Summary and Conclusions
The thirteen preceding chapters in this monograph present a review of the major areas of Medical Department activity in support of the U.S. Army in Vietnam, as derived from a variety of official documents. This final chapter, on the other hand, includes value judgments related to these activities, their successes and weaknesses, and highlights some of the more significant lessons learned. These opinions are based upon extensive review of official records and reports as well as on my own experience and observations during two tours of duty as a senior medical officer in Vietnam, interspersed with two tours of duty in the Office of The Surgeon General.
Medical Command and Control System
The preferred organization for employing and controlling military medical, resources is the vertical medical command and control system which reached its epitome in Vietnam. Medical service is an integrated system, with its treatment, evacuation, hospitalization, supply service, and communications components. It is not a subsystem of logistics, nor is it a subsystem of personnel.
To achieve maximum effectiveness and efficiency in medical service support, with the utmost economy in the utilization of scarce health care resources, there must be strong professional medical control from the most forward to the most rearward echelon. The commander of the medical command, regardless of echelon, should function as the staff surgeon to the responsible supported commander. Medical capability must not be fragmented among subordinate elements but rather centrally directed and controlled by the senior medical commander. No non-medical commanders should be interposed between the medical commander and the line commander actually responsible for the health of the command. Specifically, logistical commanders, with their broad materiel related functions, should not be made responsible for a task so critical and so uniquely professional as the provision of health services. The well-being and care of the individual soldier must not be submerged in, or subordinated to, the system responsible for the supply and maintenance of his equipment. The issues involved are too great to risk failure or marginal accomplishment.
Health of the Command
The health of the U.S. Army in Vietnam has been excellent. A major consideration in the decision to commit U.S. forces in Southeast Asia was the concern that disease in that area would decimate our troops, and that active combat operations would be impossible. This was not the case. A major contributing factor to the well-being of U.S. troops was the recognition that a 6-week period of adjustment and acclimatization was needed. This "precommitment" period provided, most definitely, one of the lessons learned in Vietnam.
Empirically, it has been observed that it takes about 5 days to adjust to the significant time zone changes and to develop a new diurnal cycle. It also takes 2 to 3 weeks to acclimatize to the heat and humidity of the Tropics, if troop stresses are gradually increased. A total of approximately 6 weeks is required to develop a "relative biological acclimatization" to the types of infectious organisms encountered in the new environment. This 6-week period of adjustment and acclimatization was a necessity; command recognized it as a physiological and biological reality, and senior commanders in Vietnam postponed commitment to major combat operations accordingly.
During this 6-week period, troops spent their time profitably. They learned again to live in the field, mess personnel became more efficient in field sanitation, and all the new arrivals developed a keen awareness of the problem of health and a greater appreciation of the necessity for a vigorous preventive medicine program- both by command and by the individual.
The diseases encountered in Vietnam were those which have plagued all armies through the years: fever of undetermined origin, diarrhea, upper respiratory infections, dermatological conditions, and malaria. Although disease accounted for more than two-thirds of all hospital admissions, the average annual disease admission rate for Vietnam (351 per 1,000 per year) was approximately one-third of that for the China-Burma-India and Southwest Pacific theaters in World War II, and more than 40 percent less than the rate for the Korean War.
Malaria was the most significant medical problem in Vietnam, but it was one which the Army Medical Department had anticipated. Studies undertaken in South America and elsewhere in Southeast Asia after World War II showed that chloroquine-resistant malaria would emerge as a problem in Vietnam. This proved to be the case in 1965, when U.S. troops began operating in the Central Highlands where there had been no real malaria eradication program because of Vietcong domination.
The precipitous rise in the, incidence of P. falciparum malaria among combat troops in contact with the Vietcong indicated that the standard chloroquine-primaquine prophylaxis was not completely effective against
this strain of plasmodium. It became apparent that another antimalarial was needed. Medical researchers concluded that DDS (4,-4´-diaminodiphenylsulfone), a drug long used in the, treatment of leprosy, seemed to be the most promising of many drugs under evaluation. Following intensive field tests on a priority basis in-country, it was found that the daily use of 25 milligrams of DDS, in addition to the standard chloroquine-primaquine weekly tablet, reduced the incidence of malaria by approximately one-half. This, therefore, became the operational regimen, and is now followed in tactical units operating in malaria risk areas in Vietnam.
