In 2000, the Department of Defense (DOD) released its grand strategy for the 21st century, which it called “Joint Vision 2020.” The document famously called for the U.S. military to achieve “full spectrum dominance” over all land, sea, air, space, electromagnetic, and information systems, with enough overwhelming power to fight and win global wars against any adversary.

Dale Smith, Ph.D., a professor of military medicine and history at the Uniformed Services University of the Health Sciences (USU), points to two trends that began during and after the Vietnam War: First, the idea of “fighting strength” began to extend beyond the notion of physical combat.

The new strategy contained a medical annex that became known as “Force Health Protection,” which by itself doesn’t sound very radical: In order to achieve full-spectrum dominance, obviously, the military needs people who are healthy enough to dominate, and who stay healthy enough to keep dominating. It’s a phrase that echoes the motto on the scroll of the Army Medical Department regimental flag: “To Conserve Fighting Strength.” Gen. George Washington was perhaps the first American commander to actively conserve fighting strength, when he quarantined his Continental Army soldiers to protect them from a rampant smallpox epidemic at the outset of the Revolutionary War – and later, in 1777, when he instituted a system of inoculating soldiers against the smallpox virus. Since World War II, the Navy Medical Department has provided a similar description of its wartime mission: “To keep as many men at as many guns as many days as possible.”

To understand what’s new about the phrase “force health protection,” it helps to realize it isn’t meant to describe a new idea: It describes a new way of thinking about an old idea.

Toward a New Military Medical Strategy

The evolution of force health protection as a strategy – which is by no means complete today – has been gradual enough that it’s difficult to point to a single cause. Dale Smith, Ph.D., a professor of military medicine and history at the Uniformed Services University of the Health Sciences (USU), points to two trends that began during and after the Vietnam War: First, the idea of “fighting strength” began to extend beyond the notion of physical combat.

Army Maj. Frederick M. Franks, suffering a grievous wound to his left leg during heavy fighting in Cambodia in 1970, eventually had the leg amputated below the knee. At the time, it was customary for military medicine to focus on conventional combat medicine and casualty care, and amputees were almost automatically considered veterans – their military service had effectively come to an end. Caring for them, then, was no longer a component of military medicine. “It’s not a military problem anymore,” Smith said, “if you’re not going to come back to duty.”

But Franks fought to remain in a combat unit after losing his leg, arguing that he could still command, even if he couldn’t fight. The Army agreed, and other officers followed Franks’ lead. Smith said: “It wasn’t until Vietnam that officers like Franks really said: ‘Wait a minute here. I’m a division-level field-grade officer. It’s not likely that I’m going to engage in hand-to-hand combat. But I can lead my battalion and serve on a staff with a fake limb.’” Franks served for another two decades with distinction, and during his career he earned several valor awards, including the Silver Star, Distinguished Flying Cross, the Bronze Star, the Air Medal, and two Purple Hearts. In the Gulf War of 1990-1991, he commanded the coalition forces’ VII Corps, which decimated Iraqi forces, including a number of Iraqi Republican Guard units. He retired in 1994 at the rank of general.

As ideas about “fitness for duty” began to shift, so too did traditional ideas about medical readiness planning.

After the military draft was abolished in 1973, Smith said, the all-volunteer force began to emphasize professionalism among its service members. Over the next two decades, the U.S. military became increasingly composed of career service members, many with families and many who would grow old in service to their country. As ideas about “fitness for duty” began to shift, so too did traditional ideas about medical readiness planning.

At the same time, the mission of military medicine began to expand in the 21st century. The 9/11 terrorists were able to plan and coordinate their attack relatively undisturbed in Afghanistan, one of the many failed states to emerge after the collapse of the bipolar world order. It became clear to U.S. military leaders that the doctrine of “full-spectrum dominance” must necessarily include operations that would help to stabilize such states before their weaknesses posed a threat to national security.

