Operations in Iraq: Lessons for the Future
CHAPTER 9 - PEOPLE
Health and Medical Issues
9.1 The UK's Armed Forces are respected throughout the world for their professionalism, discipline and resourcefulness. During the operation in Iraq, they have again shown the resilience, commitment and courage that are fundamental to the success they have achieved on this and other operations in recent years. In the course of the operation, they have drawn on their excellent training and considerable experience of peace support operations to meet the many and diverse challenges that have confronted them. They can be justifiably proud of their achievements.
Operational Welfare Support
9.2 It has long been recognised that provision of satisfactory welfare support is linked to the maintenance of morale and is therefore key to the achievement of operational capability. Initial implementation of operational welfare provision for operations in the Gulf worked well and has evolved smoothly into the welfare provision for the sustainment phase of the operation.
9.3 The Operational Welfare Package in its present form was introduced on a tri-Service basis in 2001 and used with increasing success in Kosovo, Sierra Leone, and Afghanistan, and on SAIF SAREEA II and other exercises and deployments. It replaced the purely financial element of Local Overseas Allowance and, for this operation, included free telephone calls (20 minutes per individual per week), e-mail and internet access, 'blueys' (airmail letters) and 'e-blueys', TV and radio, books and newspapers, Combined Services Entertainment shows and a variety of recreational facilities. Whilst these measures were widely welcomed, a review of the package with a number of proposed enhancements is under way. The aim of the review is to ensure that, wherever possible, all forces - especially those deployed early to theatre - receive appropriate and timely levels of provision.
|Another consignment of letters from families and frends|
9.4 It was decided in conjunction with the Royal Mail Group to provide a free postal service to theatre for packets up to 2kg for family and close friends of personnel serving in the Gulf. This service was well received, initially doubling the volume of mail dispatched to theatre to around 20 tons daily, at a cost of some £1.5m per month (the volume has now settled at about three tons per day). The Royal Mail Group's decision to waive the costs for packets delivered to the BFPO depot in UK was withdrawn in the middle of July with the costs subsequently transferring to MOD. The service will continue to cover the Christmas period.
9.5 Operational welfare provision continuously evolves to take account of the unique nature and circumstances of each deployment, based on the principles enshrined in the Department's review of operational welfare in 1999. This evolution is often conducted under the glare of the media, whose reporting of anecdote can create public pressure for reactive change. Levels of expectation are increasing and there is continued pressure from Service personnel to expand and improve facilities. Such expectations need to be managed to reflect what can sensibly, safely and securely be made available in the early stages of an operation, particularly in a war-fighting theatre.
Support to Families
9.6 Service families also have increasing expectations of entitlements and levels of support. As a new initiative, units were given a sum of £1 per week per individual deployed, to be used collectively for communications with and support to families back at the home base. The initiative was very favourably received. Early results from a survey undertaken by the Army Families' Federation (AFF) suggest that communication between families and Service personnel was good, but that families wanted more regular information on what was happening from the military unit. Respondents also requested more opportunity to contact other families in the same position. Feedback from RAF families indicates they hold similar views. Further means of providing information to families will be considered.
9.7 The families of reservists need particular consideration, as they may have had little or no contact with the Services and may not understand Service structures, administrative procedures, roles or jargon. Such families knew whom to contact, but the AFF survey showed that they still found it much more difficult than Regular Army families to find the information and answers they wanted. This will be borne in mind in considering how best to improve the support they need.
9.8 Service and civilian personnel are finding it increasingly difficult to secure adequate life insurance that covers them comprehensively during conflict without exclusions. Specific exclusions often include WMD fatalities. Some specialist personnel (such as aircrew, parachutists and bomb disposal experts, who are required to pay extra premiums against particular Service risks) receive assistance from public funds towards the extra costs incurred. However, there is a need to ensure that all Service personnel and civilians being deployed have access to life insurance schemes that do not discriminate against them and cover adequately all likely combat risks.
