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This will be a military-to-military partnership with other nations that will require DOD and Military Health System support for success. These examples highlight that successful collaboration relies heavily on predeployment preparation. Beginning in June , the U. Navy was asked to contribute personnel to this facility. This transitioned to the U. Army in prior to closure of Camp Bastion in September Early on, the UK established a thorough predeployment training and validation model. This model fully incorporated U. As with any multinational military endeavor, there are always differences in tactics, techniques, and procedures TTP.

In this case, there were distinct differences in medical TTPs within the hospital command and control procedures and in the practice of trauma care between the United States and UK. In the vast majority of cases, these differences were not better or worse—just different. These differences in roles and responsibilities and in clinical medical practice were clarified in advance of deployment to ensure trust, cooperation, and smooth interoperability among international colleagues. The UK military medical field exercise Hospex served to facilitate interoperability.

The exercise was as the culmination of a successful predeployment training and validation model. A fully experienced and trained staff hosted a week-long validation exercise covering all aspects of Role 3 command and control procedures, patient care in the emergency department, operating room, intensive care unit, and patient ward; management of multi-casualty and mass casualty scenarios; patient evacuation procedures; and detained personnel procedures. After a thorough testing period, the UK military hospital team was validated for Operation Herrick.

This predeployment medical field exercise also served as predeployment interoperability training between the UK and the United States. This successful example is a model that we should replicate for future operations. Spanish Role 2 Hospital in Herat. Spain and Italy supported combat operations in western Afghanistan for a decade. Spanish Role 2 was the largest trauma facility in Regional Command—West. Beginning in January , the U. Although not as deliberately planned, this partnership was a good example of a NATO partner assuming primary responsibility for trauma care in a specific region of a combat zone.

The presence of American military surgical teams in this Spanish facility serves as another example of the need for interoperability. In , a U. The Italian military had an existing Role 1 facility with a primary care physician and medics to provide initial trauma care. The mission of the U. Role 2 successfully supported this brief special operations mission, but prior combined training with the Italians would have yielded a stronger unity of effort.

With the potential for numerous, dispersed operations throughout the world, placement of U. Our goal should be to collaborate and develop interoperability with all of our NATO Allies in order to share the responsibility of providing care. In addition, we should seek out opportunities to collaborate with medical units from less-developed partner nations. Lieutenant Commander Justin Dye, right, and Dr.

Partnering to improve host-nation trauma care in support of its security forces is a component of medical stability operations.

For success, this effort involves military-to-military, military-to-civilian, and civilian-to-civilian partnerships involving DOD, Military Health System, civilian university and hospital institutions, and Department of State. In support of stability and security operations and counterinsurgency operations, DOD often supports infrastructure development in key PNs.

As an important component of this greater strategy, our military trauma system leadership should collaborate with PN medical leadership in order to develop their trauma system infrastructure. The purpose of this collaboration and development is not specifically for the purpose of caring for injured U. Servicemembers but for improving host-nation trauma care in support of its security forces. This pillar truly overlaps with national global health engagement GHE efforts.

A coherent plan for trauma system development for the host-nation security forces should be integrated into the overall plan when conducting operations. Health diplomacy can represent a variety of activities from formal treaties to multiple stakeholder agreements to informal collaborations. Regarding strategic efforts for global trauma system development as part of health diplomacy, it is expected that regional commands would guide these efforts to locations of the military and national security interests.

Concurrently, DOD investment in global trauma system development, as a component of GHE, has the potential to provide a measureable benefit to an overall strategy. As the United States moves forward in GHE, we must be sure that we can measure the effects of our actions. Health diplomacy must not only serve national interests but also provide a measureable benefit to the target of GHE.

Furthermore, trauma system development is not mutually exclusive of the other important pillars already discussed. This pillar builds on the previous two involving the JTS role in trauma system advisory and development in LMICs of importance to national security interests. We stand ready for a changing world that will require revolutionary change in how we wield combat power and how we measure military success. The existence of a regulatory framework widely accepted by sovereign states, elaborated by international pseudo-institutions, 4 such as the Oslo Guidelines, is in line with the theorisation of English School authors, notably Hedley Bull and Martin Wight.

