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Theater Commander's View of Medical Support
Remarks as Delivered by Gen. James Henry Binford Peay III, commander, U.S. Central Command, at the Association of Military Surgeons of the United States, San Antonio, Tuesday, November 12, 1996

Defense Issues: Volume 11, Number 102-- Theater Commander's View of Medical Support America's military medics must stand ready to contend with strenuous demands -- demands that call for visionary leadership, innovation and imagination.


Volume 11, Number 102

Theater Commander's View of Medical Support

Remarks delivered by Gen. James Henry Binford Peay III, commander, U.S. Central Command, at the Association of Military Surgeons of the United States, San Antonio, Nov. 12, 1996.

It's a pleasure to be with all of you this morning for the annual meeting of the Association of Military Surgeons of the United States. Your focus this morning is delving into the linkage between the military medical community and the warfighters -- a relationship that involves intricate matters and major challenges that defy simple solutions.

I find it curious that while the value of military medicine in contributing to victory in battle has been recognized since antiquity, our ability to deliver effective medical care is less than a century old. Writing in 600 A.D., Roman Emperor Maurice directed:

"Eight or ten of the soldiers in each tagma should be assigned as medical corpsmen to each bandon, especially in the first battle line ... They should be alert, quick, lightly clothed and without weapons. Their duty is to follow about a hundred feet to the rear of their own tagma, to pick up and give aid to anyone seriously wounded in battle ... or who has fallen off his horse, or is otherwise out of action, so they may not be trampled by the second line."

Thus, Emperor Maurice made clear the need for light, modular, flexible medical assets to preserve his fighting force.

While surgeons over the next several hundred years gained proficiency in amputating limbs, cauterizing wounds and performing basic surgical procedures, they had difficulty snuffing out ubiquitous diseases looming in the shadows, ever poised to decimate armies. Plague, dysentery, smallpox, measles, flu, malaria, infections of every sort -- these were the silent killers of soldiers through the ages. What were the great captains of history to do? They lacked the scientific knowledge and medical expertise needed to overcome seemingly mysterious afflictions.

We who serve today owe a debt to generations of scientists, medical researchers, surgeons, pathologists, nurses, preventive medicine specialists, dentists and other members of the medical profession, what I will call "medics," and you are members of those ranks. For you and they have delivered to the human race the knowledge, technology and treatments that have eradicated or controlled disease, extended life spans, reduced suffering and pain, raised the quality of the human condition to unprecedented levels and, for American military men and women, offered a greater assurance that they and their families would be well cared for in peace and war.

As a theater warfighting commander, I am concerned about these dynamics. And while all theater commanders share similar concerns, requirements in my area of responsibility, the Central Region, are particularly demanding. A vast area characterized by some of the world's most inhospitable climate and terrain, the Central Region stretches from Egypt, Sudan and East Africa through the gulf states to Afghanistan and Pakistan and includes the waters of the Red Sea, Arabian Gulf and western portion of the Indian Ocean. These ancient lands have suffered from centuries of bloody conflict and harbor some of the world's most virulent diseases.

In this daunting setting, America's military medics must stand ready to contend with strenuous demands -- demands that call for visionary leadership, innovation and imagination.

Those demands can be divided into three broad activities: Preventing casualties; promoting the readiness of our medics to handle battle and nonbattle casualties as they occur; and leveraging the full capabilities of the active and reserve medical forces. My comments this morning center on these three activities in the context of warfighting in the Central Region.

Our nation's involvement in the Central Region reflects our manifold interests in that part of the world. One of the most pressing of these is maintaining the flow of reasonably priced oil. Some 65 percent of the world's proven oil reserves are located there, from which the U.S. imports nearly 20 percent of its needs; Western Europe, 43 percent; and Japan, 68 percent -- with experts predicting these import percentages to increase by 10 percent over the next decade.

Under the circumstances, disruption of this oil trade or dramatic increases in oil prices would cripple the world economy. At the same time, our interests transcend access to regional oil. Other vital interests include ensuring freedom of navigation and access to commercial markets, protecting American citizens and property abroad, and promoting the security of regional friends in the context of a comprehensive Middle East peace.

Other important, enduring interests include countering proliferation of weapons of mass destruction, defeating terrorism, stemming the flow of narcotics, encouraging democratization, advancing economic development and promoting respect for human rights. These multifaceted interests reflect our country's long-standing effort to broker a comprehensive Middle East peace between Israel and its neighbors and our commitment to traditional American values.

