became professional soldiers serving long years in service - between sixteen and twenty years - it was therefore necessary to ensure that their training produced a return. With the growing number of border conflicts, the issue of manpower became increasingly pressing. In this way, although the soldier was seen only as an asset, the appearance of large and structured armies tended to encourage an approach which sought to preserve these assets, and a growing awareness of the value of human life as a strategic advantage.

This interest in preserving manpower was lost during the Middle Ages, at least until the Crusades, as the threat of large-scale invasions faded with the ninth century. A new military system was established in Europe, the feudal system was based on relationships between individuals, rather than between a citizen and the state. This led to the disappearance of collective health systems until the creation of crusading Hospitaller Orders.

The Renaissance brought about significant changes to the arts and medicine, but also as pointed out by Machiavelli, to political and military affairs. In 1445, France adopted a standing army, in so far as the King implemented a system by which he could raise troops in accordance with his needs. With advances in weapon technology, casualty rates

multiplied. Ambroise Paré described how “when lightning strikes it hits one man at a time, but artillery can strike a hundred men with one shot130”. Healthcare developed once again, but it was not born of an understanding of the efficiency of medical care since surgery was left until the end of the sixteenth century in the incompetent hands of barbers and others, but rather from a sense of Christian duty. It was during the siege of Metz in 1552, that the Duke of Guise created two field hospitals for his troops, the first since Roman times.

B. Man as a Servant of God or Ideology The Middle Ages was the culmination of this viewpoint in Christian societies. Social organizations were based on the feudal system which bound the vassal to his sovereign and required he followed him on military expeditions. Security needs led to the development of seigniories “which kept the peace and administered justice over a given area and anchored by a stronghold”. Villagers had to contribute to its defence by serving 40 days a year. During this period, there was little interest in caring for the wounded, de la Noue described how: “they lie in a ditch where they were struck”. Those with sufficient financial resources bought horses and warriors on horseback grew in importance with the eventual emergence of chivalry. Knights developed a military aristocracy on the backs of those it protected. They did however develop a sense of honour and courage, almost carelessness, in the face of danger. During the battle of Crecy, in 1346, French knights refused to adopt the bow and arrow used by the English, arguing that only hand-to-hand combat was honourable. In these circumstances, voicing medical concerns, in so much as the knowledge of the time allowed, would have been an intolerable admission of weakness.

During the period, kings became God’s representatives on earth and some knights chose to devote themselves entirely to God and created powerful military orders. Dying was an act of bravery, the supreme sacrifice which brought the knight to his Creator. Knights, bearers of military and moral values, enjoyed considerable prestige. Because he transgressed against God’s commandment “thou shall not kill”, the clergy was quick to define the notion of “just war” in Canon law. Systems for the caring of combatants were finally reintroduced during the Crusades after they had been obliterated during the first part of the Middle Ages. Military orders established medical facilities to care for the ‘soldiers of God’, based on the values of charity and devotion framed by strict religious rules. This close link between medicine and 130

Preface to the 11th Book of Ambroise Paré on the wounds from arquebuses and handheld canons.

religion did little to advance clinical knowledge, as the Church sought to separate medicine and surgery in the twelfth century and reduce the status of surgery further by banning dissection and linking it for a long time to heresy. The Hippocratic Oath, with its emphasis on the care of all wounded and sick - friend or foe, was also discarded during this period as only Christian patients were entitled to care. Speaking of heretics, Simon de Montfort stated131 “kill them all, God will recognize his own”.

A man entirely given to the service of God had little consideration for human live. His logic was implacable, eternal salvation requiring self-sacrifice in the name of God. Many sacrifices and massacres were carried out in the name of religion. In 1099, the Jews and Muslims of Jerusalem were killed by crusaders under the orders of Godfrey of Bouillon and the St. Bartholomew’s Day massacre in 1572 was but one example drawn from a long and terrible list.

This approach is also characteristic of ideological wars, where the cause is considered more important than life itself. Marxism also gave rise to this type of behaviour, even if it presented itself as the antithesis of religion. The destruction of human life was justified by the pursuit of ideological goals. Clausewitz believed that these symbolic stakes would lead to ‘total war’. Fanaticism knows no bounds and increasingly radical and attempts to control violence are overcome by the resentment due to ideological frustration.

During the wars of decolonisation, which often served as proxies for the opposition of communist and liberal ideologies, combatants were willing to go further in sacrificing their lives and the lives of others. “The North Vietnamese under Ho Chi Minh and Giap were prepared to go to any limits – of sacrifice, of manpower, of space and of time132 ». Obviously in these conditions medical concerns are not paramount, since they are not based on the notions of preserving assets (it is easy to train a fanatic drawn from his miserable environment) or the importance of charity (overcome by hate) or awareness of the sanctity of human life.

Current conflicts unfortunately reveal many of these characteristics, mixing religious, economic and political ideologies. This has considerably complicated the resolution of

131

Simon de Montfort (1165-1218) a leader of the Albigensian Crusade. Carver, ‘Conventional Warfare in the Nuclear Age’ in ‘Makers of Modern Strategy’ ed. P. Paret, Oxford, quoted page 787. 132

what are no longer called wars, but crises. Michel Goya133 describes the new paradigm of “localised total war” where rebels use “total means” such as suicide missions. This produces an asymmetric opposition between western forces which operate under the legal restraints of the law of armed conflict and irregular forces who use any means at their disposal, however outrageous. The medical domain in this context suffers from the same paradox. It must on the one hand defend the values of human life and non discrimination, believing it can operate under the protection of the Geneva conventions, but is regularly confronted with a total disregard for human life and the exploitation of death. Victory may require convincing local populations who have not been won over by fanaticism, of the validity of the first option.

C. When Man Serves Machines Originally, war opposed human communities who avoided unnecessary escalations of violence. Differences were settled in hand-to-hand combat. Later armies were constituted and weapons developed, but it remained a choc between opposing camps.

In ancient times, the phalanxes despised auxiliary troops who used bows (toxotes), slings (sphendonetes) or javelins (acontistes)134. Strabo quoted an inscription from the eighth century BC prohibiting the use of missiles during the Lelantine War135.

During the Middle Ages, knights advocated honourable single combat and denounced the cowardly English who used bows capable of killing at a distance without direct contact between opponents. Firearms first appeared in Europe during the siege of La Réole in 1324136. It was initially considered a cowardly weapon, which allowed the destruction of the enemy without exposing the person firing it. Men hid behind machines, avoiding the rough contact with physical suffering and death dealt and received on an individual level. Firepower increased over time as did artillery’s importance. Firepower became in the nineteenth century strategy’s most important element. After the War of 1870, General Lewal considered that “firepower is far superior to shock; firepower is essential, shock secondary”. This lasting attitude became a significant failing of the generals of the First World War. 133

Michel Goya, ‘Dix millions de dollars le milicien’, (Ten Million Dollars per Militiaman’ Politique étrangère, 1/2007. 134 Hervé Coutau-Bégarie, Traité de Stratégie (Treatise on Strategy), 6th edition, Economica, quoted p 409. 135 Victor Hanson, Le modèle occidental de la guerre, (The Western Model of War) p 41. 136 Hervé Coutau-Bégarie, Traité de Stratégie (Treatise on Strategy), 6th edition, Economica, quoted p 409..

This approach naturally had consequences on the medical domain at various levels: the number of casualties, the type of casualties and the concern with the human factor. Doctors now had to deal with a growing number of casualties, due not only to the increase in the size of military forces, but also the lethality of weapons. Military technology considerably increased the distances covered by battlefields, from the closed field of the Middle Ages, through the five hectares fought over in Nerwinden in 1693, the miles of trenches of the First World War to today where air power can reach entire countries. The problems associated with picking up casualties have therefore considerably changed.

Weaponry’s evolution has also had a strong impact on the types of wounds. The wounds inflicted by thrusting weapons, lances and arrows were followed by trauma resulting from shot in 1326, harquebuses and canon in 1524. Bullets were followed by explosive ordnance in 1886, aircraft ordnance and the atomic weapon in 1945.

Fuller divides the history of armies into a series of technological ages: “gun powder, steam, petrol, atomic energy”. Man no longer relied on his own energy to hit the enemy, but on the power of technology. But technical progress also allows better protection and treatment of soldiers, which opened new avenues for the medical domain. The lethality of weapons however increased exponentially, culminating with the atomic weapon. This can strike some leaders as an unending war. Fascination with the firepower offered by machines can make it appear more important than the man driving it. During the Korean War for instance an entire division retreated in very difficult conditions but chose to bring along its armoured vehicles and other equipment, at the cost of many human lives.

Asymmetric wars, either during the decolonization era or in their current incarnation, have shown that technological superiority is not enough in itself. Guerrillas use techniques to overcome this superiority by placing man once again at the heart of conflict. Strategists should not put all their trust in mechanical or energy power. One should not forget that: “the history of warfare is not the history of technology; it is the history of men137”.

137

Général V. Desportes, La guerre probable (The Probable War), 2nd edition, Economica, quoted p 173.

D. Man as an End in Himself Some societies have and continue to see “man as an end rather than a mean138 ». The Confucian or Taoist conception of war in Ancient China saw it not as conquest or destruction, but as a way of restoring the normal order of things. Man and civilization were at the heart of this understanding. Sun Tzu recommended war leaders “be good to enemy soldiers and feed them139”. Byzantium adopted a similarly human form of warfare, formalized in the Guerrilla Treaty of Emperor Nicephorus Phocas.

But it was Greek thought in particular which valued the individual as a human and citizen. This can be seen not only in how enemies were treated, but especially in how their own troops were treated. Xenophon described how King Agesilaus often exhorted his soldiers to treat prisoners well, not as criminals but as humans. Greek doctors were also used to treat not only leaders, as was the case in Egypt or Mesopotamia, but any wounded soldier. The Greek ideals of democracy extended to the care of its citizen soldiers.

It took the Enlightenment in the West for a truly humanist concern to reappear. However, in the previous centuries, one occasionally comes across military leaders or kings who took note of the human dimension of warfare. Louis XIV created the French Medical Service in 1708, out of a humanitarian and genuine concern for his soldiers. He told Coligny: “One must help the wounded with extraordinary care, visit them on my behalf and show how I care”. But the eighteenth century marked the real end of the total dominance of soul over body. Commander Le Vassor de la Touche, in 1780, discussed military hospitals thus: “the question is whether another refuge for humanity would not please God more than the singing of psalms in a military hospital”. Public opinion also grew more interested, under the influence of philosophy, in social issues, liberty, equality and fraternity. Faith in man grew as power gradually left the divine right of kings to reside in nations of citizens. The French Revolution echoed this evolution with this Declaration of the Rights of Man and the Citizen on 26 August 1789, inspired in part by Grotius’ Natural Rights in 1625 and the wider humanist philosophy.

The former policy of charity evolved into a policy of assistance which was perceived as a state obligation. This represented a significant shift for the medical domain and military forces in general, although the change was only gradual, hospitals in France for instance 138 139

Fernand Robert, op.cit., p 10. Sun Tzu, The Art of War

kept the name of “établissements de bienfaisance” (Charitable Establishment) until the Third Republic and medical services did not immediately benefit from these changes. Few assets were made available and requests went unheeded.

Medical disasters occurred

throughout the wars of the Napoleonic Empire, July Monarchy and Restoration. Despite the warnings sounded by physicians like Lieutenant Colonel Scrive: “to ignore the lessons of the Crimean War would be a crime against humanity140”. It took the battle of Solferino in 1859 for a universal consciousness to arise. World public opinion was touched by Henri Dunant’s description of the battle’s aftermath and a movement grew to internationalize humanitarian conventions and give them a worldwide reach.

International humanitarian law was thus born of conflict with the first Geneva Convention in 1864, later completed in 1929. But it was only after the Second World War that it was significantly expanded and detailed with the Universal Declaration of Human Rights on 10 December 1948 and the four Geneva Conventions of 12 August 1949, completed with additional protocols in 1977 and 2005. The Universal Declaration of Human Rights was defined by the General Assembly of the United Nations (UN) as the common standard of achievement for all peoples and all nations. A declaration of intention, it nevertheless gave rise to a large number legally binding international treatises dealing with human rights. Its first article proclaims the liberty, equality and fraternity of mankind.

The Catholic Church which had long encouraged a spirit of sacrifice and submission to the will of God in Europe, argued during Vatican II for non-violence while recognizing the state’s right of self-defence and made no further mention of the notion of ‘just war’. It encouraged further political power’s duty to care and protect its citizens, including its soldiers.

In these conditions, man has taken centre stage, as an end, within western societies, giving rise to a wave of sympathy for those who defended the homeland and required military authorities take systematic note of the medical domain.

The various approaches found throughout history have had a very strong influence over the consideration afforded medical issues by the military. These cultural changes continue to influence how people treat their soldiers. The western world has clearly

140

Lieutenant Colonel Scrive led the medical service of the French Army of the Orient during the Crimean War (1854-1856).

adopted a humanist approach, but remnants of the spirit of sacrifice cultivated by knights or the cult of the superiority of technology over man, continue to appear in individual behaviours. In other societies, religious or ideological beliefs continue to dictate their reactions, as is the case with the â&#x20AC;&#x2DC;Intifadaâ&#x20AC;&#x2122; for instance.

II. Command Decisions Leading men in combat requires intelligence, courage and ability. For this reason, the command of armies was originally given to chiefs who displayed these qualities. Naturally, they had complete control over every aspect of their forces. This remains the case today, although military and political powers now tend to be separate. In France, the Chief of Defence answers to the government for the efficient order of military affairs141.

The medical domain, for armed forces, is entirely under the control of the military leader. However, this relationship has changed considerably over time, as a result of medical advances and the lessons learnt from the great conflicts of history. The medical domain was originally not a real concern of military leaders, who either ignored it or considered it a useful but secondary consideration. This lack of interest was born either of ignorance or contempt, further encouraged by the constraints it imposed and the lack of return it offered, or even from deliberate strategic choices. Clearly however, the harsh realities of war would soon demonstrate that the medical domain was becoming an essential component of victory.

A. A Domain First Ignored then Held in Contempt In battle, no war leader has ever been able to completely ignore what happens to the wounded, but his level of concern varied in accordance with his cultural environment. For centuries, combat medical support remained very basic, without a specific mission and few assets. The medical domain stood outside the military world and war leaders did not have to pay it particularly attention. Tactics, and later strategy, long ignored the medical domain.

Under the Pharaohs or the Kings of Mesopotamia, the essential military object was the destruction of the greatest number of enemy soldiers. In these conditions, what is the weight attached to human life? War leaders were however accompanied by personnel physicians who cared for them, not their troops. The religious context, based on superstitions and external forces tended to discourage change, explaining the profound causes of what may appear to be a complete lack of interest. Celts did not have a concept of medical support, because they were not overly concerned with human life, whether theirs or their opponents. Human sacrifices carried out before battles were part of the 141

Decree 2005-520 dated 21 May 2005 defining the CHODâ&#x20AC;&#x2122;s Terms of Reference.

preparations made for victory. The sculpture of the ‘Dying Gaul’ shows him alone and resigned to his fate, his understanding of combat excluding even the possibility of care. We might expect that Arab warriors, given the quality of health care available to the caliphate, would enjoy some form of military medical care, but once again their notion of holy war and of the sacrifices expected of combatants long acted as a break on the development of a system of military medical care.

The Greek sense of civic duty led them to care for their ‘citizen soldiers’ while the Roman concern for military efficiency encouraged a search for ways to preserve manpower. But although the wounded were not simply abandoned, their care was often entrusted to civilians and was not considered a military activity. Greek physicians were entrusted with this duty and Romans let friendly or vanquished cities care for their wounded. During a campaign in Spain against the Celtiberians in the second century BC, the Roman wounded were cared for in the city of Aebura which had been taken the day before142. On the battlefield, the veterans’ camaraderie and experience served in the absence of a constituted medical service. As long as these arrangements worked, commanders did not feel the need for a more comprehensive organization. A few physicians were however integrated within Roman legions when they operated in isolation and valetudinaria143 were constructed but this did not lead to the organization of a permanent medical care system.

During the Middle Ages, no formally constituted military organization cared for the wounded, that duty was left to religious orders. Knights, for whom bravery and courage were paramount, understood the importance of charity but refused to concern themselves with what they considered an exaggerated concern with health issues. The contradiction between the warrior’s courage and the weakness of the human body acted (and occasionally continues to) act as a break on the development of a structured military medical service. There is a real split between the desire to spare the lives of their soldiers as much as possible and the need to sacrifice combatants. It was far easier to ignore the issue and subcontract the issue out to civilian or religious personnel.

This situation might have continued unchanged had war leaders applied it to themselves. But the Renaissance constituted a real turning point in Europe, when great military leaders brought with them physicians for their personal service. Physicians like Ambroise Paré extended the concept by offering to care for all combatants with devotion and modesty. He

142 143

Livy, History of Rome, Book XL, chapters XXXII and XXXIII. Roman military hospitals.

enjoyed a very good reputation with soldiers. During the sixteenth century, the role of military surgeons steadily grew. But their reputation varied and suffered by association with the general reputation of medicine of the time, whose therapeutic efficiency was very modest. The French word ‘carabin’ used to describe doctors, originally meant a “a light cavalryman who helped his adversaries move quickly from life to death like the “scarabin” who buried the victims of the plague and whose name came from the scarab who overturns soil144”.

During the following century, as Louvois reorganized French forces and Vauban included military hospitals in the fortresses he designed to guard the kingdom’s borders, the need for military practitioners became more pressing.

They were not however considered

officers, did not wear uniforms and could only serve during a single campaign. When Louis XIV created the Navy’s medical service and its army equivalent twenty years later, it finally gave medical personnel a permanent status, but did not significantly improve how they were viewed by the military. Although it was becoming increasingly obvious that the medical domain warranted consideration and a role in military structures, it remained constrained by its cultural environment and the poor understanding military leaders had of its role in military affairs. Percy for instance presented his ‘battle surgery’ project to remedy the carnage of imperial campaigns, but his suggestions were ignored. Napoleon had other concerns, in particular finding additional troops for his bloody battles.

The same issues plagued the American army. Created in 1818, the Medical Department was slow to acquire military prerogatives. Medical officers had no rank within the army and enjoyed a very different status. The British Medical Staff Corps was only created in 1855 since “it was thought that it was more expensive to care for a wounded soldier than to enlist a replacement145”.

Marlborough did occasionally use field hospitals and

Wellington during the Peninsula campaign asked Sir James McGrigor to organize an improved medical system.

