Emms 2022

EUROPEAN
MILITARY
MEDICAL
SERVICES
2022
The Ecoles Militaires de Santé de Lyon Biological Defence Vigorous Warrior 22 /

Bron, cradle of the French Armed Centre Těchonín, Casualty Move 22
Forces Health Service’s professionals Czech Republic
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Editorial
Content
Words of Greeting 4
The ,
cradle of the French Armed Forces Health Dear reader,
Service’s professionals

6 The Coronavirus pandemic, several wars in
Biological Defence Centre Těchonín, Africa, Middle East and Asia, some outbreaks
Czech Republic and natural disasters on top: The Military
10 Medical Services have been actively support-
Coronavirus pandemic: Oxygen for India ing troops and the people in the affected
14 regions.
And the dramatic dimension of History hit the heart of Europe on
Medical procurement solutions for NATO
24th February 2022. With Russia expanding its invasion of Ukraine,
Allies and Partners
our Ukrainian comrades are now experiencing at our doorstep battle
18
casualties management, ground medical evacuations, acute CBRN
Medical Cooperation and Coordination (Chemical, Biologic, Radiologic and Nuclear) threats, population
in Europe movements within battlefields, etc.
22 Military health services were never so useful and needed than during
1st European Union Congress on these last weeks.
Military Health Services Battle injuries, diseases and non-battle injuries, mental health, CBRN
24 risks and threats, force health protection, combat fitness and well-
Vigorous Warrior 22 / Casualty Move 22 being of the militaries, medical supply: military health services have a
(VW/CAMO 22) lot to perform, and less and less human resources to achieve it.

28 The availability of this fundamental support is now more and more a
limiting factor for deployments and combat operations, and as every
On its way to FOC – MMCC/EMC put to the test
weak point, it becomes a target during operations.
35
The EMMS journal tries to bring its very modest contribution to the
Unifi ed Multinational Civil-Military European nations’ effort to develop, improve and enhance their
Medical Situation Picture 38 military health services. This year, we cover with our articles a part
of all their missions: education and training with the French Military-
2nd international virtual Workshop on Wearable Medical Academy, supply and procurement with the German supply
Biosensors in Casualty Care 2022 (WeCARE-22) in oxygen and the NSPA, force health protection and CBRN medical
42 counter-measures with the Czech Biological Defence Centre, an inter-
Overview of all members of the MMCC 47 national meeting in Spain, and of course, the Multinational Medical
Coordination Centre / European Medical Command, offering to
Index of Advertising European Forces solutions for coordination and shared management.
AUTOFLUG GmbH 43
Dr. Benjamin Queyriaux
Dr. Franz Köhler Chemie GmbH 13
Dräger Medical Deutschland GmbH 17
Emergent BioSolutions Inc 41
Fritz Stephan GmbH 15
General Dynamics ELS GmbH 34
german ercelliance GmbH 33 Imprint
Hamilton Medical AG 45
Published by: Managing Director:
HIPS Agency GmbH 21
Beta Verlag und Marketing GmbH Heike Lange
Inovytec Medical Solutions Ltd. 9 Celsiusstraße 43
Philip Morris Products SA 25 53125 Bonn, Germany Editor in Chief
Dr. Benjamin Queyriaux
Thornhill Medical 48 Tel.: +49 (228) 919 37-10
Fax: +49 (228) 919 37-23 Advertising: Peter Geschwill
E-mail: info@beta-publishing.com Layout: Oliver Reese, Kokollektiv GbR
Production/Coordination:
www.beta-publishing.com Thorsten Menzel/Karen Thelen
www.military-medicine.com
Training in battleground medicine
for a cadet of the French Armed
Forces Health Academy
EMMS European Military Medical Services 2022 3
Words of Greeting
Dear readers,
Two years into this ongoing pandemic, the military medical services in many countries
of the European Union and the transatlantic Alliance have been pushed to their limits
in terms of both personnel and equipment. We have also learned, however, that a
global pandemic can only be overcome by cross-border international responses. But
travel restrictions due to the pandemic made meeting in person in an international
context all but impossible. Although digital formats offered an alternative, they
could not replace talking face to face. Meetings such as the COMEDS Plenary or
the recently established EU Congress on Military Health Services are essential for
building close cooperative relationships with all participating nations. As a specialist
service, the Medical Service in particular benefits from the medical expertise shared
at international scientific conferences. These conferences are not just a forum for
exchanging ideas and expertise but also for building bridges between the medical
services of different nations. By providing an opportunity for cooperation, they bring
us closer together.
Although the ongoing pandemic continues to be at the focus of our day-to-day

work, it is essential that we also respond appropriately to other challenges we face
at the same time.
Last year served as a stark reminder of how many complex tasks must be balanced simultaneously.
In the summer of 2021, parts of Germany were hit by unforeseen torrential rains and catastrophic
flooding. Members of the Medical Service were involved in civilian rescue efforts and thus were
present on the scene. At almost the same time, the evacuation operation in Afghanistan had to
be managed together with our international partners. At present, the overall volatile geopolitical
situation must be closely observed in order to draw conclusions for the Medical Service which are
appropriate for the situation and the international Alliance.
In the context of global health, issues of security will become increasingly relevant. Any solutions will
have to found in an international approach.
“All war presupposes human weakness and seeks to exploit it.” We must therefore consider the
extent to which attacks in war as defined by Clausewitz may increasingly come to target and exploit
human weakness and the weaknesses of human societies. This means that we must think beyond
the familiar military dimensions to increasingly include human resilience and all its associated
aspects in our considerations.
What is needed is a cross-dimensional approach, but also one that encompasses all of society and an
international approach. The Medical Service can contribute its experience, its medical and scientific
expertise, its contacts in the healthcare sector, as well as its tools for shaping key health factors and
thus help accomplish the common task at a crucial point.
With the Multinational Medical Coordination Centre / European Medical Command (MMCC/EMC),
we already have a coordinator and supporter of EU and NATO Medical Services. It will allow us to
further synchronise our military medical preparations, standards and procedures and to establish
closer cooperation. In view of the importance of health for security policy, Germany is putting itself
forward as a driving force for the further development of multinational medical capabilities and is
contributing its expertise and capabilities to shaping the role of Medical Lead Nation in NATO and
the EU.
Dr. Ulrich Baumgärtner

Lieutenant General (MC) and Surgeon General of the Bundeswehr
4 EMMS European Military Medical Services 2022
Overview of where the contributions in this issue come from:
Quakenbrück
Germany
Blankenburg
Koblenz
Germany
Germany
Capellen Těchonín
Luxembourg Czech Republic
Lyon
France
Madrid
Spain
We provide an open access resource for information

and debate on military medicine.
Our website provides four key resources for your use:
• Military Medical Corps Worldwide Almanac

• Military-medicine.com Journal
• DiMiMed & other military medical conferences
• Military medical business forum
For further information concerning our scientific content and our sponsoring packages, please contact:
Beta Verlag Mrs. Julia Ehlen Martin Bricknell

& Marketinggesellschaft mbH Event & Object Management Lieutenant General (retd)
Celsiusstr. 43 julia.ehlen@beta-publishing.com Editor-in Chief
53125 Bonn, Germany martin.bricknell@beta-publishing.com
The Ecoles Militaires de Santé de Lyon Bron, cradle of the French Armed Forces Health Service’s professionals
The Ecoles Militaires de Santé de Lyon Bron, cradle of

the French Armed Forces Health Service’s professionals
Thomas Colleony, Luc Aigle, Edward Jezequel
Finally, we are convinced that this year will mark a decisive and
positive turning point towards the end of the COVID crisis. At least
for our students who, fully vaccinated and strengthened by their
experience, will be able to complete the requirements of a dual
curriculum as they have done since spring 2019. They will also
be able to resume an active military lifestyle with its traditions,
culture and physical activities. These two last points are neither
folklore nor leisure since it is clear that our schools do not only
deliver technical skills and academic knowledge: they shape and
mold complete individuals whose acquired soft skills are widely
recognized and coveted, and go beyond the scope of officers and
non-commissioned officers’ duties. This short article will mainly
deal with the curriculum of our student practitioners.
History
In 1856 in Strasbourg, the first military medical school was
opened to train the French land forces physicians also known as
“Les carabins rouges.” The imperial French military medical school
eventually closed its doors after the city surrendered, which led
Alsace to integrate the German empire in 1871.
In 1888 a new Army Health Service school was established in Lyon
due to the excellent reputation of both its medical university and
Training in battle casualty management for the cadets of the French military- the staff of its hospital that was located on avenue des Ponts du
medical academy (source: EMSLB)
Midi, later renamed avenue Berthelot. Simultaneously, a school
opened in Bordeaux for physicians specialized in the navy and
Introduction colonial troops.
In 1988, the city of Bron (located to the south-east of Lyon) wel-
It is with great pleasure that we respond to the invitation from the comed the French Army Health Service (ESSA) on a former air
EMMJ to present the French Military Medical School – l’ Ecole de base. This 30-hectare site is conveniently located close to all three
Santé des Armées (ESA). Together with the medical university of medical universities, the Faculty of Pharmacy in Lyon, the hospital
Lyon 1, ESA provides medical training for all the French military
physicians and pharmacists during the two first cycles of medical
studies. ESA belongs to the EMSLB which has also been the home
of l’Ecole du personnel paramédical des armées – the paramedi-
cal army school – for over four years now.
Dynamic and resolutely future-oriented, ESA continually adapts
to the pressing needs of an increasingly demanding civilian uni-
versity curriculum and to the requirements of the army medical
training designed for our current students and soon-to-be mili-
tary healthcare professionals.
Records are made to be broken and this year the ESA’s own grad-
uating ratio for first- year medical students has never been high-
er, exceeding last year’s record-high success rate in the first-year
competitive final exam.
This is in line with current increasing recruitment efforts that have
to be made to expand headcount within the Service de Santé des
Armées – the French Army Health Service. We also broke another
record, hosting more than 950 students on site. To make it possi-
ble, an ambitious building program has begun this year, designed
to accommodate all our officer cadets and nursing students by
2024. This is concomitant with the heavy maintenance work
which is to be pursued until 2028. Baron Percy’s statement in 1811, known by heart by all cadets (source: EMSLB)
complex in the east of Lyon and the Desgenettes military teaching

hospital. In addition to student accommodation facilities, the site
has 3 lecture theatres, numerous classrooms and work rooms, a
library, an entire room dedicated to simulating the management
of certain specific medical emergencies, practical work rooms as
well as a vast sports complex including: a football pitch, a rugby
field, a gymnasium, a fencing hall, an athletics track, a weights
and fitness room and a 25-meter swimming pool. Nevertheless,
this complex has suffered... from the weight of the years and even
if it still allows our students to exercise and practice sports freely
on a daily basis, it is urgent that we give our sports facilities a
makeover!
As part of the general overhaul of the French Military Health
Service (SSA), the school in Lyon-Bron was selected in 2008 to
become the only school for initial training of physicians, phar-
macists, dentists and veterinarians of SSA. It has been the only
military medical school recruiting medical officer cadets since
August 2009. In July 2011, the Armed Forces Health School (ESA)
thereby inherited all the traditions from various Army Medical
schools including those of Lyon and Bordeaux but also the School
of Strasbourg and the naval schools of medicine founded in 18th
and 19th centuries. Cadets’ military skills (source: EMSLB)
Which are the recruitment terms

and onditions for students?
Today the SSA recruits an average of 110 to 120 first-year
medical students (PASS). After a selective written examination
(mathematics, physics, chemistry, biology, French and English)
in the middle of the last year of high school (1,971 candidates
this year), a specific number are selected to come to the school
and take a sports tests and an oral examination on the EMSLB
site in mid-June to test their motivation to commit themselves
to this demanding future profession and long studies. Additional
recruitment also allows us to meet the student headcount
requirements, with an average of fifteen to twenty students who
join our military cadets during the course of the curriculum, main-
ly in the second year but also during the second cycle.
Studying course of a student practitioner

The academy premises (source: EMSLB) at ESA
Classified as a Grande École de la Défense and a member of the
Since 2018 the school in Lyon-Bron has been the home of the Conférence des Grandes Écoles (CGE), ESA is the only military
School of Armed Forces Paramedical Personnel (EPPA), thus be- school responsible for the initial training of future army doctors
coming the Military Health Schools in Lyon-Bron(EMSLB). and pharmacists (first six years of study).
The students are both medical or pharmacy students and career
The school in a few figures officers with all the requirements that this entails.
We follow the academic career of about 950 students, i.e., They follow the same training and examinations as their civilian
677 physicians, 22 pharmacists, 3 veterinarians, 249 nurses, and counterparts (attached to and administered by the University of
2 nurse’s aides. The percentage of women is 54.4%. To ensure the Lyon 1) and an additional 1800 hours of complementary educa-
success and well-being of our students, and to provide training tion specific to medical practice within the armed forces, spread
for them, approximately one hundred civilian and active duty over the six years, given at the ESA. These 1800 hours correspond
military personnel along with twenty reservists work on a daily to a 7th year of training. They are valued by obtaining a Master’s
basis within the EMSLB. degree specialised in Army health delivered by the CGE, which
The success rate (all sectors combined) for admission to the 2nd makes it a real specificity for our students’ curriculum.
year of medicine was over 88% for the last academic year. 95% of
our nursing students obtained their registered nursing diplomas. Academic background
Regarding military training 66% and 28% of medical and nursing It scrupulously follows the requirements of the French faculties
students respectively leave school with a military certificate and of the University of Lyon 1. The ESA studies office interacts
(parachuting, commando, diving….). mainly with the faculty to adapt the university curriculum to the
specific military or medical-military train-

1ST CYCLE
ing of our students. During their studies,
they will complete at least one internship 1st year 2nd year 3rd year
in general medicine in a military medical Training in health
sciences, common for
Training
Medical
unit and one internship in a military hos-
medical, pharmaceutical, General Training in General Training in
pital allowing them to understand certain dental, maieutic and Medical Sciences Medical Sciences
specificities of their future profession. physiotherapy studies,
In addition, within the framework of freely named “PASS”
chosen optional teaching units (UELC), for
the second cycle, the school has obtained Initial, additional and specialised military training
that these UELCs are positioned on the
Training
Military
particular needs of the service, namely Introduction to the world of the armed forces:
tropical medicine in the 4th year, sports conferences, visits, training periods, military
medicine and extreme environment in 5th qualification certificates
grade and tactical medicine in 6th grade.
The reform of the first two cycles of med- Sports and physical preparation
ical studies which began a year ago, is a
major upheaval in the university world 2ND CYCLE
that we are following very closely. 4th year 5th year 6th year
For the first cycle, it has required a rapid
Training
Medical
adaptation of the teaching staff to best Advanced Training in Medical Sciences

support our students in the success of this
first year of medicine, which remains very
selective. Tropical Medicine Sports Medicine Emergency Medicine
Currently made up of nine teachers sec-
Military Training
Battleground Medicine Sports and Medicine in Challenging

onded from the national education sys- Physical Fitness Environments
tem, they will be reinforced next year by
two new biology teachers. Forward Search and Rescue, civil and military (S&R during combats)
The other upheaval is the major change
Conversational, medical and military English language
in the new sixth-grade National Ranking
Examination (ECN) which allows a choice Management and communication skills
of specialty.
The SSA has recently chosen to return to
National Ranking Test (ECN)
the system prior to the ECN reform. From
2024 onwards, all sixth-year students will 3RD CYCLE
take a first specialized study diploma (DES)
Military Teaching Hospitals
in general medicine and then, after three Ecole du Val-de-Grâce
years spent in a medical unit, they will be
able to apply for a hospital speciality DES General practice and
family medicine Other medical specialties
through a competitive examination (assis- + 3 years + 4 to 6 years
tantship) if they wish. These speciality DES
Doctorate in Medicine
positions will be opened according to the & Specialised Medicine
hospital needs of the SSA. Diploma
All these reforms are a legitimate source
of concern and questioning to which the
command responds as best and positively as possible while hop- immerse them in the units and to discover the art of leadership.
ing for a rapid clarification from the academic and political insti- Finally, throughout their curriculum, they have the opportunity
tutions of the last remaining uncertainties on this major reform. to take military qualification certificates, the main ones being the
parachuting certificate, the skier and mountaineer certificate, the
Military training on-board diver course and the commando course. They can also
It is spread out progressively throughout the six years of study participate in commando training courses in France, Guyana and
both in the military and command fields and in the teaching of even at the school, which has had its own course since last year.
combat rescue. This military training is coupled with English language training,
After an initial 15-day military training at the start of the first year, communication, management and command courses.
students follow an additional three-week military training the fol- For our sixth-year students, all of this additional training ends
lowing year and a one-week specialized military training (more with the writing of a dissertation on a military health issue,
command-oriented) at the end of the third year. which sometimes leads to the beginning of reflection for their
At the end of the second year, they complete a three-week future thesis work. This dissertation therefore validates the CGE’s
training course in a regiment, the main objective of which is to specialized master’s degree in military health.
Prospect
As mentioned above, ESA is monitor-
ing the ongoing academic reforms. For
the first cycle, this entails more help and
support for the first years; for the second
cycle, it means preparing our current 4th
year students for the new ECN exam meth-
ods. Regarding the military part, we are
continuing and adapting combat and res-
cue simulation exercises with high-fidelity
dummies. The integration in their training
of a CBRN module with the initial decon-
tamination batch of the SSA has been in
place since this year. In partnership with
the faculty’s anatomy laboratory, one day
is devoted to advanced combat and res-
cue techniques that our 6th year students
carry out on cadavers.
Conclusion Training and simulation classroom (source: EMSLB)

