The Need for and Difficulties Getting the Strategic View
The Service Secretaries, Chiefs of Staff, Surgeons General, and other senior military leaders regularly send out updates on what is happening in their world to their subordinates. The Army Chief of Staff, for example, sends out a regular update on priorities to all Army colonels. These are rarely more than one to two pages, but in the hustle and bustle of daily activities, often do not get read. Leaders rely on the news, local word of mouth, or perhaps nothing at all, to build their mental picture of what is going on outside their organization; the environment in which they work. Without a desire to see and a clear view of the greater strategic situation, military units and other organizations fail.
The military considers its colonels and generals to be strategic leaders, but as in every organization, many of these leaders spend most of their time on day to day activities. An example of the “tyranny of the urgent”, important but non-urgent strategic matters are often brushed aside so that these leaders can handle urgent matters, whether important or not. The military is not unique; leaders at all levels of government and in the private sector struggle with the same thing. Stephen Covey identified this problem in his famous book The Seven Habits of Highly Effective People.
Why is this? First, it is difficult to measure (and thus justify paying for) strategic awareness and thinking. Second, the immediacy of phone calls and emails distracts leaders and eliminates the large blocks of uninterrupted time required for deeper thought. Third, changes in technology have shortened our attention spans and changed the way that we think, as Nicholas Carr in his book The Shallows ably contends. Fourth, the problem solving skills that make leaders successful in tactical and operational roles do not lend themselves to strategic thinking, in which imagination is at least as important. Fifth, modern communication makes us aware of more problems than we can impact, and people, even leaders, often feel helpless to change anything outside their immediate control (Neil Postman, Amusing Ourselves to Death). Sixth, expectations of leaders have changed; personal issues such as money or family problems in their troops that in years past would have never come to the attention of a senior commander (because the squad or platoon leader would have handled it) now consume significant amounts of time. Some argue that the Peter Principle, the idea that people are promoted to a level at which they are no longer effective, may play a role. Time and space constrain my ability to list more.
The biggest reason for the lack of strategic awareness and strategic thinking in the military, and any organization, is that once leaders have a clear picture of the environment, or at least as clear as this inherently murky picture can be, they have to do something about it. The broad outlines of what to do may be clear; as was the case in the aftermath of the Haiti earthquake in 2010. They may be fuzzy; as was the case with the starvation in Somali in 1993. The broad outlines may be nearly indistinguishable; as is the case when considering how to defeat international terrorism. Often the proper course of action is known only after the event, when it is too late to change course. Sometimes the best answer is never entirely clear. Once leaders understand the broad outlines of what needs to be done, they have to determine specific tasks for their subordinates to accomplish. Such is no small feat, and in combat operations, the US military does it well.
At the same time for these decision makers, the relentless drumbeat of media head hunters (not all of the media, but some) means that no incorrect decision, no matter how reasonable it seemed at the time, goes unpunished. Even good decisions, which inevitably have some downside, are attacked. The attacks are not new, but their pervasiveness is. Such is, and always has been, the nature of leadership. One wonders how this impacts the desires of people today to take responsibility for others, to be leaders, or even to grow up.
The Strategic View in the Military and Military Medicine in 2012
Turning from the general to the specific, consider the current principles and priorities of the US military:
Army (Sec Army Nov 2012)
Ensure a highly capable Army within budgetary constraints
Champion soldiers, civilians and families
Enhance Army activities in the Asia-Pacific region
Transform the institutional Army
Codify Army total force policy
Adequately fund reset and modernization
Strengthen information assurance and cybersecurity
Develop effective energy solutions
Finalize Arlington National Cemetery reforms
Navy (CNO Sailing Directions Sep 2011)
Remain ready to meet current challenges today
Enable and support sailors, Navy civilians, and their families
Maintain the “watch” as ground forces draw down in the Middle East
Our Navy ethos defines us and describes the standard for character and behavior
Build a relevant and capable future force
Sustain fleet capability through effective maintenance, timely modernization, and sustained production of proven ships and aircraft
Cyberspace operationalized…providing superior awareness and control
Air Force (Chief of Staff, Jul 2011)
Partner with Joint and Coalition teams to win today’s fights, holding any target at risk
Develop and care for our airmen and their families
Establish control in air, space and cyberspace
Recapture acquisitions excellence
Continue to strengthen the Air Force nuclear enterprise
Modernize our air, space, and cyber inventories, organizations and training.
We can see common themes in these principles and priorities, themes which have not changed since Caesar crossed the Rubicon. The first priority for all of the services is to maintain a military force that is capable of accomplishing its current mission within resource constraints. Wars traditionally leave both victor and vanquished bankrupt, but the victor can loot the vanquished and pay for some of his expenses. The current US actions in Iraq and Afghanistan have been financed largely by debt; a time honored way of paying for war since the Pharaohs, Louis XIV, and the Confederate States.
