J. Biomedical Science and Engineering, 2013, 6, 8-18 JBiSE
http://dx.doi.org/10.4236/jbise.2013.610A1002 Published Online October 2013 (http://www.scirp.org/journal/jbise/)
The complicated life of a physician-soldier: Medical
readiness training exercises & the problem of dual loyalties
Sheena M. Eagan Chamberlin
Institute for the Medical Humanities, University of Texas Medical Branch, Galveston, USA
Email: Sechamberlin@me.com
Received 14 August 2013; revised 6 September 2013; accepted 12 September 2013
Copyright © 2013 Sheena M. Eagan Chamberlin. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
While physicians are generally understood as owing
moral obligation to the health and well being of their
individual patients, military health professionals can
face ethical tensions between responsibilities to indi-
vidual patients and responsibilities to the military
mission. The conflicting obligations of the two roles
held by the physician-soldier are often referred to as
the problem of dual loyalties and have long been a
topic of debate. This paper seeks to enrich the dual-
loyalties debate by examining the embedded case
study of medical civilian assistance programs. These
programs represent the use of medicine within the
military for strategic goals. Thus, a physician is ex-
pected to meet his obligation to his role as a soldier
while also practicing medicine. These programs in-
volve obligations inherent in both roles of the physi-
cian-soldier and thusly they serve as excellent exem-
plars for the problem of dual loyalties at an institu-
tional level. This paper focuses on Medical Readiness
Training Exercises (MEDRETEs). These programs
are short-term, generally taking place in low-income
nations in order to accomplish strategic goals includ-
ing training opportunities for military medical pro-
fessionals that are not possible on the home front.
This form of temporary program raises ethical con-
cerns regarding the exploitation of vulnerable popu-
lations and the value of what is termed “parachute
medicine”. The short-term nature of these interven-
tions makes long-term treatment and follow-up im-
possible, begging the question as to whether this peak
and trough approach to foreign civilian aid is of any
use. Physicians are generally understood as having
obligations towards the well being of the patient,
which these programs do not necessarily prioritize.
Rather, the programmatic intent is military, with po-
litical and strategic aims of furthering international
relations, increasing US military global presence and
providing austere and tropical training opportunities
for military healthcare providers. This can be mor-
ally problematic for the physician-soldier.
Keywords: Military Medicine; Dual Loyalty; Medical
Ethics; History of Medicine; Military History; Military
Ethics; MEDRETEs; Civic Action
Military physicians are simultaneously members of two
professions. Identifying as both soldiers and physicians
can occasionally create moral dilemmas that are unique
to military medicine. This complicated moral experience
has been called the “problem of dual-loyalties” or some-
times “mixed agency”, and has been understood as a
fundamental issue in military medical ethics. These mili-
tary medical professionals have historically found them-
selves confronted with situations where military protocol,
orders or strategy require them to act or behave in a way
that is contrary to norms of civilian medical ethics, occa-
sionally valuing the mission over the individual patient.
This creates a morally complicated space in which the
military physician must practice. Critical reflection and
inquiry are needed to understand this uniquely compli-
cated combination of professions and the moral dilem-
mas faced by these practitioners.
This paper will explore the problems faced by physi-
cian-soldiers in light of their dual-loyalty. Analysis will
use a case study design to examine the dual-loyalties
issue on an institutional level, offering an in-depth de-
scription of the dual-loyalties problem as experien ced by
military physicians as well as a broader understanding of
the medico-military intersection, where medicine and the
military strive, through a single program, for seemingly
disparate goals. The case study f ocuses on medical civil-
ian assistance programs, which include all formal, in-
formal and ad hoc missions during which uniformed per-
S. M. Eagan Chamberlin / J. Biomedical Science and Engineering 6 (2013) 8-18 9
sonnel provided medical care to civilian populations as
part of their military duties.
The security policy has shifted towards stability opera-
tions that often prioritize medical operations su ch as this.
Stability operations, including Humanitarian and civic
assistance has become an important part of the military
mission. National policy has emphasized and prioritized
these types of missions within the American armed
forces. According to Department of Defense (DOD) In-
struction 3000.05 Military stability operations (MSOs)
are a “core US military mission”, that “shall be given
priority comparable to combat operations…” [1] This
shift signifies formal recognition of America’s role on
the international level, and new technique in achieving
American military goals.