The ESA is resolutely turned towards the
future taking into consideration both the reform of the two first MC COLLEONY Thomas, Chief of the 1st Bataillon
university courses and making sure that the military medical MC AIGLE Luc, Dean of the Academy
preparation is as close as possible to the needs linked to the stra- AM JEZEQUEL Edward, Cadet in 2nd year
tegic issues and the French health service institution. The increase E-Mail: luc.aigle@intradef.gouv.fr
in recruited staff and the use of modern teaching techniques
geared towards the digital and simulation will enable the French
health service institution to meet tomorrow’s many challenges.
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Biological Defence Centre Těchonín, Czech Republic

Larisa Solichova
The Biological Defence Centre Těchonín, a modern biodefence and use of the Centre and which define its current role within
system of the Army of the Czech Republic has been built since the Czech Republic. These include, among others, Resolution of
2001 on the principles given by the Resolution of the Government the National Security Council No. 38 of 15 October 2014 on the
of the Czech Republic No. 1039 of 10 October 2001 on the „Basic isolation of patients with suspected Ebola, Resolution of the
system of protection of the citizens of the Czech Republic against Government of the Czech Republic No. 655 of 20 August 2015 on
high-risk biological agents and toxins“ and on the basis of the the further use of the BDC, and the subsequent additional Task
Task Letter of the Minister of Defence No. 642/2001-8764. The Letters of the Minister of Defence and the Chief of the General
immediate impetus for the revision of the original system were Staff of the Czech Armed Forces
the September 11, 2001 attacks on American centres and an Comprehensive construction of the Centre began in 2001 with an
assessment of possible biological threats. The system included initial plan to finish the entire complex in 2005, which failed, and
the creation of conditions for research, training and specialist the construction was suspended in 2006. At that time, the main
training of the Czech Armed Forces, NATO and the involvement of part was completed, namely the Specialised Infectious Diseases
the civilian health sector in biological defence issues. Hospital (SIDH) with a building for the disposal of infectious
Planned construction of a highly specialised medical facility waters and a building for quarantine stays for persons returning
providing diagnostics and laboratory identification of biological from foreign operations. After several years it was decided that
agents misused for combat and bioterrorist purposes with the the completion of the Centre was necessary, with a plan for its
finalization in accordance with the Concept of the Development
of the Military Medical Service until 2025. In addition to the
above-mentioned buildings, the completion of the Centre also
includes operational, technical and administrative buildings and
a science and research building, including laboratories.
Biological Defence Centre Těchonín

The Biological Defence Centre is a modern specialised military
medical facility located in the village of Těchonín in Eastern
Bohemia. It is incorporated in the command and control system
within the structure of the Military Health Institute as a biological
defence department and is directly subordinate to the director of
the Institute. The Military Health Institute in Prague is the exec-
utive element of the military hygiene and anti-epidemic service
and the biological defence system. The Specialised Infectious
Diseases Hospital (SIDH) is an organic part of the BDC.
The main tasks and objectives of the BDC are isolation and
Premises of the Biological Defence Center (Source: Biological Defence Centre Archive) treatment of persons with particularly dangerous and exotic in-
fections, ensuring quarantine stays for soldiers returning from
capability to isolate and hospitalise persons with high conse- foreign operations from epidemiologically risky areas, con-
quence infectious disease was supposed to be one of the corner- ducting biodefence research, training and education of Czech
stones of the biological defence system of the Czech Republic. and NATO military and civilian specialists in the specific field of
This facility, referred to as the Biological Defence Centre (BDC), biological protection and providing storage and preparation of
was established as a branch of the Central Military Health Institute special medical, laboratory, detection and identification equip-
(now the Military Health Institute) on the basis of the Regulation ment. The BDC together with the National Centre for Isolation
on the creation, reorganisation, relocation and abolition of units and Treatment of High Consequence Infectious Diseases of the
and facilities in the Army as of 1 April 2002. The construction of the Na Bulovce Hospital in Prague and the State Institute of Health
Centre started the delivering of the international commitments of form one of the pillars of the biological protection system for
the „Prague Initiative“ (CZ-DGP 03 – Training and Education Centre both military and civilan population of the Czech Republic. The
for Protection against Weapons of Mass Destruction) and at the collaboration among these institutions is set on the basis of the
same time the national commitment to the new defence capa- Czech Republic National Action Plan in case of an event sub-
bilities of the Alliance (CZ-BR 02 Specialised Infectious Diseases ject to the International Health Regulations and the resulting
Hospital), adopted at the NATO Summit in 2002. The Government Directive. The essential prerequisite for the use and development
of the Czech Republic, by its Resolution No. 724/2003, approved of these capabilities is close inter-ministerial cooperation with
the construction of the Biological Defence Centre as a project of the Ministry of Health (International Health Regulations 2005)
strategic character related to the integration and membership and the Ministry of Education, Youth and Sports (for science and
of the Czech Republic in NATO. These founding documents are research). Efforts to achieve the aims and objectives of the BDC
followed by others which are fundamental for the development to conduct health care culminated in 2016 with the conclusion
of an inter-ministerial Implementation Agreement between the Personnel enter and exit through their own decontamination
Ministry of Health and the Ministry of Defence and the obtain- pass. Liquid wastes go through several levels of cleaning and
ing authorization for the Military Health Institute to provide out- decontamination, while solid wastes are destined for disposal
patient, acute inpatient and acute intensive health care services in the incinerator. Air exchange is provided by a power ful air
at the Specialized Infectious Diseases Hospital in Těchonín. handling system with multi-stage filtration. The facility is built
to be fully operational in the event of interruptions to water,
History gas and electricity supplies. All systems are multi-stage backed
The village of Těchonín was not chosen for the location of the up. Maximum processes are fully automatic under the control of
BDC by chance. The area has served for military purposes since control center technicians.
the period before World War I. The current facility in Těchonín All personnel (including non medical staff ) are obliged to wear
was established at the end of the 1960s as the Institute of the specified personal protective equipment (PPE) while working
Immunology and Microbiology of the Military Medical Academy at infectous part of the hospital. The correct use of PPE must be
as a special-purpose facility to study the effects of inhaled infec- regularly properly trained. Working in PPE places high demands
tions and to test imunoprophylactic means of protection against on thermoregulation, concentration and strict adherence to all
biological warfare agents. After joining the Biological Weapons hygiene procedures, hence requires more frequent rotation of
Convention in 1972, research focused exclusively on the study of persons within a work shift. Due to the necessity to leave the in-
the body‘s immune responses and the effects of antiviral agents. fectious area by a relatively long decontamination process in a
After 1989, there was a significant reduction in research activi- decontamination chamber designed for 2 persons, the number of
ties and key experts left the facility. In February 1994, the strain workers inside the infectious area is limited regardless of the total
bank, which had been the basis for high quality scientific work, number of patients, which further increases the intensity of work
was dismantled by decision of the Ministry of Defence because in the infectious area. The use of PPE also limits intercommunica-
of concerns about its security. After 2000, when biological threats tion, which is successfully solved by the use of communicators for
and the concept of the biological defence system of the Czech all staff in the infectious section. Medical documentation is kept
Republic were reassessed, the development of the military facility according to the legislation in force in a combined form – part-
into its current form began. ly in paper form with the need to scan it into the clean section
and partly electronically using the hospital information system.
Specialized Infectious Diseases Hospital (SIDH) The results of laboratory tests are also inserted into the hospital
The Specialised Infectious Diseases Hospital is currently the main system. In the clean area, there is a technician always present in
facility of the Biological Defence Centre. The SIDH is a standby the floor control operating centre to ensure the correct function-
facility, the operation of which is initiated by starting the activa- ing of the technology and a ward manager nurse who monitors
tion process, which is determined by the Activation Plan of the the ward via a camera system, participates in communication
BDC Těchonín, Event No. 578-2/2014-6848. The building itself with medical staff and patients, provides the necessary materi-
was originally used for research purposes and was selected for als and services from the clean area and manages the rotation of
the establishment of an infectious diseases hospital for high con- shifts and staff.
sequence infectious diseases (HCID) because of its structural and
technical parameters. The SIDH is designed to meet all the organ- Building for quarantine stays
isational, technical and staffing requirements to ensure isolation Another important facility of the Biological Defence Centre is the
and care of patients with HCID at the highest level of biosafety quarantine building, which can accommodate up to 100 people
and biosecurity standards. All sophisticated technologies had to in several multi-bed rooms. There is also an isolation room for 3
be incorporated into the existing premises as well as the internal patients. It is currently used for quarantine stays for soldiers after
layout even with some compromises. The building is designed as their return from foreign operations.
a hospital with two wards on two separate floors. There is an inpa-
tient non intensive care ward, which can accommodate up to 20 Research laboratory buildings
patients and the second ward for intensive care capable to admit The activities of the Biological Defence Centre include biological
up to 8 patients. The hospital has its own laboratories for basic research, which is carried out in local laboratories. Plans to build a
heamatological, biochemical and microbiological testing. There is new science and research facility that will meet the highest stan-
an autopsy room and a morgue for 6 corpses as well. Apart from dards of modern science and the highest level of technical bio-
clinical settings, there is a waste management technology area, security are currently underway. At present, some of the laborato-
storerooms, a laundry room, a waste incinerator and extensive ries of the specialised infectious diseases hospital are temporarily
air handling system compartments. The operation of each floor is used for research work.
controlled and monitored by a floor controller worker in addition
to the central operating controlling centre, which is accessible Mobile Hospitalisation Isolation Unit (MHIU)
only from the clean section. On the top of the building, there is a The BDC also has a mobile, deployable field element called Mobile
heliport situated, designed for landing of a helicopter currently of Hospitalization Isolatin Unit to isolate patients with high conse-
7 tonnes maximum weight and is certified for day-night landings quence infectious diseases. The unit consists of special isolation
according to VFR. The infectious parts of the building are sepa- chambers with controlled negative pressure for the patients and a
rated from the clean area with decontamination rooms. Material facility for the POCT laboratory , which can be placed either in tents
movement is always unidirectional, always leaving the infectious or inside the building. The mobile hospitalisation unit includes, for
environment after sterilization and external decontamination. instance, a decontamination tent, a waste water treatment system,
a drinking water tanker, electrical generators and a control oper- care are preferred. Clinical laboratory activities also need to be
ating room. The MHIU at its maximal range could accommodate staffed by erudite personnel.
up to 24 patients for acute standard health care and 2 patients
for ICU care. The unit is not equipped with wider logistics facilities SIDH activation
and hence it must be embodied into the higher medical element As mentioned above The SIDH is a standby facility, the operation
during its deployment. Currently, the MHIU is partially deployed in of which is initiated only by starting the activation process, which
a heated hall and serves as a back-up evacuation area in case of an is anchored in the Activation Documentation approved from the
emergency during activation of the SIDH. level of the Chief of General Staff. Based on interagency agree-
ment, activation must be initiated at the request of the Ministry
Staffing of Health department within 2 hours after receipt of the signal.
Technology operation and service within the BDC, particularly The SIDH must be able to achieve initial operational capability 12
SIDH, is provided by a staff of 39 employees of the Army-Service hours after initiation, which means admition of 2 intensive care
Company (AS-PO), which is an operational and technical admin- patients, 6 standard care patients, and 30 quarantine patients.
istrator of some of the buildings and facilities within the Ministry There is a designated number of staff on alert for this purpose.
of Defence department. Individuals for a backup team of techni- At the 72nd hour after the start of activation, full operational ca-
cians in the event of SIDH activation are selected from other sites pability is to be achieved, which means care for 8 intensive care
under AS-PO management. Services such as cleaning and secu- patients, 20 standard care patients and 100 persons in quarantine.
rity are also provided by Ministry of Defence funded institution,
while catering service is outsourced. Real life
Pandemic Covid 19
In the early days of the COVID 19 pandemic, there were discussions
about activating SIDH. In the media, the hospital was present-
ed as a classified facility, able to accommodate a large number
of patients and relieve local health facilities. Given the situation
where COVID 19 spread very quickly throughout the country, the
activation of the SIDH was rightly assessed as extremely disad-
vantageous and unprofitable. Even assuming a reduction in the
biosecurity level to open two wards would have required activat-
ing more personnel than permanent staff at a time when military
medics, including BDC permanent staff, were being used to assist
in covid wards of civilian medical facilities across the country and
whose withdrawal would have severely weaken staffing of these
well established facilities. In addition, the SIDH is primarily de-
signed to isolate patients with HCID and does not have the exten-
Personnel in PPE taking care of a patient in ICU isolation chamber (IsoArk), Exercise sive complement of services available in regular medical facilities
Vigorous Warrior 2017 (source: Biological Defence Centre Archive) that are not used for patients with HCID due to the high risk of
spreading the infection (e.g., CT scans, cathetrization, endoscopic
The staff of the BDC itself consists of professional medical person- examination, surgery etc.). For COVID 19 patients, this inadequacy
nel and members of the logistics, technical support and adminis- would have lead to a reduction in the quality of care.
trative workers. In total, there are 55 employees – 40 military and Despite that, during the pandemic the BDC contributed to the
15 civilian staff. Medical staff form 4 doctors, 18 nurses, 7 clinical handling the issue. It has been used for extended quarantine
and research laboratory personnel. In the event of SIDH activa- stays for soldiers returning from operations in foreign countries.
tion the personnel of the 6th Medical Battalion of Military Medical An important contribution of BDC health workers during the
Agency is to reinforce the BDC. A new feature is the establishment COVID 19 pandemic were training activities (face-to-face con-
of Active Reserves (AR) unit, which should be fully capable to in- sultations, webinars, educational videos) in the use of PPE and
dependently perform tasks in the SIDH and replace the profes- assistance with setting up regimens and barrier measures in rest
sionals in the event of prolonged hospital operation. homes and some hospitals. This was initially a spontaneous activ-
The BDC permanent medical staff performs a variety of tasks – ity of BDC health workers, which arose from the observation of
they ensure quarantine stays of soldiers after their return from the lack of information on this issue in the mentioned facilities,
foreign operations, conduct necessary training for AR and other and eventually became one of the important tasks for a certain
personnel earmarked to work in the SIDH, optimize work pro- period of time and led to cooperation with Ministry of Labour and
cesses in the SIDH, create necessary professional guidelines and Social Affairs.
standards of care, participate in exercises involving MHIU and,
last but not least, perform all-military duties. Given the focus of Short-term hosting of refugees
the SIDH, there is also a strong emphasis on professional com- After sudden evacuation of the Afghan collaborators from their
petence, which they must maintain or improve through work in country after NATO troops withdawal, the BDC was succesfully
civilian medical facilities. For physicians, inpatient care specialties and effectively used as a facility capable to accomodate these ref-
are preferred, especially infectious medicine and intensive care ugees temporarily and ensured a high standard of complex care
medicine, while for nurses, internships and training in intensive to them.
Challenges logically due to the fact that it is a reserve military medical facili-
The activation of the SIDH is our biggest challenge. Due to the ty and in normal peacetime conditions the responsibility for the
scale of the unique technologies used, it is difficult in terms of health care is carried by the Ministry of Health and the Chief of
investment to ensure service and especially modernisation of Hygiene of the Czech Republic and the civilian health care in the
the facility. The SIDH is not an active facility, therefore it does not Czech Republic is at such a level that the need has not yet been
have experienced staff for hospital administration. It is necessary arisen. Moreover, during the Ebola epidemic there was no impor-
to ensure a consultative service of experts from other medical tation of cases into the Czech Republic and we have the civilian
specialties in case of need. To be adequately supplied in terms of first line facility to isolate and treat a few patients with HCID. The
equipment and materials in case of activation, we need apropri- CBD was prepared however.
ate numbers of logistical support staff, which is not rarely substi- On the other hand, the BDC has been realistically used several
tuted by medical staff. In addition, even the staffing tables allocat- times, although for other but not less important purposes. The
ed to the facility have not been fully occupied. This may be due to experienced medical staff of the BDC was successfully used in
the location of the facility in a less accessible region, and in case of the civilian hospitals and social service institutions during the
physicians it might be also a consequence of the non-conceptual COVID-19 pandemic, see above. Further, the facility has been
central planning of military medical doctors‘ specialties. The BDC used to provide quarantine and medical care for the Afghan refu-
faces the challenge of flexible provision with medical supplies gees after their evacuation to the Czech Republic. This shows how
and drugs in case of urgent need, as the military ordering system flexible the BDC capacity really is and that it can be used in many
is relatively rigid. other unexpected situations in the current turbulent world. These
In order to set up the optimal way of working and procedures, facts and the unpredictability of future threats give the existence
it would be advantageous to obtain information on the course of this facility a clearly understandable and unquestionable credit.
and organisation of care for real patients with HCID and the way
on how other similar facilities operate, to avoid unnecessary mis-
takes and expending energy on devising procedures that could Author:
have already been successfully implemented and tested. LTC Larisa Solichová, M.D.
Biological Defence Centre Těchonín
Conclusion Military Health Institute
In conclusion, it is fair to admit that the BDC has not really been Czech Republic
used for its main purpose (treating HCID) so far. However, this is E-Mail: solichoval@army.cz
Coronavirus pandemic: Oxygen for India

