Journal of Community Health, Vol. 19, No. 1, February 1994

COMMENTARY

CASUALTIES ABROAD AND AT HOME Discussions in both the general press and the medical literature during the period of our nation's military involvement in Desert Shield and Desert Storm touched to some degree on the issue of how to care for casualties. This issue has largely receded from public concern because American casualties (with 148 combat deaths)' were far less than had been feared. Indeed, the issue of casualties has been even further obscured by the scarcity of specific information on the estimated casualties among the opposing forces.'-' It seems worthwhile to revisit an issue that had been quite pressing only a short time ago; that is, the capability of the domestic health care system to cope with a potential sudden influx of thousands of casualties from a brief intense campaign. One aspect of military preparedness involved local medical resources, both on the ground and on hospital ships.:' This effort included military medical reservists among others, in an effort that has been described in some detail in the literature by others. Other American military facilities further from the battle area, including those in the United States proper, were available for handling of evacuated military casualties, and would by themselves perhaps have been sufficient even if the United States casualties had somewhat exceeded their actual number. The planning apparently relied heavily on the bed capacity of the Veterans Administration (VA) hospital system, '''~ and one presumes that any attempt to free up VA beds would have increased the burden on nearby civilian hospitals. 7 Indeed, the planned utilization of the civilian hospital system might have been still more direct. One disturbingly vague part of the planning for mass casualties was the assumption that civilian hospitals in the United States would be an important part of the backup system for care of the wounded. Assuming even that such casualties could be promptly brought back to the United States, one wonders how well civilian hospitals would have been able to cope with the patient load, particularly those whose medical and nursing staffs had been temporarily depleted by the call up of reservists. The problem would of course have been most acute in those specialties with the most military patients to care for, such as the surgical specialties and perhaps psychiatry. In areas such as burn victim care for example, patient care involves a hospital 9 1994 Human Sciences Press, Inc.

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infrastructure that is expensive, complex, and so not readily expandable in the civilian sector on short notice. Since these sorts of admissions begin unexpectedly for a given accident victim and are often prolonged once they have started, there may be little flexibility regarding admissions or discharges to fall back on to create available beds. In local civilian disasters, one can cope with this issue in part by drawing on resources from nearby geographic areas that have not been affected by the fire, flood, or other domestic disaster. This option too would largely be unavailable in the setting of a large influx of military casualties that one might hope to spread among the civilian hospitals nationwide. The problem of course, as has been noted in the past, would become monumentally more severe if significant domestic casualties and damage to the domestic health care system were also produced by a military conflict. ~ As a practical matter, a hospital is unlikely to want to leave hospital beds vacant, and deny care to their local population, merely on the chance that the beds may subsequently be needed for military casualties. Such a policy would impair both local health care and the fiscal stability of the hospital. Once beds are filled, it may be difficult to free up large numbers of occupied beds for the anticipated arrival of military casualties. Yet even once fighting broke out in the Persian Gulf, the federal government apparently took little action to prepare for the possibility that civilian hospital beds in the National Disaster Medical System might be needed to supplement the available military and VA beds.:' The idea of reliance on civilian hospitals for support in this situation might incur legal difficulties as well as practical ones. It should be noted that, under the Third Amendment to the Bill of Rights, "No Soldier shall, in time of peace be quartered in any house, without the consent of the Owner, nor in time of war, but in a manner to be prescribed by law." It seems reasonable to assume that the provision regarding "time of peace" would also apply to the military conflicts in which the United States may become engaged, as has been the case in recent decades, without a formal declaration of war. Although the federal courts have had scant occasion to interpret exactly what sorts of housing are covered by the Third Amendment, it does appear to embrace more than just the single family home. Thus, correction officers sought to invoke their constitutional right not to be evicted from their institutional housing, at a prison site, even by National Guardsmen sent in response to a strike by the prison guards. The majority of the judges on a federal appeals court hearing this claim felt