The military institutionalizes the dual-loyalty problem
with missions such as medical civilian assistance pro-
grams by combining both military and medical goals in to
a single program or mission. Now that these programs
are being prioritized at the same level as combat mis-
sions they must be studied. This critical reflection and
analysis is the key to the formation of institutional
knowledge. However, little analysis has taken place. In
fact, there is little institutional memory and sparse record
keeping when it comes to key medical civilian assistance
programs, and even these records do not paint a full pic-
ture of these missions. This paper introduces oral history
data into this discussion. The stories shared by these
military physicians provide valuable insight into a
uniquely complicated profession. This paper will share
those stories providing in-depth historico-ethical analysis
of these programs, as well as the problem of dual loyal-
American military medical professionals have been
providing medical care to civilian populations since the
beginning of formalized Army medicine. In fact, evi-
dence of civilian medical assistance programs dates b ack
to the Revolutionary War when the American Army first
organized [2]. During that time, military medical per-
sonnel often provided care to civilians who lived in the
vicinity of Army camps and bases. This care was pro-
vided out of a motivation to better or maintain the health
of soldiers by improving hygiene and reducing epidemic
disease, rather than to improve the health of the civilian
population. This meant that civilian assistance had a de-
cidedly strategic purpose; imp roved civilian health meant
a reduction in epidemic disease, and thus a healthy and
disease-free army, which meant a higher likelihood of
mission success. The use of medicine to accomplish stra-
tegic goals would go on to form the foundation for medi-
cal civilian assistance programs, as the military recog-
nized a new tool in its strategic arsen al. Despite the long
history of medical civilian assistance programs, these
programs were not officially formalized and emphasized
by the American military until much later.
After the Second World War, the US began to shift
away from the isolationist tendencies that had shaped its
previous foreign policy [3]. In the period between 1949-
1960 US foreign policy began to emphasize assistance to
foreign nations that were sympathetic to western democ-
racy and opposed to communism. This period was fol-
lowed by an era of US policy that shifted toward a bal-
ance of military force and humanitarian assistance [3]. In
the post-Vietnam era, US national policy took interest in
South and Central America. Official history notes that
the US recognized a low-intensity threat in Latin Amer-
ica caused by regional violence and destabilization [4].
Journalist Juan Gonzalez has argued that US economic
and military interests played a role in destabilizing Latin
America, creating a relationship of migration and de-
pendence with the United States [5]. In response to this
instability, the US Southern Command (SOUTHCOM)
command surgeon’s staff developed The Regional Medi-
cal Strategy. This strategy sought to use medical initia-
tives in conjunction with military assets to assist Latin
American host governments address the health care
needs of their country. The hope was that in assisting the
host government augment host nation medical capabili-
ties, the US would successfully preempt the possibility
that the lack of health care would become an insurgent
issue [4]. The two countries of specific focus were El
Salvador and Honduras [6].
The development, stabilization, and security assistance
missions were in line with both US national policy and
DOD directives. DOD directive 5132.3 established mili-
tary policy for security and civic assistance missions
stating, “security assistance is an integral part of the
DOD mission” [7]. In fact, many senior military officials
believed that the Army should be involved with Latin
and South American countries, as a partner for develop-
ment [8]. The US was also interested in increasing its
sphere of influence to encompass South America due to
the area’s rich natural resources, such as oil [9].
These missions involved the use of non-violent mili-
tary means, which is generally understood to mean “the
provision of training, equipment, personnel or other pro-
grams utilizing military resources” [10]. Before stabili-
zation and development assistance became a focus of US
foreign policy, non violent military means had referred to
the ramping up and scaling back of support forces before
and after hostilities. Howeve r, as the US became engag ed
in this type of nation development and assistance, it rec-
ognized that the support forces (including medical) could
be used beyond simply augmen ting combat pow er. These
support forces could be utilized as a separate and distinct
Copyright © 2013 SciRes. OPEN ACCESS
S. M. Eagan Chamberlin / J. Biomedical Science and Engineering 6 (2013) 8-18
element of power [10]. This recognition was due partly
to the perceived success of Medical Civic Action Pro-
grams (MEDCAPs) and other medical civilian assistance
programs during the Vietnam War. Thus, medical civic
action became a prominent component of stabilization
and development efforts during the later part of the twen-
tieth century in Latin, Central and South America. The
use of medicine in Latin America was recognized as “the
least controversial, most cost effective and politically
acceptable” means of furthering American military in-
terests [11]. Still, much like the programs of Vietnam that
inspired them, published commentators critiqued these
programs as small, limited and tending to “concentrate
on high impact, short range projects” [12]. Similar to
their predecessor programs in Vietnam, the short term
and temporary nature of these missions lent themselves
to contextual challenges regarding medical goals, such as
limited patient care, education and follow-up.
The Central and Latin American programs began in
Honduras, a country that would go on to receive a great
deal of medical civilian assistance from all branches of
the US military. COL Zajtchuk, part of Joint Task Force
Bravo (JTF-Bravo) amended the MEDCAP model from
Vietnam to create the modern MEDRETE. JTF-Bravo
represented US Southern Command in Honduras, work-
ing with Host-Nation governments in their area of re-
sponsibility to organize various comprehensive humani-
tarian assistance programs, as a part of the stabilization
and development missions that were now a priority
within US national policy [13]. Zajtchuk held the belief
that humanitarian and civic assistance activities or HCAs
had “the potential of becoming the greatest promoter of
developing positive US policy in Central America” [14].