Claas Gärtner
In early May 2021, almost 45 °C prevail on the almost 15 x 25 m From wish to reality
light grey concrete slab on the premises of the Sadar Vallabhbhai The first concrete steps towards the procurement of a mobile
Patel Covid Hospital in New Delhi, an improvised military hos- oxygen production system were made already in 2009. The first
pital consisting of tents. In a green 20-feet container with Red ideas for such a system and the possibility of integrating such a
Cross emblem and air vent screens high-pressure compressors system into medical facilities had developed already three years
are softly humming while only a few metres away, corona deaths before. Since, especially with a large number of severely wound-
are transported to ritual cremation at minute intervals. In the ad- ed soldiers, the success of treatment depends significantly on the
jacent tent, directly beside the container, Indian technicians are availability of medical oxygen, the Bundeswehr wanted to have
screwing adapters onto large oxygen bottles. In between, soldiers its own capability to produce oxygen.
of the Bundeswehr Medical Service who familiarise the Indian en- Before this project could be implemented, a monograph “Oxygen
gineers with the particularities of the mobile oxygen production from concentrators / oxygen 93%” had to be prepared for the
and filling system. European Pharmacopoeia (Ph. Eur.), since the process of filling
and refilling molecular sieve oxygen is a pharmaceutical produc-
tion process and oxygen 93% is a medicinal product that must
meet regulatory requirements. In 2007 already, Bundeswehr
Medical Office, Division VIII Military Pharmacy, had prepared and
harmonised with the Federal Institute for Drugs and Medical
Devices the draft of a monograph in such a way that it could be
accepted for hearing and discussion in a meeting of the European
Pharmacopoeia Commission (Ph. Eur. Com.). In cooperation with
the French Armed Forces, information on their trials on molecu-
lar sieve oxygen production were included in this draft. Finally,
the monograph No. 2455, Oxygenium 93 per centum (O2 93) was
published in the European Pharmacopoeia in 2010. Thus, the pre-
conditions had been created for the lawful production and appli-
cation of oxygen 93% as medicinal product in the Bundeswehr.
The military procurement process had to consider the general
principles of initial and resupply as well as a comprehensive and
resilient, that is consistent, supply strategy for medical oxygen.
The mobile oxygen production and filling system can be employed independently, A mobile system for the production and filling of oxygen that
but also in combination with other medical facilities. (Source: Fritz Stephan GmbH) could be integrated into the existing system of modular medical
treatment facilities (MMTF) of the Bundeswehr was ideal for this
Only ten days earlier, a team of the Bundeswehr Joint Medical purpose, because Role 1 – 3 medical treatment facilities (MTF) in
Service had travelled to New Delhi upon request of the Indian the theatre of operations as well as tactical and strategic medical
government to support the country with oxygen production evacuation (MEDEVAC) are the main users of medical oxygen.
capacities. In early May, India had to mourn several thousands of The first of six mobile oxygen production and filling systems to
corona deaths each day, and the health care system was overbur- date was handed over to the Bundeswehr in 2011. The first field
dened. Especially in the coronavirus hotspots, the life-saving gas test with its core components was performed during the then
was lacking. Here, the assistance from Germany was to set in, and ISAF mission in the camp of the Provincial Reconstruction Team
a team of 13 servicemen and women of the Bundeswehr Joint Kunduz.
Medical Service was tasked with providing India with oxygen. The The system, which consists of a 20-feet function container
team was headed by Colonel Jürgen Thym from the Bundeswehr (oxygen production, storage and transport container), one Type
Medical Service Headquarters. When the operationally experi- II standard tent with two locks, a loading platform, two 70kVA
enced senior officer received the mission, he immediately knew: power generators and a wide range of accessories, as for instance
“We go there together and will accomplish our mission. To help the ZKB15 tent air-conditioning unit, will generally be set up in
people in need and under dangerous and adverse conditions is the theatre medical logistics point or, if required, in the Medical
the core of our self-image as military medical service.” Service logistic support point and will be supplied to the med-
Within only five days after arrival at Indira Gandhi International ical treatment facilities according to the supply principle. Each
Airport, he and his small team had not only explored and pre- mobile oxygen production and filling system can produce up to
pared the installation site, and put into service the mobile oxy- 400,000 litres of oxygen per day and fill it into 2- to 50-litre com-
gen production and filling system, but also familiarised the Indian pressed-gas cylinders with a pressure of 200 bar. In addition, three
technicians with the system in three days. The goal was clear: save of the six systems are intended to feed oxygen directly into the
lives by producing about 400,000 litres of high-quality medical oxygen piping systems for instance in field hospitals and mobile
oxygen per day. surgical hospitals at low pressure. In this case, the system, as far
as the supply with POL is concerned, must be integrated into the

logistic processes of the respective medical treatment facility. The
equipment of the direct-feeding variant includes the so-called
reserve container, since the oxygen supply systems to feed oxy-
gen into medical piping systems in accordance with DIN EN ISO
10083 must have a bottle-based reserve supply source consisting
of two separate bottle lines.
Oxygen production in detail

As an autonomous system, the mobile oxygen production and
filling system can be set up and operated at almost any location in
the world. The system uses the so-called molecular sieve technol-
ogy to enrich oxygen from the ambient air up to 96%. The heart
of the system, the function container, consists of three areas: a
technical room with air-conditioning and -monitoring unit, the
main component with the oxygen enrichment unit and the two
high-pressure compressors, and finally the filling station for pres-
sure-gas cylinders.
The enrichment of oxygen from the ambient air takes place via
molecular sieves that are distributed over several platforms. First, Last check of the platforms with the AFT modules in India before putting the
system into operation. (Source: Claas Gärtner / PIC Bundeswehr Medical Service)
the ambient air is sucked via the platforms and pre-compressed
to 1.5 – 1.7 bar. The air is then ducted through the so-called ATF concentration of 96% can be achieved since also argon, a non-
module with the molecular sieves. They contain zeolites (crystal- toxic noble gas, is also enriched from the ambient air. In the pro-
line aluminosilicates) that have a high degree of adsorbability cess, the molecular sieves are quickly saturated with nitrogen and
for gases with certain molecule sizes. The zeolites used prefera- require regular regeneration. In order to enable continuous oxy-
bly adsorb nitrogen, which enables enrichment of oxygen from gen separation, several molecular sieves are always operating in
the ambient air. At optimum performance, a maximum oxygen parallel in the mobile oxygen production and filling system.
Oxygen 93% produced

wherever needed
Oxygen
Concentrators
Mobile
Containerized
Stationary
Robust
Failsafe
Military proven
Direct pipeline support
Cylinder filling
Scalable from
20 l/min. to 960 l/min.
Made in Germany
Fritz Stephan GmbH Medizintechnik ∙ Kirchstraße 19 ∙ 56412 Gackenbach ∙ Deutschland
Tel.: +49 6439 9125-0 ∙ Fax: +49 6439 9125-111 ∙ www.stephan-gmbh.com ∙ info@stephan-gmbh.com
At over 40 °C, the team set up the system on the premises of the Sadar Vallabhbhai Patel Covid Hospital, an improvised military hospital near the airport of New Delhi.
(Source: Claas Gärtner / PIC Bundeswehr Medical Service)
After separation, the oxygen is stored at 6.5 bar in two storage ATF modules, but also the repair of small compressor units. These
tanks in the container with a volume of 365 litres. From these activities require training that is carried out in modules over sev-
tanks, the oxygen then enters the high-pressure compressors, eral months.
which compress the gas to 200 bar for filling after further filtering. In addition, when transporting and deploying the system, close
Filling and production may take place simultaneously. cooperation for instance with the dangerous goods safety adviser
of the unit is of particular importance.
Complex tasks for the personnel
The 20-feet function container, oxygen production, of the mo- Experience
bile oxygen production and filling system contains cutting-edge Beside their employment in India, the oxygen production system
technology that must be safely mastered by the servicemen and of the Bundeswehr Medical Service has also been employed in
women even under adverse conditions. Knowledge of the tech- Germany during the coronavirus pandemic. The Bundeswehr
nology is indispensable for a safe operation of the system, and Medical Service deployed one system to 3 Medical Regiment in
at the same time, the pharmaceutical and legal framework must Dornstadt to be able to support the Bundeswehr Hospital Ulm
be observed. The Bundeswehr relies on a personnel combination in the event of a disruption of the civilian oxygen supply chains
of pharmacists, pharmaceutical-technical assistants and technical that was conceivable at that time. For the same purpose, a sec-
staff for operating the system. ond mobile oxygen production and filling system was installed
Task of the pharmacists and pharmaceutical-technical assis- at 2 Medical Regiment in Koblenz. Further systems are held in the
tants is to fill the oxygen into cylinders and sample the oxygen Medical Logistics Centres of the Bundeswehr in Quakenbrück and
produced. Medical oxygen 93% is a medicinal product and in Blankenburg.
accordance with a monograph of the European Pharmacopoeia Whether in Germany or India, the mobile oxygen production
is produced in bulk to keep in stock and tested by pharmaceutical and filling system proved its operational effectiveness during
personnel (pharmaceutical-technical assistants and pharmacists) the coronavirus pandemic – even outside a national/collective
(Monograph PhEur 8.0/2455: Oxygenium 93 per centum). Each defence scenario. After 18 days in India, Colonel Thym drew the
batch is also tested for identity, purity and content. Only if the same balance: “We have accomplished our mission, we have
results of the tests are in line with the guidelines, a pharmacist saved lives.”
will release the medicinal product. Pharmaceutical personnel are
trained within the scope of the training “Production of medicinal Author:
products in mission”. Kommando Sanitätsdienst der Bundeswehr
The technical staff (electricians, fitters) are responsible for the Lieutenant Colonel Claas Gärtner
operation, maintenance and care of the system. Since the mobile Falckenstein-Kaserne
oxygen production and filling system is no medicinal product but Von-Kuhl-Straße 50
a technical installation, medical technologists are not required for 56070 Koblenz
its operation. The technical staff can carry out repair and sched- E-Mail: pizsanitaetsdienst@bundeswehr.org
uled maintenance action up to maintenance level 3. This includes
for instance the exchange and servicing of components like the
Supporting you,
wherever the action is.
You can’t choose your deployment.

But you can choose your equipment.
Whether you are saving and protecting the lives of others or safeguarding your own, you can
count on us. No matter what the situation is. At home in your barracks, abroad on a mission or
in the hospital, our products and services are right where you need them – on every single
mission. www.draeger.com
3622
Medical procurement solutions for NATO Allies and Partners
Medical procurement solutions for NATO Allies