Military medical services, while still not totally assimilated within the military domain, were however subject to close monitoring. Thought incapable of understanding military implications, physicians working for the armed forces were kept under supervision. In France, the medical service was placed under the authority of the Supply Corps until 1889 144

P. Cristau, Le visage social du médecin militaire, (Social Role of the Military Physician) Médecine et armées, 2008, 36,5, quoted p 536. 145 General Voruz, Military Attaché in the French Embassy to London, sent a short report on the British medical service to the 2ème bureau de l’état-major de l’Armée, 14 September 1932. Provisional classification 9NN704, DAT, SHD.

and it was only after the First World War that it was able to define how medical support should be provided. British doctors became officers in 1891 while their French colleagues still had to plead after the war: “it is a great insult to the Medical Corps, after the many losses it suffered during the War, to continue the differentiation between them and other officers146”. At the same time in the United Sates, military doctors were awarded “all the rights and privileges of an officer and command authority over his own service147”, while in Poland, Russia and Austria they remained “military employees with a separate status”.

During the First World War, frustration was occasioned by this lack of autonomy, concerning the design and organization of medical services. Louis Maufrais, a doctor serving in the trenches remarked, not atypically: “the role of the doctor is not always considered and where to place medical stations is often left to chance148 » and “when the war broke out, the officers’ practice was to appoint as stretcher bearers, men unable to fight; but they quickly realized that the opposite was required”. The medical domain continued to be largely ignored during the Great War, although there were clear instances of medical advances and many practitioners lost their lives alongside their combatant comrades. Major Chênelot149 noted “the colonel does not appreciate the medical service, I know. [...] the Verdun campaign is now over and please note that not a single mention in dispatches has been made for a member of the medical service”. It might have been seen as an admission of weakness for military leaders to acknowledge openly the importance of the medical domain. While they might recognize its usefulness, they avoided discussing it for fear of weakening the fighting spirit of their troops. On the Somme in 1916, General Debeney had nothing compassionate to say about those who had died on the frontline and exhorted his troops to return to combat and reach the objective which the September 25th assault had failed to reach. Louis Maufrais remarked “it would be fair to say our leaders trained in the War College do not exactly display an excess of psychology. This short speech astounded us...”

Following this dark episode, commanders were able to learn from past mistakes and gave medical services the tools they needed to work, by providing them with technical

146

Draft law on the organization of the military medical service, “Background”, 1922. Provisional classification 9NN631, DAT, SHD. 147 Mission report by doctors Visbecq and Duguet, 1923. Provisional classification 9NN704, DAT, SHD. 148 In Verdun in 1916, Louis Maufrais was assigned to a medical station situated next to the ‘Ravine of Death’ and arriving on the spot found it empty. He later requested that another very exposed station be moved. The request was categorically denied. Fortunately, he took it upon himself to keep casualties further away, since the original site was targeted and destroyed. 149 Military doctor in WWI.

autonomy. It took the twentieth century for the command/medical relationship to fully mature, and although it has become stronger, the relationship is not without its scars.

B. The Constraints of the Medical Domain Napoleon, who understood the importance of military hygiene and caring for the wounded, complained about the cumbersome organization of the medical service and its disappointing results. He believed that a poorly organized medical support was more dangerous than the Cossacks, writing in 1806: “they have ruined my surgery with constant changes and useless projects”. He subsequently chose in some cases not to integrate doctors in his divisions to avoid overburdening them unnecessarily. The Grande Armée’s Medical Corps made many proposals, but they were often neglected and considered overly complicated. At Friedland, the medical caissons were halted twelve kilometres from the battlefield and left with no means of advancing other than porter age. During the Russian Campaign, medical supplies assembled at the start point were sufficient for the stated strategy, but there were no vehicles to carry them. Marshal Soult, irritated by the many suggestions Larrey made directly to the Emperor, grew to dislike him intensely, a clear illustration of the opposition between the warrior and medical instincts in practice.

When the commander had to take account of the requirements for medical support, he considered them an obstacle to the success of his operations. “In this sense, medical defence is to be considered a constraint, more exactly a constraint on execution and the problems it raises belong alongside legal and financial constraints for national defence150”.

Commanders had to face not only military, but material difficulties, such as ensuring that medical supplies followed troops in extreme conditions or applying prevention procedures to exhausted troops. Only when the immediate military threat has dissipated does it become easier to reduce the level of dispersion of forces and bring together the materiel required for medical support. During the First World War and in particular in 1915 with the use of chemicals, military circumstances were so dire that normal medical support was relegated to a secondary role: “My dear fellow, we have nothing. It is not restricted to the medical service, but extends to all forms of materiel. I will do what I can151”. 150

Colonel Costedoat, ‘Direction du service de santé au ministère de la Défense Nationale’ (Medical Service Directorate of the Defence Ministry), CHEDN, La défense sanitaire, 1917. Provisional classification 9NN656, DAT, SHD. 151 The Surgeon General writing to Louis Maufrais. Louis Maufrais, presented by Martine Veillet, ‘J’étais médecin dans les tranchée’ (I was a Doctor in the Trenches), Robert Laffont, 2008, quoted p 102.

The same situation occurred in Vietnam, when commanders considered the medical domain a burden on the operational efficiency of their troops. The South Vietnamese Army refused to allocate aircraft to a purely medical mission and it took two years of negotiations, from 1969 to 1971, for the instauration of a training programme for medical evacuations techniques.

The Americans were similarly uninterested in the notion of

reserving air assets for medical air transport. Military authorities suggested that aircraft not be reserved only for medical evacuations and the use of removable red crosses so that any unused medical helicopter could be given other tasks. Major Kelly, who commanded the 57th Medical Detachment (Helicopter Ambulance) refused and further increased his operational activities. Nowadays, the Americans have dedicated medical evacuation assets, unlike Europe.

During the Yum Kippur War, the medical service had access to a large part of the relatively limited supply of Tsahal152 helicopters, which allowed it to save many lives by treating the seriously wounded who would otherwise not have been able to receive prompt treatment. This was due to two factors: on the one hand, these relatively limited tactical use made of these assets and on the other, the determination at all levels of the military hierarchy in general and the medical service in particular, to ensure that as a matter of priority, a large part of this limited potential was made permanently accessible to answer medical needs.

Contemporary medical services offer a high-quality level of technical capability, but its cost, even more than in earlier times, is related to operational preparation constraints (vaccinations, medical checkups, etc), sanitary constraints (food, water, hygiene and security), and significant logistical constraints.

Field medical formations require

significant lift capabilities. These are partly compensated by the modular nature of these structures and technological advances such as miniaturisation, but they require that commanders take them into account during their planning. This is further the case since todayâ&#x20AC;&#x2122;s conflicts often take place far from cities and transport issues are often significant.

Commanders have begun to take systematic account of medical support requirements, which were long ignored because they were held in contempt or misunderstood.

152

Israeli Army.

C. The Need for Mutual Understanding Military leaders appeared for a long time to have little interest in their medical services. In the few instances when they did comment upon them, it was usually to deplore or praise the results of a battle. The reliance of the medical domain on commanders uninterested in medical issues often left them in the shadows. Until the eighteenth century, the ‘camp masters’ or colonels chose and paid regimental doctors, believing therefore that they should show complete obedience in all matters, even technical issues. In France the authority of the Supply Corps established in 1708 at the birth of the French medical service, or of other external bodies in western armies, hindered the development of projects or initiatives. Two arguments were put forward to justify this situation: “Firstly physicians would make poor administrators; secondly administrative duties would take up too much of their time, which would be better spent on visiting the sick and studying153”. Requests were often not relayed to military authorities and this remained the case until the First World War. Prominent medical figures made suggestions to improve the lot of wounded or sick soldiers, but they were often ignored. Despite the many achievements of doctors and surgeons on the battlefield, the number of deaths from wounds or sickness remained high. In June 1917, major Mellies could still remark: “until recently, [the medical service] saw its proposals and requests for assets rejected154”. This led to gaps and inefficiencies due to a lack of manpower or logistic support or assets. This did little to improve relations between the command level and the medical domain. No lessons were drawn from the medical disasters that occurred during the Napoleonic wars. During the Consulate, the number of medical personnel was cut and hospitals were closed for purely economic and political reasons.

An analysis of the situation in 1922 concluded that during the war “the heads of medical services within large units, especially at the army level, were too far removed from command and their proposals, which the later was to translate into orders, often suffered from a lack of understanding by military leaders155”. The Germans had learnt from the experiences of the 1870 War and had reorganized to form a real interface between the command level and the medical service. The systematic distribution of doctors at the various levels of units and staffs allowed a better adaptation of the German medical

153

Official Bulletin of Reserve Physicians, July 1912, p 1102. Provisional classification 9NN634, DAT, SHD. 154 Provisional classification 9NN670, DAT, SHD. 155 ‘Rapport sur les progrès accomplis dans le fonctionnement du service de santé pendant la guerre’ (Report on the Advances of the Medical Service during the War), 1922. Provisional classification 9NN670, DAT, SHD.

support at the start of the war, although it collapsed, as did the rest of the army after 1917. In France, following the operations of April 1917 and in order to remedy “the defects caused by the insufficient participation of personnel from the Medical Corps in military preparations, the Government was led to decree on 11 May 1917 that medical personnel should serve in headquarters staffs156”.

From this point on, doctors were associated with the planning of operations. In France, the creation of a Medical Service Directorate within the Army Staff constituted a major step, as was the presence of doctors in offices tasked with the preparation and execution of operations. Medical imperatives would now be taken into account during planning to determine requirements. Mutual knowledge could be developed to allow decision-makers to integrate ‘medical’ data in doctrine and inversely, allow the medical services to adapt to military requirements. A 1922 report157 pointed to this evolution: “a more efficient medical action appeared from May 1917 in the various orders affecting the medical service because from this point on, doctors were appointed to the CQG (Supreme Headquarters) to provide all required information and prepare estimates in relation with the activities of the service, and were themselves tasked with preparing all the orders related to the running of the medical service sent by overall commander to the general commanding armies”.

Despite the real ‘revolution’ that the First World War brought to medical services, its long history of administrative subordination long remained a significant factor “inhibiting any spirit of initiative, for both leaders and personnel apart from a few exceptions, beyond the purely technical role of military doctors158”. It was however the introduction of doctors in the Ecole de guerre (war college) in France and its equivalent in other western nations, which led to a shared effort of study and the

recognition as comrades in arms of

commanders and members of the military medical services. In 1934, general Lanne wrote: “increasingly, this close union between command and military medical service has grown during the last war to lead to a constant collaboration and I feel certain that the efficient running of the medical service requires it159”. Relations between commanders and military

156

Draft law on the organization of the military medical service, “Background”, 1922. Provisional classification 9NN631, DAT, SHD. 157 ‘Rapport sur les progrès accomplis dans le fonctionnement du service de santé pendant la guerre’ (Report on the Advances of the Medical Service during the War), 1922. Provisional classification 9NN670, DAT, SHD. 158 Le service de santé en temps de guerre (The Medical Service in Wartime), France militaire 24.4.25. Provisional classification 9NN671, DAT, SHD. 159 Général Lanne, Bases et principes de tactique sanitaire (Basis and Principles of Medical Tactics), 9 November 1934. Provisional classification 9NN704, DAT, SHD.

medical services continued to improve. The defeat of 1940 did not fundamentally alter this trend; the organisational problems of the medical service at the time were reflected throughout the army and a clear indication of the command’s overall inability to adapt to movement warfare. On the other hand, the wars of decolonisation proved a fertile ground for the medical domain and colonial medical services were able to demonstrate their efficiency and usefulness for the force and local populations.

Today, the relationship is

generally harmonious, although command may occasionally have to make strategic or tactical choices which do not favour the medical domain.

D. Strategic Choices Speaking to the British people who stood alone against Hitler’s Germany, Churchill promised “blood and tears”. Any political or military leader understands that he will have to accept human and material losses on the road to victory. The art of command is to determine at what point these losses cease to be acceptable and avoid unnecessary losses. Caesar strove to “avoid human losses and constantly manoeuvred, but within relatively small areas, in order to force his opponent to a place where he could fight with all the advantages160”. The great Turenne always sought strategic combinations which would allow him to not waste highly experienced soldiers, since this would be expensive, figuratively and literally. He combined surprise and mobility to attain victory, but also ensure the safety of his manoeuvre. Louis XV surveying the battlefield on 11 May 1745 remarked to his son: “see how expensive our victories are. The blood of our enemies is that of men. True glory resides in sparing it161”.

There was often a real desire on the part of military authorities to avoid shedding blood pointlessly. Their motivations were varied, born either of a preoccupation with scarce resources or humanitarian concerns, but in any case human losses are a real strategic interest. On the other hand, the military leader is faced with strategic choices which require a “balance between the mission which requires action and situation which requires the assessment of risks162”. Human losses are considered as a risk which is occasionally required while setting acceptable limits. The concept of “zero killed” which became popular in the United States in the 1990s is certainly not realist and can become dangerous when it paralysing strategic decision-making by taking options of the table. The medical domain, while understanding that losses are unavoidable, must diminish them as much as 160

B.H.Lindell Hart, Stratégie, Perrin. P.Burnat, J-F.Chaulet, F.Chambonnet, F.Ceppa, C.Renard, De l’apothicaire au pharmacien des armées (From Apothecary to Military Pharmacist) , médecine et armées, 2008, 36, 5. 162 Hervé Coutau-Bégarie, Conférences de stratégie, Institut de stratégie comparée, 2009. 161

possible to allow commanders to remain within the limitations they have set, while executing their chosen manoeuvre.

The strategist’s art consists in the combination of the actions of different strategic players, who may at times be in opposition. The medical domain may at times fundamentally conflict with manoeuvre that causes logistical difficulties, the violation of rules of prevention, or increased risks for combatants. Military commanders must then make difficult decisions including deliberately making human considerations secondary. During the Great War, “the absolute necessity for resistance and victory in 1914 led commanders, lacking sufficient quantities of munitions, to experience very high casualty rates. Whereas better tactics and a change in attitudes, including abandoning the attitude of ‘come what may’ or ‘holding positions whatever the cost’ might have reduced the casualty rates163”, as far as Marshal Joffre was concerned, they had to be ignored due to the need to win a war of movement164”. During this period, “at no time, apart from a few exceptions like General Pétain, did the idea of giving land up to spare men emerge165”.

In these conditions, where medical needs and strategic decisions were difficult to reconcile, such as for instance force concentration and hygiene and security, medical advisers had a vital role to play for the sake of balance. Dialogue between command and the medical domain is then necessary to carry out their mission: maintaining the condition of “a vast organism [troops], already afflicted by the weight of war and more than any other community the morbid influences of its environment166”. From October 1915 to September 1916, the Army of the Orient was under intense pressure, as it was required to carry out operations with men weakened by dysentery, malaria and even typhus. General Ruotte warned his commanders that a balance had to be found between the two requirements. He wrote that “morbidity remains high […] due to the exhausting pressures of military operations on men who have spent the summer in Macedonia167”.

It is the medical service’s duty to alert command, which while entirely master of its choices, needs the tools required to understand the situation. Errors of judgement are always possible and can sometimes make the difference between victory and defeat. In 163

August / September 1914 : 329 000 dead. Guy Pédroncini, Pétain : le soldat 1914-1940, Perrin, quoted p 123. 165 Guy Pédroncini, Pétain : le soldat 1914-1940, Perrin, quoted p 124. 166 Colonel Costedoat, ‘Direction du service de santé au ministère de la Défense Nationale’ (Medical Service Directorate of the Defence Ministry), CHEDN, La défense sanitaire, 1917. Provisional classification 9NN656, DAT, SHD. 167 Monthly report for September 1916 from ‘médecin inspecteur’ Ruotte, Senior Chief for the Allied Armies in the Orient. Provisional classification 9NN671, DAT, SHD. 164

1915, “losses were so high following bloody assaults that they had a significant impact of the health of troops and the appearance of instances of exhaustion, which were misunderstood and attributed to disobedience168”. It took almost two years for understanding to dawn on command, but starting in 1917 it, and general Pétain in particular, made troop morale one of their priorities.

Command has an ambiguous relationship with the medical domain which is seen as a real strategic player but occasionally an obstacle to manoeuvre. Throughout history, reactions were first to ignore or disregard, which was made easier by the poor technical performances of the medical domain. The First World War was a revolution for the medical domain which was able to demonstrate its efficiency (especially with the use of gas) and opened the doors of staff headquarters to military doctors. Mutual recognition advanced considerably during the twentieth century and command grew to trust the technical efficiency of the medical domain, as it had not before. Some limitations remain however: technical, organisational or ethical.

III. The Medical Domain’s Own Limitations The medical domain’s strategic potential has not been fully exploited in history, because of the cultural environment, command decisions, but also its own limitations. Some of these which affected the care of the wounded and the sick have been virtually eliminated in the wake of the extraordinary medical advances of the twentieth century. Others such as organizational issues have greatly improved, but may reappear with each new conflict, since these rarely resemble their predecessors. While military thinking must integrate the medical domain, military medical services must also understand their technical profession in the specific context of defence and the typology of modern conflict. Certain limitations, in particular ethical, have not changed since Hippocrates, but their application has varied along with cultural stances.

A. Technical Failings

Medical sciences have significantly advanced over the last two centuries and profoundly altered the relationship between military medicine and armed forces. Its efficiency is now 168

Guy Pédroncini, Pétain : le soldat 1914-1940, Perrin, quoted p 124.

undeniable, offering forces a much improved chance of survival. Although history does reveal certain instances of medical efficiency, in particular in relation to combat casualties in earlier times, it is nevertheless clear that prevention, diagnosis and treatment of illnesses was rather limited before the advent of Pasteur.

In the Iliad, the author or authors (the issue is still debated) described in some detail the work of doctors in treating wounds using the techniques of their day. The level of anatomic precision used to describe wounds, impressed later surgeons such as Malgaigne169. We find no supernatural wounds, nor miraculous recoveries, but instead a careful inventory written, it seems, for knowledgeable readers. It was however quite different for illnesses, considered collective plagues imposed on man as punishments which he could not escape. Mesopotamians showed some knowledge of the properties of medicinal plants which were used, but usually as part of magical recipes. Divination, of Egyptian or Babylonian inspiration, was dominant. It was different for wounds since it was believed “that what the hand of man causes can be repaired by man”. While Idomeneus remarked in the Illiad that “a medical man is equivalent to many others, both to cut out arrows and to apply mild remedies”, surgery was limited by the availability of technical knowhow and the prevalence of sepsis.

A more rational understanding of medicine emerged with Greek physicians, in particular Hippocrates, between the fourth and fifth centuries BC. Many surviving texts illustrate the wide breadth of medical practice, including the treatment of fractures, dislocations, diet, climatotherapy, hydrotherapy and what we would today call occupational health. Rome showed its appreciation for Greek physicians by freeing them, as did Caesar when he granted them full citizenship. Medical teaching was further encouraged through Augustus’ “schola medicorum”.

