The past

The DMS have a distinguished history in all aspects of infection with medical officers being responsible for major advances concerning malaria, trypanosomiasis, leishmaniasis, enteric fever, brucellosis, melioidosis, leptospirosis, relapsing fever, typhus, bacterial gastroenteritis, sexually-transmitted infections, infection control and vaccination. The first British experts in infection were Royal Navy physicians such as Dr James Lind (1716–1794) followed by Royal Army Medical Corps (RAMC) physicians and microbiologists as more cases were seen from overseas campaigns and colonies.2 The most influential figure in the history of sexual health in the Army was Colonel LW Harrison (Figure 1) who transformed the service that managed troops with ‘venereal disease’ (VD). He was internationally renowned for his research, and his innovation and vision created the design and guiding principles of the first sexual health clinics for both military and civilian patients, which are still relevant today.

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Figure 1

Colonel LW Harrison—the father of military venereology. Wellcome Library, London.

By 1902, there were dedicated wards for military patients with infectious and tropical diseases in both the Royal Haslar Hospital at Gosport and the Royal Victoria Hospital at Netley and also in numerous British military hospitals overseas. Microbiology laboratories were then gradually established in all UK military hospitals and during World War I (WWI) an innovative system of field laboratories was created along the Western Front by Maj Gen Sir WB Leishman.3

Meanwhile, in 1909, Colonel LW Harrison was posted to the Rochester Row Military Hospital in London, which was established for the treatment and research of VD, a term used to describe cases of syphilis and gonorrhoea. He was part of a pioneering research group that employed a novel approach of using arsenicals and mercury as a combination treatment for syphilis. This regimen was subsequently used throughout WWI and was far ahead of the civilian hospitals, which did not catch onto the use of this combined regimen until 1930.

Control of VD was very difficult during the pre-antibiotic era of the nineteenth and twentieth centuries. The government initially tried to use legislation such as The Contagious Diseases Acts of 1864, 1866 and The Royal Commission on Poor Laws (1909) in order to detain sex workers and patients who had evidence of VD.4 Stigma associated with contracting VD was huge with open castigation from society and the medical profession towards those who had ‘self-inflicted’ diseases.

In contrast, the British Army's approach to VD was far ahead of society at the time. By acknowledging the effect that VD was having on fighting forces, it implemented a well-organised system of free treatment facilities and increased health education and leisure facilities for the troops in barracks, which in turn decreased the numbers with VD. However, by 1915 during WWI, the numbers of troops with VD were increasing beyond control. Harrison was sent out to the British Expeditionary Force in Le Havre, France, and put in charge of the first British military VD hospital. Within a year, the hospital had expanded from 250 to 3000 beds5 and steps were also taken to return troops back to fighting force including the issuing of prophylactic packs of ointment of mercury and chlorine, and urethral irrigation treatment rooms for postexposure prophylaxis with potassium permanganate. Harrison oversaw all treatment schedules himself and when it was running effectively, he was recalled to London to take command of the Rochester Row Military Hospital and to become the Advisor in Venereology to the War Office.

While the Army had been providing free, well-run treatment facilities for several years, most civilian patients with VD either had to ignore their symptoms or try to receive treatment from ‘lay people’.4 The minority that had medical insurance would not be entitled to any of the related benefits as VD was seen to be due to ‘their own misconduct’. The Royal Commission did not recommend free open-access medical service for the treatment of VD until 1916. Even then, it was far from stigma-free with the commissioners referring to VD as ‘intimately connected with vicious habits’.6 The proposed reforms were widely opposed and so development of these services was slow.

Overall, the UK Role 4 Military Infection Services established during this period were maintained and then expanded to good effect during World War II, where the successful management of infections by the British forces was considered to be a battle-winning advantage.7 However, since 1945 there has been a gradual decline in the UK military population and hence in the size of the DMS. Once the defence cutbacks in the 1990s were complete,8 the Military Infection Services had only two microbiologists with one trainee, one genito-urinary medicine specialist with no trainees and no infectious diseases physicians or any trainees. Since then, all UK Role 4 military medical facilities have been merged with various National Health Service (NHS) trusts and so this is where the Role 4 Military Infection Services staff are now based. Over the last decade, there have been some improvements in staffing, but the Military Infection Services remain overstretched at present.