and Partners
Elodie Winizuk, Robert Balazs
Resilience and a rapid response are key to counter crises timely How can Nations benefit from NSPA Medical
and efficiently in any military operation. The COVID-19 pandemic Services?
or the current conflict in Ukraine have demonstrated that crises NSPA brings nations together by providing multinational coop-
are becoming increasingly complex and they become rapidly eration solutions and mechanisms that allow nations to combine
global. their efforts, consolidate and share resources and take advantage
Fighting the pandemic was a key priority of each NATO Ally of economies of scale.
and Partner over the last two years. In this context, the NATO This is also particularly important in the medical domain. A single
Support and Procurement Agency (NSPA) has played a crucial role national requirement, can be shared with other nations via NSPA
supporting NATO, its Allies and Partner nations in their response mechanisms. This generates the advantageous commonality
to tackle the pandemic. of purpose among NATO members, it increases requirement
The provision of strategic airlift capabilities; the supply and trans- volumes leading to cost effectiveness from “economies of scale”
port of key relief medical supplies and equipment; the delivery purchases.
of rapidly accessible infrastructure to augment national medical In addition, procurement processes are generally protracted and
capabilities; or the establishment of testing laboratories in oper- complex, with multiple steps and stages. This consumes signifi-
ational threats to control the outbreak, are some of the examples cant amounts of time, which is not optimal for a dynamic military
where NSPA has contributed to mitigate the impact of COVID-19. force that may have immediate needs. NSPA has a great deal of
A great part of this effort has been coordinated and managed by prior experience that can speed up activity and can sometimes
the NSPA Medical Support team, made by experts in the field of operate under NATO directions beyond individual national
biomedical engineering, medicine and pharmacy, supported by considerations.
professionals in operational logistics and procurement. The NSPA Medical Support team can help nations planning,
Today, the Medical Support team acts as the focal point for any developing, coordinating, procuring, maintaining and deploying
medical related businesses within the Agency. The team en- their individual or common medical solutions. The operational
compasses the full spectrum of capabilities of NATO medical environment is highly specialised and requires familiarity with
doctrine, including planning, developing, coordinating, procur- the situation and military processes, in order to be effective. All
ing, maintaining and deploying medical solutions for the mili- NSPA medical personnel hold prior military experience and follow
tary. This ensures that NSPA follows and maintains the doctrinal NATO doctrine, which provides the framework for deployable
guidance of NATO and the Committee of the Chiefs of Military medical activity.
Medical Services in NATO (COMEDS) when undertaking medical
procurement. By doing this, NSPA not only supports national pro- COVID-19 Support
curements but also offers alternate solutions, capabilities and ser- There is no argument that the COVID pandemic challenged many
vices using the expertise and background of the medical team in aspects of society, including within the procurement chain, the
collaboration with national experts. supply, the manufacturing and the transport functions within
NSPA has carefully selected and grown the medical capability, the industries and economies of every nation. NSPA was one of
enlisting the support of a wide range of national personnel over many options, explored by member nations when the demands
time with proven track records in medical disciplines and crucial- for both civil and military support began.
ly, with prior experience of NATO military activity. Whilst NSPA had contractual agreements in place that met some
KFOR Role 2 Basic Medical Treatment Facility in Kosovo (source: NSPA)
of the demands for support, the scale, scope and speed of the In 2007, NATO military medical planners were looking for an
requests was overwhelming in March 2020. There was a global enduring solution for medical support for the multinational
rush to secure limited production items for which no nation was forces in Kabul, Afghanistan. NSPA (NAMSA, at the time) created
fully prepared for. NSPA was not positioned to answer the large and built a fixed multinational Role 3 hospital at the airbase, re-
and sudden demand, but through its unique partnership with placing the multiple medical facilities of the combined nations
over 100,000 different industry providers, the Agency was able to and acting as a focal point for medical care in the region.
provide key and rapid assistance to meet the challenge. To provide The success of this project led to the creation of a replicate Role
an idea of the scale of the requirement, it is worth noting that, at 3 facility, built by NSPA at the airbase in Kandahar. A remarkable
the beginning of the pandemic, NSPA alone received over 1 bil- survival rate of over 95% of the battle-injured casualties arriving
lion EUR of requests for PPE (Personal Protective Equipment) and at the facilities was anecdotally reported1. This was due to the
associated equipment and supplies within a 1-month timeframe. combined capabilities offered by these two hardened medical
Neither NSPA nor industry was able to fulfil such requests in the facilities, combined with the military medical experts within that
time requested. Nevertheless, the NSPA team worked alongside provided their tremendous clinical skills.
their member nations, 24/7 to source and secure as much of the
requested items as they could. At the same time, they collabo-
rated with national experts to identify the wildly different stan-
dards from the customers that eventually emerged for the PPE
and matched them to the available manufactured products. The
required standardisation was time-consuming, yet there was no
time to spare for life-saving procurements.
During the pandemic, the NSPA Medical Support team not only
supported Nations with the provision of PPE equipment and oth-
er urgent medical supplies. They also worked closely with NATO’s
Euro-Atlantic Disaster Response Centre (EARDCC) providing the
necessary medical expertise for the donations of critical medical
equipment, and helped NATO Allies and Partners with the pro-
curement and transportation of patient monitors, thermometers,
oxygen concentrators, resuscitation modules, negative pressure
transportation chambers or pulse oximeters, among others. The
team also delivered two COVID-19 testing laboratories with staff Mockup of the KFOR Role 2 Basic Medical Treatment Facility (source: NSPA)
to increase the testing capacity of the NATO-led Resolute Support
Mission service members at the time, and the Kosovo Force
(KFOR) mission. The laboratories enabled to conduct quick virus In 2010, NSPA began to address a medical shortfall in strategic
detection to monitor the spread of the virus. The KFOR lab is still aeromedical evacuations. The few nations who had this capabil-
active and, since its delivery in September 2020, it has performed ity were coming under greater pressure due to operational task-
almost 24,000 tests, contributing to a better protection of the ing, and were in difficulty to fulfil all requests for support from
service members deployed in this NATO mission. other nations who lacked the capability. Even the larger nations
In addition, NSPA provided rapidly accessible infrastructure to were making requests for support, as their beleaguered capa-
augment national medical capabilities. In 2020, the Agency, bilities reached maximum tasking. NSPA created a commercial
through its Southern Operational Centre (SOC), prepared and co- Strategic Evacuation (STRATEVAC) contract under the scrutiny of
ordinated, within a few days, the transport and construction of its Operational Support Logistics Partnership. This enabled any
a field hospital in Luxembourg, with capacity for 100 additional NATO member nation to request a commercial STRATEVAC sup-
beds. This augmented the capabilities of one of the main hospi- port for patient movement and usefully has provided medical
tals in the country. planners with an additional option to their existing capabilities.
In September 2015, NATO asked NSPA to find a replacement
The evolution of the NSPA Medical Support capability for the French military forces who were leaving their
Before there was a true medical capability at NSPA, the Medical role after seven (7) years as the custodians of medical primary
Directorate of Allied Command Operations (ACO) engaged with care for the Camp Maréchal de Lattre de Tassigny (CMLT) at KFOR
the J4 Logisticians in designing a capability package to support base, located just outside Pristina. NSPA rapidly created a contract
a NATO deployed multinational Headquarters, where no nation for a commercial NATO Role 1 medical services, which continues
would assume the lead nation status. to the present time as part of the base services.
By 2007, ACO had developed a medical Role 1 shell capabili- In November 2016, NATO medical planners asked NSPA whether
ty: a medical presence was established at NSPA, and Capability they could provide a replacement Role 2 DCS (damage control
Package 156 was born. Since then, NSPA has maintained this capa- surgery) service contract for KFOR nations, to fill the gap left by
bility package in their storage facility in its Southern Operational the outgoing German Role 2 facility at Prizren. This facility would
Centre (SOC) in Taranto, Italy, and is ready to deploy it in support have to incorporate liaison with host nation medical capabili-
to operations and exercises. ties, coordinate blood supplies, dental emergency services and
1 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3322658/
assist patient repatriations. It needed to be in place by January As the crisis in Ukraine demands new approaches and engage-
2018. The Agency completed the task in the record time of less ment beside the rehabilitation projects, NSPA is working with
than 12 months, delivering the infrastructure, the equipment, NATO Headquarters in Brussels to deliver medical supply for
the supplies and most importantly, the medical specialist staff to civilians in Ukraine, including first aid kits, bandages, combat
run the facility. The facility is still operational at Camp Film City, simulation and training equipment.
and remains under the collective ownership of the participat-
ing nations with NSPA management oversight until the mission Looking ahead: The creation of a Medical
requires such essential capability By2017, the Medical Support Support Partnership
team had become an independent section within NSPA. To prepare for future medical challenges, future crisis or conflicts
that NATO and Allies might face over the next years and that are
of direct concern for the medical community, NSPA is concen-
trating its efforts into the creation of the first Medical Support
Partnership. This collective group would be the single point of
contact for all medical requirements, saving crucial time and con-
centrating resources and instruments to be more responsive in
the event of crisis. This would not only be beneficial in a pandem-
ic crisis, but also for NATO’s engagements in Humanitarian Aid
and Disaster Relief operations.
The Medical Support Partnership will be launched in the second
half of 2022, with the support of several Allied Nations that are
already committed to its creation. The Medical Support Team will
be directly involved and continue to provide support in identify-
ing, developing and procuring medical solutions to equip NATO
Nations and Partners with responsive, effective and optimised
medical solutions.
About NSPA
The NATO Support and Procurement Agency (NSPA) brings to-
gether, in a single organization, acquisition, logistic, medical and
infrastructural capabilities, operational and systems support and
Delivery of anesthesia machines to the Afghan National Defence Security Forces in services to the NATO nations, NATO Military Authorities and part-
Kabul (source: NSPA) ner nations. As NATO’s primary enabler, the Agency’s mission is to
provide effective and cost efficient multinational solutions to its
The team has also played an important role in supporting with stakeholders.
medical capabilities CSTC-A (Combined Security Transition Since its establishment in 1958, NSPA acquires, operates, and
Command – Afghanistan), and the Afghan National Defence maintains everything through an unbiased link between in-
and Security Forces in their mission. Over several years, NSPA dustry and the nations: from weapon systems to fuel delivery,
has provided a vast range of supplies and services to the mis- port services, airfield logistics, medical and catering services or
sion, through the NATO Trust Fund arrangement. This ranges base support services for troops stationed across the world. The
from oxygen concentrators, x-ray devices, bandages, antibiotics, Agency enables the consolidation and centralisation of logistics
halal-vaccines, clinical analysers, biomedical servicing capabil- management functions, providing a “cradle to grave” support and
ities, controlled drugs and a myriad of other support pharma- allowing its customers to achieve economies of scale.
ceuticals. This effort has required coordination with Government NSPA is a customer-funded agency, operating on a “no profit – no
officials in multiple countries, transport routes involving convoys, loss” basis. The business activity has grown nearly fourfold in the
air routes and helicopter lifts, and unimaginable levels of paper- last decade, reaching an annual business volume of €4 billion.
work. Today, further to the end of the Resolute Support Mission NSPA is headquartered in the Grand Duchy of Luxembourg, with
in Afghanistan, the team is involved in the provision of medical main operational centres in France, Hungary and Italy and the
services at one of the refugee’s camps for Afghans in Kosovo. Agency employs around 1,400 staff.
Current support in Ukraine

In 2014, the medical team supported Ukraine in developing For the authors:
essential rehabilitation capabilities. NATO Allies established Dr. Robert BALAZS
several Trust Funds in response of the conflict in Crimea and then Technical Officer (Medical)
in Ukraine. Thorough the analysis of the health care system and and Office Acting Chief
with the support of NATO Nations, the essential rehabilitation E-Mail: robert.balazs@nspa.nato.int
principles have been instated and the education of future med- Elodie WINIZUK
ical rehabilitation staff has commenced. Through the Trust Fund, Technical Officer (Biomedical Eng.)
several injured veterans have been treated abroad and have been E-Mail: elodie.winizuk@nspa.nato.int
provided with the state of the art prosthesis.
More on:
www.hips.agency
info@hips.agency
HIPS Agency GmbH

Medical Cooperation and Coordination in Europe

Thierry Lanteri
On 11 December 2017, the Council of the European Union Some of these projects have already been completed and have
decided to establish Permanent Structured Cooperation (PESCO) been provided and implemented by the MMCC/EMC in Koblenz
in the area of security and defence policy. A total of 25 EU mem- during the last two years:
ber states participated in this initiative, which offers a legal frame- - Medical situational awareness
work to jointly plan, develop and invest in shared capability Good situation assessment is a precondition for better resilience
projects and to enhance the operational readiness and contribu- and a basis for every military coordination process. A full branch is
tion of armed forces. dedicated to gathering the necessary information in a constant ef-
A project called the European Medical Command (EMC) was fort by building “medical situational awareness”. Building up a reli-
one of the first PESCO projects agreed upon in 2018. The able situational picture is one of the core tasks of the MMCC/EMC.
Bundeswehr Medical Service, which was already engaged in the
Framework Nation Concept through the Multinational Medical Stockpiling concept
Coordination Centre (MMCC), assumed primary responsibility for As a direct response to the challenges of the global COVID-19
its development. pandemic, a concept called “Military Modular Multipurpose
Epidemic/Pandemic Stockpiling” (M3-EPS) has been developed
with the aim of facilitating swifter and better crisis response. The
EMC has also studied CBRNT and has already produced a jointly
agreed list of essential products in this area. In this domain, the
next step will be the development of supplementary procure-
ment and stockpiling concepts.
Blood database
Existing European Union directives on blood and blood products
(Directive 2002/98/EC – quality and safety standards for the col-
lection, testing, processing, storage and distribution of human
blood and blood components) only specify minimum standards
and tests for the production, distribution, and use of blood and
Colonel Thierry Lanteri highlights the importance of the MMCC/EMC network for
blood products. National laws can differ from EU directives and
the accomplishment of the task. (Source: Bundeswehr/Markus Dittrich) contain their own standards. This complicates and even prevents
sharing. Another issue is different definitions for blood and blood
What is the added value of EMC? products. Depending on the national regulation, these can be
pharmaceuticals, medical devices, or blood products.
The aim of the EMC is to establish uniform medical support The MMCC/EMC considers the interoperability of blood and
coordination. This German-led PESCO project, which includes a blood products to be necessary not only in the military but also in
strong multinational component, will fill a capability gap that was the civilian sector. It conducted a survey to identify discrepancies
identified some years ago. It will provide a coordination and sup- among its participating nations and made the outcome available
port element to EU headquarters and national military medical to the directorates-general of the EU Commission. This effort is
services and, in doing so, will improve interoperability and oper- intended to support the efforts of DG SANTE (Directorate-General
ational readiness and will strengthen capability development as for Health and Food Safety) to change from a directive to uniform-
well as civil-military interaction. ly binding regulations for blood and blood products.
Based on the IOC declaration of MMCC/EMC 2019 and the
COMEDS Statement of 49th Plenary 2018, the EMC merged with Training course
the MMCC in September 2019. The MMCC is also coordinated by With the growing importance of the European Union Common
Germany. Both projects are now developed together, and the Security and Defence Policy (CSDP), the need arose to better un-
MMCC/EMC represents a lighthouse project of military and civil- derstand the mechanisms, structures and procedures that regu-
ian cooperation between the EU and NATO. The MMCC/EMC has late and guide the planning, provision and governance of medi-
established full operational capability (FOC). cal support to EU CSDP operations and missions. The MMCC/EMC
Since the creation of the MMCC/EMC, the European medical collaborated with the EU Military Staff and the EU Security and
services have further intensified their cooperation. The COVID Defence College to develop an introductory course/training to
pandemic has revealed considerable room for improvement, educate/train military medical personnel to work either with EU
however, particularly when it comes to international cooperation institutions or in CSDP operations.
between medical services as well as civil-military cooperation
within the EU. Several projects have been developed in order to Wargaming and exercises
make crisis response more efficient, thus further enhancing the During the past few months, the MMCC/EMC has developed and
EU’s ability to act as well as its resilience. implemented a series of wargames that have included extensive
external participation. Filling an identified gap in multination- from national and international institutions such as Johns
al medical support, participating nations have asked that the Hopkins University, the Fraunhofer Institute for Manufacturing
MMCC/EMC continue the wargaming series. Engineering and Automation, the British JHUBMED, represen-
The multinational exercise Resilient Response 2020 was conduct- tatives from COMEDS working groups and panels, the Swiss
ed in November 2020. It was organised as a hybrid distributed Centre for Military Medical Ethics (University of Zurich), and the
wargame dealing with a multinational response to a pandemic Netherlands Organisation of Applied Scientific Research (TNO).
crisis. It provided an opportunity to build relationships and in- The programme included 30 speakers from 17 nations (AUT, BEL,
crease the knowledge of medical military representatives of CHE, CZE, DEU, ESP, EST, FIN, FRA, GBR, GEO, HUN, ITA, NLD, SVK,
participating nations and representatives of EU institutions like SWE, USA). More than 100 participants took part in this event.
DG ECHO and DG SANTE. This exercise was an important contri- The general objective of the MMCC/EMC is to bundle knowledge
bution to preparedness for future pandemics. and consolidate the understanding of this important field for the
future. The goal is the creation of a community of interest in tele-
health and especially in wearable technology.
The next biosensor and telehealth workshop of the MMCC/EMC
will be held on 21-23 June 2022. The working title is WE CARE 22 –
“WEarable Biosensors in casualty CARE”. The primary aim is to gain
and monitor vital information on the status of injured soldiers on
the battlefield to support medical treatment in pre-hospital care.
Lecturers from different areas (civil, military, medical, emergency
services, etc.) will share their experience with wearable biosen-
sors in this specific area.
In order to keep track of the events that have taken place, important information is
clearly visible on whiteboards. (Source: Bundeswehr/Markus Dittrich
Resilient Medical Interface 2021 was conducted in November

2021 and aimed at gaining experience and developing best prac-
tices for the improvement of multinational medical coordination,
cooperation, collaboration and communication in Europe with
respect to medical information and situation awareness, disaster
relief operations, transnational patient flow management, joint
medical CBRN surveillance, and joint medical logistics.
Biosensors supporting healthcare in missions Sergeant Major Stephan G. prepares the answers for the training participants in the
situation centre from the simulation room. (Source: Bundeswehr/Anna Derr)
Again, the COVID-19 pandemic demonstrated the necessity of
enhancing capabilities with a focus on the increasing relevance
and demand for telehealth to meet critical health needs while The year 2021 was a year of success and growth and witnessed
reducing exposure. Additionally, the advantages of utilizing wear- the advancement of many projects by the Koblenz-based orga-
able biosensors to support healthcare in missions have become nization. For the next few months, its primary focus will be the
more apparent in recent years. This has led the military medical establishment of the situation centre, which will serve as a coor-
services of several nations to implement various solutions in the dination centre and broker for medical information and expertise
near future. at the operational level.
The MMCC/EMC therefore organized and hosted a virtual work- The MMCC/EMC is ready and able to support the missions and op-
shop on biosensors for supporting healthcare in missions in May erations of NATO and the EU with its operational knowledge and
2021. capabilities. This will benefit the health of our soldiers by com-
Three programme clusters took great care to present a well- bining efforts in medical support. The support already delivered
balanced and informative agenda. The first cluster and day were to EU and NATO initiatives over the past few months has been
about the implementation of biosensors that support human assessed to be very valuable and sums up our key task, namely
performance and soldier/warfighter readiness. The second day that MMCC/EMC is building a bridge between the EU and NATO.
focussed on the use of biosensors in missions, i.e. health and
medical management applications. Presentations were held Author:
about biosensors that can support triage situations and improve Colonel Thierry Lanteri
medical awareness during missions, for example. On day three, Deputy Director EU Matters
various considerations about wearable biosensors were explored MMCC/EMC
as well as ethical, legal, and CBRN-related concerns. Andernacher Straße 100, 56070 Koblenz
Conference participants included subject-matter experts E-Mail: MMCC-EMC-PAO@bundeswehr.org
1st European Union Congress on Military Health Services
1st European Union Congress on Military Health Services