He also believed that these programs would be a good
way for him to occupy the time of his staff, improving
troop morale and preventing boredom [14].
One of his largest and most successful programs was
the MEDCAP. These MEDCAPs were modeled after
those conducted in Vietnam and said to be the “mirror-
image of their Vietnam-counterparts” [15]. However,
there were some substantial changes between the MED-
CAPs in Vietnam and those being carried out in Hondu-
ras. According to Zajtchuk, the intention behind this pro-
gram was “to take advantage of a unique opportunity and
provide US physicians, nurses, administrators, medics
and support personnel field training that are unavailable
elsewhere” [15].
In Vietnam, the main focus had been psychological
warfare; in Honduras the MEDCAP was now a training
mission with the specific purpo se of enhancing a military
medical professional’s ability to practice medicine in
austere conditions [16]. As it no longer prioritized the
same goals as the MEDCAP, this reorientation led to a
change in name. The program began operating under the
name Medical Readiness Training Exercise or ME-
DRETE [16]. The title better reflected the main purpose
of the program: the training of military medical person-
nel in environments that could not be accurately repli-
cated in the US. Low-income nations and the isolated
rural populations presented diseases and illness that phy-
sicians, nurses and medics rarely saw in the US. Beyond
that, the temporary clinical setting of the impoverished
rural village was far from the western hospital in which
they trained and worked. MEDRETEs provided many
training opportunities that the military saw as advanta-
geous for military readiness and mission success.
MEDRETEs have involved many different types of
medical care and a wide variety of medical specialties.
The most common is the general multi-medical special-
ties MEDRETE. This two-week MEDRETE provides
primary care to remote, often rural, locations in low-
income nations in conjunction with the host nation’s
government and ministry of health [17]. Generally, this
includes immunizations, basic clinical care and dental
activities [17]. Some MEDRETEs also prioritize preven-
tive medicine and civilian health education [17]. More
specialized MEDRETEs include those involving spe-
cialty surgical teams performing cleft lip and palate re-
pair, hand reconstruction, plastic surgery on burn patients,
orthopedics and urology [17]. DENTRETEs also repre-
sent a popular and common subspecialty of the ME-
DRETE program, during which dentists perform tooth
extractions, tend to dental emergencies, apply fluoride
and provide oral hygiene education [17].
3.1. MEDRETE—Programmatic Intent
Although there was little doctrine to inform the behav-
iour of individual soldiers engaged in these missions, the
official intent is clearly documented. Stabilization and
development missions, such as the MEDRETE, were
understood to fall under the umbrella of military civic
action or MCA. According to Field Manual 41 - 10,
MCA projects are:
… Designed and intended to win support of the lo-
cal population for government objectives and for
the military. Properly planned and executed MCA
projects result in popular support. MCA employs
predominately indigenous military forces as labor
and is planned as short-term projects [18].
This definition, with a decidedly strategic purpose,
serves to distinguish MCA from the civic action done by
the United States Agency for International Development
or USAID, which includes forces of humanitarian assis-
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S. M. Eagan Chamberlin / J. Biomedical Science and Engineering 6 (2013) 8-18 11
tance such as disaster relief. DOD Instruction 2205.02
provides greater understanding of the military conception
of “Humanitarian and Civic Assistance Activities” or
HCAs [19]. This DOD instruction directs US Armed
Forces personnel to
Participate in HCA activities to create strategic, op-
erational, and/or tactical effects that support Com-
batant Commander objectives in theatre security
cooperation or designated contingency plans while
concurrently reinforcing skills required for the op-
erational readiness of the forces executing the HCA
mission... [19].
This doctrine is reiterated in an earlier in- struction,
2205.3: “Implementing Procedures for the Humanitarian
and Civic Assistance (HCA) Program”, which states
“HCA activities shall promote the foreign policy and
national security interests of the United States and the
Specific operational readiness skills of the US Armed
Forces who participate in the activities” [2 0]. The strate-
gic focus of these missions is also apparent in read- ing
the official website of Joint Task Force Bravo, who has
been and remains responsible for the majority of Army
MEDRETES in Honduras and other SOUTHCOM coun-
tries. According to their site,
There are several mission objectives to ME-
DRETES, to include providing US military per-
sonnel training in delivery of medical care in aus-
tere conditions, promoting diplomatic relations be-
tween the US and host nations in Central America,
and providing humanitarian and civic assistance via
a long-term proactive program. These exercises b rin g
together key members of the US and foreign mili-
taries, US Embassy Country Teams, US Non-Gov-
ernmental Organizations (NGO’s), Host Nation
(HN) government agencies and indigenous civilian
organizations [17].