The Middle Ages saw medicine take a step back since Catholicism considered both illnesses and combat casualties the results of divine will. The activities of doctors, and their reputation, were much reduced during the High Middle Ages. Clovis when ill was told by his physician that there was little he could do and that it would be preferable to seek the healing powers of Saint Maurice. The organization of healthcare and medical knowledge regressed during this period and wounded combatants suffered as a result. During the same period, Arabs scientists expanded their knowledge of biological sciences during the

169

Malgaigne (1806-1865) surgeon and anatomist.

eleventh and twelfth centuries, but this had little impact on the West and did not continue beyond the fourteenth century. However it was during this period that the first hospitals, initially out of a spirit of charity, and the first European medical universities were established in Salerno, Montpellier and Paris. Religious motivations, which often acted as a break on scientific progress by banning surgical therapies or dissection, did occasionally give way to baser motivations. The Vienna Council in 1311 felt it necessary to insist that hospitals should not become profit-making entities. The Hundred Years War and its lot of epidemics exerted a toll on hospitals. The Black Plague in 1348 overcame their meagre capabilities and it was one of humanity’s worst afflictions, with France for instance reduced from 17 to 9 million inhabitants.

The Renaissance, by prompting intellectual curiosity, encouraged the questioning of the Church’s temporal authority, scientific discoveries and the secularization of hospital administrations. Medicine throughout Europe underwent a series of advances: anatomy in the sixteenth century attained new heights of precision acquired through the dissection of cadavers, the microscope was developed during the seventeenth century, red blood cells were discovered in 1660 and physiology and anatomopathology appeared during the same period. The clinical study of illnesses and their therapies followed but it took the nineteenth century for these discoveries to produce significant results.

Within armed forces, medicine followed the general trend and remained unimpressive for much of this period, which did little to encourage the interest of commanders. Surgeons, confronted daily with the harsh realities of battle encouraged progress. Hans von Gersdorf, in the service of Duke Sigismond of Austria, wrote his « Feldbuch der Wund Arztney » published in 1517 in which he questioned contemporary practices, in particular for firearms injuries. Ambroise Paré, a few years later was the real founder of combat surgery. His expertise in amputations became part of the basic knowledge required of surgeons. Pichault de la Martinière, who developed debridement procedures and Dominique Larrey refined these theories and developed frontline surgery. But the conditions for casualties remained harsh and the use of anaesthesia, ether initially and chloroform later, only began in 1846. But these products did not produce an improvement in the survival rate since the role germs played in infection was not understood until 1860. Illnesses remained a serious problem until the beginning of the twentieth century170.

170

The first step was variolisation, an efficient method of protection against smallpox discovered by Edward Jenner in the eighteenth century. Chemistry made more efficient therapies possible (compared to those

Military doctors long relied on learning their profession on the job, without appropriate teaching structures. Their lack of prestige may have obscured this requirement. Some considered “that military medicine was to civilian medicine what military music was to classical music”. Only in the eighteenth century did medical studies become mandatory171 for military doctors in “hospital amphitheatres172”, although civilian universities had existed since the Middle Ages. The Port Schools of Surgery were created during this period in Rocherfort, Toulon and Brest. The French Revolution swept away civilian faculties which led to a serious shortage of medical recruits for the army. A period of indecision and difficulties followed, which ended with the establishment of the Imperial School of the Medical Service on 12 June 1856 in Strasbourg which closed in 1870 after the Germans captured the town. The schools of Lyon and Bordeaux followed rapidly in 1888 and 1889 and gradually took over the activities of the former port schools. Military medical services also developed a research goal “to learn more to heal better”, so that they might respond to the specific needs of the battlefield or the warship. Lowell, who led the American medical service when it was created in 1818, considered that the health domain should go beyond providing basic care to soldiers, it “being in a unique position to advance medical science173”. Military doctors demonstrated the usefulness of large doses of quinine for malaria or the effects of bromide on infection. Combat surgery also gave civilian surgery a series of advance, offering innovative techniques such as the external fixation used by the French army’s medical service. Some military researchers also made significant contributions to science and were rewarded for them, such as Alphonse Laveran174 and Henri Laborit175.

However, while medicine in general and military medical services in particular progressed considerably, the First World War showed that significant technical deficiencies remained.

offered by plants alone) at the end of the century. Pharmacy was taught in a school created in 1777. Finally, pasteurisation in the nineteenth century revolutionised medicine through the understanding of infection and vaccination. Extraordinary discoveries followed throughout the century, such as antibiotics discovered by Sir Alexander Fleming in 1945. 171 The 1747 edict which was published after the battle of Fontenoy, dealt with the general regulation for military hospitals, followed on 20 December 1748 by regulations dealing with training: “surgeons majors of hospitals and regiments must organize annual courses of surgery and anatomy for surgical aides and assistants”. 172 Royal edict dated 04 August1772 which created the Hospital Amphitheatres used to train medical officers in medicine, surgery and pharmacy to serve in France’s hospital and military services. 173 G.B.Clark, ‘Medicine in American Special Forces in Vietnam from 1969 to 1970’, Médecine et armées, 1982, 10, 3. 174 Nobel Prize in Medicine for his discovery of the malaria agent. 175 Lasker Prize for the first demonstration of a neuroleptic.

Blood transfusions had been achieved using the machine designed by Jeanbrau176, but it was difficult to use and knowledge of blood groups was still rudimentary especially regarding rhesus groups. As military medicine had to face one of its hardest challenges, the problems concerned not only medical techniques, but also organization. To quote Louis Maufrais once again: “We had nothing to use to clean [wounds]. We had barely enough water to wash our muddy hands. We use tincture of iodine on wounds to set the blood. Casualties were in shock, but in 1915 on the frontline, we had nothing to help them177”.

The lacklustre results of medicine in general and military medicine in particular long served to justify the command’s lack of interest or confidence. This naturally led to the subordination of the medical domain which was furthermore considered incapable of handling its own affairs. Although they were afforded their autonomy in the years following the Great War, medical services found it hard not to favour technical progress at the expense of organizational aspects for the support of forces. In 1927, the French military medical service experienced a serious crisis in this regard. Young military doctors were only interested in “specialisation of any branch of medicine, as long as it got them out of serving next to the troops178”. A cult of medical techniques developed during the twentieth century. General Bonnal noted early in the century that “biology has advanced so much over the last fifty years that it has become a reliable guide for statesmen interested in developing their nation. Biology therefore must serve as a basis for high command if we want it to fulfil its mission”. The wars of decolonisation encouraged the medical support of troops but it was the First Gulf War in 1991 which really demonstrated that the ‘need for results’ command expected of the medical domain required a combination of technical and organizational advances. B. Organizational Issues. The organization of medical support can be described as the “the action of organizing, structuring and arranging179” the medical structure of armed forces in order to “save the maximum number of lives while minimizing after-effects180”. History has revealed two main types of organizational issues: the lack of assets provided to medical services and the inadequacy between the design of support and the manoeuvre designed by the commander. 176

Professor Emile Jeanbrau carried out the first blood transfusion on 16 October 1914 on a dying soldier in shock using blood from another wounded soldier. 177 Louis Maufrais, presented by Martine Veillet, ‘J’étais médecin dans les tranchée’, (I was a doctor in the trenches) Robert Laffont, 2008. quoted p 153. 178 ‘La crise de la médecine militaire’ (The Crisis of Military Medicine) France militaire, 02 Feb 1927. Provisional Classification 9NN638, DAT, SHD. 179 Le Petit Larousse 2003 (French Dictionary). 180 IM 12 du 05 Janvier 1999 relative au concept interarmées du soutien sanitaire des forces en opération.

The Lack of Assets Before the creation of medical services in the eighteenth century, the lack of permanent structures to care for the sick and wounded meant that support had to be organized from scratch with every battle. Even in ancient Rome with its constant lot of frontier wars, there was no real doctrine of medical support and its corresponding capabilities. The attribution of assets to the medical domain was therefore rather uncertain. It depended on the goodwill of the military leader or king to which doctors were attached.

The actual organization of medical support improved the situation somewhat but placing it under the control of logisticians did little to alleviate its capability shortfalls. The French 1747 Ordinance specified that “medical officers are employees of an administrative service, who in peacetime and in wartime, preside over the establishment of hospitals, monitor their running and provide medical supplies and the evacuation of the sick and the wounded”. Furthermore in 1781 Louis XVI when confronted with serious economic difficulties reduced permanent military hospitals and medical manpower. The 1792 Campaign against Austria and Prussia revealed the lack of ‘medical’ assets in the French Army. Ambulatory hospitals intended to follow troops into foreign territory suffered from a chronic lack of organization. Percy and Larrey fought to get closer to the frontline and for larger structures in the rear. Their proposals were mired in the incompetence and occasional dishonesty of others.

Medical care for the campaign casualties until the end of the First Empire was often improvised. The lack of manpower and assets was a frequent issue and Napoleon’s gratitude following the battle of Eylau, when he presented one of his swords to Larrey to thank him for the efforts of his ambulances, did little to indicate a real shift in the level of interest in the medical domain. Where military operations grew in size, administrations occasionally failed to plan for adequate medical supplies or the additional vehicles required to carry them, or even make proper use of available resources. During the American Civil War, the American medical service came to understand the need for changes in direction, organization and operations. It took longer in France. Larrey in his memoirs described how some wounded soldiers had to be left behind because of a lack of suitable transportation vehicles which the supply corps had failed to provide. During the retreat from Russia, surgeons only had their personal instrument case to care for the wounded and by the time they arrived in Mainz 78

had run out of supplies, bandages and medicine. During the Italian campaign Delorme181 wrote “the dreadful lessons learnt from the war in Italy should not be forgotten. This campaign has shown clearly the pernicious influence of a deficient medical organization on combat surgery”. Unfortunately, those lessons were quickly forgotten and the War of 1870 began in a similar state of disorder. When the war ended, the Ministry of War required the organization of a committee which concluded182 : “the current organization of the military medical service is inadequate to the needs and interests of the army. This service must be placed under the authority of an independent leader, from the medical profession and whose authority extends to all matters related to the medical service183 ».

It was the “Societies for the Aid of Wounded Military” created a few years earlier under the influence of Henri Dunant and gathered under the banner with a “red cross against a white background”, which provided a real help to the medical services which had proved unable to fulfil their mission. During the First World War, the medical personnel of the International Committee of the Red Cross, especially its nurses, provided an invaluable reinforcement to the chronically undermanned medical services. Major Robert Picqué184 described how “where the quality of personnel rapidly adapted through training and dedication to its mission, their number long remained insufficient185”. Collaboration with the Red Cross therefore became necessary and the relationship was formalised between the two wars.

The First World War was for most European medical services a real turning point because it formally ended the subordination of the medical domain to the commissariat. In France, the Undersecretary for the Medical Service, Justin Godart186, appointed in 1915, pulled the service out of the “rut where the staff headquarters had left it”. But the period between the two wars was not put to good use and failed to improve the organization of medical campaign units and their supply. The 1939-1940 campaign demonstrated the lack of preparation of the medical service, as it did for the French army as a whole. They lacked radio communication equipment for medical vehicles which were therefore very hard 181

Military doctor of the Napoleonic Empire. Discussions held from 3 June to 5 August 1873. 183 Doctor Brice and Captain Bottet. Corps de santé militaire en France, son évolution – ses campagnes (French Military Medical Corps – its evolution and campaigns (1708-1882), Berger-Levrault & Cie, Editeurs, 1907, quoted p 417. 184 Robert Picqué, military doctor, who organized a network of medical air evacuations centred on the Bordeaux hospital. His accidental death while transporting a patient in 1927, ended his attempt to extend it to the national level. 185 Report of Major Robert Picqué, appointed from 2 August 1914 to 20 January 1919 to A.3/18 as Head Doctor and Surgeon of the 18th Army Corps. Provisional classification 9NN671, DAT, SHD. 186 Justin Godart trained as a lawyer, pleaded for a better medical service for 15 years, submitting several draft laws to implement the 1917 Decree. 182

pressed to get to their destination after aerial bombings. When French forces resumed combat, their medical services were structured and equipped by the United States. Starting in 1943, assets were supplied by the large-scale logistical capabilities of the American army, which had learnt in 1933 the importance of support.

During the Vietnam War, the Americans were also confronted with organizational issues when the number of casualties proved higher than initial estimates. Coordinating medical evacuations became an issue, which required the creation of a control centre to optimize the use of an insufficient number of assets.

The modern world, having understood the importance of efficient medical support gradually acquired the necessary assets, leading to the concept of ‘best efforts’ now incorporated in legal regulations. During the Yum Kippur War, Israeli forces reserved many transport assets and financial resources in order to produce a support structure that was beyond reproach. “Tsahal” concentrated on the availability of forward doctors and the speed of evacuations to hospitals. The strategic intention was to minimize losses by providing troops with the most efficient medical support possible and reverse some initial tactical losses.

The First Gulf War was a test for Western medical services, especially with the potential threat of chemical and/or biological agents. While the actual number of casualties remained low, the medical deployment was impressive, even if it became apparent that certain campaign medical structures might require modernizing.

Thus, even when

provided with sufficient assets, the design of the medical manoeuvre must be adapted to the real requirements of armies on the ground.

Adapting the Medical Concept Although it now enjoyed functional autonomy, a necessary condition of the efficiency of medical support, “on the ground, the medical manoeuvre results from a constant adaptation of resources and processes187”. This adaptation is required not only at the strategic level, by taking account of the conflict type and command objectives, but also at the tactical level through a reactive implementation of support based on the decisions of military authorities. One might extend this directly to the military world by speaking of medical strategy for issues related to concepts and doctrine and medical tactics for 187

G.Gillyboeuf, Le soutien santé en opération : règles d’or, (Medical Support to Operations : Golden Rules) Médecine et armées, 1 ,6, 1973, quoted p 14.

implementation on the ground, when it becomes a component of the wider tactical manoeuvre.

This means that an efficient concept must be developed in close collaboration with command and adapted to its needs. Several elements are essential for planning the medical manoeuvre: manpower, the dispersal of units, the level of combat mobility, level of insecurity in the operational area, type of arms (massive destruction or not), battle evolution, climate, etc. It is therefore “essential to look at techniques in the [strategic] and tactical framework in which they are expected to function. It is essential that commanders provide that framework188”.

Throughout history, war has changed many times and while there may be universal principles, strategy is constantly adapting. Furthermore, context is also changing requiring that tactics in that instance adapt to the climate, geography or human environment. It would be naive to think that the medical domain is not influenced by these changes; its leaders must therefore remain aware of these changes and understand the situation. They cannot allow themselves to be surprised by new situations or they risk limiting the efficiency of their support.

The Egyptian and Syrian expedition which began in 1798 was a new experience for the medical service, since for the first time the French Army found itself engaged in a country with a more difficult climate and whose infrastructures were inferior to the standards of the day. Larrey, to ensure decent conditions for evacuation (in a hostile country were decent hospitals were far and few between) chose to adapt his ‘flying ambulance’ to local circumstances. He replaced his carts with camels carrying litters, but the army administration quickly confiscated the animals for its own use. The medical service continued throughout the nineteenth century to adapt itself, without assets, to the requirements of these expeditions.

Colonial medical services were officially established

in France and given specific assets by a 1903 decree189.

In 1914, the war in the trenches took medical services by surprise, neither side being prepared for this kind of warfare. At the outbreak, German military doctors whose voices were heard at the staff level did better than their French colleagues. In France, the rigid 1910 regulations governing the use of medical support were an immediate obstacle to 188

General Lanne, 24 April 1930. Provisional classification 9NN704, DAT, SHD. Decree dated 4 November 1903 related to the organization of Colonial Medical Services, BO p 1627. Provisional classification 9NN637, DAT, SHD. 189

adapting the service to the new war. Following the retreat from Charleroi in 1914, the leaders of the medical service did not display the required level of determination or initiative. This lasted until 1917 when the prevailing thinking within the service found it hard to implement the conclusions of the commissions which worked on the 11 May Decree related to the place of ‘medical advisors’ and the parliamentary debate in July 1917 on the medical support’s failings during Nivelle’s spring offensive.

Between the wars, certain medical officers were sent to staff colleges so that they would be better able to understand military issues. However, more conservative leaders found it hard to integrate their proposals and did not take to heart the failures of the regulations governing the operational use of the medical domain. Medical units of battle corps were not motorized and therefore were unable to adapt to a war of movement or provide rapid evacuations to the rear. In 1939, the medical support was based on a 1921 tactical manual for large units which had not been reviewed to take account of the new 1936 instruction which included the creation of light mechanical divisions and armoured divisions. This lack of interest meant no armoured medical vehicles were provided for the tank regiments of these divisions.

The war in Indochina was very different from the war which had just ended in Europe. French troops were confronted with a guerrilla force operating in a very different climate and environment. A new medical concept was required to integrate operational readiness, hygiene and a prophylaxis adapted to the tropics, forward medical support and jungle medical evacuations, while also working on developing public health in friendly nations (Vietnam, Laos, Cambodia), providing medical support to local populations and during the last phase of the conflict deal with the large-scale liberation of Viet-Minh prisoners.

This

huge task was accomplished by a medical service led by dynamic leaders who had emancipated themselves of former constraints. The American medical service encountered similar difficulties in Vietnam, in particular in creating a traditional medical evacuation chain due to the geographical characteristics of the terrain, the poor roads and the type of warfare adopted by Viet-Cong units.

The war in Algeria was also a guerrilla war, but in a very different political and geographical context. Troops fought in steep, inaccessible and isolated mountains, far from established medical installations. The task was particularly complicated for medical evacuations. Furthermore the medical service attempted to adapt its structure to the cover

required for pacification and doctors were involved in so-called ‘nomadization’ operations designed to convince the local population of the advantages of a French presence.

The medical service was able to adapt to the different types of conflict but these recurring changes made it harder to produce a precise definition of the medical support of forces. Regulations, organization and structures for campaign units were therefore redesigned for each theatre. While this process of constant adjustment was seen as a definite improvement, it left unanswered the issue of reactivity. It was during the 1990s that durable principles for medical support (medical care / reanimation / forward surgical care and early evacuations) while modular structures were created capable of adjusting to terrain and manoeuvre. New efforts of adaptation were demanded of the medical service, with the gradual feminization of the armed forces and in 1996 the professionalization of the French armed forces, which led to new requirements such as the availability of specific psychiatric care.

The rule expressed in 1934 should continue to guide the thoughts of the leaders of the medical services: “in order to carry out is mission in future wars, [the medical service] should avoid setting rigid guidelines. While basing its wartime organization on inherited and unchanging factors, it must never cease modelling its structures on the type of conflict 190

[and social contexts]”.

One of these unchanging factors must remain medical ethics, which the medical domain can never ignore and should systematically take into account when designing the support it can offer. This aspect can however create a limitation which is hard to reconcile with mission conditions or command requirements.

