Resource

‘[In the future] increasing resource scarcity will directly influence national security. Competition for scarce raw minerals, food, water and energy resources will have global consequences.’1 By 2030, developing nations are expected to experience a substantial increase in resource demand.1 The conflicts and migrant refugee flows likely to result from these wide-ranging effects would, typically, increase infectious diseases, malnutrition, mental health problems, injury and violent death.5 The impact of resource scarcity on health may lead to an increased demand for military intervention, including the requirement to conduct humanitarian assistance (HA) and disaster relief operations (DRO). A UK military response could range from small advisory teams to a joint expeditionary force and will almost certainly consist of an integrated cross-government approach within a multinational (MN) alliance or coalition. HSS must be adequately resourced and prepared to support a MN integrated response in order to relieve the potential threats to health among the civilian population during HA and DRO, while also supporting the military community.

Potential adversaries will have greater access to innovative science and technology and will continue to obtain weapons of mass destruction/effect (WMD/E) information or material.1 Unconventional weapons have, until recently, been the preserve of state actors. Transfer of WMD/E technologies and material between states and non-state actors creates the potential for greater exploitation by terrorist groups; this risk poses a greater threat, however, to the health of UK service personnel on operations. ‘Terrorists attacks using chemical, biological and radiological weapons are likely, as are mass-casualty attacks using novel methods.’2 These types of attacks could be conducted against civil or military targets in the UK and abroad. An effective surveillance capability to rapidly detect and monitor the use of WMD/E is essential. This system must be supported by enhanced biological, chemical and radiological treatment capabilities—intervention is critically time-sensitive. Military medicine could be working in support of the UK National Health Service (NHS) and must be capable of effective integration. Above all, HSS must remain adaptive in its capability to recognise and treat emerging threats to health from increased proliferation of WMD/E.

Social

The global population is likely to grow from the current 7.1 to 8.8 billion in 2040.2 The number of infants will subsequently rise, as will the elderly population, as life expectancy increases. This will exacerbate the impact of resource scarcity on health and is likely to be more prevalent in those states that are already struggling to provide adequate healthcare support to the civilian population. ‘If the proportion [of people] suffering malnutrition stays constant then almost 500m people are likely to require periodic HA [by 2040].’2 Military medicine is currently organised to provide HSS to the military population at risk (PAR). This generally includes physically fit men and women between the ages of 18 and 55 years, although HSS does include a limited paediatric and geriatric capability. Provision of HSS to HA and DRO is likely to face a growing number of infants and elderly patients. This is partly attributable to their underdeveloped or weaker immune systems and increased vulnerability to disease and illness. Military medicine must, therefore, be capable of providing HSS to infants and the elderly at levels beyond its current capability to be fully effective on future deployments of this nature.

Natural and man-made humanitarian disasters, such as extreme weather events and chemical and nuclear accidents will continue to cause high peaks of casualties. The potential devastation caused by natural or man-made events remains ever present and the resulting destruction will be greatly increased in heavily populated cities, requiring significant amounts of aid and assistance in the post-recovery period.1 The international publicity caused by high casualty figures in the immediate aftermath of a disaster can induce a timely international response. The main threat to health, however, often emerges in the subsequent days and weeks following a catastrophe due to the lack of reliable water and energy supplies, spread of disease and inability of the indigenous healthcare system to adequately respond. The main event that causes a disaster, such as an earthquake, is therefore not always the most significant threat to health. Military medicine will form a key, and relatively apolitical, component of an international response to a natural disaster.

‘Mutations of new strains of certain viruses, or the detection of as yet undiscovered pathogens, could precipitate a pandemic not seen since the influenza pandemic of 1918-19, which is estimated to have killed between 20—40 million people.’1 The natural evolution of infectious diseases poses a significant risk to the health of civil and military populations.6 A pandemic has the potential to increase instability within weaker states that may be compounded by ensuing competition for medical resources. The provision of an international integrated approach to preserve life and alleviate suffering could be used to assist in restoring stability within affected states. There is also a threat that a pandemic could occur within the UK incapacitating elements of the civilian emergency services and armed forces. Health surveillance will play a key role in providing early warning, and a robust national resilience plan will be essential in mitigating impact. Military medicine must be prepared to respond to a pandemic at home and abroad, and must maintain, develop and deliver adaptive force protection measures to combat existing and emerging infectious diseases.

‘Cities will contain 65% of the world's population by 2040, and 95% of urban population growth will occur within developing nations’ mega cities, containing more than 10 million people each. The urban centres will generally be situated in littoral areas, which provide easier access to trade and other advantages.’1 Urbanisation will increase the likelihood that military forces may need to conduct combat or security operations in condensed urban environments. A large combat force, such as a division, will be lost in an urban environment with a population measured in millions over a large geographic area; but small combat teams of 2–4 personnel at the right place and time could be very effective.7 The provision of HSS to multiple small combat teams dispersed over a large, congested, cluttered, contested, connected and constrained urban environment will require a novel approach.3 The evacuation of casualties will be challenging, support helicopter access may be limited and movement by ground may be constrained. A large number of small combat teams over an extended urban area may require additional medical resources to meet demand and ensure access to HSS. The impact of sea basing and manoeuvre from the sea, as an alternative to holding ground, will require to be considered; lighter and more manoeuvrable medical facilities may play an important role in meeting this challenge.