9.9 The Armed Forces have suffered 53 fatalities in the Gulf, 33 of which occurred during decisive combat operations (up to 1 May). 20 Service personnel have lost their lives in the subsequent post-conflict phase. The nation's deepest sympathy goes to the families and friends of all who lost their lives.x
9.10 When a Serviceman died in theatre, initially only the broadest information on such incidents was released until the identities of casualties were confirmed and next of kin informed. However, this resulted in widespread concern among many other families whose relatives might have been involved. The policy was therefore reviewed during the operation to allow the earliest possible release of more specific information on an incident, thus reducing the number of families affected.
9.11 Casualty reporting procedures also need to take account of the increased speed of media and private communications, in order to address the needs and sensitivities of bereaved families given the inevitable media and public demand for rapid information. It was difficult to ensure that families' wishes were respected to avoid media intrusion. Some aspects of our support to bereaved families attracted intense media attention, with claims of insensitivity on a small number of occasions. A comprehensive review of bereavement procedures has been conducted to address these and other related issues raised by bereaved families. The review has resulted in harmonised and simplified tri-Service procedures that are more sympathetic to the needs of the bereaved family.
9.12 Welfare support to bereaved families is very important and is frequently reviewed. An extension of widows' benefits to unmarried partners of Service personnel was announced in September 2003. In order to ensure that these benefits were available during the Iraq campaign, an ex gratia arrangement was introduced in anticipation of this change for deaths relating to conflict. Six awards arising from the operation have been made.
9.13 Augmentation is the temporary re-distribution of individuals - whether regular forces, reservists or civilians - to enhance the manning of headquarters and other areas of critical importance to an operation. It is a crucial element of force generation and was much utilised, particularly during the deployment and combat phases of the Iraq operation. Augmentees also bring with them the perspective of their donating organisation, helping to build close links between different headquarters. For example, teams from the three front-line commands were embedded into or collocated with the operational planning staff at the Permanent Joint Headquarters, and provided valuable support to these organisations.
9.14 There was also a consistently high demand for good quality UK staff officers to support US and coalition structures. The importance of liaison officers working within key US headquarters was noted in Chapter 7. Following the conflict, the Coalition Provisional Authority was established in Iraq with responsibility for the temporary administration and reconstruction of the country. British military and civilian officials have filled positions in these organisations and liaison posts in US military structures where they could provide expertise. Inevitably augmentation often involves short-notice requirements, and mechanisms need to take this into account in prioritising postings and preparing individuals for their respective appointments. Augmentation policy is being updated to reflect the experience of this operation.
Civil Servants in Support
|MOD civil servants working with the UK logistic headquarters at Umm Qasr|
9.15 A large number of civil servants from the Ministry of Defence and other Government Departments directly supported the Armed Forces during the operation, as described in First Reflections. Many provided a critical contribution within their normal jobs; others moved either to theatre or to help provide round-the-clock manning for operational headquarters and MOD's Defence Crisis Management Organisation in the UK. The ability rapidly to augment these structures during crises is a major part of the civilian component of preparedness for operations. While the quality of augmentees was high, it took time to move suitable people from existing jobs and to bring them up to speed in their roles, given the reliance on volunteers. The Department is considering how augmentation could be made more effective. This would involve better training, earlier preparation and an improved volunteer civilian skills database. Civil servants being deployed into theatre need to be well briefed on what to expect, and a greater number need to be sent early to deal with contractual and financial issues at the start of an operation.
9.16 The Government has planned and structured the Armed Forces on the basis that any major war-fighting operation would draw on support from the Reserve Forces. This is a prudent approach that allows the maintenance of full-time Armed Forces in no greater strength than is needed for normal peacetime activity and for meeting a limited range of contingencies. The more flexible use of reservists also gives MOD the opportunity to harness skills that are appropriate for operations, but are not needed in that number on a regular or frequent basis in peacetime, and therefore are not readily found within the Regular Armed Forces. The Reserve Forces Act 1996 worked well, though we are reviewing some of its regulations, particularly those relating to financial and disciplinary issues, in the light of our experience during the operation.