Not only did the use of DDS, in conjunction with other antimalarials, reduce the incidence of malaria, but it also assisted greatly in lowering the incidence of relapse from a former high of almost 40 percent to a low of only 3 percent. Of equal importance, DDS aided in reducing the period of hospitalization by one-half, thus making it feasible to hold virtually all malaria patients in-country until fully recovered.
Infectious hepatitis did not pose a major problem. The incidence of this disease had been relatively low, and the disease in Vietnam was milder than in previous military experience. When the use of ISG, (immune serum globulin) to provide passive immunity was instituted in mid-1964, the incidence of the disease had already begun to decline from the 1962-63 experience.
In 1964, when there were relatively few U.S. troops in Vietnam, ISG was administered to all incoming troops as a precautionary measure. For both economic and medical reasons, the dose of ISG was reduced in early 1966, and in March of that year the program was further changed to administer ISG selectively to personnel on high-risk assignments or in key positions. No major problems developed from this change in policy and procedure. The lesson here is, of course, that all decisions must be evaluated constantly and changed with boldness and courage if the situation so dictates.
The exotic tropical diseases, endemic and epidemic in Southeast Asia, did not pose a problem in U.S. troops. Plague in the Vietnamese civilian, population pointed up, however, the shifting of disease patterns when the normal way of life of any peoples whose structure, economically or environmentally is altered. Vietnam is a rice-producing and rice-exporting country. Normally, the grain flowed from the rice bowls of the interior to the few major ports of the country. The rodents which infest the areas followed the path of the rice to the ports. There they were controlled; thus, the danger of a serious outbreak of plague was averted. During the war when, for economic reasons, the South Vietnamese began to import grain, a reverse situation was created. The rice was shipped from the ports into the countryside; the rodents followed the flow of the grain inland and created havoc in the form of increased incidence of
plague among the native population in areas which had heretofore been relatively free of the disease.
Contrary to experience in recent wars, neuropsychiatric illness did not constitute a significant problem. Until 1970, the rate and types of neuropsychiatric illness approximated those in the continental United States. This relatively low incidence may be attributed to the type of tactical operations being conducted; the high caliber and morale of the soldiers manning combat units; the 1-year tour; magnificent leadership; and an aggressive and effective preventive medicine program with strong command support.
However, during the wind-down in 1970, the incidence of neuropsychiatric disorders among troops increased and has remained at a disconcerting level. This increase also parallels the incidence in the United States, and has been somewhat compounded by the allegations so frequently voiced in the news media that the citizens of this country are dissatisfied with the war and the U.S. involvement therein. As the United States continues to disengage, this problem will continue, although it is known that the command, at every level, recognizes the problem and is exercising vigorous leadership to overcome it.
The wounded soldier in Vietnam received better care more quickly than in any previous conflict. This was possible because, early in the war, it was found that relatively small numbers of helicopters with an exclusive medical mission could evacuate large numbers of patients to centrally located medical facilities. As the years went by, equipment was updated, more powerful helicopters were used as air ambulances, radio communications were refined to assure more rapid response to requests for casualty evacuation, and air ambulance crews were given sufficient basic medical training to enable them to evaluate a patient's condition, to recommend the most suitable destination, and to provide resuscitative care en route. Thus, the care given to combat casualties was the finest furnished by any army to date, despite the seriousness of the wounds and the impediments to evacuation and surgical treatment.
Regardless of the criteria used- survival rates, case fatality rates, return-to-duty rates, length of hospital stay, and so forth- the Vietnam experience compares favorably with all military medical experience to date. Important factors which contributed to this record are rapid, reliable helicopter evacuation, as noted above; well-equipped stable forward, hospitals; well-trained, dedicated surgical, and support teams; improved management; and continuous availability of whole blood. The availability of whole blood, which had been a problem early in each major war to date, was not a problem in Vietnam. An efficient blood
distribution system kept pace with the increasing requirements for whole blood; in no instance was blood unavailable when, where, and in the types and amounts needed. The Military Blood Program Agency must be retained during peacetime and must be prepared for activation in war.