C. Medical Ethics The Greek physician Hippocrates had understood, three centuries before Jesus Christ, that ethics were essential to the practice of medicine and human wellbeing. Ethics was therefore far more advanced than the other aspects of medical care.

Clausewitz defined war as “an act of violence whose object is to compel by physical force the other to submit to our will191”. In these conditions, he held little regard for Grotius’192 190

Bases et principes de tactique sanitaire, (Basis and principles of Medical Tactics) 09 November 1934. Provisional classification 9NN704, DAT, SHD. 191 Clausewitz, On War.

natural rights which he considered insignificant restrictions hardly worthy of mention since they had little impact on force. But the Holocaust led to a collective recognition that the escalation of violence could not be limitless, even in war. The Universal Declaration of Human Rights and the Geneva Conventions, the expression of international and military regard for ethics were signed in 1948 and 1949. All states must continue to strive to ensure that these declarations are not merely statements of intention but are actually implemented. Clausewitz was right though in noting that the desire to destroy the enemy can lead to extremes where reason has little influence over murderous rage. He explained how “if the wars of civilized people are less cruel and destructive than those of savages, the difference arises from the social condition both of States in themselves and in their relation to one another. Out of this social condition and its relations war arises, and by it war is subjected to conditions, is controlled and modified. But these things to not belong to war itself; they are only given conditions; and to introduce into the philosophy of war itself a principle of moderation would be an absurdity193”.

It is legitimate in these conditions to wonder about the degree of compatibility between long standing and proven medical ethics and the status of the military which has so often been opposed to morality and may quickly do so again for ideological reasons for instance. Even where ethics, the set of rules and duties of a profession194 has totally permeated the military-medical world, the contradiction remains to a certain extent.

Doctors are bound by the following principles: the good of mankind, respect for human life, the primary concern for the health of the patient, medical confidentiality, a ban on discrimination, brotherhood between colleagues and the respect of one’s elders. This undertaking is a moral one and was cruelly disregarded during the Second World War in particular with regard to prisoners of war and Jewish doctors. These principles related to the individual welfare of the patient and the respect for one’s profession can occasionally contradict military requirements.

Certainly anytime military specificities, especially

operational ones, take effect they can lead to a lack of coherence between the two sets of requirements. The use of force implies the temporary inversion of all normal societal norms and conventions. Patriotic ideals may also run counter to ethical concerns, and the 192

Grotius defined in 1625 the “rights of people” which are at the root of humanitarian law. Clausewitz, On War. 194 French doctors felt it necessary to codify morality in 1947, creating a Code of Medical Ethics. Later with regard to the importance of regulating philosophy too often subject to cultural interpretation, an International Medical Code of Ethics was established in 1980. 193

physician is not exempt. The sense of belonging to one camp can be very strong and more so since the general rules of military discipline require that “medical personnel remain in solidarity and in support of their combat comrades”. This rule may run counter to the duty of non-discrimination. Furthermore, one of the basic tenets of military medicine is the preservation of manpower, which some may see as a ‘force multiplier’ action. This implies that choice has to be integrated in medical practice. In a situation of mass casualties, especially in a CBRN environment, only individuals who are considered likely to heal are treated. The civilian equivalent, emergency relief medicine, must also confront this ethical dilemma. In this instance military practitioners are not alone; the entire medical community must deal with the issue of how to view the value of life. Despite these contractions, the international and French military medical communities have attempted, as has the general military community, to integrate ethical rules in armed conflicts. The law of armed conflict includes the laws of war or The Hague Convention195, which sets out the rights and duties of belligerents and humanitarian law or Geneva Conventions which deal with the welfare of soldiers who are no longer fighting or non-combatants. The four Geneva Conventions of 1949 dealt with the wounded and the sick among campaigning armies, the wounded, sick and shipwrecked serving in navies and prisoners of war and the protection of civilians in wartime. Military medical personnel are covered by the Geneva Conventions, but are required to care for friendly or enemy soldiers. The law of armed conflict is therefore a compromise military requirements and humanitarian imperatives. Ethical imperatives cannot however be completely circumscribed by deontological rules or international humanitarian law, some issues are often left to the individual conscience of doctors.

Military doctors may see his duty as the aid he provides his commander. This

may occasionally contradict ethical considerations, which he may not necessarily perceive, for instance when highlighting medical or sanitary weakness in the enemy camp. This was one reason why leaders of the French medical service long resisted placing officers belonging to a body protected by the Geneva Conventions, in operational headquarters. But British and American medical officers were quick to serve, following the creation of the respective medical corps, in army staffs and headquarters. Ethics belong to the realm of philosophy and individual interpretations may vary, which explains the complexity of the issue. 195

The initial Hague Convention was signed in 1899, revised several times and corresponds to the right to wage war (jus ad bellum) and rules of engagement in armed conflicts.

While certain nuances may be acceptable, there are nevertheless certain basic tenets which must be respected. Command must understand that there are formal limits which the medical service cannot transgress, such as inflicting unnecessary pain or deliberate killing. This principle does not allow doctors, such as the doctors of Nazi Germany, to torture, experiment on, poison or use any other form of direct attack on human beings. This topic is a sensitive one and may be open to manipulation as was the case when Secretary of State Von Jacow addressed a note on 3 August 1914, to the German embassies in London and Rome accusing a French military doctor of attempting to poison the waters in Metz. A denial was later issued in a telegram which stated: “following an inquiry to the Joint General Staff, this information has been determined to be pure fantasy and baseless and you are requested not to publish or use such information196”. The decision is more complicated when it involves an indirect assault on the enemy, when individual physicians are left with their own conscience. Their experience, understanding and knowledge of their commanders, the situation, their convictions etc will all influence a decision on whether to use their expertise for a military purpose. For instance, providing information to command after providing medical care to local populations may be problematic if it involves betraying medical confidentiality; assessing the medical or sanitary weaknesses of the enemy may increase the likelihood of a biological attack; participation in the development of military chemicals may seem obvious to military authorities who consider it a strategic asset, but it conflicts with the respect for human life; participating in interrogations may appear as a means of ensuring certain limits are respected, but it may also be seen as an endorsement of psychological torture. Doctors are required to answer many questions using their situational intelligence and they are often caught between their mission, serving their country and medical ethics. One thing is clear; command must integrate this limitation and should not expect the medical domain to transgress ancient tenets.

Clausewitz described how “violence arms itself with the

inventions of art and science in order to contend against violence197”, but one should not see medicine’s extraordinary advances as potential weapons or risk an irredeemable corruption of its nature.

196

The medical domain is, as we saw in the first part, a strategic player. There are however a number of limitations which appeared throughout its history, some of which have survived today and should be considered intrinsic. The war on technical incompetence has been won, although further progress remains possible. Organizational issues born of a lack of assets have also diminished since the service is now considered a necessity. For organizational issues related to the needs of forces, progress also remains possible; either by improving the way the medical domain takes account of military thinking in its work, or by encouraging commanders to involve the medical service in its decision-making process. Medical ethics will remain the basis for the actions of the medical domain working for armed forces, and although command may not always be able to clearly identify the limitations it imposes, it must remain conscience of this fundamental issue.

PART THREE : The Part Played by the Medical Domain in Modern Military Thinking

Since the end of the Second World War, a new kind of warfare has appeared. It differs from its predecessors both in form and in objectives “since victory no longer depends only on the outcome of a clash of two armies on a battlefield198 ”. Warfare (although more often than not these are conflicts are no longer officially called wars, they are operations for imposing, restoring or keeping peace, etc) has become vastly more complicated, bringing together actions of various nature. Armies have seen their field of endeavour widened and their leaders are no longer restricted to dealing only with the art of war in the strict sense, but with the wider political, human or psychological aspects of crisis resolution.

‘Non

combat’199 and indirect strategies have grown in importance, since the object is now, to avoid a frontal choc, to deprive the adversary of the assets (energy resources, raw materials, foodstuffs, public opinion, etc) on which he relies. Sun Tzu had already suggested this approach, but for Western forces, it was the nuclear war which led this transformation. Atomic weapons have transformed the Clausewitz ideal of absolute war into the real threat of annihilation200. Strategists now have to seek solutions to this threat, widely seen as unacceptable. This does not mean military action no longer has a role; it has transformed and found a place in a wider, more comprehensive context to remain relevant. The coordination of varied forces is now needed to solve modern conflicts, bringing together military, political, economic, social, scientific and technical capabilities. Clausewitz has foreseen this transformation commenting that: “it seems obvious that a war where national energies clash with all their might will be conducted using different methods from those used in wars of old201”. The objective is first and foremost to exploit situations, which whenever possible have been prepared, to avoid surprises as much as possible and preserve freedom of action while hindering the adversary.

Furthermore, societies have undergone huge changes and efficiency and economy are now expected as a matter of course. The costs are financial, but also and especially human. Human life has acquired such a price, that in the West and increasingly elsewhere (aside from fanatics) the human factor must be taken into account in all cases. Armed forces, just

198

R.Trinquier, La guerre moderne (Modern War), Economica, 2008. Guy Brossolet, La non bataille (The Non Battle), Belin, 1975. 200 Hervé Coutau-Bégarie, Bréviaire stratégique, (Compendium of Strategy) ISC, cité p 33. 201 Clausewitz, On War 199

like societies, can no longer avoid applying the principles of precaution and prevention, creating a new element which must be taken into account.

This is why, the medical domain, having acquired its technical maturity over the centuries, has found a newfound place in military thinking and beyond (in diplomacy and policy). This place is made more important by the cultural constraints imposed on contemporary society, and military society in particular. Medical aspects now occupy an important place in strategic decision-making which requires taking account of four types of factors: the stakes, the assets, the risks and the circumstances. Casualties now have a major impact on the overall manoeuvre, which is why medical support influences the organization of the operation; capability limitations are constantly being pushed back by the results of medical research; health risks are now dealt with as an essential prerequisite and the medical domain is now involved in environmental control, thus influencing circumstances. At the executive level, the medical element as become a ‘proposer’, a decisive contributor. Medical strategy has become an unavoidable component of any command decision and an influential one. In France, the framing of its range and of the five strategic functions202 described in the 2008 White Paper, demonstrates the correlation between the military and medical domains, since a medical role can be ascribed to each function203.

The conduct and preparation of military operations at the highest level of command now automatically include medical aspects. Military medical services intervene at two levels: in the strategy of action and indirect strategy. The first allows the economic use of forces and assets, the preservation of an appropriate level of morale, environment control, better manoeuvre and the security of forces. It is found in all four dimensions of military strategy: time, space, force and environment. Therefore, tactics employed to reach short-term military objectives are also influenced by medical issues.

In addition to involvement in the action phase, the medical domain also seeks solutions to serve an indirect strategy, such as medical support to populations or the reconstruction of the medical infrastructure of failed states. Understanding man is at the heart of medical services. Ardant du Picq had already understood the importance of the human domain: “the study of combat must be based on knowledge of man; the human heart, not weapons, is the starting point for all matters in warfare”. Medical services thus contribute to population

202

The five strategic functions described in the document are: “knowledge and anticipation”, “prevention”, “protection”, “deterrence” and “intervention”. 203 This correlation will be treated in the following section.

control, to the management of international public opinion in times of conflict and finally to reconstruction efforts.

Furthermore it can also, even if this is not part of its normal operational role, respond to exceptional needs such as natural or humanitarian disasters. Involving military medical services in these situations serves political objectives, since beyond the support they provide, they provide an effective demonstration of reactive assets in situations which can occasionally be difficult from a security point of view. â&#x20AC;&#x153;The effective strategist takes account of both military and political dimensions when dealing with a problemâ&#x20AC;?, which is why it is so important to measure the political impact of each military player. Understanding that he has political tools available, allows the military commander to participate in crisis resolution without using forces, improving public perceptions of his actions and in the end providing a justification for the assets he requires. The medical component of armies provides a strong contribution to this important aspect of defence. Equally, providing political powers with military tools they can use to pursue their diplomatic objectives increases the range of available options. Armies are then shown to be reactive, able to provide relevant capabilities and act in difficult security circumstances.

The medical function, whether as a way of highlighting the value of military forces (for an indirect strategy, relations with policy) or as a political tool, belongs to a new dimension: medical diplomacy. The difference between it and medical strategy is related to its ultimate aim. One is intended to serve military strategy to resolve a conflict; the other contributes to political advantages which might favour internal or diplomatic negotiations. There is a middle ground common to both notions and it is likely to grow in unison with that between strategy and diplomacy. It is found at the level of the strategy of influence used by the military realm over the civilian realm and vice versa. The challenge for military medical services when medical strategy is well understood will be to open up to the diplomatic dimension at national and international levels. Internally within a nation, the role of the military medical domain can be reaffirmed as an adjunct tool but also as an expert in specific domains. In France, the national security strategy calls for the pooling of crisis management tools. The justification for a state medical function is to be found at that level. At the international level, only multinational interoperability is considered acceptable and only international involvement is likely to provide the military component of an army with the required capability for a strategy of influence.

I. Action Strategy “In a strategy of action, the operational dimension is predominant204”. Mr Coutau-Bégarie explained in his book on strategy that up to the twentieth century, European armies were organized along a fairly standard format. Material operational superiority was determined by numbers and rarely on performance which was mostly undifferentiated. Technological advances and the generalisation of asymmetric conflicts have reemphasized capability superiority. This is where the medical services of western armies have an advantage. They open, by pushing back human and scientific constraints, windows of operational opportunity and guarantee the availability of efficient assets anytime and anywhere.

Military leaders expect that the medical domain will do all it can to reach strategic objectives. The medical support of forces during operations is thus the first priority of military medical services205. Command requires that they provide medical capabilities which are adapted to their requirements. This requires a real operational contract206 between the French military staff at the strategic level and the medical service (there are equivalents in other countries). This approach to capability research is a reflexion of a real desire to acquire the means required to succeed with the chosen strategy. The medical domain, in this regard, must begin by placing its capability thinking in the context of the four dimensions (space, time, force and environment) of a strategy for action. The responsibility for action belongs to strategists, but also with those who execute, which is why medical experts are found at the strategic level, but also at the operational and tactical levels. This involvement at all levels and all dimensions of action gives the medical domain an operational role, far beyond the traditional logistical role they were limited to previously.

204

Hervé Coutau-Bégarie, Traité de stratégie, (A Treatise on Strategy) 6th edition, Economica, 2008. Decree n°91-685 dated 14 July 1991 which defined the mission of the French Medical Services. 206 PIA 00-300 dated 1 August 2008. 205

A- Space Control of space is achieved when a force can move around freely as well as avoid constraints such as obstacles, distances or terrain. Marshal Foch considered that “any terrain can be crossed if it is not defended by fire, in other words men207”. He was pointing to the importance of the human factor in controlling terrain. In other words, when the human ability to move in a given space is limited, operational capability is equally diminished.

The medical domain contributes to the freedom of manoeuvre, in a given space, as long as it is able to offer support anywhere. Currently, a military leader will only exceptionally risk deploying forces without adequate medical support. Once this principle is accepted, the medical service must be able to overcome its own limitations for the success of an operation. Medical technological advances have allowed a more efficient control of space by forces and research is continuing to enable commanders to enjoy access to the medical chain anywhere and anytime. This guarantee makes it possible for the commander to seek superiority over the enemy at the decisive point.

The control over distances offered by the medical domain allows the commander to work over long distances and enjoy greater freedom of movement. The arrival of very rapid methods of evacuation, such as aircraft, had a revolutionary impact on the medical support of forces. It was the medical use of aircraft over strategic distances and of tactical air assets (aeroplanes and helicopters) which allowed the medical domain to reassure the commander that the maximum number of lives would be saved irrespective of the distances involved in a manoeuvre. The issue of distance is related in the first instance to the distance between the theatre and the country of origin. During WWII, participation in an external operation was an issue. For medical services the object is not only providing support but also organize the flow of patients out of theatre so that they can be evacuated to the place of treatment. During Operation ‘Daguet’ in 1991 during the First Gulf War, it was necessary to deal not only with the distance between the theatre and coalition nations, but also the unusually long distances in theatre. The area of conflict was some 6 000 kilometres from France and the Daguet Division was operating 700 kilometres north of Riyadh, and the nearest base port on the Red Sea, Yambu, was 950 kilometres away. It was therefore necessary to adjust the 207

Ferdinand Foch, Des principes de la guerre (Principles of War), p 30.

evacuation chain to take account of the required preoperative timetables for the survival of wounded soldiers.

Following this conflict, a system was adopted involving the early airborne evacuation of patients in order to lessen the medical infrastructure’s footprint in theatre and thereby free up the force. Airlifts were established for instance in the Balkans where in one year (19931994) the French medical support chain airlifted 251 patients, including a relatively high number of serious injuries and suffered no deaths. Gradually, medical services acquired increasingly efficient assets for evacuation, the Germans and Americans for instance, using dedicated medical aircraft, while other nations used increasingly efficient kits. In 2008, the French medical service acquired an air asset208 enabling the rapid simultaneous evacuation of multiple casualties. This new asset allowed immediate responses to a threat against deployed forces in case of a massive influx of casualties. In theatre, medically equipped tactical aircraft can be used to overcome large distances as well as geographical, structural or security obstacles. In countries where transport infrastructures are either inexistent or destroyed, deserts, mountains or forests must be crossed and air assets are often the only solution. Commanders have come to understand this vital requirement and have included air evacuation missions in the list of missions for these units, be they from the air force or from the light aircraft component of land forces (ALAT in France). From August to December 1993, the first Combat Helicopter Regiment assigned a detachment to the French Brigade participating in the United Nations Mission in Somalia (UNOSOM II). One of its PUMA helicopters was permanently set aside for air evacuation missions.

Other capabilities have allowed medical support to reduce the impact of geographical difficulties and allow the optimal level of medical care. Naval ships, for instance, have been equipped with real hospitals, allowing the care of patients near conflict areas. While some nations, such as the United States or more recently China, have hospital ships which are used exclusively in a medical role, France has decided to integrate medical structures on board command ships. The French ‘projection and command ships’ (BPC in France) which entered service in 2005, were designed so that a full hospital could be installed on board. Furthermore, modern naval ships carry helicopters (which if needed can be equipped for medical roles). During the Falklands War, the British used this kind of seabased medical support. During Operation ‘Acanthe’ in 1989, a specialist medical support 208

Module de Réanimation pour Patient à Haute Elongation d’Evacuation (MORPHEE) (Reanimation module for caring of patients over long evacuation distances ) which can quickly be installed in strategic airlift aircraft.

ship, ‘Rance’, was used to provide military and humanitarian support in Lebanon and provide aid to civilian populations. The ‘Baliste’ evacuation operation in Lebanon in 2005 intended for the evacuation of French nationals used a similar type of sea-based support off Beirut, employing ships with medical capabilities. Controlling the maritime space will necessarily involve the ability to provide support at and from the sea.