Juan José Sánchez Ramos
From 6 to 8 October, the Centre Although most of the speeches and debates were held in person,
for Higher National Defence the technical resources deployed by the CESEDEN meant that speak-
Studies (CESEDEN) hosted the ers and attendees who were unable to travel to Madrid due to the
First European Union Congress epidemic were able to participate freely via the Internet channel set
on Military Health Services. up for this purpose by the organization.
The event was inaugurated by The scientific program was complemented on 6 October by a visit to
the Undersecretary of Defence, Torrejón Air Base, during which the delegations attended an in situ
Amparo Valcarce. exhibition of some of the military capabilities useful for supporting
The health crisis that our so- civilian authorities during a health crisis. They also attended a drill
cieties have suffered in recent that covered medical evacuation options under biosecurity condi-
months has once again demon- tions, carried out by different units of the Air Force and the Military
strated the value of the Armed Emergency Unit (UME).
Forces in supporting the civilian
population in any emergency CONCLUSIONS
situation. As part of this contribution, the Military Health Services of The Congress has yielded interesting conclusions, shared by the
the European Union nations have proven to be an effective instru- European Union member states. Among them is the consideration
ment in supporting the actions taken by States in these situations. that the threat of pandemics and epidemics is a well-analyzed factor
Every crisis is also an opportunity to learn lessons for future improve- in various national security strategies. In reality, the only uncertainty
ments. A reflection on what has happened in a type of crisis that regarding the cyclical emergence of health crises is their exact tim-
knows no borders is especially useful when there is greater collab- ing, an uncertainty that cannot therefore justify being unprepared
oration and a shared vision across the European Union. Therefore, in the future, unless one is willing to accept the dire consequenc-
under the motto Ubi concordia, ibi victoria (Where there is unity, es. Preparing for the next crisis should thus be seen as already un-
there is victory), the EU Congress on Military Health Services came derway, drawing on lessons learned from managing the COVID-19
into being with the aim of serving as an example of the importance pandemic.
of this synergy. It is also understood that, the more coordinated the implementa-
The Foreign Affairs and Defence Council held in November 2020 tion, the more effective preparation will be. It is therefore important
prompted the initiative to organize this Congress to discuss, reflect to increase cooperation between EU military health services, reflect-
and share views on military health issues related to crisis response. ing this in our structure and organization, and to improve concur-
The Spanish Ministry of Defence strongly promoted this initiative, rent planning with all the authorities being supported.
convinced of the timeliness and wisdom of its objectives and, there- Another reflection is that, although the links between health and
fore, offered to host the Congress. The response from EU nations and security are well known, in this crisis they have become evident in
agencies has been excellent. Twelve EU nations were represented by reality, highlighting the importance of the Armed Forces being in
delegations headed by the Surgeons General or relevant personnel a position to support other authorities, and ultimately the civilian
from their organizations (DE, AT, BE, CY, SK, ES, FR, EL, IT, NL, PT and population, in these emergencies. The Armed Forces represent a
RO). Likewise, the European Union Military Staff (EUMS) and the reserve that can guarantee an immediate response and can contrib-
European Medical Command (EMC) —a project created some years ute to building strategic reserves for pandemics.
ago under the umbrella of the Permanent Structured Cooperation This readiness is very much appreciated by European society. It is also
(PESCO)— participated with keynote lectures of great interest to the noted that, alongside the effort invested in the specific response to
attendees. the crisis, the European Armed Forces have been able to implement
The organizers proposed for discussion a series of topics related to measures that have enabled outbreaks to be controlled in their own
the support offered by the Armed Forces in the current situation. forces, thus minimizing the impact of the pandemic on operations in
This way, thanks to the contributions of the attending nations and order to continue to ensure security and stability.
organizations, the Congress addressed issues that benefit from a Once the conclusions had been drawn up, the Spanish Surgeon
common approach. These issues were structured in three scientific General, Major General Juan José Sánchez Ramos, closed the
panel discussions: the role of EU Military Health services in support Congress on 8 October with the wish that this first edition could be
of civilian authorities during the pandemic; the operational chal- followed by other future editions in different European locations,
lenges that states of uncertainty such as the current crisis pose to until it was consolidated as one of the main meeting forums for
medical support; and the importance of strategic health stockpiles European Union Military Health Services.
and the planning and implementation of preventive measures at
European level, including vaccination plans. Author:
The Congress was also a good opportunity to highlight the impor- Major General PHA Juan José Sánchez Ramos
tance of cooperation with civilian organizations and between mili- Head of Medical Directorate
tary health services at European level, as well as to exchange scien- Spanish Ministry of Defence
tific information and enhance mutual knowledge. jsanram@oc.mde.es
Advertorial
Public health authorities’ opinions on the impact

of switching from combustible cigarettes (CCs) to
heated tobacco products (HTPs)
Elena Scotti, Giuseppe Plebani
The World Health Organization (WHO) predicts that there will thousands of smokers who could quit with the help of an e-ciga-
continue to be over 1 billion smokers into 2025 and beyond. This rette are being put off due to false fears about safety.”.
means that many smokers will not benefit from tobacco control In conclusion, PHE stated that “Based on current knowledge, stat-
measures for curbing adoption and increasing cessation. A growing that vaping is at least 5% less harmful than smoking remains
ing number of governments are now complementing traditional a good way to communicate the large difference in relative risk
tobacco control measures with a harm reduction approach, i.e., unambiguously so that more smokers are encouraged to make
allowing access to information about scientifically substantiated the switch from smoking to vaping. It should be noted that this
less harmful products for adults who would otherwise continue does not mean e-cigarettes are safe.”
to smoke. In this review, PHE’s key findings on heated tobacco products
primarily relate to IQOS from Philip Morris International, and
United Kingdom (UK) two HTPs from British American Tobacco and Japan Tobacco
UK Department of Health International, with most studies focusing on IQOS. In the same
In July 2017, the UK Department of Health released its five-year 2018 report, PHE found that “Compared with cigarette smoke,
tobacco plan for England, aimed to cut down smoking prevalence heated tobacco products are likely to expose users and bystanders
from 15.5% to 12% by 2022. The government acknowledged that to lower levels of particulate matter and harmful and potentially
science-backed innovations can play a role in helping to achieve harmful compounds. The extent of the reduction found varies be-
that objective by helping adult smokers switch away completely tween studies.” In addition, “The available evidence suggests that
from cigarettes. heated tobacco products may be considerably less harmful than
Since 2017, the UK government has actively acknowledged adult tobacco cigarettes and more harmful than e-cigarettes.”
smokers to consider using electronic cigarettes (e-cigarettes) as In the 2020 report, PHE underlined the low prevalence of HTP
a way out of smoking, including through its annual Stoptober use among smokers and recent former smokers “indicating that
campaign, a month-long national stop smoking challenge. the proportion of people who continue to use both vaping and
Subsequent annual evidence reviews by Public Health England tobacco products (dual use) is going down. This is important to
have continued to validate the important role that e-cigarettes monitor because dual users are still exposed to the high levels of
can play in moving adult smokers away from cigarettes. harm associated with smoking.”
In November 2021, the UK government announced plans to PHE recently published its “2021 Vaping in England: Evidence
simplify the pathway to license electronic cigarettes and other Update”. While the report is generally positive on vaping as an
inhaled nicotine-containing products (NCP) as medicines in effective tool in helping traditional smokers quit smoking, it pro-
England to help reduce smoking rates, particularly among lower vides little insights on heated tobacco products. The report notes
income populations. concern around the increasing misperception of the relative risk
of vaping products and calls for “a greater emphasis on how best
Public Health England (PHE) to communicate evidence of relative harm to smokers so that
PHE, an executive agency of the United Kingdom’s (UK) they can consider all the options available to them to quit smok-
Department of Health and Social Care, releases a regular report ing completely.”
on the evidence behind cigarette alternatives. The fourth such
review published in February 2018 included information on e-cig- UK Committee on Toxicity (COT)
arettes and, for the first time, also on heated tobacco products. The UK Committee on Toxicity (COT) is an independent scientific
On e-cigarettes, the main findings of the agency are summarized committee that provides advice to the Food Standard Agency, the
below: Department of Health, and other governmental departments and
Vaping poses only a small fraction of the risks of smoking, and agencies in the UK on matters concerning toxicity of chemicals. In
switching completely from smoking to vaping conveys substan- 2017, the agency reviewed the available evidence on two heated
tial health benefits. tobacco products: IQOS from Philip Morris International and an
E-cigarettes could be contributing to at least 20,000 successful HTP from British American Tobacco. The assessment concluded
additional quits of cigarettes per year and possibly many more. that, while still harmful to health, heated tobacco products “are
E-cigarette use is associated with improved quit cigarette success likely to be less risky than smoking conventional cigarettes.” The
rates over the last year and an accelerated drop in smoking rates UK COT also stated that “There would likely be a reduction in risk
across the country. for conventional smokers deciding to use heat-not-burn tobacco
When addressing questions on impact or value (e.g., vaping- products instead of smoking cigarettes.”
related drug illnesses in the United States [US]), Prof John Newton, European Union
Director of Health Improvement at PHE, said “It would be tragic if In April 2014, the European Union (EU) provided a regulatory
Advertorial
framework, the Tobacco Products Directive, which introduced tobacco cigarettes,» based on their aerosol chemistry measure-
novel tobacco products as a separate category that can enter the ments, which are «of the same order of magnitude as in the data
market subject to the submission of prior notification to the com- of Philip Morris.»
petent national authorities by the manufacturer(art.19 of TDP). A study by Slob et al. from RIVM together with a researcher
It also defined specific measures for e-cigarettes. Before this EU from School of Earth & Environmental Sciences, University of
directive, e-cigarettes were either banned or unregulated. The EU St. Andrews, Scotland, UK, shows that heated tobacco products
directive created a separate regulatory category for e-cigarettes involve less user exposure to harmful chemicals than cigarettes.
and provided differential regulation to conventional cigarettes The authors concluded that “The CCE- change in cumulative
including different health warnings. exposure- was estimated to be 10- to 25-fold lower when using
HTPs instead of cigarettes. Such a change indicates a substan-
Germany tially smaller reduction in expected life span, based on available
German Federal Institute for Risk assessment (BfR) dose-response information in smokers. However, this is a prelim-
BfR is a branch of the Federal Ministry for Food and Agriculture inary conclusion, as only eight carcinogens were considered so
and is responsible for assessment of matters related to consum- far.”
er protection. Two scientific publications from BfR have analyzed
the aerosol of IQOS and found reductions in selected toxicants US Food and Drug Administration
(80–99%) relative to cigarette smoke. In particular, they found The FDA in general is supportive of scientifically substantiated
substantially reduced levels of aldehydes (approx. 80–95%) and alternatives to cigarettes for adult smokers who want access to
volatile and semi-volatile compounds (approx. 97–99%) in IQOS nicotine but not ready to quit cigarettes and nicotine altogether.
aerosol and confirmed that the levels of major carcinogens are In 2017, the agency announced a comprehensive plan for tobac-
markedly reduced relative to conventional cigarettes. co and nicotine products, with the goal of “striking an appropriate
These findings, published in 2018, were in line with the manu- balance between regulation and encouraging the development
facturer’s (Philip Morris International) previously published data. of innovative tobacco products that may be less dangerous than
The study states that, while further studies are required to address cigarettes.” The FDA recognizes that the primary cause of harm
the magnitude of exposure reduction, the measured reductions from smoking is burning, not nicotine.
“lead to the relevant questions of putatively reduced health risks.” “It’s not the nicotine that kills you; it’s all the other carcinogens in
lighting tobacco on fire.” – Scott Gottlieb, then FDA commissioner,
German Cancer Research Center, (dkfz) interview, Squawk Box, CNBC, Aug.24, 2017.
A study titled “E-cigarettes and tobacco heating systems – an The US has a science-based approach to new products, requiring
overview” performed by the German Cancer Research Center, manufacturers to file a premarket tobacco product application
(dkfz) confirmed the results of the BfR report in a 2020 report and (PMTA) with the FDA, providing scientific data to demonstrate
indicated that “The aerosol from tobacco heating systems con- that the product is appropriate for the protection of public health.
tains lower toxin levels than tobacco smoke. […] Consumers are US law also allows a manufacturer to submit applications for the
exposed to a lower level of toxins than when smoking.” . FDA to evaluate whether a tobacco product may be marketed
Federal Center for Health Education (BZgA) with reduced risk or exposure claims. This separate pathway is the
Furthermore, in a follow-up survey released in 2020, the Federal modified risk tobacco product application (MRTPA) process.
Center for Health Education (BZgA) published their results In October 2019, the FDA granted its first-ever modified risk
regarding THS use patterns among the German population. They orders to eight smokeless tobacco products from Swedish Match
emphasized that the rates of THS use among youth and young USA, Inc. after considering scientific data from the manufactur-
adults are low: “Experience with the use of tobacco heating sys- ers and independent researchers, concluding that “completely
tems is comparatively low among adolescents (0.5 %) and young switching from cigarettes to these authorized products lowers
adults (4.5 %)”. BZgA is a federal authority within the portfolio of certain health risks.”
the German Federal Ministry of Health. In April 2019, the FDA Center of Tobacco Products (CTP) issued
a marketing order for Philip Morris International’s IQOS Tobacco
Netherlands Heating System, allowing its introduction in the US market. The
National Institute for Public Health and the Environment (RIVM) is FDA “found that the aerosol produced by the product under con-
an agency of the Dutch Ministry of Health, Welfare, and Sport. In sideration ‘contains fewer toxic chemicals than cigarette smoke,’
2018, they published a preliminary assessment of IQOS in a fact- and many of the toxins identified are present at lower levels than
sheet that summarized their own research as well as the current in cigarette smoke. For example, the carbon monoxide exposure
scientific knowledge at the time. [resulting from this product] is comparable to environmental
The key findings of RIVM are summarized below: exposure, and levels of acrolein and formaldehyde are 89% to
• IQOS vapor can be detrimental to the health of users and 95% and 66% to 91% lower than from combustible cigarettes,
bystanders. respectively”.
• IQOS emits lower quantities of harmful substances than In July 2020, the FDA authorized the marketing of IQOS as an
cigarettes. MRTP with reduced exposure information as follows: 1. The IQOS
• It is highly unlikely that IQOS use will be more harmful than System heats tobacco but does not burn it; 2. this significantly
cigarette smoking. reduces the production of harmful and potentially harmful chem-
RIVM concluded that «The use of heatsticks with the IQOS is icals (HPHC); and 3. scientific studies have shown that switching
harmful to health, but probably less harmful than smoking completely from conventional cigarettes to the IQOS system
Advertorial
reduces your body’s exposure to harmful or potentially harmful highly likely to be much less harmful than smoking.”
chemicals. In August 2021, the New Zealand government enacted the
Smoke-free Environments and Regulated Products Act, a new
Japanese Department of Environmental regulatory framework for e-cigarettes and heated tobacco prod-
Health ucts. One of its official purposes is to “support smokers to switch
The Department of Environmental Health, a branch of the to regulated products that are significantly less harmful than
Japanese National Institute of Public Health, has conducted smoking.” The new law embraces two principles to achieve the
a study comparing the levels of chemicals in IQOS aerosol and target of a smoke-free country by 2025 — defined as when 5%
cigarette smoke. The authors concluded that “The concentra- or less of the adult population smokes. It continues to set strict
tion levels of hazardous compounds in the mainstream smoke regulation for combustible tobacco products while setting a dif-
of IQOS are much lower than those in conventional combustion ferentiated treatment for regulated vaping products, recognizing
cigarettes.” their potential harm reduction benefits compared to cigarettes.
The intention of the legislation—to move smokers away from
New Zealand combustible products—is succinctly summed up in notices that
On 23 November 2018, the New Zealand government published can be displayed by retailers instore or online:
a plan for risk-proportionate regulation for smoke-free products • “Completely replacing your cigarette with a vape will reduce
with the goal of “supporting smokers to switch to significant- harm to your health.”
ly less harmful alternatives.” The plan has the aim of amending • “If you smoke, switching completely to vaping is a much less
the applicable law to improve smokers’ access to quality vaping harmful option.”
and smokeless tobacco products, while protecting children and Other Government Agency assessments (Belgium, Norway,
young people from the risks associated with them as well as to Portugal, Korea, Iceland and Uruguay) confirm the reduced-risk
improve publicly available information on vaping. exposure to toxicants in HTP and indicate these products as a bet-
This plan incorporates the development of product safety require- ter option for smokers’ health than continuing to smoke.
ments for vaping and smokeless tobacco products to ensure con-
sistency in quality. It also provides for a public information cam- Literature with the author.
paign on the possible benefits of switching to vaping for adult PMI R&D
smokers who don’t quit, particularly in communities with high Elena Scotti PhD
smoking rates. According to the plan’s executive summary, “Many Giuseppe Plebani MD
people aim to quit smoking, but this can be difficult, especially for Philip Morris Products S.A.
those who face complex challenges in their lives. However, many Quai Jeanrenaud 5
smokers who find it hard to quit may be able to switch to much CH-2000 Neuchâtel, Switzerland
less harmful alternatives, such as vaping.” It also says, “The tar and Declaration of Interest: All authors are employees of Philip Morris
toxins in tobacco smoke, rather than the nicotine, are responsi- International.
ble for most of the harm associated with tobacco use. Vaping and Funding Statement: Philip Morris International is the sole source
smokeless tobacco products do not combust and are, therefore, of funding and sponsor of this research.
Vigorous Warrior 22 / Casualty Move 22