U.S. military personnel have often deployed to provide stability and support operations (SASO), mostly for humanitarian reasons, but the clear security threats posed by failed states have made SASO not only a moral but a strategic imperative for the DOD. The Military Health System adopted SASO as a stated mission in 2002, and the National Defense Strategy has since elevated SASO to be a mission on par with the military’s traditional combat missions, offense and defense. It’s a historic change in how the U.S. military sees itself: Its mission is not only to win battles, but to create space for negotiation by providing a controlled, nonviolent environment and by providing aid to civilians. DOD participation in the global response to the 2014 Ebola outbreak in West Africa is a noteworthy example of such an operation: In addition to the command-control and logistical support provided by soldiers, sailors, and Marines, Operation United Assistance featured crucial assistance from the military’s – and the world’s – leading infectious disease experts. Researchers and physicians from the Army, Navy, and Air Force diagnosed cases, prevented the spread of the virus, and researched and field-tested Ebola treatments and vaccines.

Such deployments, obviously, elevate certain health risks for service members. “You’re much more likely to be exposed to disease if you go in to fight Ebola,” Smith said, “than if you go in to fight insurgents.”

Studies revealed much higher rates of chronic multi-symptom illness among Gulf War veterans than among the general population: About 250,000 of the 700,000 U.S. personnel deployed to the region suffered from persistent, unexplained symptoms including fatigue, muscle and joint pain, rashes, and cognitive problems.

The strategic evolution toward force health protection – in particular, a stronger emphasis on health surveillance – gained considerable momentum after the Gulf War, where medical personnel from all branches performed well, both in theater and in European hospitals to which some wounded were evacuated.

But what happened after the war caught the military medical community off guard: A significant number of both veterans and civilian workers returning from the Persian Gulf experienced a chronic multi-symptom disorder that became known as Gulf War Syndrome. Studies revealed much higher rates of chronic multi-symptom illness among Gulf War veterans than among the general population: About 250,000 of the 700,000 U.S. personnel deployed to the region suffered from persistent, unexplained symptoms including fatigue, muscle and joint pain, rashes, and cognitive problems.

Investigations by the military and the Department of Veterans Affairs (VA) into the nature and causes of these illnesses were severely hindered by a lack of health and deployment data. It wasn’t until six years after the war’s end, in the National Defense Authorization Act of 1998, that Congress directed the DOD to establish a system for assessing the medical condition of service members before and after deployment. A longitudinal health record (LHR) was implemented to provide and track data before, during, and after deployment. The object in forming this “cradle-to-grave” data set was to enable military medical professionals both to foresee and prevent any service-related health issues, and to connect emerging issues with existing information regarding deployment and exposures. The Pentagon established a deployment health quality assurance program in 2004, launching the development of readiness standards and metrics, as well as a joint-service automated theater-wide health data surveillance and reporting system.

The DOD directive issued in 2004 described force health protection measures as “encompassing the full spectrum of missions, responsibilities, and actions of the DOD Components in establishing, sustaining, restoring, and improving the health of their forces.”

Around the time this program was established, the DOD released its revised force health protection vision document, which described how the 9/11 attacks and the ensuing global war on terrorism had further transformed American military service. Military deployments, the authors said in their introduction, had increased in number and frequency, and the Pentagon was satisfying those requirements with a smaller force, comprising both active and Reserve components – with an increased proportion of reserves. “In short,” the authors wrote, “U.S. forces are more active, mobile, and dispersed than they were in the past, and they are also more likely to work in joint operations and partnerships with others. The well-being and fitness of U.S. forces for duty is more important and more complicated than ever.”

What Force Health Protection Looks Like Today

This accumulation of post-Vietnam considerations broadened military medicine’s focus in two ways: It extended the focus in terms of time, to consider health both before and after deployment, and in terms of the nature of one’s service, beyond a strict focus on combat arms. The DOD directive issued in 2004 described force health protection measures as “encompassing the full spectrum of missions, responsibilities, and actions of the DOD Components in establishing, sustaining, restoring, and improving the health of their forces.”