9.17 This operation involved the largest compulsory call-out of Reserve forces since the 1956 Suez Crisis. Over 8000 reservists were called out for the deployment and campaign phases, with over 5200 taken into service. Following further incremental call-outs in April and August 2003, an additional 3300 reservists were taken into service for roulement purposes, and a further requirement for some 1100 will be met by mobilisations in January. Further call-outs may be made for future roulements. Most reservists were drawn from the Volunteer Reserve Forces together with a smaller number from Army and RAF Regular Reserves, and Sponsored Reserves such as those manning our roll-on-roll-off ferries and employed in the Mobile Meteorological Unit. Their successful employment demonstrated that the vision in the Strategic Defence Review for more integrated, relevant and useable Reserve forces to provide additional capability in time of crisis has been realised. And in addition to the military skills in which reservists are trained, the professional skills and experience which many reservists brought from their civilian life proved indispensable to the post-combat reconstruction process. Examples include merchant bankers running Coalition Provisional Authority finances, pylon erectors, water plant workers and telephone engineers. Many reservists also possess very useful broader project management skills.
9.18 However, the utility of the Reserves will need to evolve further, to meet the need for compressed planning and preparation time-scales and a more rapid transition to expeditionary war-fighting. In future, Reserve forces may be required for a greater number of more frequent, short-notice operations. There is a balance to be struck between using Reserves to fill shortages in regular manpower (particularly specialist capabilities) for this purpose and in formed units providing key enabling capabilities. There is a risk that using reservists solely to plug shortfalls will affect recruitment, although nearly 10% of reservists demobilised after serving during the operation have expressed an interest in joining the regular forces or undertaking further full-time service.
9.19 The mobilisation of Reserves highlighted a number of issues. Some Reserve units that provide key specialist enabler capabilities where Regular capability is insufficient (e.g. movements and intelligence) were required during the early stages of the operation, and had to be called out more quickly than was desirable. Many specialist manning gaps within Regular units could only be filled by Reserves once their mobilisation had been authorised and their pre-deployment training completed, which adversely affected the pre-deployment preparation for these units. Furthermore, in some specialisations, Reserve force mobilisation afforded only a 'one-shot' capability: roulement for an enduring commitment remains a challenge.
9.20 The aspiration was to give reservists 14 days' notice of mobilisation, but for this operation, mobilisation time was clearly very short. Operational requirements meant that some 'early enablers' had to be called out at shorter notice. For example, the first tranche of the TA Port Regiment called up were given four to seven days' notice, as they were required to operate Marchwood Military Port, releasing regulars to deploy to receive shipping in theatre. Where possible, this was achieved by negotiation: for example, of the 57 Royal Naval Reserve Amphibious Warfare officers available, 14 were able to meet a three-day timescale (to sail with the Amphibious Task Group), and 12 were selected. Nevertheless, for the bulk of the call-out, 14 days was the intended notice time. That this was not always achieved was often due to reservists' absence from home, postal delays, and how soon the reservist could tell his or her employer.
9.21 It remains important to ensure that the volunteer ethos of the reservist and the goodwill of both families and employers are not prejudiced by mobilisation issues. The desired notice has therefore been revised to 21 days, and this aspiration has been achieved in subsequent mobilisations for Iraq. Inevitably, however, operational requirements may still require shorter notice periods on occasion.
9.22 The support of reservists' employers is crucial and much appreciated. The Supporting Britain's Reservists and Employers (SaBRE) organisation played a key role during the operation, dealing with some 30 employers' enquiries per day during January and February 2003. This increased during the roulement phase, possibly because the continuing need for reservists was not widely understood. The Service Adjudication Officers took note of employers' needs, granting exemptions where operational conditions allowed within the terms of the relevant legislation. MOD has initiated a study to measure the degree of employer support for the mobilisation of Reserves.