The present

The Role 4 Military Infectious Diseases & Tropical Medicine Service now has a single military consultant (Lt Col Mark Bailey RAMC) based in the Department of Infection and Tropical Medicine at Birmingham Heartlands Hospital (BHH) and cover from civilian colleagues is provided when he is deployed in his role as a general physician. Each year, there are approximately 100 new military referrals with 150 or so out-patient appointments, about 12 inpatient admissions and daily telephone and email enquiries. Records show that the number of inpatient admissions has fallen significantly since the causes and clinical management of ‘Helmand Fever’ were established9 and the service's activity levels and trends are published periodically.10 The infectious disease cases seen on current military deployments can be extremely challenging for non-specialist medical personnel and so a ‘reach-back’ service is also available via mobile telephone or secure email.

Three of our five military specialist registrars in infectious diseases are now undertaking their training at BHH, which gives them valuable experience of dealing with military infectious disease patients. This also means that the medical officers involved are well placed to provide feedback to military public health services, teach on various military courses, undertake military-relevant research and assist in the development of military policies.

The Role 4 Military Sexual Health & HIV Medicine Service now has a new consultant lead (Lt Col Ngozi Dufty RAMC) based at the Department of Sexual Health at BHH and a cadre of sexual health specialist nurses who provide a service across parts of the world where British Forces are based. Hence specialist nurse-delivered sexual health services are currently available in Catterick, Frimley Park, Northern Ireland, Cyprus, Germany and the field hospital in Camp Bastion for Operation Herrick. These clinics are able to offer comprehensive management of sexually-transmitted infections and other related conditions since specialist nurses are being trained to deliver onsite microscopy and many are independent prescribers. They are also able to conduct partner notification and other health promotion activities. Delivering health education talks and visits to surrounding units is also within their remit and a way of providing a friendly face to the specialty. The centralisation of military HIV services is now in place and all military patients should be reviewed at BHH in order to allow specific advice, specialist opinion for employment standards, liaison with units where required and ensure a consistent approach to their care.

The service ‘hub’ at BHH provides ongoing training and education for the sexual health specialist nurse cadre and other healthcare professionals including doctors. Teaching of medical officers, civilian medical practitioners, nursing officers, nurses and paramedical staff through various other medical courses is provided by the consultant and specialist nurses. Overarching governance comes from the consultant at the hub and this is also where the on-call emergency reach-back service for sexual health and HIV medicine is coordinated from. An on-call mobile and email service is available 24 h a day to the Army, Navy and Royal Air Force and is already being accessed from bases all over the world for a fast, accessible and military-focused service.

The future

The work of the Military Infectious Diseases & Tropical Medicine Service is likely to remain just as busy and become more complex in the future. The overall reduction in British Armed Forces personnel will be offset by the return of troops from British Forces Germany who were previously managed by the German healthcare system. Also the reduction in workload from Afghanistan will be offset by training exercises and contingency operations in a much greater variety of locations with less capable medical support. A greater diversity of military infectious disease problems in the future will require improved communications with military primary healthcare services on deployments and in the UK if this service (including its reach-back elements) is to remain effective in the future. Other challenges may come from the new commissioning processes for NHS clinical services in infectious diseases and tropical medicine and the military service is fortunate to be located at an established and thriving NHS unit. There will also be increased teaching requirements as the Military Infectious Diseases & Tropical Medicine Course and Military Travel Medicine Course are relaunched in 2013.

The future delivery of civilian sexual health and HIV medicine services is currently unknown due to the current chaotic transition in how clinical services are commissioned in the UK. Sexual health services will be commissioned under the auspices of local government authorities, whereas HIV medicine services will be commissioned under the NHS Commissioning Board. This leaves sexual health in a vulnerable position with services being put up for tender and open to takeover by private, profit-making organisations. This has already happened in some regions with great concern that expensive (but essential) services such as complicated infections, partner notification and teaching and training of staff may have restricted provision due to limited financial returns. This means that there could be significant differences with the delivery and quality of sexual health services between different regions within the UK. Hence it is vital to have a robust military sexual health service that troops can access if they wish to do so. Delivery of such a service within regional primary care settings by sexual health specialist nurses and the widespread training of primary care healthcare professionals in surrounding bases with simple, designated pathways for onward referral would ensure an accessible, standardised service for all. Opportunities would then be available for regional onsite training and ongoing education programmes. A military sexual health needs assessment has been completed and will shortly be available detailing the requirements for a sexual health service, the current unmet needs and recommendations for the way the new service will be provided.