First a confession. I practiced medicine in the military system for three decades. My only time in “civilian” health care were the three years of my pediatric fellowship at an urban children’s hospital and the last two years in my current (largely) administrative role. So I admit up front to a bias that comes from having spent the bulk of my post-pubertal life in uniform.
A second bias comes from being a pediatrician and working alongside pediatricians for much of my professional career, a group that my wife has identified as inherently nice people. (She has her own biases.) Although my last decade or so in uniform was spent helping to run military hospitals and health systems I still always gravitated towards uniformed pediatrics as a source of professional identity and perspective.
It from this biased perspective that I have recently considered some of the distinctly positive advantages of military medicine; advantages that remind me how good American medicine could be for all Americans.
For those who might wonder why we even have pediatricians in the Armed Services, military physicians have cared for the children of American service members for as long as the nation has had a standing military, peace to maintain and “frontiers” to defend. These conditions were first realized in the late nineteenth century during the wars against the Native American peoples of the North American west. For example, enterprising clinicians were cautioned in the 1884 Defense Appropriation Bill that “The Medical Officer of the Army and contract surgeon shall, wherever practicable, attend the families of officers and soldiers free of charge” (Potter. Mil Med. 1990;155:45).
American pediatrics and pediatric training in both military and civilian facilities emerged from the shadow of internal medicine in the early twentieth century (Callahan et al. Pediatr 1999;103:1298). The need for military pediatric care became urgent in pre-World War II America as the nation mobilized for war and families settled near the military bases where young men were inducted into the uniformed services. After the war, thousands of American service members were stationed overseas and many either started families in the communities where they were stationed or brought their families with them. In 1956, the “Dependents Medical Care Act” became law and mandated the provision of medical care for all military dependents wherever they were stationed. Today there are 9.4 million Americans in the Military Health System (MHS) including 4.2 million family members cared for in scores of uniformed clinics, hospitals and medical centers around the globe as well as in the civilian TriCare network.
Pediatricians have served in a variety of roles in every major armed conflict since the Spanish–American War (Burnett. Pediatr 2012;129:S33). In the current wars in the Middle East, the longest conflicts fought by volunteers in our nation’s history, pediatricians are among the most frequently deployed specialists serving in roles from battalion surgeons to hospital and health system administrators. Between deployments, uniformed pediatricians serve alongside civilian government service and contracted colleagues in a health system with features that should serve as goals for American healthcare.
Military medicine is longitudinal. Between job changes and shopping for new insurance under the Affordable Care Act, nonmilitary managed care plans suffer a 10-20% turnover every year. For some plans turnover may be as high as 30%. While retired military service members and their families who are eligible for care in military facilities tend to be stable, active duty families move approximately every three years. However they usually move to another military site with the same health benefits. Since the hospitals are in general managed centrally, the different sites are similar in the way they operate and in the outcomes that they follow.
In the United States’ volunteer military, as many as 40% of military service members had parents in the military. So many received care in military treatment facilities while they were growing up. In a real sense the children of today’s military members will be the core of tomorrow’s military force. Population health interventions directed towards children and adolescents by uniformed pediatricians who uniquely understand the military family can positively impact the future health of the American armed services, and could potentially affect the health of those who will one day receive care from the Veteran’s Administration.
Military medicine is part of a worldwide integrated healthcare system. My daughter (mentioned with her permission) has a chronic medical condition that has required surgery in at least six military and civilian facilities from Hawaii to Washington D.C. Since a single electronic medical record was fielded by the Military Health System nearly 15 years ago, all of her records from across the country were available in one electronic location for access by her pediatricians, pediatric specialists and surgeons. For all its foibles, the Armed Forces Health Longitudinal Technology Application (AHLTA) has established something almost without precedent elsewhere in the United States. It provides the opportunity to coordinate the primary and specialty care of individual patients who frequently relocate and it gives unique insight into the health outcomes of specific, well-defined patient populations. With these data, decisions for the allocation of healthcare resources can be made based on population needs and outcomes rather than merely healthcare supply or market forces.
Military medicine is equitable. For more than a century researchers have noted that the infant mortality rate (IMR) of black infants in the United States was at least twice that of whites (Brosco. Pediatr 1999;103:478). For example in our nation’s capital, the IMR in Ward 8 which is poor and predominately black is ten times that of the more affluent and predominantly white Ward 3. In 1992, Army neonatologists published a review of fifteen thousand births at an Army medical center between 1985 and 1990 and demonstrated no statistical difference between IMR for black and white infants despite an increased rate of premature birth and low-birth weight in black infants (Rawlings et al. Am J Dis Child 1992;146:313). While the experience with the military population (i.e. employed, housed, educated, with access to food and resources) may not be easily generalized to the American public, the infants in this review shared the same thing that children cared for across the MHS enjoy today: stable social determinants of health and equitable access to high quality, low cost or free maternal and pediatric healthcare.
Military pediatrics is approaching its sixtieth anniversary. In 1959, the American Academy of Pediatrics executive board voted to approve a section on military pediatrics to advocate for the unique needs of the military child and to address the needs of the uniformed pediatrician. The original section included 25 members. Today more than 900 pediatricians are members of the section. They continue to serve and advocate for the military family.
These uniformed clinicians, their adult-focused counterparts, civilian government service and contracted colleagues belong to a healthcare system that the Nation might do well to pay attention to; one that is longitudinal, integrated and equitable. It is a system that should serve as an example: This is how good American healthcare could really be.
Chuck Callahan Henry V 4.3 – Lead from the Front https://henryv43.wordpress.com/
Henry V 4.3 