(VW/CAMO 22)
A joint exercise by NATO MilMed CoE and MMCC/EMC
Madelaine Schillerwein
The staff responsible for the simulation within the wargame discuss the next task for the situation centre. (Source: Bundeswehr/Markus Dittrich)
March 2022 on tactical level and under NATO’s auspices. The series date back
The NATO Joint Multinational Medical Exercise VW/CAMO 22 – to 2011 with 5 participating Nations in Hungary, expanded to 11
with considerable NATO, EU and Partner Nations and civilian insti- Nations by 2013 in Germany, 14 by 2015 in the Czech Republic,
tutions participating – is linked to the Wargaming Casualty Move 26 by 2017 in Germany again, in 2019 in Romania with 38 Nations
which is a multinational wargame for training the medical sup- and a considerable civilian component. Due to the pandemic,
port of a larger formations conducted by Multinational Medical the 2021 iteration had to be postponed and the NATO MilMed
Coordination Centre/European Medical Command, Koblenz. CoE with its partner, the Multinational Medical Coordination
Germany (MMCC/EMC). VW/CAMO 22 is a collaborative project Centre/European Medical Command (MMCC/EMC) has decided
between the MMCC/EMC and the NATO Centre of Excellence for to host a special, live tabletop exercise, capitalizing on the spe-
Military Medicine, Budapest, Hungary (MilMed CoE), which or- cial expertise of MMCC/EMC in tabletop exercises/wargaming
ganizes VW 22 on tactical level. MMCC/EMC contributes with its and NATO MilMed CoE’s legacy in running the Vigorous Warrior,
wargaming expertise for both exercise components. Therefore, with 22 Nations already on board. The exercise also grew in scope,
MMCC/EMC EXCON is also responsible for the development of the focusing on various issues ranging from the Framework Nation
exercise scenario and the vignettes as well as the overall exercise Concept to Force Health Protection, manoeuvring with medical
control. The VW/CAMO 22 shows NATO’s medical services ready units, Medical Evaluation (MEDEVAL), Concept Development and
and unified to support NATO Major Joint Operations; thereby it is Experimentation (CD&E) and multiple other facets of the mili-
a part of deterrence as it develops critical capabilities and knowl- tary-medical sciences and its concepts.
edge and helps to improve our readiness status and compatibility. The Casualty Move Wargaming is a multinational wargame for
The Vigorous Warrior Exercise Series is arguably the most compre- training the medical support of larger formations. The MMCC/
hensive, dedicated multinational medical exercise in NATO, orga- EMC primarily conducted a multinational wargame in 2020 to test
nized bi-annually by the NATO MilMedCoE COE and a voluntary the medical support of a larger multinational formation, in this
host nation. Its objectives always aim to tackle the most relevant case 1st Armoured Division, in the framework of a NATO Article
questions of the military-medical realm in a multinational setting, V major joint operation (MJO). The medical wargame CAMO
2020 was developed based on the data of a previous exercise of replace live exercises (LIVEX), however, as the current COVID-19
1st Armoured Division which was integrated into the so called situation is still ongoing, it is a feasible solution to conduct such
SKOLKAN 1 scenario of NATO. an exercise within a controlled setting and scenario, having a
The exercise focused on concepts, processes and procedures of qualified and experience pool of military taking part. This article
medical command, control, communications, computers and deals with planning such a big exercise internationally and the
information (C4I) and patient flow management. The primary exercise’s aims and structure, too.
training audience (PTA) was the medical staff elements of 1st
Armoured Division and its subordinate brigades. The secondary The two lighthouse projects of Military
training audience (STA) was the parent 1st German/Netherlands Medical Service in Europe
Corps and the employed medical task forces (MedTF). The most Representing the two joint institutions of the Medical Military
important lesson learned was that, for the medical support of an Service in Europe, the NATO MilMed CoE and the MMCC/EMC are
MJO with expected loss rates, a decentralised system of patient lighthouse projects of the Medical Service in Europe with a radi-
flow management had advantages over a centralised system. ating impact. They follow a clearly delineated and complementa-
This decentralised system is based primarily on capabilities of ry programme of work. The MilMed CoE, hosted by Hungary and
the MedTF. The NATO capability codes / capability standards for a located in Budapest, is as the Department Head for Training re-
MedTF is not yet represented in. This links to CAMO 22, which has sponsible for matching the requirements with E&T solutions and
the aim is to test and train the interoperability of the multination- ensuring that solutions identified are delivered in the most effec-
al medical support system in a simulated NATO MJO+ mainly at tive, efficient and affordable manner. It is also actively exploring
the operational level and to gain experience for the future SHAPE and implementing online/virtual training opportunities, support-
Patient Flow Management Concept. lf MEDEVAC is not appropri- ed by a lot of expertise through its member nations. Its training is
ately managed, the increased number of patients has the real conducted on a tactical level (known as small unit tactics), there-
potential to overwhelm the capacity of the Medical Treatment by conducting tactical unit level exercises (LIVEX, MEDEX like
Facilities (MTFs) in the JOA The question is, what is the best way Vigorous Warrior), as well as individual training.
to organize the movement of patients from a Role 3 MTF to a Role It is the MMCC/EMC’s mission to act upon request from the par-
4 MTF in time. ticipating nations, EU and NATO HQs as a network facilitator and
To avoid a gap of 4 years till the next LIVEX of the VW series, a Table connector, linking nations and organisations in the medical arena.
Top Exercise will be organized and take place in Hungary from The spectrum of MMCC/EMC’s activity focuses on the following
03-09 April 2022 in close cooperation with MMCC/EMC which three main areas.
provides its exclusive expertise in wargaming. The VW/CAMO 22 1. the preparation of operational engagements, which includes e.g
aims to test and train medical support system, including logistic - civil-military medical situational awareness and networking,
resilience and interoperability, in a simulated NATO Major Joint - support of capability development and enhancement of
Operation both at the operational and tactical level. The ambition medical services,
of the NATO MilMed CoE and MMCC/EMC is for VW 22 – CAMO 22 - stockpiling definition and procurement,
to include three separate Table Top Exercises that will run simulta- 2. the operational readiness of medical C3 and organisations in
neously and are linked to each other: two at tactical level and one the field of the conduct of medical operations, for the benefit
at operational level. of the participating nations, the EU and NATO HQs, especially
Approximately 170 participants (military and civilian) from about through exercises and wargaming;
20 nations are expected to take part in this exercise, with over 3. the support of operational engagements of the participating
150 of them on-site. Now being more important than ever, full nations, through:
combat readiness is vital for a country’s armed forces – even bet- - transnational medical evacuation,
ter, if most of the processes are compatible with those of other - medical situational awareness,
nations to be able to react professionally and as fast as possible to - civil-military interaction.
surfacing problems and issues. This can only be achieved by reg- It is compiling command and control principles and operation-
ular training and exercising, especially in specialised and complex al procedures, providing expertise to support the planning and
areas like the medical support in a Major Joint Operation. Medical conduct of Collective Training & Exercise on operational level -as
training and exercises are taking place jointly and/or combined opposed to the MilMed CoE, which is focused on the operation-
from a quite low level of exercising already, sometimes even with al level. Further, it is developing a Medical Wargaming Expertise
civilian stakeholders and NGOs to ensure the fastest but also best in support of NATO and EU, supporting the maintenance of
medical treatment. For such a training event a lot of expertise is the JEMM (Joint Exercise Module Management)-database on
required. The two biggest influencing factors in combining both ACO’s (Allied Command Operation) request, and integrates LL/
exercises were the optimization of resources (also expertise) as LI (Lessons Learned/Lessons Identified) outcome into wargam-
well as the current global circumstances – exercises had been ing and exercise to improve the NATO/EU Medical Command &
postponed or even cancelled because of the COVID-19 pandem- Control.
ic situation. Hence the decision for a joint exercise, conducting
it in a Wargame TTX. In general, wargaming is an economic, Medical Wargame Expertise at MMCC/EMC:
resource-friendly yet highly efficient method to e.g., practise and tri-annual exercise cycle
enhance existing concepts, as is the case for this exercise. The The MMCC/EMC is a broker of information and has set up a tri-
main focus of VW/CAMO22 lies on exercising the present Patient annual exercise cycle to provide NATO, EU and the medical com-
Flow Management (PFM) Concept. Wargaming can and will not munity with relevant medical wargaming expertise, appealing
to a wide audience. It’s carrying out exercises based on different • Disaster Relief Operation;
scenarios with alternating audiences to establish organisation- • Joint transnational Patient Flow Management in support of the
al connectivity and learning. While doing so, MMCC/EMC either nations;
functions as the PTA (Primary Training Audience) or main exercise • Joint Medical CBRN Surveillance/Defence;
organiser, or both – with NATO & EU HQ, offices and agencies, • Joint Medical Logistics.
GO/NGO’s, (member) nations, response units (civil and military), The MMCC/EMC’s SITCEN has demonstrated its operational capa-
and other CoEs. The medical wargames offered are adaptable and bility by using established procedures.
conducted in a 3-year cycle, being listed in a national database
and NATO’s. Each wargame has a different focus. “Adapting the exercise execution during a
CAMO (CASUALTY MOVE): Next execution in 2022. This exercise pandemic” OR “merging two exercises into
trains and develops Medical C3 for Larger Formations operations one to optimize resources” or similar
in an adaptable combat scenario on an operational level. The Due to the ongoing worldwide pandemic situation, Medical
MMCC/EMC is the organiser, facilitator and primary response cell. Military Services had to reduce and adapt the execution of exer-
RER (RESILIENT RESPONSE): Next execution in 2023. This is an cises that were initially planned. However, if exercises were car-
adaptable crisis response exercise that trains and develops a resil- ried out, appropriate hygienic measures were put in place and
ient response by collaborative work from multinational, multi-dis- had to be adhered to.
ciplinary teams and organisations. The MMCC/EMC is the main The SACEUR’s (Supreme Allied Commander Europe) annual guid-
organiser in collaboration with other parties. ance on ETEE for 2022 (SAGE22) was issued in November 2021.
REMI (RESILIENT MEDICAL INTERFACE): Next execution in 2024. This One of its aims is to optimize resources for the execution of mili-
exercise trains the MMCC/EMC in its role as an operational coordi- tary exercises.
nating body in crises situations for Medical Situational Awareness, NATO MilMed CoE and MMCC/EMC decided to merge both their
Patient Flow, Medical Intelligence/CBRN, Telehealth and Medical individual exercises, VIGOROUR WARRIOR (VW22) and CASUALTY
Logistics. The MMCC/EMC is the organiser, facilitator and PTA. MOVE (CAMO22), into one Table-Top Exercise. A combined
EXSPEC (Exercise Specification) was signed in June 2021.
The combined exercise was conducted on a tactical and opera-
tional level, including internal and component level exercises and
preparations. The exercise’s aim was:
• to test and train multinational medical support system, includ-
ing logistic resilience and interoperability, simulated in a NATO
Major Joint Operation at both operational and tactical levels.
The two organizing institutions have in VW/CAMO 22 their indi-
vidual main tasks. They fulfilled special roles within the exercise,
i.e.:
• The MilMed CoE was taking care of the HN, administra-
tion, location and support by bringing in their expertise in
experimentation;
• MMCC/EMC contributes with its extensive wargaming expertise
for both exercise components. Therefore, MMCC/EMC EXCON is
also responsible for the development of the exercise scenario
and the vignettes as well as the overall exercise control.
Planning and organisation of a combined

exercise
The first preparatory meetings for planning the combined exer-
cise started in June 2021. The organizational framework was very
Alexander J. briefly describes the mechanism for the activation of the situation
complex due to the high number of entities, units and nations
centre (SitCen) (Source: Bundeswehr/Markus Dittrich) involved. In addition to this, two levels of wargaming (tactical &
operational) had to be considered while developing the content
The most recent wargame conducted within the MMCC/EMC of the exercise. To reduce traveling across borders to a minimum,
was the RESILIENT MEDICAL INTERFACE (REMI21) exercise with almost all conferences and preparatory activities were conduct-
the aim to train the development and exercise the competency ed virtually. Four dedicated SVWG (scenario vignette writing
of MMCC/EMC’s initial concept for medical coordination on an group) workshops were held to deal with the exercise’s content.
operational level during a deterrence phase. It was also designed The working groups created an appropriate TTX structure, con-
to gain experience and best practices for the improvement of the tent and scenario to serve as a Multilevel (technical – tactical –
following capabilities: operational) wargame, meanwhile offering by the NATO MilMed
• Multinational Medical Coordination; CoE the opportunity to conduct experimentation activities. NATO
• Cooperation; MilMed CoE has become one of the expert organizations with-
• Collaboration and Communications for Joint Situational in NATO, taking responsibility for cooperating and participating
Awareness; in military medical CD&E activities. The MMCC/EMC is the expert
VW22/CAMO22 Exercise
Organisation
organization for NATO and EU for the the coordination of opera- of the exercise, the OCASSUS scenario, its timelines and the re-
tional medical capabilities and units by implementing medical C3 quired battle spaces were adapted to the need of the exercise.
best practices and standards through wargaming and exercising. Thus, it was possible to enable the achievement of the different
The MMCC/EMC Patient Flow wargame of 2018 assisted ACO to exercise objectives by providing a challenging wargame environ-
develop the initial NATO Guideline and the CAMO20 exercise to ment. The exercise served to accept and tackle the challenges of
develop Medical C2 and patient evacuation procedures at a level high intensity warfare.
up to a Land Armored Division in a MJO (Major Joint Operation) A substantial objective of the exercise was to manage the conti-
scenario. VW22/CAMO22 offer the platform and opportunity to nuity of a comprehensive medical support system including its
develop and refine patient evacuation procedures from a di- sustainability and reinforcement, with the focus on Patient Flow
visional and corps level via the Component rear to the nations. Management from the Components Rear Area to national desti-
Following the Medical experimentation carried out during nations (Command and Control for movement of the Role 3 to
VW19, Experiments/Transformational Activities (Experimentation the Role 4 MTF). Another objective was to exercise the resilience
Themes) conducted during the VW22/CAMO22 exercise were: of the multinational logistic plans and develop practices for mul-
- Medical Modular Approaches (MCDC MMA) Employment; tinational medical logistic functions including blood products
- Medical Headquarter Integrated Command & Control/Civil- from nations into the Components Rear Area and the onward for-
Military Medical Coordination Functions. ward movement.
- Medical Logistic Resilience Assessment Exercise The wargame was played over four days, in real time and a day-
time-battle rhythm. Some military units, especially from HICON
Scenario with a 4-day battle rhythm on two and LOCON, were operated (simulated) by the Simulation Cell
different training tables (SIM CELL). The participants, taking over roles within Brigades,
A NATO Major MJO (Major Joint Operation) and COMEDS train- Divisions and MTFs, had to react to scripted vignettes and injects
ing goals formed the scenario. This was the responsibility of the that were played during a basic storyline and set within the NATO
EXCON / Scenario Writing Group. It included the following: OCASSUS scenario. The following diagram shows the exercise’s
• Major regional actors; Medical Command & Control Relationships, further highlighting
• A description of the crisis with some historical background to the units being dealt with in the operational (OPS) as well as the
give a better understanding of the major political, military, eco- tactical (TAC) table.
nomical cultural, humanitarian and other related conditions. At the beginning of the wargame, the participants on both the
For this scenario, the OCASSUS setting was used for the TTX tactical and operational table had to deal with preparative mea-
VW22/CAMO22. sures for a delayed operation and a counterattack following
The content was further developed to meet the approved Exercise afterwards. The focus was on organising the Tactical Brigade and
Objectives and Training Objectives for the TA within a NATO MJO a Joint Operational Area battlespace. Additionally, friendly forces
context. The situation in the crisis region was supposed to be suf- delaying in front conducted a rearward passage (RPOL). The train-
ficiently credible in order to make NATO’s involvement realistic. ing audience faced regular contact reports and a rising number
Furthermore, it accommodated the following parameters: in- of battle injuries. The desired outcome included the regulation
tense force activities to support relevant flow of casualties; joint of the patient flow through to TACEVAC (Tactical Evacuation)
sustainment; supportive civilian environment; toxic industrial from the (DIV) Division, coordinated by MTFs , BDE (Brigade),
material defence; non-austere conditions. During the preparation DIV and Corps. There was an increased demand for PECC (Patient
Medical Command & Control Relationships for VW/CAMO22
Evacuation Coordination Cell) coordination and management of even stricter rules and regulations for their own personnel. This
DNBI (disease and non-battle injuries). concept was amended at any time prior to the wargame if the de-
Consequently, the second day started with a delayed operation velopment of the pandemic situation required stricter rules and
after the friendly forces passed through their Assembly Area. regulations or gave leeway to relax some of these regulations. For
This phase increased subsequent pressure on the participants this reason, at least one experienced Public Health Inspector as
that had to deal with continuously raising numbers of casualties, well as an FHP team were present to oversee and enforce the im-
stressing the C2 and requiring good coordination procedures plementation of and compliance with the rules outlined in this
(MEDAD, PECC, MEDEVAC, MTFs). hygiene concept.
The exercise trained both the tactical and the operational table This joint wargame marked a big step towards meeting the re-
alike. Nevertheless, the injected vignettes had an impact into quirements for a modern way of exercising medical processes
both directions, causing OPS and TAC to act. The basic storyline such as patient flow management within JOA and to the Role 4
shifted to a defensive operation, further increasing the pressure MTFs of the nations. . Together, participants from various NATO
on the TA that had to deal with supply and personnel shortages, and EU nations learned how to improve information flow and
facing the challenge to finding a solution to coordinate the redis- manage international medical coordination. Regarding this as a
tribution of patients. The coordination between different acting first step in conducting wargames internationally, multinational
units require a solid analysis, evaluation and articulation of med- cooperation needs to be kept in training and developed. This can
ical information and plans, including civil-military cooperation. and will be achieved during regular trainings, using e.g., the VW/
At this point in time, the tension curve almost will reach its peak CAMO22 setting to achieve the goals set and ensure high-quality
as the scenario made a further step towards joint and combined patient treatment and flow management.
content. The last step in this scenario has been the implementa- The exercise will be truly finished after the Post Exercise Discussion
tion of additional medical operational orders for a CATK (counter- on 10/11 May 2022 in Koblenz, Germany. In this event the Final
attack) of a brigade, involving the handling of an overwhelmed Exercise Report (FER) will be discussed and released, thus giving
medical support system. all nations and the COMEDs the opportunity to use the informa-
tion acquired in this exercise for further development, and the
Safety Measures: Risk Assessment before the experiences gained during the exercise for the adaptation and
execution of the exercise organisation of future exercises including medical perspectives
With regards to the pandemic situation, the VW/CAMO22 exercise and challenges.
execution had to follow a consistent and strict hygienic concept.
Therefore, MilMed CoE’s Force Health Protection Branch (FHBPB) Author:
had to put in place regulations and rules to enable a safe and Captain Madelaine Schillerwein
responsible conduct of the VW/CAMO22 exercise. Compliance MMCC/EMC
with regulations outlined in the hygiene concept were crucial for Andernacher Straße 100, 56070 Koblenz
the protection of the participants’ health and the success of the MMCC-EMC-PAO@bundeswehr.org
exercise. It was up to the participating nations to implementing
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Findings and experience gained in the course of the project so far
Jochen Thumser
Since initial operational capability (IOC) was achieved in 29 German billets of MMCC/EMC were opened for manning with
September 2019, the Multinational Medical Coordination Centre/ effect from 1 October 2019. Out of a nucleus of a few officers and
European Medical Command (MMCC/EMC) has been in a continu- non-commissioned officers (NCO), a completely new structural
ous and ambitious build-up process. The task was to establish full element, thus, was created. The provision of personnel to this
operational capability (FOC) in a little more than two years, that is element was an indispensable prerequisite for the success of the
by late 2021. Germany is the Lead Nation for the Cluster Medical project. Furthermore, the provision of support from the staff of
Support of the MMCC project from the Framework Nations BwMedSHQ is essential, both in general staff functions and pro-
Concept as well as the Framework Nation for the PESCO initiative fessional expertise. Without this support, effective and efficient
of the EMC project. In keeping with its motto “Combining efforts duty routine would not be possible. It was important that, along
in medical support”, MMCC/EMC supports especially the medical with the German billets, also manning of the designated multi-
services of its participating nations and – upon request – NATO national billets started. The focus here was on feasible and flexi-
and EU institutions and headquarters through coordination and ble solutions for the multinational personnel support. The range
operational knowledge. The experiences of the past years and of options, from part-time support (project-related) to the per-
the current security developments in the Ukraine have proven manent assignment of personnel, made it possible to optimise
the requirement for a coordination element on the operational cooperation with regard to the availability of personnel of the
level that can cooperate both with the military and civilian organ- participating nations. So far, BEL, FRA, LUX, NLD and HUN have
isations of NATO and EU. permanently assigned personnel to MMCC/EMC whilst SVK plans
The build-up process is looked at from the perspective of a mem- to dispatch an officer to Koblenz in 2022. In addition, the USA as a
ber of MMCC/EMC with its determining factors and parameters contributing nation provides a part-time liaison officer.
that have influenced these build-up efforts. The experience Each of the so far 18 nations participating1 in MMCC/EMC has
gained, findings and assessments certainly are preliminary, be- signed the IOC declaration and is involved through either the
cause even after the achievement of FOC the development pro- FNC/MMCC, the PESCO/EMC, or both projects. The MMCC/EMC
cess is not completed yet. These experiences, findings and assess- Steering Committee consists of the 18 participating nations en-
ments should enter the further build-up efforts of MMCC/EMC. In titled to vote. Observer and contributing nations have no right
addition, also the question should be addressed what it means to vote in the Steering Committee. The same applies to the med-
to implement multinationality and cooperation in the military ical advisers of ACO, IMS, ACT, and EUMS, as well as the liaison
medical field in a combined approach within the scope of perma- officer to the COMEDS chairperson. Based on the IOC declaration
nent structured cooperation (PESCO) and the Framework Nations and the functional framework, Steering Committee decisions, as
Concept (FNC). Both, PESCO and FNC, act under the EU and NATO for instance on the Programme of Work (PoW), are made under
flags, respectively. the consensus principle. Multinationality and consensus princi-
ple have contributed to strengthening the project in day-to-day
1. Strategic and operational parameters work.
The declaration of IOC and the approval of the MMCC/EMC A necessary step to formalise the working relations, therefore, was
framework concept by the meanwhile 18 participating nations taken by the Exchange of Letters between FMOD and SHAPE on
in September 2019 set the formal frame for the development the one side and FMOD and EUMS on the other. It is important in
of MMCC/EMC. Core element of the declaration was that two this context to continue filling the existing agreements with life.
projects (MMCC under FNC, and EMC under PESCO) were to be To which extent this strategic positioning will succeed depends
merged and developed into one common entity. More than 80% on the support by the nations and member states of NATO and
of the participating nations are members both of NATO and EU. EU on the one hand, and of the actors in the headquarters and
At the same time, it was determined to establish FOC by late 2021 institutions of NATO and EU, especially on their medical advisers,
also in view of the fact that this should be accomplished in step on the other. And not least, MMCC/EMC itself will be measured by
with other initiatives, e.g. the Joint Support Enabling Command its performance capability.
(JSEC) in Ulm. Thus it is ensured to be able to offer in particular Simultaneous cooperation with NATO and EU has proved to be
the provision of support for an important new element of the a challenge, although organisations exist that have been cooper-
NATO force structure. Within the limits of the rather rough stra- ating with both for years, as for instance the Centre of Excellence
tegic frame specified, it was then important to describe common for Countering Hybrid Threats, FIN, the Movement Coordination
requirements that are as precise as possible and determine the Centre Europe, NLD, or the Multinational Geospatial and METOC
target of and course to FOC. Support Group, DEU. The possibility to draw on the coordination
The organisational frame for achieving FOC was set by the and support services of MMCC/EMC could be used even more as
Bundeswehr Medical Service Headquarters (BwMedSHQ). The an opportunity by the actors involved.
1 (BEL, CZE, DEU, EST, ESP, FRA, GBR, GRC, HUN, ITA, LUX, LTU, NLD, NOR, POL, ROU, SVK, SWE)
The effects of the COVID-19 pandemic have impeded the build-