How must military medicine behave as a result? Sometimes medical personnel act as though what we do is so important that price should be no object. As noble as that may sound, cost is always a factor. A decision to do an intervention in one patient is a decision not to do one in another, or to forgo some other worthwhile activity. Resources are always limited, and the reaction “make the other guy pay” can’t be sustained forever. Many things that we do in medicine are not effective, much less cost effective, but we do them anyway. Other things (such as vaccinations and public health) are effective and cost effective but we don’t do them. Clinical practice guidelines, evidence based design, evidence based medicine, and coordinated care are some of the key ways for military medicine to meet these priorities.
The second priority is that leaders must take care of those who fight the battles. Good leaders recognize the need to care for fighting men (and women) and their families. If soldiers cannot fight, their army cannot win. Napoleon noted that “an army marches on its stomach.” Sun Tzu wrote:
“Regard your soldiers as your children, and they will follow you into the deepest valleys; look upon them as your own beloved sons, and they will stand by you even unto death. If, however, you are indulgent, but unable to make your authority felt; kind hearted, but unable to enforce your commands; and incapable, moreover, of quelling disorder; then your soldiers must be likened to spoilt children; they are useless for any practical purpose.”
Even tyrants from Julius Caesar to Adolf Hitler took care of their most loyal soldiers, giving special favors to the Praetorian Guard and Schutzstaffel (SS), respectively, to get them into power and keep them there. Medical forces must provide the best medical care for the entire force, and must train and equip medical forces. Every day we must make progress towards these goals. Medical leaders must see themselves not only as clinicians, but also as soldiers, sailors, airmen, and officers. They must then behave as such.
The third priority is to go where the action is. The Middle East has been a global hot spot since Cain killed Abel and shows no sign of cooling down. However, while Europe was a consistent center of power and frequent theater of combat in the past five centuries, it has cooled. Asia, with six of the ten most powerful nations in the world, is heating up. US forces need to increase their presence there, and so does military medicine. Humanitarian efforts such as the annual USNS Mercy cruise, and public health efforts need to augment current military medical forces in the region, whether ashore (Hawaii, Korea, Japan) or afloat.
The fourth priority has to do with legitimacy. The Services have endured many scandals in recent years, from sexual scandals to acquisitions scandals. In order to retain the trust of the American people, those who pay the bills and provide the warriors, the Armed Forces must be perceived by Americans as legitimate. During Vietnam the services faced a crisis of legitimacy, and the broken and demoralized force of the 1970s was the national result. Broken and demoralized veterans were the personal result. The problem at Arlington Cemetery is also a problem with legitimacy.
Military medicine must also continually strive for legitimacy with the American people. We must be the world leaders in what we do, combat casualty care and rehabilitation, and in public health. We must be excellent in primary care and all other areas. Our warriors and families need, and the taxpayers demand, nothing less. Honest mistakes can and must be tolerated, but incompetence at any level cannot be.
The fifth priority has to do with reset, transformation and modernization. After long fights, such as the past decade in Afghanistan and Iraq, people and equipment need to be retrained, rested, and repaired. In the long run, militaries cannot use the technologies of yesteryear and expect to win, or even survive. The Mamelukes of Egypt tried and were crushed by the Ottomans in the Battle of Merj Dabik (1515). They also cannot use the tactics of yesteryear with the weapons of today – both sides discovered this early in the American Civil War, losing huge numbers of soldiers in Napoleonic charges against Minie Balls, rifled cannon, and other modern weapons. The signature platforms of the Army (tanks, trucks, artillery), the Navy (ships), and the Air Force (aircraft), and every other technology, need regular updating to keep the advantage over potential foes.
What should military medicine do? We seem to have a never ending array of new equipment, but often don’t work out the specifics on how to best use it to care for our patients. Imaging such as magnetic resonance imaging is no substitute for a good history and physical exam, and remote monitoring is no substitute for attentive nursing care. Defensive medicine wastes time and money. Research must be applied to the bedside, and process improvement must become a way of life.
America gained worldwide supremacy in all of the elements of national power; diplomatic, informational, military and economic, because of its people. Industrious and visionary leaders and followers teamed up to make our nation a force for good in the world. Military followers and leaders must do no less. Despite the difficulties and the opposition, we must take the time to gain the strategic view and give it to our teams. Leaders must then translate that view into day to day operations. Only then we will fulfill our mandate as leaders and lead our units, our organizations and our nation to be what it was meant to be; as John Winthrop (1630) and Ronald Reagan (1989) put it, “a shining city on a hill.”