Executive Summary

The idea of war with an advanced adversary, or worse, a two front war is daunting, needing every bit of ingenuity that one can muster. Force multipliers are one such, employed to overcome the difficulties against a numerically superior adversary.

This paper brings out Combat Casualty Management (CCM) as an inexpensive force multiplier. This has been inferred from the number of injured saved from dying by Ukraine vis a vis Russia, the number returned to battlefield reducing the need for recruitment and training, and the improvement of morale that such services provide, amongst others.

The paper further highlights some areas where the lessons learnt from the Ukraine war, along with other operations including Gaza could be employed by the Indian Armed Forces Medical Services (AFMS).

Introduction?

A ‘Force Multiplier’, as the name suggests, multiplies the force levels in combat. Usual examples of force multipliers include Aircraft Carriers, Air-to-Air Refuelling, Standoff Munitions, Airborne Warning and Control System (AWACS) assisted combat etc. All of these are prohibitively expensive, but are employed as their utility far outweighs their cost. This paper argues that CCM is a low-cost force multiplier that can greatly enhance force levels of the military. The Ukraine conflict has been taken as an example to explain this fact.

The estimates of dead and injured in the Russia-Ukraine conflict are uncertain at best, as recounted by numerous authors.^[1][2][3] This paper uses the estimate of Radford et al, which may be more precise, as it has attempted to remove bias through mathematical modelling. The estimated casualties by Oct 23 are estimated at: -

Table 1: Ratio of Wounded To Dead

Differences Between Ukrainian and Russian CCM and Implications

This paper argues that differences in the CCM provided by Ukrainian and Russian forces impacted the survival rate of soldiers, resulting in lesser deaths amongst the Ukrainians than the Russians. It further brings out the other benefits of better-quality medical care, including that on morale, battle effectiveness, and troop strength in the near term, as well as draft numbers and rules, training and preparedness and finally war outcome, in the long term.

Medical Support to Russian Troops; At the beginning of the Ukraine war, the visuals of numerous large convoys heading into Ukraine filled our TV screens. However, one finds it difficult to remember seeing a single ambulance or medical vehicle in the convoys, as they were few. When soldiers started getting wounded, they were evacuated back to Russia, at a logistical as well as human cost. This situation persisted till Apr-May 2023, when the Russian army not only moved medical elements ahead, but also resurrected some captured Ukrainian hospitals for treatment of injured Russian soldiers.
Medical Support to Ukrainian Troops: Unlike the Russians, the Ukrainians were fighting at home, obviating the need for medical echelons to move forward. The injured were treated at military as well as civil facilities. As of Apr 2024, there have been 1382 recorded attacks on Ukrainian healthcare facilities. This has resulted in a serious compromise of healthcare facilities in Ukraine and backward evacuation of casualties to other countries in Europe. By Apr 2024, more than 25,000 Ukrainians have been treated at other European countries. This is despite the fact that even today, there are 244 Ukrainian hospitals providing combat casualty care.^[4] Approximately 62% of the surviving injured were returned to the battlefield within three months of the injury.^[5]

Impact of CCM on Outcomes in Modern Battlefields

Wounded to Dead Ratio: The starkest contrast is the ratio of wounded to dead between the Russian (3:1) and Ukrainian (5:1) injured soldiers, which almost certainly stemmed from the quality of healthcare provided. As has been brought out above, the Russian attacking forces did not cater to any credible medical support, perhaps in the initial belief that the attack would be met with little resistance from the Ukrainian side.

Worldwide Wounded to Dead Ratio: It would be instructive to discuss the above ratio in the context of the world average. The Ukrainian ratio of 5:1 viz 20%, has been the average all over the world for a long time. The best was achieved by the US troops during the 2nd Gulf War, where this was brought down to almost 2.5%.^[6] Here, however, the resources used were enormous, which may not be possible where a large number of casualties are expected. Notably, during the Afghan war, the toll rose to ~13%, which is closer to the average.^[7] Compared to this, the Russians had a very large number of deaths, almost thrice of the Afghan war and 1.5 times the Ukrainians.