This military doctrine is clearly strategic. The mis-
sions are not humanitarian in nature but rather seek to
fulfill military goals, and emphasize strategic aims in-
cluding training and international diplomacy. Medical
civic action programs, which were reoriented and re-
named medical readiness training exercises during this
period, fell under the umbrella of MCA and HCA doc-
trine. Thus, their primary motivation is military not
The strategic purpose of these programs was not lost
on participants. In a letter to the editor that was published
in the journal Military Medicine, one author who had
experience developing these programs wrote, “the pri-
mary missions of MEDRETES has never been to resolve
health problems of the people in the host-nation, but to
train our military service elements to be ready for war”
[21]. Importantly the author also described the many
benefits that these programs can have for the host nation
civilian populatio ns.
As training missions, MEDRETES have been in-
valuable and worth much more in skill learning,
time and money than the simulated domestic (US)
training of our active and reserve components. As
benefits for foreign host-nation recipients, ME-
DRETEs serve a limited but good, useful service,
including some preventive medicine teaching as
part of care [21].
Participants and commentators recognized the poten-
tial benefits and the potential pitfalls of these programs,
almost from their first implementation in the post-Viet-
nam era. These programs offered an inexpensive and
excellent opportunity for public relations and training
[22]. Although they were recognized as a significant and
powerful policy tool if they were conducted properly,
many believed that irresponsibly conducted medical ci-
vilian assistance could be counterproductive [23]. They
feared that if the Vietnam MEDCAP style was perpetu-
ated, where strategic concerns subverted medical goals
leading to the provision of subpar medical care, the mili-
tary interests could suffer from the distrust that this could
3.2. The Promise & Pitfalls of MEDRETEs
The recognition of both the potential positive benefits
and negative consequences of these programs is promi-
nent in the written and interview discussions with par-
ticipants who reflect on their own experiences on spe-
cific missions. Honduras was the recipient of a substan-
tial amount of medical civilian assistance during this
time period. The US was motivated to assist the Hondu-
rans in nation building and enhance the image of the US
while expanding its sphere of influence and providing
maximal training experience for its personnel [24]. Pro-
grams like MEDCAPs and MEDRETEs were often well
recieved in Honduras because of the state of medicine
there. Although there was an appearance of a local public
health system, it had many shortcommings that stymied
its success. These included staff shortages, with doctors
gathered in large city centers, leaving isolated rural areas
without medical care and severe budgetary constraints.
Thus, the US military decided to assist Honduras with its
medical care and infrastructure problems to ensure stabi-
lization and promote development. HCA in Honduras
was approached in a four tiered way: 1) hospital/clinics;
2) village outreach programs (transitory MEDRETEs); 3)
contingency response; and 4) quarterly visits from max-
illo-facial plastic surgery (Operation Smile-cleft lip and
palate repair) [24].
The MEDRETEs were usually set up in a village
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S. M. Eagan Chamberlin / J. Biomedical Science and Engineering 6 (2013) 8-18
school or church [25]. The majority of their patients were
women and children, who are reported to have occasion-
ally created fictionalized complaints simply for the op-
portunity to see a western doctor [25,26]. Other patients
who were actually ill believed that the mere presence of
a western physician could cure them [25].
These missions involved many types of medical inter-
ventions including primary care and preventive medicine,
public health lectures deliv ered in Sp anish, den tistry, sur-
gery and even deworming [25]. Operation Smile is often
hailed as an enormous success due to the visual impact
of repairing a child’s cleft and lip palate [27]. A team of
plastic surgeons from William Beaumont Army Medical
Center in El Paso TX would travel to Honduras four
times a year and select patients for this surgery from pre-
determined villages [27]. Much like in Vietnam, the lo-
cation of MEDRETEs was determined by the US mili-
tary MEDRETE coordinator in consultation with Hon-
duran military and local civilian officials based on a
“particular need” [25]. Specific patient populations were
also chosen by US and Honduran military, civilian and
government officials, leading some physicians to express
discontent at the limitations being placed on them in the
clinical setting [25]. Rarely did MEDRETE teams revisit
the same village.
Many military physicians who had participated in
MEDRETEs expressed critiques of these programs. One
point of discontent was the constraints placed on medical
care by political and strategic requirements and necessity.
These critiques often focused on the constraints and limi-
tations placed on them by both the US military and the
host nation government. Often the ability of a ME-
DRETE team to return to a specific village was dictated
by the host nation government [28]. Thus, a physician or
planner could no t choose to return to a sp ecific village to
maintain continu ity of care; these decisions were dictated
by those higher up the chain of command in conversation
with the host nation themselves. One participant ex-
pressed the concern that he felt that they were making
villagers dependent on American military medical care
by introducing these people to western medicine, and
then never returning to provide follow up care [29]. This
presented him with a type of moral dile mma, identifying
chronic conditions for which he could do nothing. Other
constraints included the fact that the host nation often
dictated the patient population that could be seen, the
villages that could be visited, as well as what services
could be provided and what medications could be dis-
tributed [30].