The medical component is increasingly involved in contributing to the control of space by developing modern space management capabilities. Research work is on-going on remote medicine, allowing isolated physicians to benefit from the support of medical and surgical facilities using the internet, thus reducing the issue of distance and providing a better level of care for patients, irrespective of their geographical situation. Communication and information systems have become significant factors for the medical function. The ability to trace patients, offer centralized management of medical evacuations and control medical logistics are the next steps for operational medical support. These new functions also contribute to the efficient use of assets and the reduction of the logistics footprint in theatre while improving the quality of care, thereby further freeing the commander from constraints when conducting his manoeuvre. One can imagine that further progress will take place in the future, such as remote diagnosis through the medical monitoring of soldiers (this is planned for the new French ‘Félin’ combatant equipment line), or the miniaturisation of equipment allowing medical technical equipment to be carried anywhere and in any circumstances (infiltration by special forces, design of lighter airdrop devices etc.).

The medical domain is therefore a strategic player for the control of space is so far as it guarantees the availability of medical care to the commander, irrespective of force dispersal, obstacles or distances.

One should not underestimate the importance of

maintaining an unbroken medical support chain, from the theatre up to the treatment of after-effects and all the steps in between, for strategic planning.

Furthermore, since

operational tempo has increased and coalition warfare is now virtually the norm, the challenge will be to think about controlling space in a multinational framework. The interoperability of these systems will therefore become a necessary condition for victory. Allied medical services will have to work together in order to optimize their care capabilities and save precious time.

B- Time

“Space must be combined with another, equally important, factor: time. It is not enough to be the most powerful player on the theatre of operations; you have to be the strongest at the right time209”. The time factor is therefore defined by strategists as the ability to achieve superiority at the decisive moment.

The speed of execution and movement is

related to the principles of initiative, flexibility and surprise.

The medical domain is significantly affected by the time factor, especially since the lives of patients may depend on it. There is a constant race against time. Where it is able to overcome this constraint, the medical service will provide commanders with a greater freedom of manoeuvre. Naturally, mastery of the space factor optimizes the time factor since “time is increasingly dependent on distance210”, but other factors are also involved, such as anticipation through planning or by optimizing the organization of medical support. The medical domain, by being involved from the start in planning activities, can contribute to the design of a manoeuvre by providing a structure which is self-sufficient in assets for the length of time required. A complete initial chain, allowing for an initial logistical autonomy, can avoid a break in the continuity of care during the entry phase for instance. Any delays in the setup of a medical structure are essential for the commander so that he can determine when to begin the engagement following the arrival of the first troops. Furthermore determining the required autonomy at the start or during an operation allows military leaders to ensure for a given time span the availability of medical care for combatants, even within an operational enclave.

The planning of medical support also allows the commander to foresee the use of rapid reaction assets in exceptional circumstances. This is the case for instance when swamped by the massive arrival of casualties. Actual experiences have shown that “the object nowadays must be to seek the deployment of the appropriate medical support calculated with regards not to a daily casualty rate, but on its ability to cope simultaneously with an influx of casualties211”. Forces are confronted with new kinds of conflicts, with bombings

209

Hervé Coutau-Bégarie, Traité de stratégie (Treatise on Strategy), 6th edition, Economica, 2008. P.Godart, Peut-on parler de stratégie opérationnelle du soutien santé ? (Is there an operational strategy for medical support ?), Médecine et armées, 2007, 35, 5. 211 J.Vlaminck, E.Darré, G.Laurent, Soutien sanitaire des opérations extérieures, évolutions récentes (Medical Support of Deployed Operations, Recent Changes), Médecine et armées, 2005, 33, 1. 210

such as those directed against a German military bus in Kabul in June 2003 or in Iraq. Medical services must be able to cope on a permanent basis with the simultaneous influx of around twenty casualties. In Afghanistan, in 2006, a fratricide incident left 16 wounded while an improvised explosive device required the care of 33 soldiers. France was also affected, in August 2008 in the Uzbin Valley where it suffered 8 dead and 12 wounded following a clash with the Taliban. In cases like these, more so than in classical situations, what is needed is not only the correct capability mix, but also the appropriate distribution of assets.

Surgical urgency is extremely important since it is essential that preoperative timescales be respected. Usage in NATO defines a ‘Golden Hour212”, during which a doctor must execute live-saving actions. The entire organization of medical support is therefore centred on the principle of ‘surgical deadlines’. While there is a degree of variation among medical cultures, forward medical support is a constant. It is provided by specially trained paramedics in Anglo-Saxon armies, or by doctors in French and German forces, but in all cases the object is to assume care of the patient as soon as possible. French doctrine favours forward medical treatment / reanimation / surgery and early medical evacuations213. Any cultural differences concerning the organization of care often overlap in the constant search for optimization of medical support. The Americans are studying the possibility of ‘Forward Surgical Teams’ while the French are examining the role of forward paramedics. One organizational tool used to accelerate surgical treatment is the use of triage. This principle was used by military doctors during WWI, and while it may appear shocking at first, it allows the highest number of soldiers to be saved in the shortest time possible. The medical tactic is intended to provide the earliest possible care for the largest number of casualties, while taking account of the requirements of each unit. Mignon214 in relation to WWI commented that “this level of triage might seem exaggerated. But they were directly responsible for the good order that prevailed and avoided sending the wounded to the wrong place”. In 1917, triage became the mainstay of allied medical services. “Triage is at the root of any successful evacuation215”.

Medical evacuations, tailored to the terrain, in particular using air assets are a key factor in respecting treatment deadlines. During combat operations in Southern Afghanistan in October and November 2006, three medical helicopters were constantly in use. They were 212

AJP 4.10: Allied Joint Medical Support Doctrine. Instruction n° 12 dated 5 January 1999 ‘Joint Concept for Medical Support of Forces during Operations’. 214 Mignon: ‘Médecin Inspecteur Général’ during the First World War. 215 A. Lacan, Historique du triage militaire (A History of Military Triage), Médecine et armées, 1994, 22, 8, quoted p 676. 213

largely responsible for allowing 93% of patients to reach an emergency surgical unit within two hours. Those evacuations which were unable to keep to treatment timetables were due to difficult operational circumstances such as unsecured landing zones for helicopters or difficulties associated with clearing minefields. In Afghanistan, most medical evacuations require protection assets. Close collaboration between the medical domain and command is therefore a prerequisite for success. Dialogue is especially required since operational issues can complicate ideal treatment. Control of the time factor is only effective when command provides the medical domain with the assets it requires to reduce as much as possible the impact of tactical conditions, such as unsecure situations due to enemy fire or precision guidance to the location of casualties. The involvement of the medical domain in information exchanges, by including its requirements in the digitalization of the battle space, also allows it to keep one step ahead in understanding the operational situation. It is once again, the necessary interpenetration of the military and the medical domains. Any time-saving measure provides a win-win. Commanders in allocating assets to medical support allow it to improve its race against time, which in turn by evacuating the wounded and saving lives contributes to freedom of manoeuvre, manpower and morale.

C- Force

Armed force is the indispensable means for the delivery of power in the pursuit of military strategy. The equipment and human resources involved deserve the complete attention of its chiefs if they want to enjoy its full operational capability. The French 2008 White Paper points out that “the protection of forces is not only a human imperative, but a strategic – to maintain cohesion – and tactical – for success – requirement”.

The medical domain plays a vital role since it serves to guarantee individual combat ability. It contributes to power not only by protecting individuals but also by providing collective protection against natural risks and by preparing for and preventing medical threats.

Providing medical care for injured soldiers was historically the first function of the medical domain. As was described in previous chapters, the results were for a long time disappointing, but current clinical and technical knowledge have allowed an excellent level of efficiency. Sickness is no longer considered a fatality and wounds can often be treated

and leave no functional after-effects, but medical services can also prevent pathologies using prevention measures in theatre. During operations, changes to living and hygiene conditions can encourage the spread of infectious diseases. The history of warfare is full of epidemics. Operational preparation and prevention measures have led to a considerable reduction of the risks associated with transmittable diseases. Infectious diseases morbidity has decreased but not disappeared. Medical services establish prophylactic measures, including vaccinations or medications, distribute information intended to reduce risky behaviour and advises commanders on operational hygiene. The support of the command level is indispensable if they are to implement medical advice, impose regulations and punish those who disregard them. Any relaxation of prevention measures may lead to serious epidemics as was the case with the spread of leishmaniasis in Guyanna in 1986 or the 113 soldiers affected by bilharziasis from a company operating in the Central African Republic in the 1990s or the men of half a company brought down by malaria in the Ivory Coast in 2002. Medical services are tasked with designating the prevention measures they are monitoring.

This

epidemiological monitoring has an important role to play in ensuring the operational availability of their forces. The French military medical service now uses a real-time epidemiological monitoring system216, allowing the early detection of the emergence of any new epidemiological situation, the assessment of the efficiency of strategies adopted to prevent diseases and the adjustment of measures in accordance with the data received.

Medical care is provided, once a specific pathology has been detected, using increasingly efficient campaign structures relying on an uninterrupted flow of medical supplies. Medical posts are now able to provide emergency medical care at a level similar to that offered in specialized services at home. The contemporary medical domain has considerably progressed since WWI when Doctor Louis Maufrais217 had to make do with a little iodine to disinfect, but no tools for anaesthesia or transfusion. Campaign hospitals are now equipped with scanners (as is the case in Afghanistan), laboratories, operating blocks comparable to western standards and even blood banks. Blood, a particularly sensitive product, is brought in from the home nation or built up by blood donations. The blood supply chain is delicate due to the fragility of the product and its conservation. Over the last century, the quality of medical care has jumped ahead and throughout its operations, very few wounded soldiers treated by French surgical units, often in difficult conditions, 216

System managed by the ASTER software (Alerte et Surveillance en TEmps Réel – Real-time warning and monitoring). 217 Louis Maufrais, presented by Martine Veillet, J’étais médecin dans les tranchée (I was a doctor in the trenches), Robert Laffont, 2008.

have died. These impressive results are due in large part due to the provision of forward care. Medical posts are well equipped, but command’s commitment was also a factor. It requires that all combatants receive first aid training, carry first aid kits and selfadministered medication, such as painkillers, but also CBRN medical countermeasures (pyridostigmine, three compartment self-injector, other antidotes). The range of increasingly advanced healthcare has also grown. In the 1990s, operations Daguet, Libage, Yankee and UNPROFOR

revealed that dental care was essential during deployed

operations, over and above selection measures. Dental surgeons are now present in theatre. Significant technological breakthroughs are expected, which will have strategic consequences on medical support. Cell therapy and nanotechnology, which may become available by 2025, will allow the treatment of tissue damaged by fire, irradiation or mechanical assault and the combatant’s recovery. The medical component has confirmed through its actions, its capacity to act as a strategic player by preserving with increasing efficiency the human potential of forces.

It therefore contributes to numerical strength but also to morale. The simple fact of being able to rely on quality care reinforces a soldier’s psychological makeup. The mere presence of a doctor alongside soldiers on the ground can have a significant impact on their morale. Medical services also contribute by selecting individuals on the basis of their psychological profile and treat problems engendered by the violent situations combatants face. Preserving the human potential of armed forces involves the psychiatric dimension and accepting that military action can upset, sometimes seriously, the psychological stability of men, even without high intensity warfare. This dimension has only truly been integrated in military thinking in the last forty years. In order to reduce the impact of operational circumstances which will inevitably expose personnel to potentially traumatic situations, individuals will be subjected to a selection process in order to assess their aptitude. Unit doctors and psychiatrists have a major role to play in this process. When a specific event leads to serious trauma, an individual’s initial psychological balance may be affected. Early care is then required. The principle of using a short forward psychological intervention is then essential to allow soldiers suffering from a psychological injury to return to combat and continue their military career beyond the immediate mission. During both world wars, the number of soldiers brought to the rear for psychiatric problems who subsequently returned to the frontline was very low. During the first months of the Korean War, American forces experienced a very high ratio of psychiatric casualties (250/1000). These soldiers, who were evacuated to Japan or the 99

United States never returned to theatre. Forward psychological care became systematic during the Vietnam War. The percentage of psychiatric casualties was much lower (around 11%). In France, psychiatrists became involved in operations from the 90s onwards. During the First Gulf War, encouraged by the then Head Doctor Bernard Lafont218, France developed doctrinal procedures for the place and role of psychiatrists in operations. In Rwanda, in 1994, and Former Yugoslavia, in 1995, psychiatrists were integrated within deployed medical/surgical structures. Their function in theatre involved the detection, treatment or evacuation of subjects displaying behavioural problems or who were considered a risk. They can also contribute to collective mental health by providing advice to the command. The role of the military psychiatrist is now acknowledged in operations. Psychological treatment can also take place after the return from an operation. Experience in Vietnam showed that while early action was effective in dealing with acute troubles, significant numbers of behavioural problems were noted after soldiers’ returned home. This led to the diagnosis of posttraumatic stress disorder (PTSD). The first Gulf War confirmed the appearance of problems after the return of soldiers. They were grouped under the description of ‘Gulf War Syndrome’. In the early 1990s, it was difficult to make the case for considering psychological trauma a real injury. This pathology is now recognized not only by the civilian219 and military medical community, but also by military commanders. Which is why, in addition to forward psychological support, it has been generally accepted that tracking post-return problems and follow-up when required are equally necessary. Commanders now accept Napoleon’s maxim that in war “morale is three times as important as physical strength”. Even though this ratio may be open to discussion, the notion that morale is a key element of an army’s power is now a widely accepted military tenet220. The action of medical services is therefore reinforced by those armies which have created emergency medical-psychological cells and follow-up structures. In France, the national Gendarmerie has a support cell providing psycho-traumatic support, the Army has the CISPAT221, the Navy the SLPA222 and recently the Air Force has added its own psychological support cell. The Americans, have established ‘Combat Stress teams’ at the

218

Central Director of the Army’s medical service from 1 October 2005 to 1 October 2009. Professor Louis Crocq, a psychiatrist specialized in combat neurosis and the reactions of populations subjected to bombings, was the creator of medical-psychological emergency cells which care for victims of terrorist attacks, accidents and natural disasters. 220 The French General Staff wrote a directive in 1997 dealing with ‘psychological support during deployed operations’. 221 CISPAT: Cellule d’intervention et de soutien psychologique de l’armée de terre (Army Psychological intervention and support cell) . 222 SLPA: Services locaux de psychologie appliqué (Local Applied Psychology Services). 219

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brigade level. They include a psychiatrist, one or more psychologists, a social worker, psychiatric nurses, a chaplain and several specially trained personnel. While medical personnel remain in charge of selection, identifying and treating psychological problems, the commander also has a role to play. This shared responsibility works well since all have understood that avoiding or managing reactions to combat can provide a real operational and human advantage. Aside from space, time and force, there remains one final aspect which offers strategic value added: the environment. The medical function has once again a special role to play.

D- Environment

Controlling the environment is related to the freedom of action in so far as it frees the force from constraints which are not related to the enemy and can lead to superiority and ultimately victory. Sun Tzu believed that “one must be unassailable”, the medical domain, although it cannot offer this capability, can significantly reduce vulnerability.

Deploying forces in regions with health risks which may be misunderstood and with poor hygiene conditions requires the control of the climatic and biological environment. An extension of normal campaign hygiene, the objective is to define a series of necessary measures for controlling and preventing illnesses due to climate, water, air, food, animal or insect carriers. This control requires coordinated action by unit doctors, epidemiologists and veterinary biologists.

Diseases and accidents due to climate may have caused more casualties than combat. Napoleon’s 1812 Russian campaign is a striking example, as is the more recent battle of Stalingrad (1942 to 1943). During the First Gulf War, the theatre was a flat, sandy and stony desert with very hot days and cold nights. The environment was therefore particularly harsh, requiring severe individual and collective adaptation measures. Troops currently in Afghanistan are also subjected to risks related to heat, cold, dust and altitude. The medical domain plays a major role in preparing combatants for extreme conditions. Through its research, it can push back the psychological limits of combatants.

Controlling the biological environment has now become indispensable since armed forces, like society in general, are not exempt from taking safety and prevention measures, individually or collectively. At the beginning of the twentieth century, General Bonnal declared that “biology has made such progress over the last fifty years that it has become a 101

reliable guide for statesmen concerned with their nation’s progress. Biology will serve as a basis for high command if it wants to reach its objectives”. This control requires the coordinated action of the medical domain, through a partnership of epidemiologists / veterinarians and command. This partnership was recently reinforced, for instance with the request by the French general staff in 2004 to involve military veterinarians as early as the planning phase. They were involved not only in the assessment of risks posed by animals present in the environment, such as envenimation or zoonosis, but also in planning and organizing an army’s housing, feeding and water supply. With regard to drinking water in particular, NATO has confirmed its importance in operational settings by setting quality objectives. This is part of the more general approach intended to guarantee more efficiently the operational medical safety required by military forces. The medical services of member nations, alongside other players (engineers, commissariat), are entrusted with monitoring, expertise and advisory roles.

Important advances have been made by medical services in the field of epidemiological monitoring. There are now regular real-time monitoring actions223 and exhaustive databases. The medical domain has even gone beyond mere epidemiological monitoring by establishing analysis cells to deal with medical risks and threats. This analysis work has become a preliminary to any operational deployment. New requirements for information, the monitoring and analysis of health risks and new threats, in particular in CBRN conditions, have appeared. The medical assessment of risks is conducted by medical experts, especially epidemiologists; as well as other disciplines which allow the analysis of environmental information (on populations, ecosystems, industrial infrastructures, etc). It determines the prevention policy and the adoption of medical counter-measures. When confronted with the possibility of a CBRN threat, military medical services will have a major role to play in providing expertise and contribution to decision-making. In the current strategic context, data produced by the medical assessment of risks is now one of the elements to be taken into account, at all levels.

Beyond the control of natural risks and the assessment of threats, medical experts are also strongly involved in controlling risks resulting from human activities. Waste management is one of the actions needed to ensure the salubrity of the areas where troops are stationed. Veterinarians contribute to the implementation of rules of conduct required to ensure and maintain operational health, including for the elimination of waste. Command is also very engaged, in particularly in France, since a “prevention-security-environment” section was 223

Including the use of ASTER software (Alerte et Surveillance en Temps réel) in France and now NATO.

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created in 2003. It deals with risks of accidents, intoxication or disease linked directly or indirectly with military duties. Waste management is handled at this level, especially medical waste. The waste left by artillery munitions in Kosovo in the 1990s led to a debate about the consequences of the presence of depleted uranium on the health of local populations and military personnel. Coordinated action by medical services involved in the operation and commanders was launched in order to assess the risks. Furthermore, industrial risks, resulting from human activities, are also significant. During Operation Trident, many problems related to the industrial environment and technological risks were raised. It was necessary to include the risks linked to lead poisoning.