Said Smith: “These various components related to recruitment, preventive medicine, and rehabilitation all began to be brought together after the First Gulf War, into this new overall rubric of force health protection. There’s nothing new in it, except it’s now a single doctrinal node.”

Preventive military medicine dates to Washington and the Siege of Boston, but it wasn’t until 2010, when the U.S. Army Public Health Command was established, that the Army elevated it to the level of a command.

Today, this doctrine balances the Military Health System’s primary mandates: to promote and sustain health and wellness throughout each person’s military service; to prevent acute and chronic illnesses and injuries during training and deployment; and to rapidly stabilize, treat, and evacuate casualties. “Force health protection,” said Terry Rauch, Ph.D., acting deputy assistant secretary of Defense for Health Readiness Policy and Oversight, “is basically all measures taken by commanders, supervisors, individual service members, and our medical enterprise to promote, protect, improve, and restore the mental and physical well-being of service members. And that spans all military activities and operations. These force health protection measures enable the fielding of a healthy and fit force, help us prevent injuries and illnesses, and protect the force from health hazards generated by military operations. They also provide rehab care to wounded, ill, and injured.”

That description covers a lot – it’s meant to – but it doesn’t explain how military medicine might look different in the force health protection era. The key difference, Rauch said, is that, “all of our components implement these programs and processes of force health protection” – if you’re a military neurosurgeon, for example, you will learn about things such as dietary standards, dental health, public health research, tobacco use, and stress management techniques. If you’re a deployed service member, you may, in the near future, be outfitted with a wearable array of sensors that will monitor and analyze the interplay between what’s going on inside you – your vital signs, for example – and outside you in the environment. Several such systems, researched for the last several years among the separate branches, have evolved into a single joint development program. “Our goal in this,” said Rauch, “is to have a suite of sensors, worn by the individual service member, that would capture data on all exposures and experiences at any point in time, analyze it, and send that analysis to inform decision-makers of anything potentially harmful to that service member.” Such a system will be a natural evolution of the cradle-to-grave data set, to include real-time updates on the hazards confronted by deployed service members.

If standardized TCCC becomes DOD policy, Smith said, “then at all the new recruit stations … people are going to begin to learn some level of tactical combat casualty care. That will be a new evolution in force health protection.

Preventive military medicine dates to Washington and the Siege of Boston, but it wasn’t until 2010, when the U.S. Army Public Health Command was established, that the Army elevated it to the level of a command. Force health protection requires all military doctors to learn some preventive medicine – a stipulation that yielded immediate results in 2003, when Joint Task Force Liberia, with an operational component of 3,000 U.S. Marines, deployed to help stabilize the West Africa nation in the midst of a civil war that had created a refugee crisis. “In Liberia,” said Smith, “it was a surgeon who recognized that some of those Marines had malaria. Why? Because he had extra preventive medicine training that a surgeon wouldn’t normally get, because the military was refocusing on this new force health protection strategy.”

Because force health protection is envisioned as life-cycle health support, the same holds true on the battlefield, as the military’s Joint Trauma System has promoted the idea that knowledge of the military’s evidence-based Tactical Combat Casualty Care (TCCC) guidelines should go beyond forward medical teams to reach the combatants themselves. The most recent version of the National Defense Authorization Act calls for standardized TCCC training for combatants as well as forward medical teams. “If you’re going to return wounded people to duty,” Smith said, “you’ve got to keep them alive. And often the medic can’t keep them alive, because the medic is not there. So we’ve got to teach people enough about it to keep their buddies alive until the medic can reach them.” If standardized TCCC becomes DOD policy, Smith said, “then at all the new recruit stations … people are going to begin to learn some level of tactical combat casualty care. That will be a new evolution in force health protection. So in both prevention and in returning people to duty, force health protection continues to be dynamic and evolving.”