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that, depending on the particular facts of their situation, the correction officers might well have had their Third Amendment rights violated.'" If similarly a hospital inpatient bed indeed is housing covered by the Third Amendment, then it seems questionable at best whether civilian patients could constitutionally be evicted from civilian hospital beds to make way for military casualties from an undeclared war. The planning for the civilian hospitals that had been contemplated apparently was to have relied, not on forcing hospitals to evict patients against the wishes of the hospitals, but rather on their voluntary" cooperation through the National Disaster Medical System. "-' This sort of planning by hospitals and the government may facilitate cooperation on the institutional level, but it of course does not guarantee the cooperation of individual health care workers, or indeed of the individual patients who happen to be in hospital at the time of a national emergency and who may not be willing or able to leave prematurely. The National Medical Disaster System was used in 1989 to deal with the effects of hurricane Hugo in the Virgin Islands, largely by bringing in medical personnel to assist on the scene.':' It may well be easier for a hospital to cope with the loss of a few of its professional personnel temporarily than it would be for a hospital to cope with a sudden influx of new military patients. Paper commitments previously given by an institution that it would accept military patients might prove difficult to honor in practice, particularly if the hospital in question had lost significant numbers of its staff to prior reserve callups by the military. Why should Americans generally be concerned about such paper arrangements for care of military personnel in civilian hospitals, if they are in fact unlikely to ever actually be implemented successfully? I think there are several reasons. First, to have in place disaster plans that may not work, but whose ramifications may not be critically examined until they actually are needed, is a recipe for confusion and disorganization. With the capability for air evacuation of casualties, after all, the interval between the first wave of casualties and their return to the United States may only be a matter of days, too short to resolve complex organizational issues when the country's decision-makers would presumptively be preoccupied with the concerns of an ongoing military and foreign policy crisis. In addition, an over-reliance on civilian backup creates an incentive for military budgeters to economize now by spending less on the excess military medical infrastructure that must sit unused just to be ready in case of a sudden rush of casualties. Hospital ships and the like

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are obviously expensive to build and maintain, but the supply of such capital assets could not be expanded rapidly in the event of a sudden need for them. One suspects that concerns of public perception may also have influenced the relatively low profile of the issue of military casualties. Detailed plans by the military for anticipated casualties obviously depend in part on their educated guess about the number of casualties that may be generated if the conflict goes badly, information they may not wish to make available to a military adversary. On the domestic front too such casualty estimates may be of importance, as is the symbolism of the empty hospital beds waiting to accommodate them, but these potential costs of battle are not likely to be the issues emphasized to the public by a national leadership rallying the country to support an anticipated military intervention. It would be unfortunate if concerns of public relations meant that the medical needs of our citizens, military and civilian, were not adequately met. Nell J. Nusbaum, JD, MD Clinical Assistant Professor Department of Preventive Medicine and Community Health State University of New York Health Science Center at Brooklyn Attending Physician Department of Medicine The Brookdale Hospital Medical Center Linden Blvd at Brookdale Plaza Brooklyn, NY 11212

REFERENCES I. Schmidt WE: 9 Deaths in Gull- British ask 'Wily?' New York Times, May ! i, 1992, p.A3, 2. Schmitt E: Study lists lower tally of Iraqi tr~mps in Gulf wan'. New York Times, April 24, 1992, p.A6. 3. Meth BM, Harviel JD, Bray JG: Operation Desert Shield experience. Cri! Care Med 19: 1079-80, 1991. 4. Marwick M: VA hospitals prepare fi~r Desert Storm casuahies.JAMA 265:701, 1991. 5. Cohen KL: Correspundence: Medical aspects of Operation Desert Storm. New Engl J Med 325:970, 1991. 6. Packer J: VA budget gets boust fi'om Gulf War. MtKlern Healthcare, April 22, 1991, p.22. 7. Greene .1, Gardner E, Pallarito K, Taravella S, Tokarski C: Nation's hospitals brace tor casualties. M~Jern Healthcare,January 21, 1991, pp. 2 & 3.

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8. Chivian E, ('hivian S, Lifton RL, Mack ,] E: (Eds.) I.xL~tAid: The mediral dime,.~imL~r~" nuclem" zt~,'. San Franci.~o, W.H. Freeman and Company, 1982, pp. 181-201. 9. McCnrmick B: U.S. hospital disaster network nut needed yet, Defense rays. Amerirttn Mrdiral News, February 4, 1991, p.3 & 34. i0. Engblom v. Carey, 677 F.2d 957 (2d Cir. 1982). il. Health Re.~mrc~ and ,Services Administration. National Di.~ster Medical System; Medical manpower component establishment. Federal Register 53,12994-95, April 20, 1988. 12. Gunby P: Medical efforts intensify in D e l f t Storm's fourth week.JAMA 265:692-693, 1991. 13. Roth PB, Vogel A, Key G, Hall D, Sua:khoff CT: The St. ('roix disaster and the National Disaster Medical System. Ann Eme~g Med 20:391-395, 1991.