The final constituent of the environment, long overlooked, is the human environment. Nowadays, “the notion that it is possible to scientifically control human behaviour is developing224”. A social analysis of the operational theatre is now part of the strategic decision criteria and it influences tactical disposition. Understanding the relationship between the local population and the military is important so that individual and collective behaviour can be channelled in the right direction. Crowds can become virtual weapons, and must therefore be avoided. Le Bon225 in his “La psychologie des foules” (Crowd Psychology) analysed the threats they can represent in particular from a military point of view. The management of local populations in theatre has become a priority for command, the objective being to encourage positive public opinion and gain an advantage over the enemy. Military medical services are in good position to ‘win them over’ since they can provide healthcare to which the local population might not otherwise have access. Their interpenetration in the local milieu allows medical professionals to get a feel for popular feelings and alert command when necessary. The objective is not individual intelligence, which medical confidentiality forbids, but rather the development of receptivity to any changes in the environment and any potential local complaints. Concerning medical support to populations, its efficiency has transformed it into a significant contributor to indirect strategy.

These four strategic dimensions are closely related and influence one another. Time is dependent on space, space “only matters as far as available assets are provided and how they are used226”, the environment is related to the terrain and force is influenced by all three. The combination of these four factors determines the success of an action 224

R.Trinquier, La guerre moderne, (Modern War) Economica, 2008. Gustave Le Bon (1841-1931): French anthropologist, social psychologist, and amateur scientist. 226 Hervé Coutau-Bégarie, Traité de stratégie,(A Treatise On Strategy) 6th edition, Economica, 2008. 225

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strategy. For this reason, the medical domain by encouraging the execution of strategic principles in these four dimensions, has become a significant player in military thinking. “Medical support thus became essential for operational efficiency227”. Lessons learned from recent operations have shown that the medical function encourages a strategy of action made more efficient through the “knowledge and anticipation” of health risks and threats; “prevention” through the operational preparation of combatants; “protection” using counter-measures, technological innovations; “deterrence” by its ability to reduce the vulnerability of armed forces to CBRN attack; and finally “intervention” in so far as it offers an improved operational capability with a reactive medical support228, the provision of adequate medical treatment for the circumstances and the environment and by pushing back the psychological limits of combatants. We must therefore take account of medical considerations earlier in the process of strategic thinking, not to attempt a rough adaptation of medical support to the chosen military structure, but to work together on an efficient strategy and limit human costs. In practical terms, the concept of operations should integrate the consideration of medical support and devote a specific paragraph to it. Medical experts must be involved in the initial assessment of the theatre in order to integrate these aspects starting with the initial planning directive. Finally, a medical advisor should be included in the operational planning group, for each planning step, execution and adaptive planning. Some obstacles remain concerning the initial phase. A real change in attitudes is required to make this way of working the norm.

227

French White Paper on Defence and National Security June 2008. In France the Operational Medical Monitoring Service (‘Dispositif santé de veille opérationnelle DSVO’), can provide initial medical support within 24 hours. 228

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II. Indirect Strategy The indirect strategy, described by Asians centuries ago, is increasingly being studied by western countries. As the types of conflict evolve, irregular forms of warfare often supplanting traditional combat, war has become but one aspect of military strategy. Since this strategy serves political objectives, which often seeks to avoid a direct clash, it has increasingly turned to non-military modes of action. The objective is to “unbalance or weaken the enemy before the decisive blow and tire out the adversary229”. This type of strategy was previously considered as a tool of the weak since the strong would have no apparent need for it. Clausewitz however understood that “a war where national energies clash with all their might will be conducted using different methods from those used in wars of old». The nuclear era has fundamentally modified this approach; the goal is now to avoid combat as much as possible. This is due both to a fear of the irreparable and the humanist philosophy prevalent in public opinion.

One of the tools of indirect strategy concerns population control. Clausewitz had previously identified populations as a decisive element and part of the wider range of defence tools. “However imperceptible the influence a regular inhabitant of the theatre of operations in wartime, it should be compared to a drop of water in a stream; even when there is little chance of popular insurrection, the collective influence of the nationals of a country on war is far from imperceptible230”. In current conflicts; “the enemy” of western nations is fighting on his home ground, and that presents a significant advantage when dealing with public opinion which is often sympathetic or at least easier to manipulate. The support (voluntary or not) of local inhabitants provides a considerable advantage; especially since the local populations may even take up arms, transforming an entire people into partisans and enemies. This was the case in Vietnam, where confronted with a chronic lack of manpower, the French command immediately called upon the locals to add to their ranks. The situation was similar during the conflict in Algeria. The population dimension thus became a significant issue starting with the wars of decolonisation. More recently, General Petreus’ ANACONDA strategy in Afghanistan is designed to ‘suffocate’ the Taliban by cutting their supply routes through local villages.

Military leaders have

generally accepted the importance of the population dimension. They have at their disposal two tools to influence this dimension: civil-military actions and reconstruction aid. “These actions have become inseparable from strictly military actions231”. The medical domain, 229

Hervé Coutau-Bégarie, Traité de stratégie (Treatise on Strategy), 6th édition, Economica, 2008. Clausewitz, On War. 231 White Paper on Defence and National Security, June 2008. 230

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with its fundamentally humanist function, has an important role to play. Lyautey expressed it thus “nothing is clearer than the efficiency of the doctor’s role as an agent for attracting and pacifying locals”. The Americans consider that in Afghanistan, “American medicine is a powerful “weapon of freedom” in our nation’s arsenal against terrorists and the forces of oppression232.

A- Medical Aid to Populations

Contemporary conflicts have grave consequences for civilians. During the First World War 80% of victims were military, but starting with the Second World War, followed by the wars of decolonisation and finally during the peace-keeping missions of the 1990s, the majority of casualties were civilian. Civilian populations find themselves at the heart of combat and are often subjected to violent methods, moral and physical terror. The mediatisation of civilian suffering has become an influent factor in how conflicts are conducted. Forces now seek to limit as much as possible the consequences of combat. Their concern is humane, but it is also a strategic and political. Sparing and helping local populations earns the force a degree of gratefulness and encourages a positive and fruitful partnership. This behaviour can be useful in avoiding international condemnation and public opprobrium.

Armies carry out civil-military actions which facilitate relations with civilian actors, in order to preserve the legitimacy of their action, thereby contributing to force protection. During the Vietnam War, the Americans invested between 500 and 750 million dollars in a Medical Civic Action Program (MEDCAP) and treated over 40 million civilian patients. The current requirements of the different peace-making, peace-building, peacekeeping and peace enforcement operations reinforce this need for caring for populations, especially since the relationships between armies, international organizations and civilian populations are important. This range of actions, intended for an external environment, plays a real role in the insertion and legitimacy of armed forces. The concept has recently been reinforced by its positive results for the protection of French interests at the diplomatic, cultural and commercial levels.

The medical function has a particular role in this range of activities. Medical aid to populations is an important pillar of civil-military cooperation which is an obvious requirement when armed forces are the only actor able to act in a coordinated fashion in 232

Jay B.Baker, Military Review, Sept-Oct, 2007.

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theatre, when confronted with a difficult security conditions. The French definition of medical aid to populations is as follows: “medical aid to populations covers the range of activities conducted by the personnel of the medical service of a deployed force, in support of the wider civil-military cooperation in order to improve the medical conditions for civilian populations in the area where this force operates233”. Medical activities led by military medical services are an integral part of the plan of operation, a testimony to the strategic importance of the medical domain. However this aid must be executed in accordance with the first priority which remains the support of the force. Having acknowledged this limitation, the objective is to “respond to the vital needs of the population to avoid worsening the medical situation resulting from the crisis, and thereby worsening the crisis itself or its extension with potential negative effects on the mission of the armed forces”. It contributes to the acceptance of the force’s presence. Its execution must however respect a number of important principles to avoid having a paradoxical deleterious effect. The principle of dual use rests on the fact that the medical support of forces must remain a priority even when it can be used to serve civilians; the principle of management control requires that the medical support of populations cannot affect the quality of the support given combatants; the principle of relevance requires that medical aid to populations must be coherent with the overall civil-military action; the principle of exemplarity requires that humanist values be respected; the principle of non-interference requires that military medical services not compete with local health systems. It is therefore necessary “to define in accordance with the context and local health policies, the most frequent medical and surgical pathologies which can be provided in a sustainable fashion in the full respect of medical ethics”. All the operations of the last twenty years in which France has participated have included the provision of medical aid to local populations. In Kosovo, Lebanon, Djibouti, Ivory Coast, Chad or Afghanistan, practitioners (doctors, dentists, and veterinarians) and paramedics provided their help to civilians. The real success achieved by these activities has convinced command of its indispensable value. This activity is only possible however when the level of overall or local risk is acceptable for the force and when there is a real relationship with the local population. The First Gulf War was an exception due to the stationing of troops in the desert and the level of threat. The medical domain has thus found an opportunity to confirm both its position as strategic player and satisfy its medical ethics duty, as long as it keeps in mind its priorities.

233

PIA 09.101 dated 15 May 2009.

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B. Rebuilding the Health Network The notion of aid to populations now goes far beyond the action carried out during the period the force is engaged. To accelerate the end of a crisis and avoid later reoccurrences, the comprehensive strategy is currently to encourage the reconstruction of a failed or failing state.

Colonial wars further contributed to this awareness. Gallieni for one had understood the need to provide support to the construction and modernization of colonies. This became official policy at the end of the nineteenth century with an instruction in which it was specified that “destroying is easy, rebuilding is more difficult234”. But it was the wars of decolonisation which affirmed reconstruction as a stabilization tool. The medical domain was invited to contribute. Many doctors continued to be posted to former colonies to manage dispensaries and provide care, until those nations became medically self-sufficient. The experience acquired by military doctors concerning tropical diseases was also immensely useful. The posting of several hundred officers from the French military medical service to the Ministry of Cooperation was a clear example of their contribution to political aims.

But it was only in the modern era that reconstruction became a real strategy for ending a crisis. It is during the exit phase that the first reconstruction programmes, intended to restore infrastructure and encourage social development, are launched. The material part of reconstruction is normally an economic challenge since the international influence of states is reflected in their ability to secure reconstruction contracts for national companies. The other aspect of state post-crisis intervention is related to social development. This involves long term structural support to social groups weakened by conflict. Establishing social, health, professional or education programmes is then absolutely necessary. Armies are normally the initiators of this cooperation because latent insecurity and the level of risk for companies are major characteristics of the environment as the country emerges from a crisis. The Alliance developed the ‘Provincial Reconstruction Team’ concept, entrusted with facilitating this exit.

NATO’s mandate in Afghanistan includes rendering the territory safe enough to facilitate the development of Afghan governmental structures throughout the country, assisting reconstruction by facilitating international humanitarian aid and training new Afghan 234

Instruction dated 22 May1898.

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defence and security forces. The Americans, who are responsible of the reconstruction and development pillar in Afghanistan, help local authorities develop their medical services. This is a long term project and is part of the overall exit strategy. Americans are trying to apply the same policy in Iraq. In 2005, the National Strategy for Victory in Iraq made specific mention of the “the value of building and rehabilitating health care facilities”. Once a situation has stabilized, industry, development agencies235 or non-governmental organizations take over. The departure and ending of medical support to local populations are critical times. The reduction and ceasing of medical of service must be carefully planned and reviewed before they are implemented. The intervention of military medical services must cease when there is a risk of interference, for operational or humanitarian reasons, with international or non-governmental organizations active, with the permission of local authorities, in the reconstruction of the local medical system. In the medical field, organizations such as ‘Médecins du Monde’, the Medical Committee of ‘Action contre la Faim’ or ‘Aide Médicale internationale’ continue the long term reconstruction work.

The role of military medical services in reconstruction is vital since they can provide a satisfactory level of care during a period of transition and encourage the self-dependency of local health structures, using for instance training and exchange projects. NATO’s Medical Branch is currently attempting to formalize this type of action in a reference document and reinforce its links with humanitarian players.

The medical domain, because of its specifically humanist dimension, may be used by armed forces as a symbol of its goodwill towards local populations. Medical actions are highly and immediately visible for public opinion. Some, although this remains a minority view among humanitarian organizations, may see this as an attempt at manipulation or a tool intended mainly to benefit national interests which would compromise the required neutrality of humanitarian action. However this in no way compromises medical ethics since medical aid actions offered to populations and reconstruction can efficiently encourage locals to accept the presence of a force and contribute to resolving a crisis, they are equally useful for local populations confronted with catastrophic health conditions. Besides, military medical services and NGOs can complement one another, as long as each respects a clearly delineated role. In certain unsecured environments or capability deficits may encourage a form of 235

Such as the United Nations Development Programme (UNDP).

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cooperation based on support in the fields of information sharing, logistics or security, and a gradual handover, leading to a real win-win situation. This complementarity may be further exploited for political reasons, during natural disasters for instance or to manage public opinion. In this regard, some nations may be called upon to become true ‘medical nations’ where providing state medical assets is a part of ‘Medical Diplomacy236’.

236

A concept developed by the Americans in 2007.

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III. Political Tool

Since Antiquity, the art of war has sought to promote the political project of a group, usually a nation, expressing a common desire and level of ambition. “The notable innovation of our times is the avowed use of the military instrument for demonstrations of power without the actual use, or only limited use, of force237”. The fusion of the political and military realms goes further today since it tends to merge strategy and diplomacy. Raymond Aron described a form of “politico-strategic conduct”. Political power thus came to consider the military tool as a part of a global strategy of influence. For these reasons, the use of military capabilities to carry out functions such as humanitarian actions, which do not belong to their initial operational function, to satisfy public opinion or implement a global strategy is now accepted and even recommended.

The 2008 French White Paper acknowledges this globalization of national security and the combined involvement of all state players. “The National Security Strategy embraces both external security as well as domestic security, military as well as civil, together with economic and diplomatic means. It needs to take into account all of the phenomena, risks and threats that could prove detrimental to the life of the nation238”. This definition widens the range of use of military resources. Security can be threatened by an attack from a state or a group, but also by natural or medical disasters.

In accordance with this viewpoint, military medical services, just like armies in general, constitute a response to a political request. Over the last fifteen years, the humanitarian realm has become a political and strategic issue. The politicians’ will to make humanitarian work an instrument for solving crises has opened a new field of action to the military medical domain: humanitarian medical aid. Furthermore, nations’ growing concern with health crises has made military medical services (principally French and American) an additional state tool to solve national crises and aid with public opinion. By becoming a political tool, the medical domain has become a true diplomatic tool. A. Participating in Disaster Relief

Using military capabilities to provide immediate help to populations subjected to a great calamity is a political decision.

The appropriateness of using armed forces must be

guaranteed when the use of violence is not an objective. How a military presence is 237 238

Hervé Coutau-Bégarie, ‘Conférences de stratégie’, Institut de stratégie comparée, 2009, p 81. White Paper on Defence and National Security June 2008.

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perceived can occasionally be delicate, especially for humanitarian workers who tend to highlight the risks associated with the militarization of humanitarian aid. This kind of intervention also has predominant diplomatic repercussions. These “emergency aid external operations239” represent a significant component of a state’s action outside of its national borders and its armed forces are quite naturally called upon to participate. These are true security actions since natural, technological or health disasters can undermine entire regions for long periods of time.

States who have suffered a disaster either lack the required assets or are unable to cope with events and contributing nations send their support in response to their calls for help; state sovereignty is respected. But the sending of military forces can nevertheless be perceived as an attempt at interference in the internal affairs of a sovereign state. This was the case in 2005 following the earthquake in Pakistan, where the sending of assets belonging to the NATO Response Force was not well received by Pakistani authorities. The presence of NATO in Pakistan constituted for some a loaded symbol. The same occurred in Burma in 2008 when despite large-scale flooding, the junta refused aid from certain nations and categorically refused access to military forces. But armed forces are often well placed to provide the level of reactivity and the required assets. Faced with certain huge disasters, military forces are the only ones capable of providing the intervention tools required for a specific emergency and often difficult security conditions.

The actions of military medical services are less likely to be questioned since the medical domain has by definition a humanitarian objective. There are occasionally voices raised against their presence, but they usually belong to other medical organizations. Civilians and local authorities are less likely to object to the involvement of military medical formations than they are to the use of other military capabilities. Politicians therefore have at their disposal an efficient intervention tool. The French military medical service acquired at the end of the 1960s a Rapid Intervention Military Medical Element (EMMIR) whose objective was to carry out military-humanitarian intervention missions. It intervened in many places: between 1968 and 1970 to aid children in Biafra, in 1972 in Peru following the Anta earthquake, in Mexico in 1975 and in Columbia in November 1985, and in Armenia following the terrible earthquake of 1988. Other assets have been used, such as the floating hospitals on board naval vessels, such as the Jeanne d’Arc in 1988 to help the Boat People for instance. Field hospitals have also been used to provide

239

PIA n°03-154 dated 10 January 2008.

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humanitarian aid to populations, as was the case in 1992 during Operation Libage240 in Kurdistan, whose mission was to ‘protect, feed and heal’ Kurdish refugees threatened by the Iraqi Army. In crisis countries, medical services can also provide a valuable biological and technological aid. What was then known as the French ‘Bioforce’, took part in campaigns against cholera in 1991 in Peru and 1992 in Argentina, as well as vaccination and epidemiological missions to Chad and the Central African Republic in 1992.

Confronted with the multiplication of specialized humanitarian NGOs, a new concept appeared during the first decade of the 21st century which “framed the military contribution within a value-added and complementarity approach”241. This meant that armed forces were no longer required to maintain a specific external humanitarian action capability. They simply had to make available to their authorities their own assets depending on the actual requirement. However this lack of specificity did not compromise their ability to provide an initial response in case of disaster. Thus medical services, and in particular those belonging to NATO countries, no longer maintain dedicated humanitarian assets. In France, the Rapid Intervention Military Humanitarian Task Force (force d’action humanitaire militaire d’intervention rapide - FAHMIR) to which the EMMIR belonged, no longer exists. Armies now have subsidiarity as an objective242. This evolution corresponds to a stated political desire to reassure humanitarian specialists. Recent experiences have shown, however, that military capabilities remain very much in demand, as was the case following the 2004 Tsunami or the 2005 Pakistani earthquake.

The

military medical domain which finds itself in the frontline of humanitarian interventions must however integrate this dimension in its operational preparations. It must, for instance, have the required competence and emergency tools to treat very young and very old patients. Without actually developing specific capabilities, they must have the minimum required, in order to render assistance to persons in danger.

Humanitarian medical aid is a political tool where military medical services occasionally have to use their capabilities to aid distressed populations, in cooperation with other players, governmental or international organizations. This involvement, beyond the diplomatic advantages it may bring, is useful for managing public opinion, both internally and internationally. 240

‘Libage’ was integrated within “Operation Provide Comfort’ set up by the USA and the United Kingdom in the framework of UNSC Resolution 688. 241 PIA n°03-154 dated 10 January 2008. 242 Corresponding to the following rule: support required when assets are ‘unavailable, inadequate, insufficient or nonexistent’ (called the ‘4 Is’ rule in French ‘Indisponibles, Inadaptés, Insuffisants ou Inexistants’).