Return to Battlefield: Death is always sad and demoralizing. However, if viewed dispassionately and from a military perspective, perhaps a more important issue is that 62% of the surviving wounded returned to the battlefield within three months of being wounded, ^[8] thus reducing the cost of recruitment and training. It is true that some of these soldiers, who had lost limbs had limited capacity to fight, but have been employed in other roles like communication, training, strategy development etc. Still, this is the equivalent of training nearly 47,000 soldiers, to a level beyond ab initio. The financial impact of this can be estimated from Table-2 below. In addition, it entails a saving of three to six months in terms of training time, and providing much better trained soldiers.^[9]

Table 2: Cost of Soldier Training

Availability of Soldiers: The shortage of Ukrainian soldiers has been in the headlines for some time now. The increase in age for draft in the Ukrainian army has been increased to overcome this crunch. Similarly, there are reports of various mercenaries including Gorkhas fighting in the Russian army, something that was heretofore unheard of. Early return of casualties to the battlefield has the potential to alleviate this deficiency to some extent.
Morale: Military morale is the military’s confidence in its ability. It enhances resilience and mental resistance to complex and difficult situations that results in mission accomplishment. Morale has been called an essential dimension of military power. ^[16] In the cost-benefit analysis that follows, the benefit of high morale outweighs any cost of healthcare by a factor so vast that it cannot be calculated.

Cost-Benefit Analysis: The cost of providing CCM is not easily estimable. However, the costs can be estimated using other analogous methods. Perhaps the most expensive surgery and treatment regime is that for cancers. In India, cancer surgery costs anywhere between USD 200-1000.^[17][18] Even if the cost of cancer treatment is equated with the cost of casualty care, the cost is still about 1/50th of that for training a soldier. It is thus understandable that a good and efficient CCM is perhaps the cheapest and most effective resource for providing trained, motivated and experienced soldiers to the battlefield.

The Way Forward for the Armed Forces Medical Services (AFMS)

‘What if?’ Instead of ‘Will it Happen?’ The long period of peace since the WW-II has been mentioned as the longest ever in human history. For India, peace has largely persisted despite fragile border situations on the western border since 1999, and that on the northern border since 2017. However, at times the hostile actions by our adversaries increase the possibility of war. So far, we have always asked, “Will war ever happen?” It is believed that the time has come to ask, “What if war happens? Are we prepared?” ^[19] by all echelons of the armed forces including the AFMS.

Change in the Battlefield: So far, most wars by independent India have been fought in the plains, along borders that have a large number of well-connected hospitals. The only exceptions to this have been the Kargil and 1962 wars. Both resulted in a disproportionately large number of casualties, as well as a high wounded to fatality ratio. With our primary adversary across the northern borders, the next war is much more likely to be similar to these.

Casualty Estimation in the Indian Context: The Shekatkar Committee, after the Kargil war audited estimation of casualties and called the estimate too conservative, increasing it to 150%. The Ukraine as well as Gaza wars have brought out two major issues, which would require a higher estimation of casualties: -

1. Injury Potential of Modern Weapons: The injury potential of modern weapons is larger, and has been paired with a change in tactics, both in Ukraine and Gaza. Earlier, the war on the battle-front was fought with rifles and grenades, between two armies facing each other. Today, even the battle front is receiving precision, high-fragmentation weapons delivered from a distance. This has greatly increased the injury potential and hence would increase the casualty estimation.
2. Casualties in Depth: All past wars, including the Gulf Wars, Kargil War and so on, had casualties only at the battlefront. However, the Ukraine and Gaza wars, as well as the potential of the Chinese rocket force, compel us to think of casualties in depth. The reach of the enemy is extending to greater depth within our territory, especially if not neutralized by a strong air force. In all such cases, casualties will have to be estimated not only in the battlefield, but also in depth, in one’s own territory.

Combat Orientation: As a part of ‘What If’, combat orientation of AFMS is imperative. This would involve orientation at various levels. Some of these have been brought out in the subsequent paragraphs. This list is not exhaustive, but should give a fair idea of the challenges that are required to be recognized.

Doctrine: At the highest level, this orientation involves a doctrinal narrative. The time is perhaps appropriate for issuance of a doctrine spelling out current and envisaged improvements in Combat Casualty Management (CCM), equipment for patient transportation, indigenous development of equipment, and casualty evacuation (casevac). The doctrine could also stress the wartime role of the AFMS, which may differ from its peacetime role.

Training: Lessons learnt from Op Pawan, Op Meghdoot, Op Parakram, CI Ops in the northern and north-eastern regions of the country, and Op Safed Sagar could be specifically incorporated into training of Doctors, Nurses and Paramedics. Considering the military role of the AFMS, this could form a specific three-month capsule for all military doctors, whether generalists or specialists, including non-surgical specialities like General Medicine, Paediatrics, Psychiatry, Community Medicine and so on. Considering their role connected with Operational Medicine, an even greater emphasis should be given to such training for trainees of Aviation and Marine Medicine.

Types of Casualties: It would be worthwhile to look at the kind of casualties we would expect. We are likely to get a large number of casualties, in a moribund state, coming in batches (rather than a steady stream), after having travelled long distances. Each of these issues results in specific challenges that need to be addressed.