Other constraints dealt with context and environment.
These included the lack of support services, language
barriers and being unfamiliar with the local culture, en-
demic diseases, the local health-care system, and stan-
dards of care [31]. There were also a large number of
patients to see in a short amount of time. Often patients
travelled from neighbouring villages for the opportunity
to see an American physician [32]. The short-term and
temporary nature of MEDRETEs were also a source of
constant critique and discontent for the military physi-
cian. Often called “parachute medicine” training opera-
tions because teams dropped in and provided care for a
short time and then left, this short-term model prevented
long-term and follow up care for patients with chronic
conditions [33]. Many participants recognized the need
for long-term projects, and re-occurring MEDRETEs
Discontent was not limited to the physician partici-
pants. The host nation governments were also critical of
the benefit of early MEDRETEs [35]. The Ministry of
Health in Honduras, as well as the Honduran College of
Medicine, questioned the utility of the MEDRETEs [35].
Even Army South Command or SOUTHCOM recog-
nized the shortcomings of the MEDRETE program. In a
SOUTHCOM memorandum they stated,
We have done a good job winning the minds and
heart of our hemisphere neighbors using these train-
ing vehicles. However, despite these efforts we are
not able to demonstrate that we have actually done
anything to improve the health of those we have
treated in the past. The mere provision of a few
medicines on a periodic basis can generate a great
number of patients seen during a particular visit, but
says nothing about the impact of our effort on the
health of the population [35].
The medical practitioners provide the care then re-
peat these same critiques. The majority of participants
interviewed expressed beliefs that the medical impact of
MEDRETEs was minimal [29,32,36]. One participant
thought that medically the MEDRETE was, “a disservice
to the local population” [29]. This same participant was
in Honduras from 1999-2000 and explained that prevail-
ing physician sentiment was, “MEDRETEs would be a
disservice to the local population and there was a lot of
truth to that” [29]. Another participant referred to ME-
DRETEs as “band-aid medicine” [32]. The concept of
“band-aid” medicine refers to the idea that little is done
for the patients beyond putting on band aids and doling
out multi-vitamins. For these reasons one physician de-
scribed MEDRETEs as having, “no impact at all on a
medical basis” [36].
3.3. Positive Provider Experiences
However, not all shared these critiques. Many providers
felt that the medical care that was provided was of bene-
fit to the MEDRETE patients. These perceived benefits
on the part of the participants mark a drastic departure
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S. M. Eagan Chamberlin / J. Biomedical Science and Engineering 6 (2013) 8-18 13
from the Vietnam MEDCAP. Clearly, the MEDRETE is
not a “mirror-image” of the Vietnam-style MEDCAP.
One author stated, “The hospital, and the MEDRETES,
may not have contributed to the long-term development
of a health service, but it made a long-term difference to
the patients” [28]. Another military physician who had
the opportunity to participate in both a MEDCAP and a
MEDRETE explained that the medical value of the latter
was far superior to the former [37]. This opinion was
reiterated in the literature as many were beginning to
realize that the traditional MEDCAP could be counter-
productive and fail in its goal of creating confidence in
the local host nation government due to lack of coordina-
tion and subpar medical care [38].
There were specific medical procedures and aspects of
medical care that physicians recognized as useful in the
MEDRETE setting. Internal medicine physicians were
quick to note their limitations in this context. As one par-
ticipant noted, “internal medicine is the management of
chronic disease, there is not much internal medicine can
do in a one day clinic at a MEDRETE” [39]. However,
internists did discover the value of draining and injecting
arthritic joints [36,39]. Surgeons were found to be ex-
tremely valuable for cleft lip and palate repairs, amputa-
tions, and draining abscesses [36]. Pediatricians felt great
satisfaction and saw huge impact with deworming cam-
paigns, and dentists had a significant impact on oral
health by way of tooth extraction [36,49]. Optometrists
have also had considerable success distributing perscrip-
tion glasses. Although medicine was limited in the field,
physicians were able to find avenues by which to make a
therapeutic difference. Many MEDRETE participants
found their experience rewarding, remembering these
benefits and the appreciation of the patients [29,32,36,
Although there were many benefits to the MEDRETE
and some participants had positive experiences, others
still called for increased reform of civilian medical assis-
tance programs. Physician participants and commenta-
tors were beginning to call for programs that, unlike the
traditional MEDCAP, prioritized medical goals and sus-
tained long-term benefits [38]. Other commentators
called for more drastic reform of medical civilian assis-
tance. Regina Gaillard is critical of the historical link
between civic action and counterinsurgency, as well as
low intensity conflict [40]. She argues that the linkage of
a strategic and humanitarian mission has tainted the ide-
alist qualities of the concept causing these programs to
be counterproductive in achieving the US military’s
Gaillard argues that a reorientation effort should at-
tempt to delink civic action programs and humanitarian
and civic assistance activities from counterinsurgency
and low intensity conflict (LIC) [40]. Gaillard was es-
sentially calling for a prioritization of medical goals over
military goals. Contemporary programs show that Gail-
lard’s desired delinking of civic action and counterinsur-
gency of LIC has not been accomplished. Physician ex-
perience tells that MEDCAPs in Afghanistan and Iraq are
aligned with the PSYOPs goals of counterinsurgency and
LIC [41]. Cramblet has similar critiques and calls for a
necessary distinction between war and low-intensity co n-
flict. Programs developed during times of conflict, such
as MEDCAPs, cannot simply be transplanted into peace-
time or low-intensity conflict operations [42]. Cramblet
also highlights noteworthy aspects of a successful ME-
DRETE such as sustainability, which includes the suc-
cessful hand off of programs to locals and simplicity
necessary for program continuation in developing na-
tions [43].