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B. Managing Public Opinion

Public opinion can be a formidable weapon, both for armed conflict and politics in general. Its management is particularly important since it can easily be manipulated. “An aerial bombing may be transformed by an opponent’s propaganda into a terrorist raid which the world press may use against us243”. The power of the media is extremely important, it encourages psychological actions directed at populations which must then be reassured, convinced and encouraged.

The power of public opinion is such that it can influence the end of a conflict. 1968 was a crucial year for the Vietnam War, when in February the American people became aware of a large scale enemy assault in South Vietnam, the increasingly unpopular American involvement was widely condemned. The War in Iraq is also proving to be a long-term conflict and its popularity among American public opinion is falling. Polls carried out in early August 2006 showed that around 60% of Americans did not want to see the American mission prolonged. Furthermore, the willingness of public opinion to tolerate casualties in wartime has gradually decreased over time compared with previous centuries. The global sociological evolution, reinforced by globalization, tends towards individualism, an unwillingness to accept death, a sense of entitlement to healthcare, the safety-first principle and the right to compensation. Man is his own finality and medicine became particularly important in a world seeking a level of ‘zero deaths’ including in wartime. This evolution has forced politicians and military leaders to include in their calculations the need to present a case for the use of military assets which is perceived as legitimate by public opinion and whose risks have been carefully assessed. There is a real need to guarantee minimal casualties and therefore create conditions allowing the population or the soldier, even if he is subject to the risks of combat, to benefit from the most advanced modern medical techniques. It is therefore necessary to pursue constant improvements. General Monchal, Chief of Staff of the French army said in 1995244: “evolution is needed in an area we have always been attached to, preserving human lives”. This evolution is noticeable at the combat level, but also in how public opinion views intolerable humanitarian situations displayed for the world by the media and also within society itself where the principle of ‘safety-first’ has become paramount. 243 244

R.Trinquier, La guerre moderne, (Modern War) Economica, 2008. General Marc Monchal, French Chief of Staff of the Army April 1991 - August 1996.

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In combat, “while the high command is entrusted with the ultimate responsibility for offensive or defensive success, the leadership of the medical service answers both to the same high command whose manpower it must preserve for tactical objectives and towards public opinion which while it may accept necessary sacrifices, requires that sickness does not achieve what enemy fire could not245 ». This sentiment, expressed at the end of the First World War, showed that public feelings about combat were evolving and expectations were growing. This understanding has since considerably evolved, since this responsibility has extended beyond the medical domain to include the command and political levels. Public opinion is also apparently increasingly unwilling to admit even “unavoidable sacrifices”. The death of two young French soldiers in the Ivory Coast in August 2003 had a large impact, encouraged by the press which highlighted the risks of deployed operations. In August 2008 the Uzbin ambush which cost the lives of 8 French soldiers and left 12 wounded was a traumatic experience for the entire country. The medical domain therefore has a major role to play in limiting casualties in these circumstances and avoid further losses to disease. This is at the heart of the ‘protection’ concept where shrapnel, just like the malaria parasite, are perceived as uncertainties which might give rise to reparation. Reparation goes beyond treatment and includes the care of veterans. Modern societies now want old soldiers to receive the thanks of the nation. The American soldier was made ‘Man of the Year’ by Time Magazine in 2006. Americans, remembering the treatment of Vietnam veterans, refused to accept the Walter Reed scandal in 2007 revealed by the Washington Post246. Without constant and efficient care (before, during and after a conflict) the state might be confronted with the wrath of public opinion. “An army can only campaign with the moral support of the nation247”. A further aspect of contemporary societies must be taken into account to fully grasp the importance of the medical domain today. This is a highly evolved concept of humanism, born of the horrors of war. Rules have been developed to limit suffering and provide access to care for the wounded and the sick. It was following the Second World War that humanitarian law was considerably reinforced and defined by the Universal Declaration of Human Rights (UDHR) dated 10 December 1948 and the four Geneva Conventions dated 12 August 1949, with additional protocols in 1977 and 2005. The UDHR was defined by 245

Colonel Costedoat, ‘Direction du service de santé au ministère de la Défense Nationale’ (Medical Service Directorate of the Defence Ministry), CHEDN, La défense sanitaire, 1917. Provisional classification 9NN656, DAT, SHD. 246 Two articles described the neglect of veterans in the Walter Reed Military Hospital. The Secretary of Defence, Robert Gates, removed its commander, Major General George W. Weightman. The scandal also led to a complete review of veteran care in the USA. 247 R.Trinquier, La guerre moderne, (Modern War) Economica, 2008.

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the United Nations General Assembly as “a common standard of achievement for all peoples and all nations”. While originally a declaration of intention, it has inspired a wide range of binding international treatises related to human rights, whatever the circumstances. The first article thus proclaims the freedom, equality, fraternity of all mankind. Some248 have defended the notion of a ‘right to interfere249’ in countries responsible for humanitarian disasters. Since the 1990s, states have regularly intervened with military assets to set up humanitarian corridors. Two operations in particular illustrate this kind of intervention: operation ‘Restore Hope’ in Somalia which ran from December 1992 to the end of 1993 which was intended to save populations living under threat and operation “Turquoise” in Rwanda in July and August 1994 intended to protect refugee populations. These kinds of operations, which strictly speaking might be counter to international law250, were considered legitimate by public opinion because of their humanitarian nature. Military medical services contribute one of the fundamental tools of this kind of action, since they provide medical care for local populations. The justification for these kinds of interventions would be lessened without the medical contribution.

Public opinion also wants military medical services to show solidarity with the wider medical community. This is why the French military medical service has since 2005 adopted a dual mission: support of the armed forces and public service. The 2008 White Paper in its global approach to national security has reaffirmed the complementarity of civilian and military actors. This is partly a result of public pressure which cannot accept that a specific tool available to the state might not be used to serve the people in a national emergency.

This combined action is intended for natural disasters where the military

medical services will complement the civil emergency plans and in cases of pandemics where they have an important role to play in preparing and managing a crisis. They are part of the warning and monitoring network, are involved in the production, stocking and distribution of counter-measures, and contribute to the provision of care. This is currently 248

It has ardent defenders248 such as Doctor Bernard Kouchner and Mario Bettati, a lawyer, who presented it in 1987 during a conference on the theme of ‘humanitarian law and morality’, but it concerns certain legal experts because of the potential drift towards partial unilateral interventions. 249 This is related to the right states have to ignore the national sovereignty of another state, should massive violation of human rights occur. There is also the duty of interference which imposes on a state the duty to offer assistance in case of a humanitarian emergency. However interference has not been legally codified and article 2, paragraph 7, of the UN Charter makes non-interference a fundamental principle of international relations. The UN General Assembly currently invites states to facilitate the transport of humanitarian aid, but does not authorize their enforcement. Article 70 of the 1st Protocol of the Geneva Convention does however specify that “Offers of such relief shall not be regarded as interference in the armed conflict or as unfriendly acts”. 250 A violation of the fundamental principle of national sovereignty.

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the case for instance with the flu pandemic which appeared in the spring of 2009. This medical solidarity is intended to avoid a health crisis developing into a humanitarian, economic, security or institutional crisis. The state must be seen to use all available competent staff and hospital infrastructure within its borders. Furthermore, citizens want to be kept informed, and the medical domain has a part to play in advising the authorities: “the citizen is blind without the help of experts251”.

Finally, public opinion is also an agent of transformation for the way the political or military authorities approach the medical domain. It is clear now that most of the constraints which limited its full and complete use in strategy have been overcome, encouraged by public opinion. The current cultural environment is resolutely centred on man, command decisions are influenced by the popular vision of the results and strategy becomes global as military strategy, diplomacy and public policy merge together.

C. Medical Diplomacy Medical Diplomacy is an American concept which sees the medical domain as a means of building relations between states and people. The goal is to develop relations of trust based on the provision of medical aid. This approach can be applied to civilian and military domains and is coherent with a global approach to international relations.

The objective is to encourage cooperation, exchanges or aid in the medical field which are relatively easy to implement and have a wide impact. Developing countries often suffer from an inadequate medical infrastructure and providing development aid and care to populations is well received. The United States therefore takes part in programmes intended to combat AIDS, malaria, as well as vaccination campaigns throughout the world and in particular in Africa where they are seeking to consolidate these programmes. Medical intervention is therefore an important component of a diplomatic strategy designed to provide or regain a moral authority for American actions.

In the military domain which concerns us, ‘medical diplomacy’ is closely related to the medical component of the indirect strategy intended for counter insurrection actions. Mao

251

Michel Godet, Démocratie ou démagogie, (Democracy or Demagogy) Le Monde 24 January 2007.

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Tse Tung described insurgents as “moving amongst the people as a fish swims in the sea252”. The object is this instance is to separate the fish from the sea.

The concept of using the military medical domain can be extended to relations between states. Medical aid is considered as a political tool by western nations for nations experiencing asymmetric warfare, or for failed states, but medical aid cannot also become a political issue among western nations. We have seen how operations cannot today take place without medical support and that medical aspects are integral parts of a strategy of action. But contemporary operations are mostly organized under the umbrella of ad hoc coalitions or international organizations. For this reason the ability to deploy a solid military medical service on the ground, with a complete medical supply chain, constitutes an important diplomatic advantage. Currently three military medical services are equipped with the full chain: the United States, Germany and France. There is therefore a real opportunity for them to become ‘medical nations’. Capability deficits are noticeable in the medical support of current operations, including those run by NATO.

The Alliance is

currently working on solutions to this capability deficit. By becoming major contributors of medical capabilities, nations gain influence within NATO and vis-à-vis the other supported nations. Having a high-level medical capability provides armed forces a level of autonomy and influence over other nations. Smaller nations have opted, according to their means, for developing an expertise in medical niches, such as level 1 or 2 care or CBRN capabilities, which allows them to take part in operations.

Medical diplomacy is the ability of nations to use its medical assets in the service of international relations. The Bouffard Hospital, managed by the French military medical service in Djibouti, is an example of a structure with a political objective. 80% of its activity goes to supporting the Djibouti armed forces, their families and the general population. The service thereby serves essentially the Ministry of Foreign Affairs and the French development aid policy. The difference between a medical strategy and medical diplomacy resides in the use made of the medical domain. Both concepts are obviously interrelated and complementary. Medical strategy is concerned with providing strategic advantages to command, while medical diplomacy is related more clearly to the political level. But, just as described by

252

Donald. F. Thompson, The role of Medical Diplomacy in Stabilizing Afghanistan, ‘Defense Horizons’, #63, May 2008, quoted page 3.

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Aron’s political-strategic conduct, both concepts merge when the object is to use the medical domain in the service of an indirect strategy or as a political tool.

Military medical services are now occasionally used for purposes which go beyond their normal operational mission, for large-scale humanitarian or natural disasters, to win over national or international public opinions and gain significant diplomatic advantages. They are currently instrumentalized by their national authorities but this provides them with opportunities for transformation. Having won recognition, autonomy and achieved technological, efficiency and organizational progress, military medical services are now confronted with the challenge of gaining interagency and international recognition, which will allow them to thrive in a new world order. It has now become essential, beyond reassuring the wounded that ‘no losses would result from lack of effort’, to secure a return on investment for this tool of the state. The military medical services must demonstrate their cost-effectiveness. This will no doubt ensuring the complementarity of the tools available to the various national public services, of the interoperability of medical support capabilities during multinational operations and developing the financial value of certain expertise niches253.

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Reimbursing healthcare services, producing and selling certain strategic drugs, secure an international return for the HIA (Military Teaching Hospitals), etc…

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CONCLUSION

Michel Goya’s book “La chair et l’acier” (Flesh and Steel), highlighted the difference between the medical domain and war. The first is concerned with the fragility of human life, the second with clash and death. They have little in common at first glance, but combat requires manpower. While in the distant future, we might conceive of war without humans, led by machines, it will certainly continue to have an effect on humans. Medicine and armies have therefore long cohabitated, but they have only recently held a proper dialogue. The human factor long had little impact on societies and their military commands.

Only since the end of Napoleonic wars, has this factor been given strategic consideration. “Those who favour precision fire, prefer light troops who fight in scattered order, but this requires soldiers be trained to develop initiative and individual courage. Those who favour mass shock believe on the other hand that a high level of morale is required to overcome the enemy fire254”. Man is finally placed at the heart of warfare. His welfare is now a prerequisite for success.

This revolution is impossible without the medical domain. It ensures the physical and mental health of combatants. To do this, it must “predict, understand and want, these are the guiding principles for those who have been entrusted with preserving the wonderful youth of the nation255”. The astonishing technical advances made by medical science now allow the military medical domain to make full use of its potential. It was long held back by its lack of efficiency and was therefore unable to gain the trust of military authorities. But the military medical domain has another arrow in its quiver, “the need to produce results”, which allows it to present a compelling case for its capability requests, thus avoiding the issues it suffered when medical services were not run autonomously. The final great advance, made possible by learning from past experiences, is related to the posting within headquarters of ‘medical advisors’. This dialogue was institutionalized and the needs of all were taken into account. Misunderstandings may occasionally resurface especially since their respective interests do not necessarily coincide. Mutual understanding continues to advance, but the medical domain is not yet automatically 254

Michel Goya, La chair et l’acier, L’armée française et l’invention de la guerre moderne (Flesh and Steel, the French Army and the invention of modern warfare) (1914-1918), Tallander, quoted p 50. 255 Colonel Costedoat, ‘Direction du service de santé au ministère de la Défense Nationale’ (Medical Service Directorate of the Defence Ministry), CHEDN, La défense sanitaire, 1917. Provisional classification 9NN656, DAT, SHD.

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considered a separate and full military domain. Its operational involvement is undeniable, it is well understood at the tactical level but it remains a challenge to integrate it in strategic theory. Military leaders do not think ‘health’, the medical aspect is often dealt with at the end of the development process and only afforded a few seconds in a briefing. The object is certainly not to make it the most important aspect, but rather to integrate it from the very start in the thought process where many military leaders already consider it useful.

We have shown in this study that the medical domain has a strong potential, which while always present throughout the centuries, has been difficult to exploit, because of external constraints. It is now seen as a valuable actor who can offer the commander increased power, freedom of action and a guarantee of security in manoeuvre.

It has other

advantages, including those who favour the indirect strategy. It is a useful tool to isolate the adversary from his local population, weaken him mentally and open the way to a bloodless victory. This kind of strategy is increasingly important when dealing with asymmetric conflicts where the human dimension has overtaken “technician armies256”.

Faced with all these changes, medical strategy has found a full and complete role. Ardant du Picq had already understood the importance of the human domain in 1870: “the study of combat must be based on knowledge of man; the human heart, not weapons, is the starting point for all matters in warfare”. He was concerned essentially with human reactions, but upon reflection, we believe everything is linked, mental prowess can only function when the body allows it. Moving beyond the combatant’s concerns, modern civilizations are especially attuned to public opinion which have a strong pull on the political world and therefore on the military realm. These two environments have separated in most nations, but a close link survives in the exercise of their respective functions. The art of war is intended to promote the specific political project of a community. For this reason, military forces are a tool of policy and are increasingly used as such. To do this, the military performs tasks other than war, including the resolution of complex crises by managing political, economical and environmental issues. The medical domain has a special role to play as a political tool. It is easier to use, not to provide the traditional military ‘hard power’, but ‘soft power257”, a capability that armies are developing using the civil-military concept. The medical domain may also serve to promote the value of military forces to

256

Hervé Coutau-Bégarie, Bréviaire stratégique (Compendium of Strategy), ISC, cité p 52. Joseph Nye, born 1937, is a geopolitical scientist who specializes in international relations who teaches at the Kennedy School of Government at Harvard. 257

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politicians, by serving in humanitarian disasters, by displaying the military capabilities sent on a coalition mission or by its ability to appease public opinion.

Medical strategy is now a reality, but it must still be integrated systematically in the planning and thinking of military leaders. The medical domain has matured; its challenges are now less technical than they were previously; the issue is now finding a way of being accepted and proving its full value to headquarters and armed forces. Acquiring knowledge of military thinking to plan medical manoeuvres and appreciate the intricacies of medical requirements is necessary, as is its integration within command levels. Progress was slow, but the medical domain is now at the highest level of its capability in terms of scientific knowledge, and it would be a shame not to make use of it. Man may one day no longer be at the heart of military issues, but that may require an end to war itself.

In the meantime, military medical services must continue to transform so that they can answer the expectations of their nations and their allies. The pace of change has accelerated compared with previous centuries and medical strategy while not entirely integrated within military thinking, must continue to adapt. This would include the recent concept of medical diplomacy born of health crises, humanitarian disasters and the health issues encountered during the wars in Iraq and Afghanistan. This is essential if it is to acquire a real influence, on the national and international scene.

The medical domain has evolved over twenty centuries to reach a level of strategic, and now, political recognition. This change was progressive and followed the evolution of society. War continues to exist, but the human factor has penetrated even the realm of absolute violence. The medical era is now open, and â&#x20AC;&#x153;if there is a virtue superior to love of homeland, it is love of humanity258â&#x20AC;?.

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AbbĂŠ Gabriel Bonnot de Mably (1709-1789): French philosopher.

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Ouvrages traitant du domaine politique 1.

Julien Freund, Qu’est-ce que la politique ?, Paris, Seuil, Politique, 1967.

Ouvrages de référence 1. 2. 3.

Livre Blanc, défense et sécurité nationale, 2008. Conventions de Genève, 12 août 1949 et protocoles additionnels PI, PII,1977 et PIII, 2005. Le petit Larousse, 2003.

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Ouvrages traitant de la médecine militaire 1. 2. 3. 4. 5. 6. 7.

Sous la direction de Pierre Lefebvre, Histoire de la médecine aux armées, Tomes I, II, III, Lavauzelle, 1982. P.Juillet, P.Moutin, Psychiatrie militaire, Masson et cie, 1969. Jourdan Le Cointe, La santé de Mars, 1790. Louis Maufrais, présenté par Martine Veillet, J’étais médecin dans les tranchée, Robert Laffont, 2008. Sous la direction d’Eric Deroo, La médecine militaire, ECPAD, 2008. Guy Briole, François Lebigot, Bernard Lafont, Psychiatrie militaire en situation opérationnelle, Addim, 1998. Docteur Brice et Capitaine Bottet. Corps de santé militaire en France, son évolution – ses campagnes (1708-1882), Berger-Levrault & Cie, Editeurs, 1907.

II- Les revues Revue Médecine et armées 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26.