9.23 Following the operation, MOD is adjusting the arrangements for the higher management of Reserves. This includes the reorganisation of the Directorate of Reserve Forces and Cadets under the direct command of the Vice-Chief of the Defence Staff.
Prisoners of War
9.24 The UK retained responsibility as Detaining Power for all UK-captured Prisoners of War (POWs) and for all other people captured and detained by UK forces - a total of 2628 up to the end of August. The handling of POWs is a complex and sensitive area that requires considerable preparation in the initial planning phase of an operation. Specific manpower assets and materiel resources need to be identified to undertake guarding and other tasks during the operation, and handling arrangements need to be discussed with the International Committee of the Red Cross (ICRC). A central MOD focal point for development and co-ordination of POW policy would help improve planning and liaison. A Memorandum of Understanding between the US, UK and Australia was negotiated to set out agreed joint procedures in advance. In the event, considerably fewer POWs were taken than had been predicted.
9.25 POW guarding responsibilities were split between the coalition partners: the UK took the lead in guarding during the opening phase of the campaign, until large US-run camps had been set up within Iraq. The UK then fulfilled its responsibilities using liaison officers, and working closely with the ICRC. POWs were detained in well-managed camps and were well treated. Interpreters deployed at the POW facilities eased the passage of information and reduced the risk of frustration and misunderstanding. However, personal possessions often arrived separately from their owners and (contrary to instruction) without labels, resulting in POWs being released without their personal effects. A small number of allegations were made of misconduct against POWs by individual UK Service personnel, which are currently under formal investigation.
9.26 The Geneva Convention seeks to protect POWs from public curiosity by not allowing the publication of photos from which they could be identified. The UK took rapid action in response to early transgressions, but not all of the media followed the practice of blurring faces. Military commanders will continue to do what they can to remind the media of the law, and ensure that cameras are not allowed into POW facilities.
9.27 Overall, however, the British Red Cross observed that "the MOD's commitment to respect international humanitarian law during the recent armed conflict in Iraq, both in words and in practice, was very positive", and that "it was evident that the MOD wished to help ensure that the UK conducted its operations entirely in accordance with the Geneva Conventions and any other relevant laws".
9.28 The short time available for deployment of forces before operations began did not allow for a long period of training in theatre. That UK forces can perform successfully and confidently with minimal in-theatre training demonstrates the value of having a training foundation that generates well-prepared and trained forces, and the importance of the maxim "train as you mean to fight" - i.e. that routine training should prepare units for the conditions and experience of warfighting. Most deployed land units and formations were at a high state of training, had trained in the UK beforehand, and undertook some desert training. At the individual level, UK Service personnel had been well trained in engendering fighting spirit, overcoming difficulties and addressing complex tactical problems. This was demonstrated in their ability to assume responsibility and display considerable initiative throughout the operation. Training must continue to be demanding and realistic.
9.29 Of particular value was the considerable local operational experience gained by the Royal Navy and Royal Air Force since the 1991 Gulf Conflict, working with US forces in the region to enforce UN sanctions and patrol the no-fly zones. Indeed, with the no-fly zone operations now having ended with the removal of Saddam Hussein's regime, it will be a considerable challenge to find suitable training opportunities to maintain the momentum of integrated coalition activity for future aircrew and support personnel. More generally, the recent employment of UK forces on a variety of combat and peace support operations and exercises around the world clearly helped UK personnel prepare and adjust to the needs of an expeditionary campaign.
9.30 The need for training to simulate the conditions of operations was noted above. Many soldiers and marines observed that it took time to adjust to the shock, percussion effects, disorientation, smells and sounds associated with combat. Training constraints imposed by safety regulations, particularly in the urban environment, contribute to this difficulty. This was overcome in the Gulf by strong junior leadership and initiative during the early stages of land fighting. As training becomes more dependent on simulation and virtual environments, it will be essential to replicate the hard edge of battle as far as possible.