TWO circumstances make this record even more remarkable. While the distribution between high velocity and fragment wounds in Vietnam approximated that of World War II and Korea, the incidence of mine and boobytrap wounds was more than triple that in the other two wars. These injuries, often multiple, always devastating, pose the most formidable threat to life and the greatest challenge to the surgeon. The helicopter contributed to survivability by delivering to hospitals greater numbers of more seriously wounded than in any war to date. These casualties included many with wounds that in past wars proved fatal before the casualty could be evacuated to a treatment facility. Despite these two factors, the survival rate remained high.
Hospital support was ample for the task, both quantitatively and qualitatively Semipermanent hospitals, located in base areas, with the most sophisticated equipment, with air-conditioned surgical and recovery suites and intensive care wards, permitted the application of the latest techniques of modern medicine in the forward battle area. Procedures that were rarely performed in the combat zone in previous ways were done on a routine daily basis in all hospitals in Vietnam.
Longer term care for patients suffering from malaria and hepatitis, or recuperating from, surgery, was also provided in-country. The convalescent center at Cam Ranh Bay was used to oversee the reconditioning of the longer term patients. Availability of this convalescent center, as well as the excellent Army Medical Department facilities in Japan for those patients who could not be accommodated in Vietnam- not because facilities were not available, but rather because it was always necessary to maintain a fairly substantial number of empty beds for possible peak influx of patients- assured the command as a whole, and thus the American people, that casualties of all types who did not require onward evacuation to the continental United States, could receive all of the care necessary. Upon recovery, these men could be expeditiously returned to their units, in-country, to carry on with their assigned duties, thus conserving manpower in the theater of operations.
Environmental control within the hospital was, clearly demonstrated as essential to proper military medical practice. The MUST (Medical Unit, Self-contained, Transportable) was a practical answer to control in a mobile situation. The MUST is a good concept, and Vietnam was
the right war for its employment; however, there were some management deficiencies in its utilization. The MUST should have been used to establish an immediate treatment facility in new areas of operations, then replaced by less expensive semipermanent hospitals when the continuing need became apparent and construction, support became available. This was not done, and the "T" (transportability) capability, was not exploited.
The adequacy of hospitalization, in-country and offshore, was evidenced by the favorable survival and return-to-duty rates in both areas. The efficiency of hospitalization was greatly enhanced by effective Army and Air Force aeromedical evacuation and by a smoothly functioning medical regulating system.
Many people and many elements were responsible for the excellent record achieved in the care and treatment of the soldiers in Vietnam. The judicious and bold use of hospital facilities was certainly a major facet in this success- "bold," since hospitals in Vietnam were actually assigned missions beyond their normal TOE capabilities. Evacuation and field hospitals really functioned as 400-bed general hospitals. The 30-day evacuation policy plus the relative stability of hospitals, made possible in large measure by the outstanding in-country evacuation system, combined to permit sophisticated procedures and contributed to a high return-to-duty rate in-country.
In essence, hospitalization in Vietnam combined that normally found in the communications zone in a classic theater of operations with that found in the combat zone.
Army Medical Department helicopter evacuation, in addition to moving casualties swiftly and comfortably from the battlefield to supporting hospitals, proved to be an important tool of modern military medical management. Adequate and reliable medical helicopter evacuation, with a medical radio network and an efficient medical regulating system, permitted more efficient and more economical use of medical resources.
With helicopter evacuation, hospitals can be stabilized for more efficient operation, without losing responsiveness to changing tactical situations. Hospitals need not be moved so often, with expensive "downtime" and loss of continuous support. The flexibility and versatility of helicopter evacuation under medical regulation and control permits the utilization of all the hospitals all of the time. Surgical lags are reduced. It is no longer necessary to staff every hospital with every specialty, because the casualty can be directed to that hospital best suited for the special attention he needs. At the same time, a specialty surgical capability
is placed in direct support of every forward medical activity. Fewer hospitals and fewer professional personnel are required for a given operation, owing to the medical management inherent in such evacuation system as that developed in Vietnam. Despite the cost of helicopter procurement, operation, and maintenance, a medical system which includes helicopters is just as economical as one without helicopters, when the total costs in national resources are considered.