‘Increased human interconnectedness brings a heightened threat due to the potential spread of disease in regions where public healthcare is limited. Major epidemics could start and rapidly spread due to higher levels of urbanisation and increasing mass air travel.’1 The time available to monitor and track potential epidemics could decrease, thereby impacting on the ability of the international community to quickly respond. Rapidly deployable military forces are anticipated to play a critical role in the future responding to any potential outbreaks and mitigating the risk of an epidemic. Military medicine is likely to form a key component of a rapidly deployable military force in order to primarily support the military population and potentially relieve suffering among the civilian population.

Political

The public expectation for military medicine to sustain life to the same levels experienced on recent operations in Afghanistan and Iraq, through short clinical timelines and significant interventions may not be possible in the future and may have an adverse political impact. HSS will continue to be provided in accordance with clinical need, however, the ‘Died of Wounds’ to ‘Killed in Action’ ratio is likely to increase, however, and could be misinterpreted as military failure. In fact, this increase is likely to represent a change in operational context rather than failure. Additionally, the number of serving and retired service personnel and disabled survivors suffering from mental health issues is likely to increase in the future due to the sustained operations over the last decade. This will place an increasing burden on the NHS and will need to be effectively managed in order to avoid becoming a political issue, and may require to be supported by the military medical community.

Military

Financial constraints affecting all of the UK's anticipated partners mean shared responsibility between nations is likely to be the desired norm in the future. HSS provision on operations, while doctrinally remaining the responsibility of each troop contributing nation, is now shared; the Role 3 Medical Treatment Facility in Camp Bastion, Afghanistan, is joint and combined. If this shared responsibility is likely to be the desired future norm, it requires to be rehearsed in peacetime.7 ‘While early entry operations will demand a core of staff with military skills, contractorisation is likely to become more prevalent as the size of the uniformed Services shrinks.’7 The employment of contractors to supplement specialist clinical skills in situations where there is no substantial security risk, such as HA and DRO, may benefit defence and should be considered. The NHS is likely to remain a fundamental partner in force, generating secondary healthcare specialists to meet the operational demand. The NHS is also likely to become the primary source of experience for secondary healthcare specialists following the military's withdrawal from Afghanistan in 2015. Fostering the relationship between the government, MOD and NHS is, therefore, critical.

Technology

The accelerating cycles of exploration, discovery and exploitation of technologies will combine to bring rapid change in the future. Advances in robotics, biotechnology, regenerative medicine, nanotechnology and more powerful computing will combine to produce improvements in the delivery of military medicine. Robotic-based surgical procedures are growing rapidly, rising from 80 000 in 2007 to 205 000 in 2010.8 Robotic systems can enable surgeons to conduct complex procedures with a shorter inpatient stay; this may reduce individual recovery times. Although, robotic systems are currently large and expensive, they are likely to become smaller and more affordable. Their application within the military is therefore predicted to become prevalent. Surgeons may use robotic systems to perform operations remotely, thereby reducing the requirement to conduct movement on the battlefield that might expose personnel to risk. Robotic technology has already created a substitute battlefield rescuer that can collect and transport a casualty, reducing the exposure of human rescuers to direct fire or contamination from biological, chemical, radiological or nuclear hazards.7 Future application of such technology could reduce potential timelines of rescue in a non-permissive environment.

Advancements in biotechnology will continue to extend life expectancy, improve health and cure illness.1 Developments are likely to increase fitness levels and could improve the number of personnel that are fit to deploy on operations. Regenerative medicine has enormous potential; the emerging fields include stem cell transplantation, cell reprogramming and synthetic organ creation. Early results are promising and have the potential to revolutionise the supply of organs for transplantation. These advancements could have huge benefits in the treatment and rehabilitation of those personnel that suffer potentially life-changing injuries. Nanotechnology presents a range of potential and proposed development opportunities for future military medicine. This includes internal imaging to support surgery, improved drug delivery systems and monitoring of an individual's physiology with feedback sent to a central computer. This may allow commanders to remotely monitor the location, physiology and relative activity of personnel and, thereby, provide useful data following injury.7 Such applications have the ability to improve the delivery of HSS on the battlefield.

Technological advances could transform interactions between clinicians and their patients. Civilian practitioners can already conduct consultations, monitor and deliver care to patients at home using remote technologies and video conferencing. This trend is likely to continue and will have a practical application on operations; the ability of clinical personnel to remotely communicate with their patients by voice and through real-time video, could aid diagnosis and allow treatments to be administered and monitored. This system could be used to extend reach in congested and contested urban areas. Advances in technology are also likely to improve the deployability of clinical hardware including monitors, diagnostic equipment and interventional equipment.7 Partnerships and cooperation with industry will therefore remain an important mechanism to influence future developments. Opportunities should be sought to develop capability, while reducing size and weight.

Economic

The latest financial crisis, economic stagnation and growing levels of national debt have intensified the pressure on decision makers to reduce defence spending even further. The impact of these events is likely to be felt well into the future. The ratio of regular to reserve, civilian and contractor is expected to be subject to continued scrutiny with enduring pressure to reduce the number of uniformed personnel.1 This will place an increasing pressure on military medicine to demonstrate an efficient use of resources and capabilities from a defence perspective. Budgetary constraints are likely to act as a major hurdle in the adoption of new medical technologies.2 A rigorous evidence-based approach will, therefore, continue to be required in order to obtain funds. An effective governance system will play a key role in capturing evidence and identifying critical areas where investment in HSS is most required.