Safeguarding these diverse national interests is an uphill battle. More than a dozen internal and external conflicts plague the region daily. These conflicts are rooted in long-standing religious and tribal strife among the region's 430 million people and flow from border disputes, competition for resources, economic distress and exploding populations. For simplicity, these regional threats can be grouped into five broad categories: Iraq, Iran, proliferation of ballistic missiles and weapons of mass destruction, terrorism and general regional instability.

With its reorganized and streamlined forces and refurbished military hardware, Iraq is the most dangerous near-term threat to regional peace and stability. Though half its gulf war size, Iraq's army remains the region's largest and continues to threaten Kuwait and Saudi Arabia. A master of deception and brutality, Saddam [Hussein] has cynically defied and manipulated postgulf war United Nations Security Council resolutions. As the international community edges closer toward allowing Iraq to sell oil for humanitarian purposes, we must guard against Saddam diverting resources to amass an even stronger force, one equipped with more advanced conventional arms and weapons of mass destruction.

The long-term threat to regional peace and stability is Iran. In the 16th year of its revolution, Iran competes with Iraq for dominance of the gulf and is committed to leading the Islamic world. At first glance, it appears Iran faces severe obstacles in achieving such aims. It suffers from an intense internal power struggle, economic malaise, declining oil revenues, overpopulation, high unemployment and large debt. At the same time, its army and air force are in poor shape, better postured to defend its borders and occupy disputed Arabian Gulf islands rather than to undertake foreign adventures.

Despite these significant shortcomings, Iran must be viewed relative to weaker and less populous neighbors. With nearly 70 million people, large number of highly educated engineers and technicians and large oil reserves, Iran retains the means, over the long term, to endanger other gulf states and U.S. interests. Its two Kilo submarines and 20 modern patrol boats, several of which are armed with C-802 anti-ship cruise missiles, endow Tehran with the means of threatening Persian Gulf shipping lanes. In addition, Iran compensates for its limited military capabilities by supporting terrorist groups and individuals: terrorists prepared to attack U.S. interests worldwide.

Magnifying these Iraqi and Iranian dynamics is the continuing proliferation of ballistic missiles, chemical and biological weapons and nuclear technology. The situation has deteriorated during the past 12 months, with Iraq, Iran and others in the region pursuing missile and nuclear technology aggressively and advancing their WMD (weapons of mass destruction) research and development programs. To the dismay of the United States and other countries who are struggling to stem the flow of this destructive weaponry, nations such as China, North Korea and Russia have supported these efforts.

This worrisome trend is aggravated by the ever-expanding inventory of off-the-shelf technology that reduces time lines for developing and fielding unconventional weapons. Intrusive U.N. inspections reveal Saddam is concealing key parts of his WMD program. Iran is pursuing similar programs and has erected underground bunkers to protect command and control and missile related infrastructure.

Armed with these lethal weapons, Iraq, Iran and other rogue states in the region could soon possess the means to strike unprotected civilians, paralyze governments worldwide with fear and indecision, erode coalition resolve and directly threaten U.S. interests with more advanced systems.

Exacerbating these perils is the evolving terrorist menace, one that reflects various religious, political, ethnic, tribal causes. Though it has afflicted the greater Middle East for decades, terrorism is just now beginning to plague the gulf states.

Various state, nongovernment and private sponsors provide funding, administrative assistance, training and sanctuary to groups like Hamas, Hizballah and Al-Jihad.

Of greater concern are the emerging "transnational" groups, made up of Islamic extremists, many of whom fought in Afghanistan, who now drift among regional states to topple traditional governments, attack U.S. interests and establish fundamentalist regimes. Detecting, monitoring and countering these groups is difficult because they consist of small, cellular structures and generally operate with little centralized direction.

In addition to those already described, other regional states face grave challenges. Egypt, a major regional military power and a cornerstone of the American-led effort to achieve a comprehensive Middle East peace, battles political and religious extremists. These extremists are supported by Sudan, a nation that sponsors unrest throughout Africa, to include Ethiopia, Eritrea and Kenya. Owing to Sudan's dominance of the headwaters of the Nile River, its civil war and conflict with neighboring states is alarming.

In the Horn of Africa, Eritrea and Yemen are trapped in a tense contest over control of the Hanish Islands in the Red Sea, while Somalia continues to hemorrhage from clan bloodshed. In South Asia, Pakistan and India are locked in a bitter clash of wills over Kashmir, with both parties committed to pursuing long-range missiles and weapons of mass destruction. At the same time, Afghanistan suffers from a costly civil war and tribal rivalries that threaten to spill over into neighboring states.