Bernard Lafont, Editorial : Hier, aujourd’hui, demain…, Médecine et armées, 2008, 36,5. R. Forissier, Crise du soutien sanitaire du corps de bataille français au cours de la retraite de maijuin 1940, Médecine et armées, 1999, 27,8. G.Gillyboeuf, Le service de santé des armées en guerre : ses règles d’or, médecine et armées,1,6,1973. P.Doury, Lyautey et la médecine, Médecine et armées, 1999, 27, 8. R.Forissier, M.Damandieu, La guerre du Grand Pardon, Médecine et armées, 1976, 4, 7. D.Esquivié, P.Arvers, D.Leifflen, Soutien médico- psychologique des personnels en opérations, Médecine et armées, 2006, 34,1. Raingeard, Regard d’un médecin d’unité sur sa fonction d’hygiéniste mental, Médecine et armées, 1997, 25,5. E.Dumas, M.Freulon, D.Davis, J-Y.Kervella, Le rôle des vétérinaires des armées dans l’évolution de la médecine vétérinaire, Médecine et armées, 2008, 36,2. D.Vidal, R.Deloince, Trois siècles de recherche et de découvertes au sein du service de santé des armées, Médecine et Armées, 2008, 36, 5. J.L.Rey, Service de santé des armées et actions civilo-militaires au Kosovo : de la théorie à la pratique, Médecine et armées, 2001, 29,2. J-N.Giroux, Evacuations sanitaires héliportées au cours du conflit vietnamien, médecine et armées, 2001, 29, 3. P. Cristau, Le visage social du médecin militaire, Médecine et armées, 2008, 36,5. P.Burnat, J-F.Chaulet, F.Chambonnet, F.Ceppa, C.Renard, De l’apothicaire au pharmacien des armées, médecine te armées, 2008, 36, 5. G.B.Clark, La médecine dans les forces spéciales américaines, au Vietnam de 1969 à 1970, Médecine et armées, 1982, 10, 3. J.Renault, Soutien médical du détachement d’intervention « Guépard », Médecine et armées, 1982, 10, 3. L.J.Courbil, A.Barbier, Les antennes chirurgicales parachutistes en Afrique du nord, Médecine et armées, 1982, 10, 3. J.P.Thomas, N.Foures, Les antennes chirurgicales parachutistes en Indochine (1947-1954), Médecine et armées, 1982, 10, 3. J.N.Ferret, R.Forisser, L’opération du 2ème REP sur Kolwezi au Zaïre, Médecine et armées, 1982, 10, 3. J.Ch.de Saint Salvy, L’antenne chirurgicale parachutiste, Médecine et armées, 1982, 10, 3. J-N.Giroux, La médecine aérospatiale au cours de l’histoire, Médecine et armées, 2000, 28, 5. G.Pagliano, La chirurgie militaire à Strasbourg, des origines à 1870, Médecine et armées, 1999, 27, 8. J-L.Suberchicot, Trois siècles d’histoire hospitalière à Rochefort, Médecine et armées, 1999, 27, 8. F.Lebigot, La folie de la guerre de 1914-1918, Médecine et armées, 1995, 23, 3. R.Forissier, Crise du soutien sanitaire du corps de bataille français, au cours de la retraite de maijuin 1940, Médecine et armées, 1999, 27, 8. J-N.Giroux, Généralités sur l’arme biologique, Médecine et armées, 2001, 29, 4. F.Honoré, G.Laurent, Evacuation sanitaire stratégique par voie aérienne, point de situation et évolution, Médecine et armées, 2005, 33, 1.

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27. H.Boisseaux, Psychiatres et OPEX, être présent au-delà de l’urgence, Médecine et armées, 2005, 33, 1. 28. A.Capdebielle, L’activité médicale à l’Hôtel des Invalides, Médecine et armées, 1981, 9,7. 29. D.Vallet, J-D.Favre, Spécificités de la psychiatrie dans les armées, 2005, 33, 5. 30. P.Clervoy, Psychiatrie du combattant : évolution sur trois siècles, Médecine et armées, 2008, 36, 5. 31. J.M.Le Minor, L.Schlaefli, Hôpital militaire de Strasbourg, un document inédit de 1685 illustrant ses débuts, Médecine et armées, 1999, 27, 8. 32. D.Vidal, R.Deloince, Trois siècles de recherche et de découvertes au sein du service de santé des armées, Médecine et armées, 2008, 36, 5. 33. A.Fabre, Les traditions de la médecine de l’avant, Médecine et armées, 1980, 8, 10. 34. J-Cl.Laparra, Le service de santé allemand 1914-1918, l’exemple du saillant de Saint-Mithiel, Médecine et armées, 2003, 31, 2. 35. J-N.Giroux, Naissance et premiers défis de la médecine militaire américaine au XIXème siècle Médecine et armées, 2000, 28, 3. 36. M.Curet, P.Huard, A.Carre, J.Veron, R.Henaff, Les traditions de la Marine, une médecine de la mer, Médecine et armées, 1980, 8, 10. 37. J.Vlaminck, E.Darré, G.Laurent, Soutien sanitaire des opérations extérieures, évolutions récentes, Médecine et armées, 2005, 33, 1. 38. L.Clerc, E.Darré, J.Vlaminck, R.Tymen, G.Laurent, Soutien sanitaire : le retour d’expérience, enseignements du Kosovo de 1998 à 2001, Médecine et armées, 2001, 29, 6. 39. R.Tymen, P.Godart, G.Laurent, Les grandes évolutions actuelles du soutien médical en opérations, Médecine et armées, 2001, 29, 6. 40. J.Voelckel, Les traditions du service outre-mer, Médecine et armées, 1980, 8, 10. 41. R.Forissier, M.Darmandieu, La guerre du « grand pardon » et le service de santé de l’armées d’Israël, Médecine et armées, 1976, 4, 7. 42. M.Curet, A.Carre, R.Henaff, Les hôpitaux des ports, Médecine et armées, 1980, 8, 10. 43. P.M.Niaussat, L’activité scientifique des médecins et pharmaciens de la marine du XVIIème siècle à nos jours, Médecine et armées, 1980, 8, 10. 44. J.Guillermand, L’Iliade ou le commencement, Médecine et armées, 1980, 8, 6. 45. D.Moysan, M.Bernicot, Le service de santé des armées et l’évolution du concept hospitalier en France, Médecine et armées, 2008, 36, 5. 46. R.Tymen, Equipements techniques modulaires du service de santé des armées, Médecine et armées, 1994, 22, 5., 47. L.Falandry, Œuvre humanitaire pour la construction de la paix, Médecine et armées, 1994, 22, 7. 48. A.Larcan, Historique du triage militaire, Médecine et armées, 1994, 22, 8. 49. E.Kaiser, Soutien médical de l’opération Baumier au Zaïre, Médecine et armées, 1993, 21,1. 50. A.Malfosse, M.Nugeyre, B.Groscaude, A.Pierre, G.Poyot, Soutien sanitaire de l’opération Daguet, Médecine et armées, 1992, 20 1. 51. J.Videlaine, P.Rocher, Le service de santé dans la guerre du Golfe, Médecine et armées, 1992, 20, 1. 52. A.Puidupin, M.Puidupin, T.Lefort, J.P.Gomis, Y.Sauces, Services de santé régimentaires au cours de l’opération Daguet, réflexions à propos de la médicalisation de l’avant, Médecine et armées, 1992, 20, 1. 53. J-M.Ramirez-Martinez, C.Bay, B.Tramont, J.P.Reiss, R.Dupeyron, Décontamination de blessés chimiques, expérience de la division Daguet, Médecine et armées, 1992, 20, 1. 54. J.Y.Kervella, C.Perraudin, G.Nedelec, Hygiène des denrées alimentaires et de la restauration collective au cours de l’opération Daguet : soutien vétérinaire, Médecine et armées, 1992, 20, 1. 55. B.Lafont, D.Raingeard, Psychiatrie dans le Golfe, Médecine et armées, 1992, 20, 3. 56. J.P.Taillemite, Mission Prométhée, bilan de l’activité du service de santé du porte-avions Clémenceau, Médecine et armées, 1991, 19, 9. 57. G.Dupeyron, J.C.Rouveure, Application de l’informatique à la conduite des évacuations sanitaires par voie aérienne, Médecine et armées, 1990, 18, 1. 58. G.Chanussot, R.Taxit, J.Maire, B.Davoust, Y.Polvèche, Alimentation et hygiène en opérations, Médecine et armées, 1990, 18, 5. 59. A.Lacan, Historique du triage militaire, Médecine et armées, 1994, 22, 8. 60. E.Kaiser, Soutien médical de l’opération Baumier au Zaïre, Médecine et armées, 1993, 21, 1. 61. A.Malafosse, M.Nugeyre, B.Grosclaude, A.Pierre, G.Poyot, Soutien sanitaire de l’opération Daguet, Médecine et armées, 1992, 20, 1. 62. J.Videlaine, P.Rocher, Le service de santé dans la guerre du Golfe, Médecine et armées, 1992, 20, 1. 63. A.Puidupin, M.Puidupin, T.Lefort, J.P.Gomis, Y.Sauces, Services de santé régimentaires au cours de l’opération Daguet – Réflexions à propos de la médicalisation de l’avant, Médecine et armées, 1992, 20, 1. 64. J.M.Ramirez-Martinez, C.Bay, B.Tramont, J.P.Reiss, R.Dupeyron, Décontamination de blessés chimiques : expérience de la division Daguet, Médecine et armées, 1992, 20, 1.

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65. R.Tymen, Equipements techniques modulaires du service de santé des armées – Mise au point, Médecine et armées, 1994, 22, 5. 66. J.Y.Kervella, C.Perraudin, G.Nedelec, Hygiène des denrées alimentaires et de la restauration collective au cours de l’opération Daguet : soutien vétérinaire, Médecine et armées, 1992, 20, 1. 67. B.Lafont, D.Raingeard, Psychiatre dans le Golfe, Médecine et armées, 1992, 20, 3. 68. F.Perello, Soutien sanitaire au cours de l’opération ONUSOM II – Contribution du détachement de l’ALAT, Médecine et armées, 1995, 23, 1. 69. P.Barriot, J.N.Ferret, Ch.Mourareau, L.Dechazal, Y.Le Gallou, Réflexion sur la médicalisation de l’avant en ambiance chimique, Médecine et armées, 1990, 18, 8. 70. P.Godart, Peut-on parler de stratégie opérationnelle du soutien santé ?, Médecine et armées, 2007, 35, 5. 71. G.Tinland, D.Le Fol, J.Rousvoal, M.Durassier, FORPRONU – Rôle de l’adjoint santé auprès du commandement, Médecine et armées, 1995, 23, 4. 72. F.Pons, S.Rigal, Ch.Dupeyron, Opération Turquoise – Antenne chirurgicale parachutiste à Goma, Médecine et armées, 1995, 23, 4. 73. J.M.Rousseau, M.Galzin, J.L.Marle, D.Morin, Opération ORYX – Antenne Médico-chirurgicale en Somalie, Médecine et armées, 1995, 23, 4. 74. J.P.Boutin, Approche de la communication sanitaire en situation de crise, Médecine et armées, 2005, 35, 3. 75. D.Vallet, P.Arvers, P.Furtwengler, C.Renaud, F.Neel, O.Renaut, E.Brandmeyer, C.Giacardi, Etude exploratoire sur l’état de stress post-traumatique dans deux unités opérationnelles de l’armée de terre, Médecine et armées, 2005, 33, 5. 76. P.Clervoy, Soutien psychologique d’une force navale en opération, Médecine et armées, 2005, 33, 5. 77. D.Vallet, J.-D.Favre, Spécificités de la psychiatrie dans les armées, Médecine et armées, 2005, 33, 5. 78. E.Dumas, P.Lavier, Participation d’un vétérinaire des armées à la planification d’un exercice multinational – Golfe 2004, Médecine et armées, 2005, 33, 1.

Autres revues 1.

2. 3. 4. 5. 6. 7.

9. 10. 11. 12. 13. 14.

Dejan Bajcetic, Stojan jovelic, Danilo Krstic, Nebojsa Jovic et Milovan Novovic, Experience in evacuation wounded and sick on the territory of the former Yugoslavia in the war time 1991-1995, F.Y.R.O.Macedonia, revue internationale des services de santé des forces armées, Vol 76/1, 2003. Michel Godet, Démocratie ou démagogie, Le monde 2007 ; janvier 1924. Le service de santé en temps de guerre, France militaire 24.4.25. La crise de la médecine militaire, France militaire, 02 février 1927. R.Picqué, L’état actuel de l’aviation sanitaire, Revue de l’aéronautique militaire, 1925. Chirurgie de guerre :la leçon des Malouines, Quotidien du médecin, 1983, 3003. Earl W.Mabry M.D., Robert A.Munson MD, Londe A.Richardson MD, The Wartime Need for Aeromedical Evacuation Physicians: The U.S Air Force Experience During Operation Desert Storm, Aviation, Space and Environmental Medicine, Technical note, October 1993. Terence J.Lyons MD, M.P.H, Susan B.Connor, R.N.S.C, M.S.N, Increased Flight Surgeon Role in Military Aeromedical Evacuation, Aviation, Space and Environmental Medicine, Vol 66, No. 10, October 1995. Jean Timbal, Le service de santé de l’Air d’Afrique du Nord. De novembre 1942 à la fin de la guerre, Médecine aéronautique et spatiale, Tome 47, n°176, 2006. David M.Lam, To pop a Balloon : Aeromedical Evacuation in the 1870 Siege of Paris, Aviation, Space and Environmental Medicine, Historical Note ,October 1988. Jay.B.Baker, Medical Diplomacy in full-spectrum operations, Military Review, Sept-Oct 2007. Donald. F.Thompson, The role of Medical Diplomacy in Stabilizing Afghanistan, Defense Horizons, N°63, May 2008. Michael McNerney, Stabilization and reconstruction in Afghanistan: are PRTs a Model or a Muddle?, Parameters, 32-33, Winter 2005/2006. Jay B.Baker, La médecine américaine est une “arme de la paix” puissante dans l’arsenal national contre les terroristes et les forces d’oppression, Military Review, Sept-Oct, 2007.

III- Les documents historiques et les archives

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Les documents historiques 79. 80. 81. 82. 83. 84. 85.

Edit du ROY, donné à Versailles au mois de janvier 1708, enregistré au parlement le 22 mars 1708. XIème livre d’Ambroise Paré sur les plaies par arquebuses et bastons à feu, XVIème siècle. Pigafetta, Il viaggio fatto da gli Spagnivoli a torno a’l mondo. Traduction G.Bolliet. Manuscrit espagnol n°214, Fol.31r° et v°-Bibliothèque Nationale. Deutéronome, XXIII, 12. et XX, 10-20. Traduction du rabbinat français. Voltaire, XIème lettre philosophique, 1734. Catinat, Mémoire contenant les moyens de faire la guerre offensivement dans le piémont en 1694 adressé au roi. 86. Tite-Live, Histoire romaine, Livre XL, chapitres XXXII et XXXIII. Traduction V.Verger. 87. Ordonnance portant sur le règlement général des hôpitaux militaires, éditée en 1747 après la bataille de Fontenoy, 88. Ordonnance royale créant les « hôpitaux amphithéâtres », du 04 août 1772. Archives du service historique de la défense, direction de l’armée de terre Côte provisoire 9NN621 1. Lettre du Dr Martin-Sisteron au ministère de la guerre, 24 janvier 1936. 2. Général Huntziger, commandant supérieur des troupes du Levant, Lettre au service de santé des armées, en 1936. Côte provisoire 9NN624 1. Circulaire n°1921 B du 20 mars 1924. Côte provisoire 9NN631 1. Projet de loi sur le SSA, 1922. 2. Projet de loi sur le SSA, 1927. 3. Décret du 29 mars 1811. Côte provisoire 9NN634 1. Bulletin officiel des médecins en réserve, juillet 1912, p 1102. Côte provisoire 9NN637 1. Correspondance de la direction des troupes coloniales, 1er bureau, bureau technique, n°2.354-1/8-1er octobre 1924. 2. Décret du 04 novembre 1903 relatif à l’organisation des services de santé coloniaux, BO p 1627. Côte provisoire 9NN656 1. La défense sanitaire, 1917. Côte provisoire 9NN670 1. Correspondance officielle. 2. Rapport de l’Etat-major de l’Armée, 1919. 3. Bilan du service de santé. 4. Document écrit par le Médecin Major de première classe Coudray, 1923. 5. Document de l’Etat-major Général / direction de l’arrière 1663 DA. 6. Correspondance du Médecin Principal de 2ème classe Mellies, juin 1917. 7. Rapport sur les progrès accomplis dans le fonctionnement du service de santé pendant la guerre, 1922. Côte provisoire 9NN671 1. Rapport mensuel du mois de septembre 1916 du médecin inspecteur Ruotte, chef supérieur du service de santé des armées alliées en Orient. 2. Rapport du Médecin major de 1ère classe Robert Picqué, affecté du 02 août 1914 au 20 janvier 1919 à l’A.3/18 comme médecin chef et chirurgien consultant du 18ème Corps d’Armée. Côte provisoire 9NN691 1. Lettre du sous-secrétaire d’Etat de la guerre « Artillerie et Munitions » au sous-secrétaire d’Etat du service de santé militaire, 21 août 1915.

Côte provisoire 9NN704

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1. Rapport du général Voruz, attaché militaire à l’ambassade de France à Londres, relatif à l’historique sommaire du service de santé britannique, au 2ème bureau de l’état-major de l’Armée, le 14 septembre 1932. 2. Rapport de mission des médecins principaux de 1ère classe Visbecq et Duguet, 1923. 3. Général Lanne, Bases et principes de tactique sanitaire, 9 novembre 1934.

IV. Textes réglementaires 1. Instruction n°1826/DEF/EMA/SLI/PSE du 13 septembre 2005, relative à l’hygiène et la sécurité en opération. 2. Directive de 1997, relative aux ACM au Kosovo. 3. Décret 2005-520 du 21 mai 2005 fixant les attributions des chefs d’état-major. 4. Instruction n° 12 du 05 Janvier 1999 relative au concept interarmées du soutien sanitaire des forces en opération. 5. Décret n°91-685 du 14 juillet 1991 fixant les attributions du service de santé des armées. 6. Décret n° 81-60 du 16 janvier 1981, relatif au code de déontologie médico-militaire. 7. PIA-03.154, relative au concept interarmées d’intervention extérieure de secours d’urgence (IESU), 10 janvier 2008. 8. PIA-04.101, relative au concept interarmées d’évaluation sanitaire des risques, juin 2008. 9. PIA-09.101, relative à la doctrine interarmées de l’aide médicale aux populations, 15 mai 2009. 10. AJP4.10, relative à la doctrine du soutien médical allié interarmées. 11. PIA-00-300, relative au contrat opérationnel, du 1er août 2008.

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