Tactical and strategic aeromedical evacuation support of the Army by the Air Force was magnificent and contributed in large measure to the effectiveness of the Army medical operations. The enthusiastic responsiveness of the Air Force and its ability to move large numbers of patients rapidly, on short notice, made it possible for in-country hospitals to maintain a higher bed occupancy rate in the interest of conservation of strength, without sacrificing the capacity to accommodate waves of casualties. Generally, the Air Force moved patients between larger hospitals along the coast and offshore; however, it also evacuated casualties directly from forward brigade and division bases, when requested to do so.
Similarly, there was enthusiastic cross-service support among Air Force, Navy, and Army medical facilities, in-country and offshore, as promulgated in Joint Chiefs of Staff Publication No. 3. U.S. Navy hospital ships provided invaluable augmentation to shore-based medical facilities, especially in the I Corps Tactical Zone. Interservice medical cooperation was outstanding.
Medical supply support for the U.S. Army in Vietnam was superb, considering the many problems and impediments encountered. Early in the war, there was much criticism of medical supply, and a major reorganization of the existing system was required to provide adequate support. (See Chapter V.) It was again demonstrated, and most forcibly, that medical supply is part of the over-all medical support system, and that it must remain in that system, under professional medical control, if it is to be effective.
In addition to the existence of an unsatisfactory medical materiel management system in 1965-66, certain medical supply problems were iatrogenic ("caused by the physician").
For example, early in the buildup, it was decided to upgrade the capabilities of all hospitals in-country, because of the stability that was available and the remoteness of the objective area from the nearest offshore support. Essentially, the evacuation and field hospitals functioned as small general hospitals, and the surgical hospitals were similarly
upgraded. The TOE's of these hospitals were inadequate for the expanded mission. Specialty oriented physicians immediately required different and more sophisticated types of surgical, X-ray, laboratory, and recovery and ward equipment. The impact of these requirements on medical supply and maintenance support is obvious. Also, in late 1965, medical authorities decided to add the daily DDS tablet to the weekly chloroquine-primaquine tablet in the chemoprophylaxis against falciparum malaria. That decision immediately created "a serious medical supply shortage" that was felt throughout the system, including the manufacturer.
The wisdom of these and other operational decisions in improving the medical care in Vietnam is documented in this monograph. Medical supply was never accepted as a constraint to medical capabilities planning, and the system responded in a commendable manner.
All the hospitals in Vietnam were inundated with outpatients referred for specialized consultation by physicians in troop dispensaries and divisional medical activities. These hospitals were not staffed or equipped to accommodate this unprogrammed workload. Adequate facilities to house and feed the referrals were usually not available; and significant discipline, control, and transportation problems arose.
The thrust of modern medical education contributed significantly to the difficulty. Many of the physicians on duty in Vietnam had come directly from civilian practice or training. Modern medical school curricula place increased emphasis on specialization and the use of specialist consultants. The sophistication of modern medicine, the desire of the physician to provide the very best care for his patient, and the increasing awareness of malpractice suits added further to the problem.
A twofold approach to resolving this problem is underway. The new modular combat support hospital, which is intended to replace the surgical and evacuation hospitals will have a realistic outpatient capability. Of more importance, in restructuring the medical service support within the division, consideration is being given to including certain specialists in the medical battalion. Thus, outpatient consultant capability in such specialties as internal medicine, dermatology, ophthalmology, and orthopedic surgery will be available in the division base, preventing the unnecessary evacuation of many patients and keeping the troops under division control. These specialists will consult freely with other division medical officers and will also reach and visit dispensaries. In the interest of economy and mobility, division medical facilities for inpatient specialist care, will not be augmented.