Cadre: A look at the cadre of the AFMS, specifically keeping in mind the need to treat a large number of casualties, is likely to bear fruit. There may be two ways to address this problem, and the best may be a combination of the two.

1. Combat Care Doctors: There is an urgent need to increase the number of doctors specialized in combat care, whether through accretion or by tweaking the ratio of combat care doctors against others.
2. Paramedics as Primary Responders: It is recommended that the number of paramedics be increased, and they be trained to become the primary trauma care giver, with the doctors assuming the role of providing definitive treatment. Practically, this would mean that paramedics are used more effectively for providing life support, as is already the case in many advanced nations. This is now becoming possible with a much better education and awareness amongst paramedics, than was available 50 years ago, around the 1971 war.
3. A Combination of Both Strategies: This may provide the best mix of the two.

Research and Development

1. Following the 1st Gulf War, the US developed a different approach to casualty management, focussing specifically on eye injuries, pneumothorax and severe bleeding.
• They introduced the concept of 10-1-2 viz 10 min from battlefield injury to First Aid, one hour to Advanced Resuscitation and two hours to damage control surgery. This resulted in the number of deaths reducing to 2.5% of wounded i.e. 40:1, and has now been enshrined not only as a NATO Standard,^[20] but also as a UN Standard, since MINUSMA. ^[21]It is now being followed by many militaries.
• They introduced the 9-Line Report, a method for demanding casevac, which has been known to reduce the ratio by 50%.^{[22] [23]}
2. The AFMS has adopted some of these recommendations with good results. Notwithstanding, the Indian Armed Forces have dealt with a much larger number of casualties in the past two decades than the US Armed Forces. There is a requirement for R&D into best practices for CCM in the Indian context.
3. Additionally, medical equipment can prove a choke point in case of a conflict. This had manifested during the COVID-19 pandemic. There is a need for indigenous development of medical equipment as well as Active Pharmaceutical Ingredients (APIs). Essentially, Atmanirbharta in defence production should include medical equipment and APIs.
4. So far, our concepts of casevac have depended upon the available equipment. There is need to develop our own concepts and design the equipment suited to our concepts viz tailor equipment to our concepts, rather than tailoring concepts to available equipment.

Development of Hospitals: As has been brought out above, our hospitals have been sited catering to earlier battlefields on eastern and western borders. There is an urgent need for development of new hospitals for the new battlefields.

Ambulances for Evacuation of Casualties from Difficult Terrain: The terrain for the next war may be much more difficult than that in which all previous wars have been fought. There is an urgent need to upgrade to all terrain, light, bullet proof ambulances to achieve this goal. Use of modern technology like Whipple’s Shield, or Metal-Ceramic-Epoxy-Ceramic sandwich would allow for lightweight bullet-proofing along with better thermal insulation.

Portable Life-Support: As the availability of life-support equipment is rising and the cost falling, it is becoming practicable to provide adequate, lightweight, versatile life-support equipment at a relatively affordable cost. Such life-support patient transportation units can greatly reduce mortality and act as force multipliers.

CCM as a Force Multiplier

CCM as an inexpensive force multiplier is the crux of this paper. The reasons for this belief have been brought out above. This belief, however, also dictates some doctrinal beliefs, not only for the medical services, but also for the armed forces in general.

Teeth to Tail Ratio: The teeth to tail ratio of the armed forces has been in discussion in the last decade, with good reason. So far, the medical services have been grouped as the tail. This paper brings out that CCM as an inexpensive force multiplier is actually a part of the ‘teeth’, and has been so since antiquity, whether one considers Sushen from the Ramayana, Satyaki, Nakul and Sahadev of the Mahabharata or Machoan and Podalirius of the Iliad and Odyssey.

Summary and Conclusions

Even if cliched, it is true that the more one sweats in peace the less one bleeds in war. Conflicts in Ukraine and Gaza have ready lessons to be learnt. We have a choice. We can either learn from these wars, or we can allow the status quo ante to continue.

These wars have been cited, as well as earlier wars like the Gulf Wars, and our own operations of the past two to three decades. Some lessons that can be gleaned have been brought out above and pertain to both abstract concepts like doctrine and combat orientation, as well as concrete lessons like R&D into casualty management, development of hospitals and reorientation to the new battlefield.

Combat Casualty Management, is an inexpensive and effective force multiplier. However, to harness the potential of this relatively inexpensive and highly effective tool there is an urgent need to address certain issues that have been brought out in this paper.

References

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^[8] Pl see N. 5
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^[19] Sinha PM. What If. Personal Communication.
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^[22] See N.19
^[23] See N.20

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