up process in several respects. COVID-19 has significantly com-
plicated physical meetings, both internally within the MMCC/
EMC team and with all parties involved, required for the intensive
coordination within the scope of the project work. Since March
2020 for instance, the Steering Committee meeting has been
held in the form of a VTC only. Projects had to be adapted to the
pandemic conditions. The attention of the actors from this time
on has been on pandemic management. Despite the restrictions,
it was important for MMCC/EMC to resolutely pursue its own
build-up efforts and to seize the resulting thematic opportuni-
ties for pandemic response. This succeeded in particular through
the projects triggered by the COVID-19 pandemic in the form of
the war game Resilient Response (RERE) 2020 and the Medical
Stockpiling Concept for NATO’s Pandemic Response Trust Fund,
from which various nations benefitted. From this resulted the
Military Modular Multipurpose Epidemic/Pandemic Stockpiling
(M3-EPS) Concept. FOC criteria as core responsibilities
2. Conceptual framework and further Mission statement

foundations The MMCC/EMC acts upon request from the participating nations,
The conceptual framework was set by the IOC declaration, incl. EU and NATO HQs as a network facilitator and connector, linking
the framework concept, in 2019. This general orientation had to nations and organisations in the medical arena. The spectrum of
be refined and narrowed down. Especially the extensive range of MMCC/EMC’s activity focuses on the following three main areas.
tasks within the scope of MMCC/EMC’s mission had to be prior- Each of them concerns specific activities and beneficiaries. These
itised and consolidated. From this, the capabilities to be devel- areas of activities are:
oped were derived, which were defined as guiding principles for • the preparation of operational engagements;
achieving FOC and with the consent of the participating nations. • the operational readiness of medical C3 and organisations
The delineation of own tasks vis-à-vis other organisations, espe- (in the field of the conduct of medical operations, for the benefit
cially NATO MILMED CoE, the acceptance vis-à-vis other stake- of the participating nations, the EU and NATO HQs, and aiming
holders in NATO and EU, but also the communication towards the at building a group of preferred augmentees for EU or NATO
members of MMCC/EMC required our full attention and particular HQs in operation and mission, especially through exercises and
efforts. Setbacks and delays had to be taken into account, com- war gaming);
pensated for by readjustments, if possible, or accepted. Although • the support of operational engagements of the participat-
it almost sounds like a common place: The clearer and more real- ing nations, (through: transnational medical evacuation for
istic the guidelines are in terms of mission and tasks, the greater the nations, medical situational awareness and civil-military
the chances to develop capabilities appropriate for the task. interaction.)
In accordance with the decision of the 56th COMEDS Plenary, ad- Beside the build-up efforts, first issues and work packages IAW an
ditional requirements for a concept will be identified after achiev- approved programme of work (PoW) had to be implemented in
ing FOC that will describe in more detail the future cooperation addition. So far, about 25 key projects on more than 50 subjects
with NATO and EU. For internal operations, a staff handbook, an have been included in the PoW and their processing has start-
exercise concept, and various Standing Operating Instructions ed. The PoW is updated and adapted to current support require-
(SOI) had to be prepared in particular for information and mis- ments and work progress twice a year. Highly esteemed are the
sion management, as well as for the activation and operation of projects that conclude with a concrete product, as for instance
a situation centre (SITCEN). For 2022/2023, in addition, the devel- the direct support of a participating military medical service with-
opment of a technical agreement (TA) is on the agenda to govern in the scope of the preparation for deployment, the execution of
in particular the services to be provided by Germany as the lead an exercise, a workshop or the preparation of a working paper.
nation towards the multinational MMCC/EMC members. The process has been accompanied by the “classical” tools for
strategic control (as for instance regular situation briefings in
3. Ways, means and ends the COMEDS context, progress reports in the FNC and PESCO con-
Appropriate tools for project control had to be developed and text). A particular challenge in the achievement of the defined in-
used along the “vision and mission” to meet the FOC criteria in a termediate objectives was the task-appropriate IT connection
targeted manner. Core tool was a roadmap to FOC as a milestone to NATO and EU (NS WAN and EU OPSWAN), satisfaction of the
plan that correlates the degree of realisation on the time axis on immediate requirements regarding VTC capabilities owing to the
the basis of the FOC criteria and the known DOTMLPFI2 factors. coronavirus pandemic, and the establishment of appropriate in-
The FOC criteria were developed and specified in dialogue with formation exchange platforms, which is a necessary precondition
the participating nations. for a coordination element at the operational level.
2 Doctrine, organisation, training, material, leadership and education, personnel, facilities and interoperability
Achievement of FOC was verified in a three-month evaluation

process (September to November 2021). By means of a ques-
tionnaire based on the FOC criteria, the status achieved in the
different planning categories was determined, documented and
evaluated. Both the questionnaire and the multinational eval-
uation team were specified and designated by the MMCC/EMC
Steering Committee. The exercise Resilient Medical Interface
2021 (REMI21), during which MMCC/EMC and its situation centre
(SITCEN) gave proof of their performance capability, concluded
the evaluation process. The participating nations approved the
evaluation report of the evaluation team in December 2021. Here,
it was declared that with the achievement of FOC MMCC/EMC
“will be available to the EU, NATO and its participating nations,
acting as a coordination entity within the field of medical sup-
port during Baseline Activities and Current Operations (BACO)
and Common Security and Defence Policy (CSDP) Operations and
Missions”.
4. Findings Situation centre
Looking back at the two-year process from IOC to FOC, findings manpower control. Periods of assignment of three years should
and experiences gained can be summarised for the following be the rule. Changes of personnel or staff vacancies during the
aspects: build-up phase to a certain extent could be compensated for by
• Personnel: The substantial staff augmentation within a short reservists. The augmentation in the field of multinational billets
time, the necessary integration into the team and the qualifi- is pleasing – altogether nine international Medical Service of-
cation of personnel to execute multinational tasks that are new ficers and non-commissioned officers as of summer 2022. The
to all parties involved require particular attention and leader- employment of experienced and high-performance officers
ship performance. In this context, personnel management is of and NCOs to date has contributed significantly to the overall
particular importance with regard to personnel selection and success.
A strong NATO partner

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• Basic work versus quick wins: A par-

ticular field of tension resulted from
the conceptual, organisational and
infrastructural basic work that had to
be done for a sustainable build-up on
the one hand, and the implementa-
tion of projects to document the per-
formance capability already achieved
(‘quick wins’) on the other. A solution
for this field of tension could not be
found prior to FOC achievement, so
that major elements of the necessary
basic work have to continue beyond
FOC achievement.
• Communication and key leader/
stakeholder engagement: The need
for a target-oriented communication
strategy to support and accompany
the buildup phase was recognised at
an early stage. The employment of a
part-time press officer, the close coor-
dination with and support by the Press and Information Centre towards FOC, but had to accept challenges caused by external
of the Bundeswehr Medical Service (PIC BwMedS), the prepa- circumstances. The performance capability of MMCC/EMC will
ration of a communication concept, as well as the provision of grow, especially with the further specification of core topics and
a website in English have taken this into account. Despite the areas as well as the increasing cooperation with partner nations
restrictions owed to the coronavirus pandemic, the establish- and institutions. As an innovative and flexible muscle of NATO
ment and maintenance of communication with key leaders and and EU, the basic work, projects and “quick wins” will continue to
stakeholders had to be pursued intensively and actively. Besides determine our flexible daily work in the same way.
raising the level of awareness of MMCC/EMC, the crucial factor
was to lay the foundation for an expert network in the various Author:
focus areas of MMCC/EMC. In the future, it will be important to Jochen Thumser
continue and intensify especially the efforts in the direct com- Col (GS), Executive Officer MMCC/EMC
munication with the participating nations. Andernacher Straße 100, 56070 Koblenz
MMCC/EMC has already overcome many obstacles on its way E-Mail: MMCC-EMC-PAO@bundeswehr.org
Unified Multinational Civil-Military

Medical Situation Picture
Rico Maderthoner
Status Quo national situational pictures of their medical services and their
In terms of Medical Situational Awareness (MedSA), no institution countries’ civilian health systems, though they are non-standard-
in NATO and the EU currently maintains a standardized and multi- ized as yet.
national medical situational picture for the European theatre in From a civil-military perspective, the experience of the COVID-19
peacetime. The reporting systems presently in place at NATO and pandemic or the war in Ukraine has once again underscored the
the EU are based on the requirements of the operational com- need to have access to a comprehensive multinational medical
manders of the respective Joint Area of Operations (JOA). The service situational picture with regard to a wide variety of medical
COVID Pandemic and the current crisis in Ukraine increased the service data and information.
activaties of EU and NATO entities, civilian and military, to devel- In order to fill this gap, the MMCC/EMC has included in its task
op such medical situational picture for the European theatre. portfolio the development of a concept for the establishment
All nations participating in the MMCC/EMC also have their own and provision of a multinational medical situational picture
Unified Multinational Civil-Military Medical Situation Picture
as a contribution to a well-founded medical situation assess- and DG SANTE. In addition, a valuable contribution can be made
ment, hereinafter referred to as “Medical Situational Awareness to the overall military-strategic NATO/EU medical situation
(MedSA)”. This is one of the core missions of the MMCC/EMC, for picture.
which the first activities stared end of 2019. The MMCC/EMC will provide the information, as released by the
One result of these activities has been the “Medical Situational nations, to participating nations and organizations in NATO and
Awareness” concept, which is intended to describe and define objec- the EU for a comprehensive MedSA. The first step is to develop
tives, framework conditions, analysis options and reporting scope. a common understanding and assessment of the medical situ-
The joint development of a Medical Situational Awareness con- ation of the MMCC/EMC participating nations, with the goal of
cept, coordinated and approved by all member nations, ensures contributing to the overall medical situation assessment for NATO
that the scope and objectives of Medical Situational Awareness (especially with regard to SACEUR’s Area of Responsibilty) and the
correspond with the ideas and requirements of the member EU in the future.
nations. To achieve a balance between the requirement for an op-
timized effort and the need to be able to react very quickly to the The Role of The MMCC/EMC – Coordination.
most diverse events, the idea of an „incident-based“-system was Support. Service.
introduced. Based on experience and work results it is regularly Since the last months the Joint Enablement Command (JSEC),
validated and adapted. as part of the NATO Force Structure adapted its mission. “JSEC’s
mission is to operationalize a multi-domain network in SACEUR’s
First Developments Area of Responsibility (AOR) to guarantee the enablement of
The aim of the project is to develop a comprehensive multina- the Alliance to reinforce and sustain military forces in the Euro-
tional medical situation picture for valid medical situational Atlantic area with a 360 degree approach. JSEC’s alliance-wide,
awareness (MedSA). overarching logistic domain affects the land, air and sea domains
There is fundament of knowledge, the basic layer of our system, to be crossed by the troops to reach their area of operations, and
data which changes very rarely and which can be used for almost it concerns the cyber and space domains as well. Particularly,
all conceivable events. The advanced layer contains data that JSEC focusses on enabling all troop sending, transiting and host
changes on a more regular basis but is neither time sensitive nor nations, and sustaining the reinforcements – in peacetime, crisis
highly specific for an incident. The data will be collected regular- and conflict” (source: https://jsec.nato.int).
ly. The incident-based layer contains data that is
highly specific for an incident and can be time
sensitive..
The success of our work depends on the SME
network of our participating nations.
In cooperation with the member nations, the
situation picture is intended to support the
multinational decision-making processes of the
medical services and improve their response ca-
pability in ensuring rapid assistance in the con-
text of emergencies, disasters and current crises.
The management of the medical service data
and information exchange includes activities
of collection, evaluation, analysis and provision
of the information and data for the Medical Overview of possible military and or civilian incidents (Source: MMCC/EMC)
Situational Awareness.
For this purpose, the medical service data from various sources Based on these developments MMCC/EMC should act as a sup-
(e.g. internet/messages from member nations, etc.) are combined. porting entity, which supports JSEC`s enabling efforts, especially
Part of this situational awareness includes the medical capaci- for the topic medical situational awareness. ,
ties and capabilities of the medical services of the participating An important task of the MMCC/EMC is to provide continuous
nations of the MMCC/EMC. evaluation, analysis and assessment of Medical Situational
In cooperation with other services from NATO and EU institutions Awareness data.
(MilMedCoE/ ERCC/ JSEC), additional Medical Intelligence and To accomplish this task as efficiently as possible, comprehensive
Information data is collected. When appropriate and necessary, coordination, support, and “networking” services must be
the situation picture will be consolidated and expanded with provided.
regard to civilian health care systems. A successful example for ad hoc development of medical situa-
To establish effective reporting, it is ensured that notifications tional awareness happened in August 2021. After the withdrawal
from nations trigger activities and feedback at the MMCC/EMC. In of the NATO troops in Afghanistan, the nations organized a Non-
doing so, the MMCC/EMC always verifies that only relevant infor- Combatant Evacuation Operation (NEO) for their citizens and
mation is collected. Afghan local workers. The operation changed to a combatant en-
A side effect of MedSA is the establishment of a military-civilian vironment by the ISIL threat and terrorist attacks. At 18 Aug 07:00
health care expert network in Europe. MMCC/EMC has devolved (Z-time) the MMCC/EMC received an information request regard-
a first small network with EU Instituitons like DG ECHO, DG HERA ing the medical support concept for that operation from the Joint
Unified Multinational Civil-Military Medical Situation Picture
Requests from member nations to the