A significant issue for the MEDRETE program, which
had also plagued the MEDCAP missions that preceded
them, was a lack of military doctrine that specifically
instructed participants in how to act in these environ-
ments. This lack of military doctrine was recognized by
many commentators [11,44]. As Gonzalez wrote, “At
present and in the past, even though medicine has been
extensively used, there has never been a doctrine for its
proper utilization in Latin America” [45]. The lack of
doctrine on the topic is problematic because of the foun-
dational role that it plays within the military institution.
Military doctrine is essential in shaping the behaviour of
soldiers and dictating their proper conduct. Thus, a lack
of doctrine leaves participants in these programs without
These types of missions are au thorized under Title 10,
US Code. Section 401. Programs established under this
statute are intended as opportunities for training. A sec-
ondary goal is non-threatening engagement with a for-
eign nation. It is crucial to note that humanitarian goals
are not mentioned. Medical care is not the purpose of
these programs; the main purpose is training, while
medical care is specifically ancillary. In a way this serves
to distinguish medical civilian assistance programs from
other military, as well as non-military humanitarian pro-
grams. Funding has continued for these programs that are
specifically earmarked for military training, rather than
humanitarian assistance, stabilization, or foreign devel-
opment. The clear emphasis placed on training can be
understood a number of ways. Firstly, it can be under-
stood as protecting the program and rationalizing it
within the military budget, allowing physicians to pro-
vide at least some care to patients in need. In fact, many
physicians believe in the care that MEDRETEs provide,
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S. M. Eagan Chamberlin / J. Biomedical Science and Engineering 6 (2013) 8-18
and find it rewarding as both a training and humanitarian
mission. Another way to understand the prioritization of
training is that the military is being honest about its in-
tentions. As opposed to the Vietnam-era MEDCAPs,
which sometimes in- volved dishonesty and deception,
this program presents itself as a training operation with
ancillary benefit to host-n ation patients.
FM 27-5 addressed public health, sanitation and pre-
ventive medicine initiatives but did not address direct
patient contact programs such as MEDCAPs or ME-
DRETEs [46]. FM100-20-, “Military Operations in Low
Intensity Conflict”, provides vague and uninstructive
information regarding these missions, with no mention of
the medical mission. At this time, LIC was a catchall
term with little distinct doctrine [47]. Joint Publication
3-07.6, “Doctrine for Military Operations Other Than
War” (MOOTW), provides additional guidance, stating
that the first priority of military medicine is to US troop s.
However, “when planning for MOOTW, the potential to
treat HN [host nation] population of allied military per-
sonnel must be considered” [48]. Authorized care to for-
eign civilians should be within resource limitations and
should urge continued coordination between the medical
and intelligence elements [48]. In fact, this publication
recognizes medical operations in MOOTW as a “valu-
able intelligence source” [48]. Joint Publication 4-02,
Doctrine for Health Service Support in Joint Operations,
reiterates that no operation should supplant or compete
with the existing local medical infrastructure [49]. This
piece of doctrine recognizes the necessity of not creating
redundant healthcare systems that simply duplicate local
services. History has shown that competing or duplicat-
ing local services undermine the local economy, create
hostile relations with the local medical community and
thus they can be a disservice to the healthcare of the local
community and the mission.
Taken toge ther these do ctrines provid e little in the way
of helpful guidance for military physicians participating
in these missions, however, the doctrine does clearly
establish these missions as being of strategic intent:
aimed at training and engagement. In this way, the doc-
trine clearly established a political mission for these hu-
manitarian programs. Thus, the doctrine is straightfor-
ward in its use of medicine as a “non-lethal weapon” or
tool, employed toward military ends. However, beyond
the basic programmatic intent and goals of medical ci-
vilian assistance, this doctrine provides little guidance
for soldiers engaged in this work.