Therefore, there would be a consensual constraint of national interests on the basis of something understood as beneficial to this society as a whole, such as restraints on the use of force. For the latter, international relations are governed by rules that normalise relations between sovereign states, thus reaching a degree of order that could not be expected in an anarchical system. Wight believed that in an international society where there is an asymmetrical distribution of power, the system functioning depends on the existence of regular mechanisms of communication between states and a set of rules that regulate the context within which the states operate.

The defence of common interests in maintaining the interstate system, either through the balance of power or through collective security, is defined in terms of a contradictory relationship that sometimes takes on the same time aspects of co-operation and conflict Wight The application of military means to essentially co-operative activities, such as aid to the victims of sudden natural disasters, finds support in this contradictory relation, without necessarily excluding the fundamental character of the existence of the armed forces, namely conflict.

It is understood in this work that the use of the logistical means of the fast-acting forces in humanitarian actions, although co-operative, is also a deterrent. By designing military forces to deploy to difficult-to-reach regions with little or no prior warning, NATO, for example, has demonstrated operational capabilities that discourage potential or actual opponents of possible or presumed future war intentions.

Particularly for European allies, this is an important tool in trying to secure the status quo before the great powers. In the early stages of the disaster, for example, the best method in terms of speed and security for distributing food aid, medicine, and drinking water is air transport, by airdrop. This special technique of supply is practical, since it avoids the need for landing strips, which may be poorly maintained, non-existent or short, all of which will in turn restrict the size of aircraft carrying the aid Beresford and Pettit Road transport, in turn, is more flexible than air.

It is less susceptible to weather conditions; roads can transport all types of supplies and require a type of infrastructure usually available in most countries, so roads can normally provide a door-to-door service. This type of transport, however, is entirely dependent on the conditions of the road, which can be seriously damaged due to the magnitude of the disaster Long and Wood McClintock stresses that road transport has the advantage of having local operators who would be able to organise a fleet of trucks and deploy them relatively simply.

Armies also have their own fleet of trucks to deploy when and where the need arises. Waterways, if available and navigable, are able to carry large volumes of freight at lower costs. It is possible to operate specialised vessels, such as hospitals, command and control, airfields or helipads close to the affected area. However, waterways are often segmented by sections of rapids or waterfalls and, as a consequence, are normally used as part of multimodal solutions in the relief activities Beresford and Pettit From the arguments presented, it is possible to say that civil defence and humanitarian assistance actions in response to a sudden natural disaster occur in an institutionalised and inter-agency environment.

After the natural phenomenon, the first 72 hours are crucial to saving lives. At that moment, the participation of joint military forces may be intense, due to characteristics such as readiness and adequate logistics provided by air, sea and land assets. The main tasks performed by the military forces are related to indirect assistance and infrastructure support. In democratic societies such as the European Union, it is necessary to demonstrate how defence spending can contribute to social welfare through a final output of security and peace.

In peacetime, since few and possibly none of the threat scenarios might materialise, investment in military assets would be only viable under the inevitable artificial circumstances of exercises and simulations or through MOOTW, such as humanitarian relief operations Markowski, Hall and Wylie NATO then had to examine its vulnerabilities and develop strategies for crisis prevention and contingencies with new capabilities Santos Following the end of the Gulf War, a first major change happened when the Alliance was challenged to include the capability of intervention out-of-area 7 in its strategic concept.

At that time, most European allies were frustrated because of the inability of NATO to project military power beyond the continent.

The Future of Strategic Military Leadership

The large and well-armed forces that were deployed in Europe lacked the strategic mobility and power projection assets to carry out operations in distant areas Kugler Vulnerabilities other than lack of strategic mobility were also to be considered. When the Kosovo War erupted in , the military campaign to pressure Serbian forces to withdraw from Kosovo was based on air power.