MMCC/EMC are also to be submitted
by means of “Request for Information”.
These are also entitled to complete-
ness, validity and the fastest possible
response by the respective MMCC/
EMC branch.
Various different types of information
can then be queried for a specific
event. This information may be (very)
specific, such as: the location and/or
basic capacity of hospitals; contact
details of national or multinational
poison control centers; level 3/4 mi-
crobiology laboratories or patient
coordination centers/control centers.
Similarly, certain data can also be
Example Incident-based Medical Situational Awareness „Awareness Board“ (Source: MMCC/EMC)
presented transparently using an
Medical Service of one of the participating nations. They were “Awareness Board”.
asking us to assist in the build up of a MEDCOP regarding the The MMCC/EMC will only share or distribute the information
medical capabilities, deployed to KABUL airport or in the region. provided to third parties upon approval by the member nations,
MMCC/EMC activated the SITCEN. Based on our network, MMCC/ which requires the willingness of all participating nations to
EMC have been able to connect with different important stake- cooperate.
holders. It took 5 hours to build up a valid medical picture for In the context of event development and description, the scope
our nations, like deployed medical treatment facilities and FW of data collection is always coupled with the question: who is in
MEDEVAC assets – including their capabilities and capacities. need of which required information for their decision-making
It is not the main intention to collect huge amounts of data. The process? This will automatically define who is a potential user of
focus lays on keeping only those data which either change very the data.
rarely or never and which are most likely needed on a regular ba-
sis – especially in the case of crisis-related developments. In order Quo Vadis MedSA? – MMCC/EMC as
to be able to provide the most up-to-date version of the other Information Manager For Medical
relevant data at all times, it is planned to keep the current contact Situational Awareness?
information of contact persons, responsible persons and organi- By this project, we are breaking new ground. MMCC/EMC’s intent
zations available at all times. is, to be a broker of information or better a broker of the infor-
Via these contacts, information can be obtained at short notice mation, how to reach the right SME, who knows the required
and made available for specific events. information.
In this way, the amount of data to be reported by member nations Medical Situational Awareness is an ambitious project. First data
to the MMCC/EMC can be reduced to a minimum. Moreover, the collection has started. As we have to cover a lot of topics, the work
MMCC/EMC also takes into account the fact that much of the rel- is and will be still on progress and not finalized. The strength of
evant information is already part of individual nations’ situational MMCC/EMC is, that our organization has strong access to NATO
picture or is freely available. The effort for the nations therefore and especially to EU institutions, military and civilian.
remains limited. MMCC/EMC will use of open source whenever possible and in-
volving member nations whenever necessary. The aim is achiev-
Detailed Processes ing unity of effort and increasing the efficient use of the scarce
The respective MMCC/EMC branches independently collect, eval- capabilities and capacities for the benefit of patients.
uate and maintain the information and data required for their
specialist area, which is applicable to both military and civilian Author:
subject areas and contacts. Rico Maderthoner
All MMCC/EMC branches forward their information and data Commander j.g. (OF-3) DEU Navy
to the Interoperability/Civil-Military Interface Branch (MedSA/ MMCC/EMC
CivMil) on a regular basis or upon request. Based on the infor- Coordination of Public Affairs
mation and data provided, this develops the Medical Situational Andernacher Str. 100, 56070 Koblenz
Awareness. E-Mail: MMCC-EMC-PAO@bundeswehr.org
Member nations will also provide information and data to the
MMCC/EMC. These inputs are to be provided by the member
nations to the respective requesting MMCC/EMC branch via
“Request for Information” (RFI) in a complete, valid and timely
manner. For this, the well-founded support of the nations in-
volved in the MMCC/EMC is mandatory.
Protecting People Worldwide
EMERGENT STANDS READY TO PROTECT AND ENHANCE LIFE.
MMCC/EMC – Combining Efforts in Medical Support
2nd international virtual Workshop on Wearable

Biosensors in Casualty Care 2022 (WeCARE-22)
Mario Unrecht
MMCC/EMC 1st virtual Biosensors Workshop 2021. CPT Dr. Rausch and 1st LT Schaebler leading through the workshop (from right to left)
The use of Biosensors as an innovative field of action for the future miniaturization nowadays allow biosensors to measure a wide
in military medical services: The Koblenz Multinational Medical range of body functions, which are then simply transmitted via
Coordination Centre/European Medical Command (MMCC/EMC), NFC (near field communication) or BT (Bluetooth) as data to a
in close cooperation with NATO COMEDS TeleHealth Panel (HIST watch, smartphone or special device. A wide variety of fitness
WG), is continuing the workshop series successfully launched in apps now help to evaluate the data. There, they are processed
2021, thus creating a knowledge platform for a broad internation- and stored and sent on to all places in the world via the internet
al network of experts for innovative further development in the to be stored, analyzed and evaluated. Scientists and doctors can
field of biosensors/wearables. stay accurately informed about the athlete’s condition this way
“Wearables” are small computer systems that are worn directly on and give direct feedback.
the body. As mobile measuring devices they record vital data and The military is also taking advantage of this technological ad-
transmit them to a microchip. This then transmits all the informa- vance. Soldiers can use it to specifically improve their personal
tion relevant to the user. It is read off, for example, as diagrams fitness and also check their performance status in extreme envi-
or other valuable analyses and insights. The targeted increase in ronmental situations, for example in extreme heat. Additionally
physical performance with the help of wearables has been prov- wearables are use used to monitor the rehabilitation of wounded
en in many scientific studies. Competitive athletes have been soldiers.
using this modern technology for years to monitor and improve Biosensors play a very special role in military medicine – especially
their performance. in the rescue of wounded soldiers. They can help to speed up pro-
Sophisticated sensors can be used to monitor pulse and blood cesses, determining the degree of injury and giving medical per-
pressure, respiration, oxygen saturation and even sleep patterns sonnel more confidence in their actions.
and body temperature, among other things. As a result, they have The COVID-19 pandemic triggered by SARS-COV-2 showed the
now become one of the everyday helpers for a healthy and fit increasing importance and demand for telemedicine (TeleHealth)
lifestyle. in the past two years, especially for the military sector within the
Instead of an entire laboratory, technical progress and European Union (EU) and North Atlantic Treaty Organization
(NATO). In times of scarce material and human resources and the

requirement to seek for ways to safely access and deliver health-
care, the COVID-19 Pandemic demonstrated the increasing rele-
vance and demand for Tele-Health/Telemedicine. Telemedicine
MULTIBASE
will a more important topic as a component of modern military
medicine.
In line with the vision “Combining Efforts in Medical Support”,
MMCC/EMC with its operational knowledge provides support
to the medical services of eighteen member nations, the EU and – READY FOR CHANGE-OFF
NATO, and helps to improve interoperability, in accordance with
NATO and EU guidelines, for telemedicine, biosensors/wearables
and digital competence.
The specially established TeleHealth/Medical CBRN-Protection
Branch (TH/MedCBRN) makes a significant contribution to this
within the framework of innovative capability development and
promotion in the field of wearable biosensors.
Once a year, the TH/MedCBRN branch organizes a virtual work-
shop on biosensors in close cooperation with the NATO COMEDS
TeleHealth Panel, thus creating a platform for a broad internation-
al network of leading experts to exchange knowledge
Biosensors Workshop 2021 – first digital

workshop attracts more than 100 participants
The civil-military digital event, organized by MMCC/EMC from
May 18-20, 2021, offered a comprehensive program and forum
with thirty high-level speakers from science and the user side.
The 130 registered participants from around twenty nations
followed highly topical and interesting presentations on the
defined key topics of the three-day workshop: “Fitness for Service”,
“Biosensors as a Support for Medical Service Care” and possible
“Ethical and Legal Requirements in the Application of Biosensors”.
In addition to the content from the various subject areas and
disciplines, such as biology, physics, medicine, military medicine,
cyber security and sports and health sciences, a partially contro-
versial discussion was initiated about the use of biosensors or
wearables in the medical service.
sustainable
■ Minimal conversion times
■ No need to keep specially-equipped aircraft
on standby
■ Use of existing equipment still possible
extremely flexible
■ Full conversion of an aircraft into a flying
hospital in a few hours
■ With full medical capabilities
safe
■ 16g crash safe passenger seats, according
to EASA CS25 requirements
■ Emergency oxygen supply and life jackets
MMCC/EMC 1st virtual Biosensors Workshop 2021. Interview with LTC

Prof Dr. rer. Nat. Scheid, Chair NATO COMEDS TeleHealth Panel (HIST WG)
www.autoflug.de
“As a sports scientist and runner, biosensors accompany me almost 95% of the respondents found the event very well to excellent
daily. I myself monitor physiological and performance data such as organized.
my heart rate, running speed and distances. They have long been The greatest need for further development is seen in the follow-
indispensable in sports, so why not in the military? I’m convinced ing areas:
biosensors can improve military performance and provide meaning- • biosensor quality, reliability and validity of data
ful support for training.” • sufficient robustness of biosensors
Captain Dr. Monika Rausch, part of the MMCC/EMC organizing team. • data security and protection in a military environment
International speakers demonstrated first positive experiences
and show that to some extent medical services of the armed Author:
forces of the EU and NATO are also already taking advantage of Mario Unrecht
this technological progress. Soldiers also have to go to their per- Lieutenant Commander
formance limits and even beyond in many situations. Biosensors Branch Head Telehealth/Medical CBRN
can be used to support health-promoting and preventive
measures. They offer a special role in military medicine – especial-
ly in the treatment of wounded soldiers. They can speed up deci-
sion-making processes, record the health status of the wounded
more quickly and thus relieve the burden on medical personnel.
After the workshop, the attendees got a detailed questionnaire.
First results of evaluation of the questionnaire, based on a response
quota of 55 % show:
Saving lives in critical situations

First Lieutenant Alexander Schaebler, who also organized the 2. Which data are useful for optimizing our efforts – how does
workshop, can report from his own experience: the collected data support the courses of action in the
“As an operations officer, I have already experienced several different settings and what effects do we want to achieve?
serious situations and therefore know how important it is to 3. “Which expectations towards wearable medical Biosensors
maintain an overview in critical moments. In an event with many do military users and medical providers have?”
casualties, the delay-free measurement and transmission of 4. “Are there already existing clusters of subject matter experts
casualty data, i.e. the data of the injured and wounded soldiers, or ongoing projects for this more precise application? What
can be ensured, thereby saving lives.” is the current state and what are the main study results?”
5. “Which aspects from an ethical, legal, cyber and data-based
Outlook for the Biosensors Workshop 2022 viewpoint need to be considered to successfully imple-
– Building on last year’s success ment and apply wearable medical Biosensors in a military
This year’s virtual workshop will take place from 21 to 23 June prehospital/primary care environment?”
2022 and will again bring together a group of international
civilian and military leading experts in the field of biosensors/ Future focus and highly relevant challenge
wearables. The MMCC/EMC is involved in the operational use of this
Building on the insights and successes of the first work- promising field of medical service provision. This is one focal
shop, the MMCC/EMC aims to expand collaboration with point of its future tasks. Telemedicine/TeleHealth is a highly
NATO’s COMEDS working groups and panels (MHC WG, EmP, relevant challenge. In cooperation with the NATO COMEDS
SOFMedP, MedNavP) to create an even better platform for TeleHealth Panel, the MMCC/EMC intends to further con-
open dialogue and knowledge exchange. tribute to establishing a “COI- community of interest” on the
WeCare-22 aims to illustrate the diverse roles that wearable topic of wearables/TeleHealth by networking leading experts
biosensors will play in preclinical healthcare and to stimulate a in the field of biosensors.
sustained exchange between the existing expert community.
We will focus on the following key questions for the use of Interested to become a participant or presenter in our
Wearable Medical Biosensors for Casualty Care: Workshop? – Contact us to sign up or for further details:
1. Which data should be collected by medical providers Admin / Invitation Management:
during prehospital/primary care using wearable med- MCPO Stefanie Hippler
ical Biosensors especially for Point-of-Care-Sensors? +49 261 896 53300
What is the reliable and valid are the collected data for E-Mail: MMCCinvitationmanagement@bundeswehr.org
decision-making?
HAMILTON-T1 Military.
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Health Service Delivery and Support
for the Catastrophes and Complex Emergencies
in the next Decade
will be discussed at
10th DiMiMED
INTERNATIONAL CONFERENCE ON DISASTER AND MILITARY MEDICINE
November 14-15, 2022

Trade Fair Duesseldorf
Team Chairmen
Rob van der Meer, MD Gerald M. Kerr Erwin Dhondt, MD

Brigadier General (ret) Colonel (ret) Brigadier General (ret)
Former Surgeon General Former Surgeon General Former Director General
of the Netherlands Armed Forces & Director Medical Corps Health & Well-being
Irish Defence Forces of the Belgian Defence
For registration and further information please visit:

www.dimimed-duesseldorf.de
Beta Verlag & Marketinggesellschaft mbH

Julia Ehlen • Eventmanagement within the framework of
events@beta-publishing.com MEDICA Trade Fair
+49 228/91937-30
Overview of all members of the MMCC/EMC
Surgeon General
Belgium, Kingdom of Pierre Neirinckx MD, Major General MC
Surgeon General
Czech Republic Zoltan Bubenik MD, Brigadier General
Surgeon General
Estonia Targo Lusti, Lieutenant Colonel
Surgeon General
French Republic Dr Philippe Rouanet de Berchoux, Lieutenant General
Surgeon General
Germany, Federal Republic of Dr Ulrich Baumgärtner, Lieutenant General
Surgeon General
Greece (Hellenic Republic) Dimitrios Hatzigeorgiou, Major General
Surgeon General
Hungary, Republic of Dr István Kopcsó, Brigadier General
Surgeon General
Italian Republic Nicola Sebastiani, Major General
Surgeon General
Lithuania Raimundas Blavieščiūnas, Lieutenant Colonel
Surgeon General
Luxembourg, Grand Douchy of Cyrille Dupont MD, Lieutenant Colonel
Surgeon General
Netherlands, Kingdom of the Remco Willem Blom, Commandeur (Rear Admiral)
Surgeon General
Norway, Kingdom of Jon Gerhard Reichelt, Major General
Surgeon General (Civ)

Poland, Republic of Dr Aurelia OSTROWSKA, Director
Surgeon General
Romania, Republic of Dragoș-Marian Popescu MD PhD, Major General
Surgeon General
Slovak Republic Dr Roman Jantoš, Brigadier General
Surgeon General
Spain, Kingdom of Juan Jose Sanchez Ramos, Major General
Surgeon General
Sweden, Kingdom of Claes Ivgren DVM, Colonel
United Kingdom of Great Britain Surgeon General

And Northern Ireland Timothy Hodgetts, Major General
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EUROPEAN

The Ecoles Militaires de Santé de Lyon Biological Defence Vigorous Warrior 22 /

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Resilient Medical Interface 2021 was conducted in November

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On its way to FOC – MMCC/EMC put to the test

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2. Conceptual framework and further Mission statement

Achievement of FOC was verified in a three-month evaluation

4. Findings Situation centre

A strong NATO partner

Emergency ventilator MEDUVENT Standard

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