9.31 Operational experience is complemented by a variety of training methods. Two major exercises proved of especial benefit to the Iraq campaign, by bringing together and testing our personnel, logistics, equipment and procedures in operational scenarios. The UK's participation in the large-scale Exercise SAIF SAREEA II in Oman in 2001 provided our joint forces with valuable training experience and exposure to the practical difficulties associated with expeditionary operations in a very challenging environment. Lessons learned from this exercise also led to some significant equipment upgrades that resulted in the outstanding availability rates achieved in Iraq (see Chapter 5). However, large-scale exercises of this nature require considerable time and resources, and can occur only at four- or five-year intervals. An increased emphasis on joint training opportunities closer to home can supplement such exercises, serving to develop further effective co-ordination between the Services, and providing valuable training opportunities for joint commanders.
9.32 Shortly before the end of 2002, the UK participated in a long-planned US exercise, Exercise INTERNAL LOOK 02, run by the US Central Command. In practice, this also served for the US as a mission rehearsal for the Iraq operation, which was of course the contingency uppermost in planners' minds at the time. This not only allowed headquarters staff to practise and prepare for running a coalition operation with the US, but directly assisted the UK's ability to influence mission planning.
Cultural Knowledge and Language Training
9.33 The ability to communicate with the local Iraqi population was critical to the success of the operation, resulting in a requirement for large numbers of interpreters throughout. The Department will review the provision of interpreters for future operations. By recording the training which personnel (including Reserves) have undertaken in particular languages and cultures, good quality interpreters could be more easily sourced at short notice. This would enhance the UK's overall military capability in future operations.
Single Service Training
9.34 'All-arms training' involves combining training of armour, artillery, infantry, engineers and aviation. Elements of 3 Commando Brigade RM undertook an all-arms exercise with the US Marine Corps in the US in autumn 2002, while 1(UK) Armoured Division took part in similar exercises in Kuwait in April 2002 and the full programme of exercises with NATO's Allied Rapid Reaction Corps that year. Many soldiers have emphasised the value of this high intensity training, with the facilities at the British Army Training Unit Suffield in Canada receiving particular praise. With the UK's defence posture increasingly based around expeditionary operations and power projection, collective training for high readiness, support and enabling forces will continue to play a vital role, based on the scenarios in which they are likely to fight, including the urban environment.
9.35 Land forces required more in-theatre training than their maritime and air counterparts owing to the environment. In the Gulf, this focused on command and staff training and field training - the latter essentially involving a live-firing exercise on the Udairi desert ranges in Kuwait. Limited conversion training was also conducted with new equipment procured specifically for the operation, such as NBC force protection equipment. Land training is built around training for high intensity war-fighting operations; however, the training emphasis for forces due to deploy to Iraq has now shifted to focus more on peace support activities. The ability of UK forces to move rapidly from high-intensity combat to stabilisation operations was much admired. It is a vital skill in campaigns such as in Iraq where peace support/internal security operations and humanitarian assistance need to be conducted concurrently with warfighting.
9.36 Maritime personnel prepared through a combination of traditional pre-deployment training in home waters and the recently introduced Flag Officer Sea Training Mobile Training teams. These teams provided training packages specifically tailored to the particular theatre for each ship, including Royal Fleet Auxiliary vessels, while they were en route. Amphibious forces integrated with their US counterparts in the Gulf; their training included full mission rehearsals in theatre.
9.37 Air operations were facilitated by the close professional relationship that has developed over many years between the RAF and the USAF, in particular through training and operating together in the Gulf region, the no-fly zones over Iraq and operations in Afghanistan. Personnel undertook a variety of pre-deployment training for operations both at home and overseas, and some units carried out a series of invaluable training deployments to the United States. The RAF is currently conducting a review of operational training to ensure that the enduring demands of training at home and overseas are met in the future.
9.38 Current training models are frequently reviewed to ensure they remain valid and relevant to evolving operations; the requirement to refine training on air/land integration identified in Chapter 6 is a good example. A balance will need to be established between the need to exercise with likely coalition partners and the need to exercise in particular parts of the world to foster relationships between the UK and potential host nations and allies.