The Europeans lacked capabilities in such critical areas as smart munitions, secure communications and day-night operations. After the terrorist strikes of 11 September , when the United States declared Article 5 of the North Atlantic Treaty 8 emergency, several European allies offered help in fighting al Qaeda and the Taliban, but they were surprised when the US military refused the offers for the reason that most European militaries lacked the sophisticated capabilities to contribute to new-era operations Kugler NATO should have an expeditionary strike force that can move fast Mihalka Its purpose is to increase stability, diminish threats to peace and build strengthened security relationships between NATO and non-member countries in regions considered strategic for the Alliance.

The CJTF concept is particularly important since a military force is deemed to be effective not only because it is equipped with some of the latest technologies, but because they train and exercise together Mihalka They called for a force that would be large enough to be militarily meaningful yet small enough to be affordable and politically attractive to European allies Kugler Thus, the NRF became a joint multinational force ready to deploy a force of up to 21, men wherever the Alliance requires within five days.

Its logistic means are tailor-made for operational autonomy without further support for 30 days, or longer if re-supplied NATO b: Therefore, the NRF is made up of land, air and maritime components. Its land component consists of a brigade-size 11 group with forced entry capability. The naval task force is composed of one carrier battle group, 12 an amphibious task group and a surface action group.

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The air component is capable of performing combat sorties a day NATOc NRF operation is based on the principle of rotation with three different stages of six months each. In the first stage, the force is certified to the highest standards after a training programme. In the second, the force is then put on active duty and, finally, in the last stage the force stands down from recently completed duty.

Thus, the NRF does not have a fixed organisation. Different countries participate with different troops in each of the rotations. Basically, this is the same practice the US Navy follows in aircraft carrier rotations Kugler The NRF missions are determined on a case-by-case basis by the North Atlantic Council without any present geographical limit. As a force created in a scenario of new threats and financial constraints, it is expected to deploy as a stand-alone force for evacuation operations, support for disaster relief management including chemical, biological, radiological and nuclear events , humanitarian assistance and counter-terrorism operations; as an initial entry force facilitating the arrival of follow-on forces; and as a demonstrative force NATO c: An examination of the use of expeditionary forces since has revealed very few operations where more than a brigade-size force was used with short notice.

On the contrary, it is the smaller type of missions such as NEOs or humanitarian assistance that usually demand them with little warning. These types of operations usually demand quick deployment and integral sustainment for a rapid and efficient response Mihalka In short, it is possible to say that the NRF has made NATO responsive to the security needs of the twenty-first century, particularly with regard to the need for a new strategic concept of deployment.

For this reason, this article states that the NATO transformation in the post-Cold War era occurred through institutional maturation based on the common interest of its members, which were keen on developing capabilities that could act in scenarios of either co-operation or conflict, expressed in a set of international institutions outlined by Martin Wight, notably diplomacy, war and the balance of power. Many towns and villages were totally destroyed. It is estimated that the earthquake affected an area of approximately 30, km2 and caused the destruction of more than half of the existing homes, healthcare facilities, communications infrastructure and schools.

The roads and infrastructure for water supply also collapsed. Some available figures indicated that approximately 73, died, , had been injured and five million had been made homeless USAID The local government agencies became ineffective in performing their duties, with their members of staff being either dead, injured or helping relatives affected by the earthquake. As a result, there was a total dependence on the military component to start the civil defence actions Phister et al According to Ahmad The state of readiness and the existence of operational equipment came in useful for relief operations; equipment including helicopters, trucks, excavators and tractors facilitated the tasks performed by the military.

As armed forces are in charge of defence, it is important to note that their personnel are usually familiar with national geography and the roads used to connect different places, thus making search and rescue actions easier. In the initial moments after the disaster, the Pakistani military played a central and effective role in the co-ordination of the relief effort, despite shortfalls in both equipment and personnel due to the nature and magnitude of the disaster CFE-DM According to the president, Pakistan needed cargo helicopter support to reach isolated regions, financial help and aid supplies BBC Online The UN did not have the human and logistical resources to provide the necessary logistics for a catastrophe of that size in a timely manner.