Finally, there is the long-term challenge of assisting regional friends in undertaking peaceful and stable political change as aging leaders turn over control to the next generation -- a development that has far-reaching implications for our country and the world.

Iran, Iraq, proliferation of WMD, terrorism and regional stability: These are the five major regional threats with which our nation must contend. These are the five major threats that I focus on 24 hours a day, seven days a week.

So what are we to do about these threats? How do we secure the mutual interests of our country and regional friends? What do these threats portend for our military forces in times of conflict and war? And how does all of this impact on you, our medical experts?

Clearly, we must be equipped, trained and postured to handle all of the challenges I have described.

With this in mind, we have designed a theater strategy that meets the demands of operating over lines of communication extending more than 7,000 air miles and over 12,000 sea miles between the continental United States and the gulf, accounts for limited formal agreements, provides the means for defeating our many adversaries and contends with the harsh climate and rugged terrain of the region.

It is a theater strategy that supports unilateral action when required but recognizes America's long-term regional goals are achieved best by working cooperatively with regional friends in partnerships and coalitions. Cooperative relationships, in turn, provide the access that supports deployment and employment of U.S. military force in the region. It is a theater strategy that also promotes military partnerships and coalitions with regional states as part of a long-term effort -- a 20- to 25-year process.

Our theater strategy recognizes that generating the combat power needed to contend with the myriad of regional threats requires more than over-the-horizon forces. We must harness the complementary capabilities of all of our armed services, some on land, some on sea, some in the air, to deter conflict and win decisively if deterrence fails. We need such a combination to cement the coalition during crisis.

Meanwhile, we are sensitive to oversaturating regional partners with excessive military forces and to respecting regional values. We are acting in a way that minimizes the danger of growing a generation that embraces anti-Americanism and political extremism. With these thoughts in mind, we place the minimum number of personnel ashore and position them in a manner that accomplishes the mission while mitigating their vulnerability to terrorist attack.

These strategic precepts and activities are embedded in five core elements or strategic pillars: forward presence, power projection, combined exercises, security assistance and readiness to fight. Together, these pillars safeguard America's interests in peace and war.

It is in the context of this theater strategy that we can understand the role of our medics in preventing casualties when possible, maintaining combat readiness to handle casualties as they occur and leveraging the full capabilities of the active and reserve medical forces.

The first pillar, power projection, reflects our military's ability to rapidly move extraregional forces to the region during crisis and posturing them for combat operations. This requires aircraft like the C-5 and C-17 and sealift like the fast roll-on /roll- off ships. Meeting stringent deployment times means having access to a global chain of airfields and seaports. Reducing the window of vulnerability to U.S. and friendly forces arrayed in defensive positions involves drawing on hardware and supplies loaded on ships in overseas anchorages like Guam or Diego Garcia and capitalizing on the advances in total asset visibility.

In the medical arena, power projection translates into fielding units that are light, modular and flexible. In future crises, we will not have long lead times for deploying organizations, setting up large numbers of field hospitals and building up supplies. The need for speed in responding to regional threats means positioning selected assets afloat, packaging them in the U.S. for ease of movement and gaining maximum benefit from the capabilities of all the services around the world.

To lighten the medical infrastructure without losing quality and responsiveness means acquiring light, flexible medical units able to resuscitate and stabilize patients as far forward on the battlefield as possible. These forward medical units must be complemented by a robust, efficient air evacuation capability able to handle freshly stabilized patients and maintain accurate patient tracking. They must concurrently be able to exploit communications technologies, such as telemedicine, to promote a distributed medical network linking medical assets forward with those in the communications zone and continental United States.

What's more, we must be able to quickly transition individual medics from stateside hospitals and reserve units to forward-deployed tactical organizations while simultaneously backfilling our medical organizations with splendid reservists. And we must do these things consistent with tight timelines and without compromising on readiness or care for our military families.

Closely related to power projection is the second strategic pillar, forward presence. This includes the relatively small but lethal mix of air, ground and sea forces maintained forward in the gulf. Through forward presence, we deter conflict, enhance access to regional states and support the transition from peace to war. To reduce the time required for deploying additional forces, we pre-position stockpiles of supplies and equipment ashore throughout the region, to include deployable hospitals and medical equipment, supplies and vehicles.

In keeping with the need to maintain a relatively small footprint forward in the region, we tailor medical organizations forward to provide routine medical care and establish the basis for rapidly expanding them during crisis. Success requires networking military organizations with one another and with assets belonging to the Department of State and host nation.