Medical Rules of Engagement—“Life Limb or
Aside from military directives and instructions, there are
other rules that could inform, and thus help to shape, the
conduct of officers while on medical civilian assistance
missions. Many of the participants who shared oral his-
tories identified the medical rules of engagement as the
way by which they often balance their twin roles as a
physician and a soldier [30,50,51]. These rules of en-
gagement represent another form of military doctrine that
provides guidance and informs the actions as well as the
medical and strategic decision-making of the military
Medical Rules of Engagement (MROE) are used to
outline the current military restrictions on whom physi-
cians can and cannot treat, for strategic reasons [52]. The
name draws an analogy with the military “Rules of En-
gagement” (ROE) that determine the limita tions and dic-
tate the appropriate situations when a so ldier can respond
with his or her weapon. The restrictions are dictated by
command for strategic and political purposes. Similarly,
medical rules of engagement are meant to determine
when and how medical personnel can respond with their
medical skills and technology. For instance, while the
Geneva conventions require the treatment of enemy
combatant personnel, foreign civilian populations are not
always treated within the combat zone due to scarcity of
resources or security concerns. That being said, injuries
concerning “life, limb or eyesight” are understood to be a
deciding and over-riding factor [50 ]. If a patient presents
with an injury that threatens their life, limb or vision,
physicians are allowed to treat them, regardless of other
factors. Unfortunately, although physicians use MROE
as their litmus test for providing civilian care, “life, limb
or eyesight” does not make treatment mandatory or ex-
pected. Tensions are still reported between physicians
and commanding officers over whether or not to treat
injured and diseased civilians presenting during times of
hostilities and scare resources [50].
Medical rules of engagement provide another example,
and more substantive eviden ce, to the life of the military
physician as simultaneously existing in two professional
roles: the soldier-with rules of engagement and the doc-
tor-with patient obligations. The balance necessary for
this kind of medical assistance mission is exemplified in
the concept of “integration” drawn from doctrine and put
forth by LtCOL Peter Cramblet in his US Army War Col-
lege paper entitled, “US Medical Imperatives for Low
Intensity Conflict”. Drawing on experiences in Honduras,
LtCOL Cramblet holds that
Medical commanders must understand the first
principal of war, objective, and integrate their ef-
forts with other elements of national power to en-
sure accomplishment… well meaning commanders
with sometimes bored, medical staff assume im-
plied medical missions which do not always suppor t
LIC objectives [53] .
Cramblet highlights that the balance expected of mili-
Copyright © 2013 SciRes. OPEN ACCESS
S. M. Eagan Chamberlin / J. Biomedical Science and Engineering 6 (2013) 8-18 15
tary physicians is understood by the military to prioritize
the mission. Institutional messages are mixed when they
are treated like physicians, asked to practice medicine
and yet expected to fulfill obligations to their role as a
soldier. They are expected to do more than just doctor,
and this balance can be delicate to maintain. However,
the blame should not fall solely on the shoulders of the
physician. Cramblet blamed a lack of clear mission
statements in LIC environments. The themes of ambigu-
ous mission statements, lack of doctrine and unclear di-
rectives are prevalent throughout the history of these
Beyond the lack of doctrine, participants in these pro-
grams also receive little or no training prior to their in-
volvement. A recent study showed that a quarter of the
polled participants received no training for their humani-
tarian assistance missions [54]. Of those that received
training, it was primarily on the job and in th e field train-
ing. There was no formal, pre-deployment training [54].
This lack of training was found to have a negative impact
on the effectiveness of the mission [54]. It also may ex-
plain why physicians are unaware of the strategic goals
of these missions, expecting them to be solely humani-
tarian missions without strategic intent.
In looking at primary source materials, the goals may
seem apparent. However, many oral histories confirm
that those involved in these programs were not always
aware of the strategic aim of these programs. The am-
biguous nature of the programmatic goals, and their lack
of dissemination made it difficult for physicians to un-
derstand and achieve success. While command sought
strategic achievement, physicians aimed for medical and
humanitarian triumph. The two goals had different and
sometimes conflicting methods and end-points [55]. Ac-
cording to Robert Wilen sky, the MEDCAP program was
based upon both the “altruistic inclinations of their par-
ticipants and the political aims of the US government”
[56]. The distinction between the aims and inclinations
of those people with “boots on the ground” and those de-
veloping the policy resulted in unmet expectations, con-
fusion over roles and responsibilities, successes, end-
points and inappropriate policy implementation. This
uncertainty and confusion only caused more frustration
for the military medical professional.