Although there were some precedents for deploying NATO military assets in humanitarian crises and natural disasters, the action was considered a new challenge because of the large distances over which it would need to be carried out NATO b: NATO launched a two-stage military response. The first stage was indirect assistance focused on the airlift of supplies from Europe to Pakistan Figure 5. The second stage of the operation added support for infrastructure and additional indirect assistance, drawn from the NRF, including a deployed headquarters command and control structure, engineering units and helicopters, all with appropriate support Jochems Direct medical aid, performed by the NATO military field hospitals, was also necessary due to the large number of casualties.

The two stages were not necessarily independent of each other, the difference between them being simply the time at which they began and the resources employed. The first stage began as soon as NATO agreed to undertake the humanitarian assistance and involved air assets.


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The second stage, in turn, began a few days after the first one and comprised land and air components. Cosgrave and Herson The authors point out that helicopter transport is expensive, but there was no alternative for reaching mountain villages given that many roads had been cut off and aftershocks had made road travel dangerous.

The large number of helicopters needed meant that military provision was unique in capability and availability. The military logistical assets were essentially employed in indirect actions and infrastructure support, despite the fact that no restrictions on direct actions had been imposed by the Pakistani government. This trend of using military transport, engineering and medical units for humanitarian purposes had already been observed by Seybolt, as previously explained.

It shows military logistics have a dual-use characteristic that can be used for both peaceful and military aims. It must be said that the dual-use characteristic as mentioned above cannot be applied to the humanitarian logistical aspect as well. In simple terms, a helicopter designed for search and rescue purposes could hardly be used in high-intensity combat operations due to the absence of essential capabilities. In short, investments in rapid response forces contribute to the final output of any armed force, whether for war or MOOTW. Theory, studies and the performance of the rapid response forces in a real situation converge on the idea that such military structures are fundamental to responding to a sudden natural disaster.

The number of lives saved is directly related to the existence of forces that are held in a state of readiness with strategic mobility. In Brazil, the use of military forces in civil defence efforts is covered by article 16 of the federal Complementary Law 97 of Although first committed to its main constitutional destination of national defence, it is the responsibility of the armed forces to co-operate with civil defence as a subsidiary role.

It is also possible to find other regulations on the subject in several ministerial-level documents, which seek to contribute to the interoperability of the armed forces with the bodies participating in the National System of Protection and Civil Defence and to strengthen the bases for the elaboration of guidelines for disaster prevention and response actions. Readiness may be the main point for discussion.

The Process of Transformation of the Army, 3rd Edition These reasons are shown as critical vulnerabilities identified in the Brazilian Land Force. Low readiness is the first one. According to the publication, the crisis experienced with the Haitian earthquake demonstrated the limited operational readiness and force projection capability of the Brazilian Armed Forces.

It took three weeks and the involvement of 84 Army units to place a peacekeeping infantry battalion around men in Haiti.

Trauma Care in Support of Global Military Operations

It should be noted that there are no joint response forces under unified command in the Brazilian military structure. There are response units organised only within each individual service. Although relevant, they may prove to be ineffective in certain situations. For example, there is no way to deploy an army response force far away from its current location at short notice without strategic airlift provided by the Brazilian Air Force. If a mission is to be accomplished overseas, in a hypothetical scenario, naval support is necessary.

In addition, as stated by Mihalka Financial constraints may also be one of the reasons for absence of a joint response force. Although recent opinion polling indicates high levels of reliability in the armed forces, it has been quite hard to transform public support in terms of financial support. The lack of imminent threats to the national defence could be an explanation for this difficulty. The power asymmetry between Brazil and countries of its strategic surrounding, as well as the existence of a hemispheric great power capable of deterring any attack from overseas, generates a sense of security within society in relation to external threats, which can be translated into low priority in defence issues.