Vietnam, and other recent experience in division and brigade medical support, has shown that it is no longer necessary nor desirable to assign medical officers to combat battalions. The impact of helicopter evacuation, frequently overflying battalion aid stations and going directly to supporting medical facilities, is only one of the considerations. Equally important is the nature of modern medical education and modern medicine, and the orientation of today's young physician, who depends heavily on laboratory and X-ray facilities, and on consultations with other physicians. This is the best way to practice medicine and field medical organization is being modified to accommodate this reality.
The battalion surgeon is being removed from the combat battalion. His clinical replacement will be a well-qualified technician, probably in the grade of warrant officer, and modeled after the "physician's assistant" in civilian practice. The technician will work under the direction of physicians in the brigade base and will provide initial resuscitation to wounded and do screening at sick call. The general practice of medicine will be moved from the battalion to the brigade base.
Impact of Policies
The 1-year tour of duty, unique to the Vietnam experience, had a definite impact on the medical support system. The favorable effect of the 1-year tour on morale and the reduction of neuropsychiatric illness has been described. A more subtle effect has been on the traditional emphasis placed by the medics, and the line, on "conserving the fighting strength." Contrary to U.S. experience in conventional "open ended," or "duration plus six months" wars, this emphasis seems to have diminished in Vietnam. The political and military wisdom of certain personnel policies on evacuation and return to duty implemented in Vietnam is obvious, and the medical service must be prepared to modify its approach accordingly.
Patients medically qualified for return to duty from offshore hospitals, but with less than 60 days remaining on their Vietnam tour, were not sent back to Vietnam. Those received in offshore hospitals with less than 60 days to DEROS (date eligible for return from overseas) were further evacuated to the continental United States when the medical condition permitted. This practice lowered the return-to-duty rates and the workloads of the various hospitals in the chain of evacuation. Approximately one-sixth of the patients evacuated offshore were administratively ineligible to return to duty in Vietnam, regardless of the medical condition or the degree of recovery. This reason, among others, contributed to the
decision to have a 60-day offshore evacuation policy, rather than the traditional 120-day holding policy.
This "60 days remaining on DEROS" policy was also one of the factors responsible for the increase of the in-country holding policy from 15 to 30 days. (There, are other more cogent ones.) The increased capability and holding capacity of in-country hospitals led to more, selective evacuation of complicated cases, largely surgical, to the offshore hospitals in Japan and elsewhere. Patients with simple surgical, medical, and neuropsychiatric ailments, were treated in-country and returned to duty there. The imbalance between the types of patients received offshore, and the balanced staff prepared to receive them, created a management problem. Repeatedly, the Army was challenged on "under utilization," of offshore capability by "managers" who could not understand why a 1,000-bed general hospital was "full" with only 650 patients. In fact, a 1,000-bed general hospital, staffed for a 40-40-20 percent mix of medical, surgical, and neuropsychiatric patients, was inundated with 650 patients, most of whom required complicated surgery, often orthopedic.
A more insidious policy, which troubled me as a physician and staff officer, was the provision that patients evacuated to the continental United States, or home of record, would be given tour-completion credit and would not be required to return to Vietnam. Originally the policy applied to battle wounded only, but later it also included disease and nonbattle injury cases. This expansion of the policy gave me the most concern, because it damaged the safety and preventive medicine programs by giving a, bonus to the careless or disaffected manipulator. There was a time, in the fall of 1965, when the best way for a soldier to insure being home with his family on Christmas was to contract malaria in the Highlands, or to be seriously injured in a Honda accident in Saigon, or to receive a bad "accidental" burn in Nha Trang. At the subconscious level, where a soldier is really motivated, such a bonus in illness or injury can have a most negative effect.
In late 1968, USARV made extraordinary efforts to meet in-country strength ceilings imposed by higher authority. Although the so-called "patient account" portion of the USARV troop strength was, established at 3,500, the surgeon was directed to reduce the number of patients occupying beds to no more than 3,000, to provide spaces to cover accesses in in-country temporary duty personnel. Also, some 5,000 hospital beds were available during that period. There seemed to be little command concern about the overevacuation offshore to accomplish tile reduction. In fact, when informed that certain patients who would be fit for return to duty within, say, 5 days, were, being evacuated to Japan one senior commander said that he sent troops to Japan for only 5 days on a recurrent basis- the R&R (rest and recuperation) Program. In short, there seemed
to be less command concern in retaining experienced combat troops in-country, because of the ready availability of replacements.
