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How can we reduce the Burden?
CBRN(E) CHALLENGES FOR MILITARY AND CIVIL MEDICAL SERVICES IN THE 21st CENTURY – SILENT WEAPONS OR OCCUPATIONAL HAZARDS?
AA How can we reduce the Burden?
CBRN(E) CHALLENGES FOR MILITARY AND CIVIL MEDICAL SERVICES IN THE 21st CENTURY – SILENT WEAPONS OR OCCUPATIONAL HAZARDS?
The last two decades has seen a paradigm shift between ‘Cold War’ concepts of operations and those that we
practice today. This implies that there is a need then to break out of the 20th Century mindset of manoeuvre
warfare and to develop a philosophy that meets the needs of defence, in its widest sense, for the 21st Century.
TX Hammes thesis on 4th Generation Warfare, Rupert Smith’s utility of force in war amongst the people and Philip
Bobbit’s articulation of the move from industrialized sovereign states to the market state provide the philosophical
foundation for this discussion piece. This was summarized well at the recent Royal United Services Institute Annual
Resilience Conference in London which suggested that 18th Century ‘Enlightenment’ models may be more appropriate
than the staid concepts of manoeuvre that we continue to practice and teach. A more open-minded approach might
provide us with the requirements sets needed to be more responsive against the most likely threats rather than the
worst case scenario which is arguably unaffordable in both political and financial terms in the 21st Century.
This short paper is not the opinion of the
United Kingdom Ministry of Defence or
the Defence Medical Services Department
but a think piece to provoke debate about
how the medical community, civilian and
military, might tackle the challenges that
CBRN(E) presents in the 21st Century mission
space. It considers NATO’s Comprehensive
Political Guidance as a framework
for prosecuting campaigns where the civilian
machinery is integral to mission success.
Open sources highlight a number of significant
trends in the use of NBC/ CBRN(E)
and the preparation of people to survive the
hazards caused by these weapons or substances.
The change of terminology from
NBC to CBRN then CBRN(E) is testimony to
this evolution reflecting the move from a
strategic ‘state-on-state’ concept of use
based on nuclear stand-off to exploiting the
tactical effect of hazards presented by
CBRN(E). The inclusion of Environmental
and Industrial Hazards (EIH) along side
CBRN(E) is beginning to emerge as doctrine
with a number of countries recognizing that
the hazard rather than the means is the
most important factor when planning to
mitigate the risks. This approach considers
the whole as a hazard ‘spectrum’. It also recognizes
those toxic chemicals that are readily
available in industry which also provide
a potent threat if accessible. This then requires
an ‘all hazards’ approach more akin
to how fire and rescue services operate than
the traditional military response to indicators
and warnings.
How do your fire and rescue services operate
and what is their approach to emergency medical
care in a ‘hot zone’? Are you able to translate
this into a military practice? There are of
course equipment and training issues that need
to be considered.
This hazard spectrum is applicable across the
21st Century mission space and includes
physical hazards presented by climate, terrain
and protective measures such as personal
protective equipment. Indeed these
may even be exploited or manipulated by an
adversary to deliver or accentuate an ronmental or industrial hazard. This reduces
the likelihood of detection and
identification of an event which means
that classical indicators and warnings are
less likely to present in the modern mission
space. This leads to the expectation
of surprise and the need to respond appropriately
in order to reduce the effect or
‘shock of attack’. Civilian experience
over the last two decades provides many
lessons as does that of military forces
around the world stretching back even
longer. The lessons from these experiences,
both real and simulated, need to be
fused. It is assumed that the principles of
CBRN(E) defence or mitigation of EIH remain
constant through time as well as
across the military and civilian domains.
This is often masked by the context and
tactical scenarios which do change and
present localized problems but are more
tangible and therefore easier to work
through. A more intelligent response is
therefore required based on the factors and
priorities dictated by the situation but with
an underlying set of principles. This will
facilitate teaching and planning as well as
promoting a common set of user requirements
that will provide the foundations for
interoperability.
Principles of preventative medicine and occupational
health already exist and should be adopted
universally as the evidence base for CBRN medicine.
What do you think?
The requirement to be more intelligent in response
to CBRN(E) demands a culture of
planning rather producing libraries of plans.
This requires that operators (including medical
providers) and commanders change
their attitude to planning or risk management.
Intelligence may provide the luxury
of space and time that can be used to prevent
or prepare for attack but this can not be
guaranteed. A lack of intelligence resulting
in surprise demands that the organization
fights through or survives the shock of attack,
manages the consequences and gets on
with the mission, demonstrates resilience in
civilian terms. Medical force protection
measures contribute to wider force protection
including CBRN(E). Surprise will by
definition ‘unbalance’ the ill prepared and a
military adversary or criminal entity’s intent
might be to achieve this for military, political
or economic gain. An integrated approach
combining medical and general
planning will help to reduce the impact of
attacks, accidental release or environmental
hazards.
How can you build ‘survive to fight’ or improvements
to resilience into your everyday practice?
Deployment of CBRN(E) weapons or the
manipulation of the environment and industrial
landscape could be difficult to detect
but not impossible. The response to this has
been the increasing importance being placed
on medical intelligence preparation of the
battle space as a means of predicting problems
whilst planning to prevent or mitigate
hazards through prophylaxis or rapid treatment
systems. Disease surveillance and
tools to support rapid diagnosis are increasing
in their importance as post attack or
post-exposure responses are adopted. These
tools provide the time and space required to
break the kill chain early. Training clinicians
to recognize syndromes and to make diagnoses
on few clinical signs remains a challenge
but improvements are being made
through education programmes that raise
the indices of suspicion whilst providing
confidence to make appropriate decisions.
What do you understand by the terms sentinel, presumptive
and confirmatory results? What decisions
are you able to make at each level?
‘War amongst the people’ demands a more
comprehensive approach to operations with
information, political and economic lines of
operation planned with appropriate importance
alongside the military. This level of
planning will ensure that each agency understands
its role and responsibilities, ensures
co-ordination of effort clearly
identifying who is supporting and supported
as well as ensuring that appropriate resources,
including additional capacity if required,
are allocated. This is of particular
importance in those countries with no
EIH/CBRN(E) experience or where a fragile public health infrastructure exists. International
and regional guidance published
by the WHO, European Union, Centres for
Disease Control and others provide planning
frameworks including advice on reporting
health issues. A recognition of the
need to place greater reliance on support
from other government departments, international
organizations, non-governmental
organizations, industry and
academia must be realized. Early involvement
in planning will ensure that roles and
responsibilities are understood, will reduce
prejudice and bias across agencies resulting
in greater unity of effort. This also needs to
be built into education and training programmes.
Have you experience of successful inter-agency
working that you are willing to share?
In summary the burden of effects caused
by EIH/CBRN(E) may be reduced through
a more pragmatic approach to tackling
the most likely problems. This starts with
improving situational awareness and developing
a greater understanding of
threats and risks to troops or the mission.
Integrating this into every day education
and training presents opportunities for
learning from experience, burden sharing
as well as ensuring unity of effort. This
improved co-operative working across
military and civilian sectors will identify
common user requirements which will
feed into policy, doctrine and capability
development presenting more opportunities
for inter-operability.
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