Health and Medical Issues
|A soldier dries her hair after having to wash it in the desert for the first time|
9.39 Overall, the provision of in-theatre medical care throughout the operation was very successful. Medical provision followed the model of previous successful operations with a comprehensive hierarchy of medical facilities. These ranged from life-saving first aid on the battlefield, through emergency aid and support at medical outposts, to land-based field hospitals and the Primary Casualty Receiving Ship (RFA ARGUS) all capable of providing primary surgery. In addition, all troops receive training in battlefield first aid with a proportion receiving enhanced skills training. Thankfully, the number of UK casualties was low, but the treatment of Iraqi civilians and combatants resulted in hospital occupancy being regularly in excess of 60%.
9.40 The Iraq operation saw the largest deployment of Service medical resources since the 1991 Gulf Conflict, with the majority of the UK's deployable medical facilities and around 2800 medical personnel present in theatre. Details of the units deployed were provided in First Reflections11. Medical manning has historically suffered from major shortages, particularly in certain key clinical specialities, and a deployment on this scale was only achieved by using some 760 medical reservists from all three Services. The Reserve medical personnel not only provided support to Regular medical formations as individual reinforcements, but also deployed and manned a complete 200-bed field hospital. The close working relationship developed with the Department of Health in recent years helped minimise difficulties when NHS employers were required to release reservists. The combined deployment of Regular and Reserve medical personnel contributed to a most successful military campaign, where all medical objectives were achieved.
9.41 Medical equipment modules were not available off-the-shelf and needed to be constructed by the Medical Supplies Agency. With up to 200 different suppliers per module, procurement was a challenge. Because of the lead-time for the supply of some key items of medical equipment, some modules arrived in theatre incomplete. Deficiencies were rectified as soon as supplies became available from manufacturers. There were also shortfalls in some medical stocks, including ComboPens (self-injection antidotes for nerve agent poisoning) prior to deployment. However, procurement of additional stocks, redeployment of stocks from ships to ashore, and a programme that extended the shelf life of ComboPens ensured there were sufficient supplies to meet the requirement.
9.42 At the beginning of combat operations the take-up of immunisation against anthrax among deployed personnel was around 70% overall and higher in some front-line units. This represents a marked advance since the 1998 operations in the Gulf (when it was around 30% overall) but there is still room for improvement. The Department must continue efforts to make immunisation against anthrax routine; this should help to allay the concerns of some Service personnel, increase take-up to levels similar to those of public health immunisations, and improve readiness.
Medical Treatment of Civilians
9.43 The Defence Medical Services are configured to deliver medical support to coalition military personnel and POWs. This role dictates the clinical specialities and equipment modules required to deliver requisite levels of medical capability. However, as the campaign progressed, military medical facilities were approached by Iraqi civilians (including women and children) who requested treatment. The military medical personnel had neither the equipment nor the requisite clinical breadth to deal comprehensively with this diverse patient base. Policy on the medical treatment of the local civilian population is being reviewed, taking into account the positive impact that effective medical treatment of the local population through military means can have on 'hearts and minds'.
9.44 The arrangements for post-operational healthcare for personnel returning from the Gulf were described in First Reflections12. These included research that MOD has commissioned from King's College, London into the physical and psychological health of personnel who deployed. The research involves the issue of questionnaires to a representative group of those who were deployed, seeking data on health status and exposures. The same questionnaire will be distributed to a control group who did not deploy to provide a comparison. Researchers have conducted interviews with over 60 personnel to collect data on any emerging concerns about exposures and health effects. The issues raised will be followed up in a major study due to commence early next year. However, to date, we are not aware of any unusual pattern of ill-health in returning personnel. A detailed paper on the health lessons identified since the 1991 Gulf Conflict, taking account of experience on recent operations in the Gulf, will be published in the New Year.
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