These observations are not intended to be critical, but they should be considered when developing future policy related to eligibility to return to combat zones after illness or injury. Modifications of Medical Department policy and procedure, and the allocation of resources among successive medical treatment echelons, most also be done in light of these realities.
Lack of Responsiveness of The Army Authorization Document System
A major problem, encountered in the buildup phase was the lack of responsiveness to TAADS (The Army Authorization Document System) in the combat situation. When the decision was made in 1965 to upgrade the capabilities of in-country hospitals, their Toe's were grossly inadequate for the expanded missions. Authorizations for the additional personnel and equipment required were hopelessly delayed, first by the moratorium in effect on TAADS, then by the inertia of the system. The most frustrating part of the problem was securing authorizations against which to requisition non-medical equipment and enlisted personnel (including medical).
Through the use of effective technical channels, The Surgeon General most expeditiously provided the Medical Department officers and the medical equipment needed for the expanded hospital missions. Enlisted personnel and the non-medical equipment, however, had to be processed through non-medical channels, involving months of delay.
While TAADS may be, all effective way to manage force structure in peacetime, it should be waived in the combat situation to permit timely implementation of decisions necessary to support operations.
Clinical research, surgical and medical, in forward combat hospitals, essential to the finest practice of medicine and to the improvement of technique and materiel procedures, was done most effectively in Vietnam. Adequate photographic as well as written documentation of combat medical experience was also furnished for review and evaluation in the refinement of procedures.
Vietnamese Civilian Care
While providing the best in medical care for US. forces, the Medical Department made significant contributions to the rare, of sick and injured Vietnamese civilians from the earliest days of U.S. involvement. These
efforts, of considerable magnitude and scope, were well integrated with other United States and Vietnamese efforts and contributed to the improvement of Vietnamese medical practices.
Despite frequent and continuing political allegations to the contrary, U.S. troops were compassionate and did provide full assistance to the disrupted Vietnamese nation. Apart from the humanitarian aspects of the various civilian medical assistance programs, this involvement provided US, medical personnel gainful and rewarding activity during lulls between peak military medical support requirements. This, in turn, contributed to the high morale of committed U.S. "medics."
In every major war, medical advances, are made which have a strong positive influence on the over-all practice of medicine in civilian society. Vietnam was no exception. Skilled surgical and research teams, developed improved techniques for managing trauma in individuals and in groups. Examples of specific advances are contained in the body of this monograph. Less obvious is the tremendous contribution that physicians and surgeons are making to American medicine as a result of their in-depth experience in Vietnam. Throughout the Nation, there are young surgeons completely competent to handle the most, complicated and serious of injuries, whether due to accident, natural disaster, or war. Similarly, physicians returning to their civilian practices bring with them diagnostic and therapeutic capability to manage the most baffling and complicated medical conditions. No other country in the, world is so blessed.
Improved medical management, developed on, the field of battle, has direct application in civilian practice. Regionalization of medical care delivery and increased utilization of ancillary health care personnel under the team concept, now receiving so much attention at national and local, levels, are, patterned on the military model that has been used for many years. The medical control concept, medical radio network and helicopter evacuation- the systems approach which proved so successful in Vietnam- is now being used for efficient, effective regionalized health care delivery in the United States.
The highly successful MAST (Military Assistance to Safety in Traffic) Program is but one prime example of the adaptation of the military model to the civilian requirement. This demonstration project cannot help but expand, and the hope is that before too long the civilian community, rural and metropolitan, may achieve a real emergency medical care system approaching the effectiveness of that provided in Vietnam. The Vietnam veteran, having seen what can he done half way around the world, is now demanding that the same capability be provided here at home.
As in previous wars, the medical experience gained in Vietnam is likely to contribute to the saving of more lives in the future than were lost during the conflict.
This, then, is the story of the medical support of the U.S. Army in Vietnam. The challenge was met with vigor and enthusiasm, and the mission was accomplished in the highest tradition of the U.S. Army and its Medical Department.