This situation is worsened when put side by side with major national challenges such as basic sanitation, public safety, education and healthcare.

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National defence cannot be improvised. It is not possible to invest only when a threat materialises or becomes imminent. The act of raising the awareness of the public and decision-makers about the need for a ready-to-respond, high-cost force, however, is not an easy task. As already described by Markowski, Hall and Wylie If national defence against foreign threats has not been a persuasive argument, other outputs can be added.

It is important to mention that this force is organised and trained for employment in subsidiary actions and does not have any operational use in war operations. It is not a high-readiness combat force with available logistical resources for other than war scenarios, as is the case with the NRF. Rather, the Army Northeast Command Humanitarian Assistance Force is a temporary establishment of human and material resources from many different army units none of them with high readiness , dedicated to improving local civil defence capabilities.

Although there are notable gains for a sudden natural disaster response action, where a massive use of military assets is observed in the immediate post-disaster period, as mentioned before, the investment allocated in such a force may provide modest gains for national defence. The NRF structure is tailored for logistical autonomy without further support for 30 days and for rapid response to emerging crises, ranging from MOOTW, such as humanitarian assistance or peacekeeping, to high-intensity war-fighting operations.

All military force, by nature, demands logistical effort. Land forces consume materiel which needs to be moved to them in the most dangerous and demanding of circumstances, since they cannot easily disengage themselves to be administered in logistics hubs. Casualties need to be evacuated for treatment. Furthermore, when large land formations move within a battlespace, they create physical trails across the landscape, which, if cut or closed off, quickly cause the moving formation either to halt or to run short of supply UK Army Readiness and operational autonomy are two features of the rapid response forces that increase logistical challenges.

These forces are deployed in distant, difficult-to-reach and hostile environments at short notice with little or no external support. Logistics is critical to military power projection Pagonis and Krause The use of the NRF in the earthquake of 8 October can be analysed not only from the co-operative point of view, but also from one of strategic deterrence. Whatever the point of view, the deployment of the NRF in a distant and difficult-to-access region has demonstrated how decisive a rapid response force can be in the very first moments of a given natural disaster.

It is an important actor to meet the humanitarian demands. The case in study is therefore convergent with the Haas, Kates and Bowden response model, which indicates the large use of military resources in the first phase of natural disasters, called the emergency phase. The use of the NRF in this phase was due to its logistical and tactical capabilities, which fit a massive demand for human and material resources, often in regions degraded by severe damage to the local infrastructure. The article intends to contribute to the theory by arguing that the Haas, Kates and Bowden model is directly related to the existence of military forces in a state of readiness and with adequate logistics.

Although it can be argued that these are features for military formation as a whole, in peacetime, financial and political constraints create different levels of readiness within the armed forces. Finally, in addition to their great deterrent effect, rapid reaction forces proved critical to humanitarian operations.

They must also be sustainable and remain in the field for as long as required. The rapid reaction capability thus stems from rapidity, deployability, sustainability and interoperability St. In the classical English School, these were the great powers, diplomacy, the balance of power and international law.

Collective defence is the heart of the Treaty and is enshrined in Article 5. It commits members to protect each other and sets a spirit of solidarity within the Alliance NATO According to the US Army, full-spectrum operations combine offensive, defensive, stability and civil support operations simultaneously as part of an interdependent joint or combined force to seize, retain, and exploit the initiative US Army Typically, a carrier strike group might have a carrier, a cruiser, two destroyers, an attack submarine and a logistical support ship US Navy Pakistan Horizon 58 4: Bamforth, Thomas and Jawad H Qureshi.

Journal of Humanitarian Assistance, 16 January. Business Science Reference, pp. Beresford, Anthony and Stephen Pettit. A Study of World Politics. A disaster management handbook. Cosgrave, John and Maurice Herson. Instituto de Altos Estudos Militares. Daalder, Ivo and James Goldgeier. Foreign Affairs 85 5: The New York Times, 25 September.