The strategic intent of the doctrine that dictates these
programs is unden iable. That being said the particip ants’
motivations for involvement were often remarkably dif-
ferent. Anecdotal evidence, oral histories and a recent
study by the Center for Disaster and Humanitarian As-
sistance Medicine CDHAM have shown that physicians
are motivated by altruism and actively seek out these
programs. The study included all branches, active duty
and reserves from various duty positions. It showed that
nearly half of the physicians surveyed indicated that hu-
manitarian missions were a factor in their decision to join
the military [57]. These numbers allow us to understand
the values of the physicians participating in medical ci-
vilian assistance missions, and und erstand how physician
participants may differ from the command in reference to
the goals of the program. These missions appeal to a
humanitarian urge rather than a strategic one. Although
many military physicians may also agree with larger
military goals, this study highlights the crucial role that
humanitarian and altruistic values play in shaping the
identity and cho ices of the military physician. Reg ardless
of their views on strategic goals, military physicians
place a high value on the possibility of participating in
humanitarian missions as part of their military duties.
“Many applicants to the USUHS... expressed positive
feelings about the potential to go overseas… humanitar-
ian missions are one of the key factors that led them to
apply to USUHS and to prefer a career as a military phy-
sician [58].” Their identity as military physicians is
thusly shaped by this beneficent drive, to provide medi-
cal care in a capacity they thought civilian life could not
offer. The significance for the Army is also apparent.
These programs are a key contributing factor to physi-
cian career planning. These missions also play a vital
role in retention and recruitment. The same CDHAM
study showed that 60% of respondents reported that hu-
manitarian assistance missions were influential in their
decision to stay in the military [58]. Due to the impor-
tance of these programs to military providers, their ex-
perience within these missions deserves closer attention.
The significance of humanitarian missions in physician
decision-making provides insight into the morally com-
plicated space of the historical medical civilian assis-
tance model. Medical civilian assistance programs have
historically been a well-intentioned, misdirected and
frustrating experience for physicians. While they ex-
pected a humanitarian operation of beneficent medical
care, they were faced with the reality of a military ope ra-
tion with secondary medical goals.
Physician-soldiers are not exempt from the horror and
realities of war. While MEDCAPs and MEDRETEs do
not involve the trauma of IEDs and mass casualties, one
must not discount the psychological impact of providing
care in dangerous places, and the disappointment, frus-
tration and impotence felt providing care felt to be in-
adequate. Within the setting of the MEDCAP or ME-
DRETE, a physician is the agent of a program with goals
that represent his twin-roles. Physicians of contemporary
western medicine are used to the comforts of the hospital.
They are accustomed to diagnostic tests, support staff,
specialist consults, patient follow-up and well-stocked
pharmacies. These missions challenge physicians. They
are forced to see patients with chronic diseases that
would be curable, or at least manageable, stateside but
Copyright © 2013 SciRes. OPEN ACCESS
S. M. Eagan Chamberlin / J. Biomedical Science and Engineering 6 (2013) 8-18
for which a MEDCAP or MEDRETE can do nothing.
Instead, providers are confronted with the realities of
these missions.
Although such activities collect large numbers of
villagers, the procedure appears to confirm the
peasant’s belief in magic merely with the statement
that Western magic is more powerful than local
magic. Such a procedure may win an election, but
in the long run it is truly dangerous and represents
an inexcusable prostitution of medical facilities
The feeling of provider impotence frustrates them as
they dispense multi-vitamins, aspirin, ibuprofen or a few
days’ course of antibio tics. This frustration is palpable in
the way providers joke with each other to alleviate the
tension; as one participant shared, his team would often
say “All we have done here today is maybe given a cou-
ple of people ulcers from taking too much ibuprofen”
[41]. This type of frustration has led other participants to
see this work to be, “of limited value medically, it is an
outstanding tool for propaganda” [60]. CPT John Irving
described one Medical Civic Action Program as a “mili-
tary maneuver”, rather than a humanitarian mission [60].
The moral complexity does not appear to lie with the use
of medicine as a strategic tool. Rather, what lies at the
heart of provider complaints is the prioritization of strat-
egy above all else. This reality becomes apparent in the
fact that when medical goals are emphasized, and medi-
cal good is achieved, physicians find these experiences
rewarding and positive. However, when these military
physicians are morally ch allenged by an order to provide
medical care that they believe to be inadequate and they
often feel conflicted. This problem is one of dual loyalty.
I would like to thank my academic mentors who have guided my re-
search and writing on this project: Dr. Jason Glenn, Dr. Howard Brody,
Laura Hermer, Dr. John Fraser and Dr. Sanders Marble. Their guidance
made this work come to fruition. The Institute for the Medical Humani-
ties and the Graduate School for Biomedical Sciences at the University
of Texas Medical Branch also provided academic and research support
throughout this proj ec t.
I also wish to extend my special gratitude to the physician-soldiers
who shared their personal stories with me. These oral histories enriched
my study of military medicine and provided valuable insight into a
uniquely complicated profession. Lastly I would like to acknowledge
the never-ending support of my family and my husband, who motivate
me in all I do.
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