Part of this effort includes working closely with host nations to identify their capability to augment U.S. military medical units and to assist them in raising their standards of clean water and general sanitation. Another component of forward presence is the medical research on diseases and new treatments we are engaged in throughout the region. Such efforts improve both the readiness of our own forces and the health of regional populations.

The third and fourth pillars, security assistance and combined exercises, bolster power projection and forward presence. Through combined exercises, we reinforce forward-positioned forces with units and individuals participating in exercises. Such activities provide our own personnel valuable environmental training while simultaneously promoting readiness of regional partners. These efforts are reinforced by security assistance, which includes foreign military sales, foreign military financing, security assistance teams, and international military education and training.

In the course of our exercises and security assistance programs, we train regional physicians, nurses, administrators and other medical personnel. This refines our capability to carry out coalition medical operations, enhances the ability of regional medical personnel to support U.S. medics during crisis and raises their ability to care for their own citizens. Cumulatively, these activities cement relations with regional friends, thereby furthering long-term regional stability.

The fifth and final pillar, readiness to fight, means carrying out detailed operational planning, establishing procedures for speedy crisis deployment and exercising senior battle staffs to conduct high tempo, joint and multinational operations.

From the medic's perspective, readiness to fight means standing up and equipping flexible medical organizations and training medics, both active and reserve, to perform wartime tasks. This includes devising techniques and fielding equipment that support treatment of the full spectrum of injuries, from curing the individual service member with an infection to handling mass casualty situations to dealing with the unique demands associated with weapons of mass destruction. It also calls for stockpiling serums, antidotes and antibiotics.

Readiness to fight also means preparing service members for combat operations, the essence of preventing casualties. This includes undergoing periodic physicals and dental checks, getting vaccinations, carrying out individual predeployment readiness training and completing predeployment screening. Another aspect of preparing personnel for combat is assuring the depth of medical care by training all nonmedical military personnel on first aid and combat life saving techniques, skills that preserve lives during accidents, natural disasters, terrorist attacks and war.

Medical readiness to fight extends beyond the theater of operations. It includes our services maintaining superb military medical schools and training programs and integrating medical subjects into the curricula of other military schools. It means maintaining a reliable, affordable medical system that meets the needs of military dependents and retirees.

Our service men and women must have the confidence that their loved ones will be cared for if they are deployed overnight to a distant battlefield. Reliable medical benefits for our retirees is a visible demonstration of commitment to those that dedicate themselves to the profession of arms, while eroding those benefits can have a chilling effect on recruitment and retention.

These five strategic pillars and all that they involve facilitate accomplishment of our strategic ends in the region. They promote stability, deter conflict, limit the scope of conflict if deterrence fails and posture our forces to fight and win, if required.

During Desert Storm, the United States military pulled out all stops to deploy sufficient medical resources to handle what was feared would be massive casualties. Such fears were well founded. We knew Iraq had accumulated large inventories of chemical munitions and suspected the potential for biological weapons and, possibly, some form of rudimentary radiation device.

By February 1991, deployed hospitals comprising more than 13,530 beds and 24,000 medics -- making up almost 5 percent of the total deployed force -- were positioned in the gulf. Mobilizing, deploying, supplying and employing such organizations was accomplished at great expense and placed enormous pressure on the total military force. Meeting the massive needs in the theater of operations and at U.S. military hospitals around the world meant employing on a grand scale our active and reserve medics.

Fortunately, the number of casualties feared never materialized. Our servicemen and women were highly disciplined and in good shape, enjoyed generally good health, had access to clean water and food and were spared disease brought on by insects and other disease vectors. More important, the enemy did not employ the horrific weapons we feared and was overpowered by our superior military forces. At the same time, the high quality of our medical support contributed to an unprecedented level of care for treatment of U.S., allied and enemy casualties, to include thousands of Iraqi civilians.

In the years since the gulf war, we have seen all of our military services decline in strength. Our medics have not been spared. As we look to the future, the challenge for you, the medical experts, will be to continue to enhance your competency as both medical providers and members of your individual services -- to be the best soldiers, sailors, airmen and marines.

You must do this while never missing a beat, offering premier medical care to our service members and their families. You must do all of these things while standing up to the multiple demands I have outlined today, remaining ever ready to fight any foe, on any battlefield, now and in the future.


Published for internal information use by the American Forces Information Service, a field activity of the Office of the Assistant Secretary of Defense (Public Affairs), Washington, D.C. Parenthetical entries are speaker/author notes; bracketed entries are editorial notes. This material is in the public domain and may be reprinted without permission. Defense Issues is available on the Internet via the World Wide Web at