Twenty-five Dutch soldiers lost their lives in Afghanistan during two decades and many were (seriously) injured. “During a war such as the one in Ukraine, a brigade counts so many dead and wounded after half a morning of fighting,” says Remco Blom (61), who has just retired as a commander doctor – the chief of the medical service in the Dutch armed forces.
Since the invasion of Russia, the Dutch armed forces have been preparing for a possible war to defend their own territory and that of NATO allies in Europe. The Netherlands is structurally earmarking an extra 5 billion euros for defence, 40 percent more than now. With that money, for example, additional F-35 aircraft and missiles are bought, according to the recently published report Defense memorandum, but also ‘medical support’. Because in a bloody war like Ukraine, the armed forces need, according to Blom, “a good and also large medical system” for the removal and treatment of the many wounded.
About ten years ago, the umpteenth cutbacks in the armed forces still involved “tremendous interventions in medical care”, says Blom, who has worked as a military doctor for over thirty years. Soldiers still have their own medical care, with a general practitioner, hospital and rehabilitation center. And in a risky mission, such as in Afghanistan or Mali, a medical safety net is stretched for possible wounded. “But the medical support for the fight for the protection of its own territory was then discontinued,” says Blom.
Where does that money go?
“Medical support means: taking care of all the injured, quickly and correctly determining who needs to be operated on immediately and ensuring that those selected injured are on the operating table within an hour. In Afghanistan and Mali we were able to land with the helicopter next to a wounded person, because we had air dominance. It is unlikely that we also have an air superiority in the defense of our own territory. So you have to stop the bleeding on the spot and take the injured out of the line of fire with the car. So at least you need enough armored vehicles; we have that in the Netherlands. Those vehicles then take the injured to a small operating room, in a converted container or ready-to-use vehicle. We don’t have it and we have to buy it. We can now do that too.”
What do you do in an operating room like that?
“You can repair the worst damage in a maximum of one and a half hours. Damage control surgery that’s called. You stop the most serious bleeding, give the patient enough donated blood to keep the blood circulation going and ensure that the blood can clot again. Then you move someone ‘to the back’, where the operation is completed in a larger field hospital. You do that as quickly as possible, if only to make room for the next one.”
Are there lessons to be learned from the war in Ukraine?
“Ukraine confirms the knowledge we have gained in recent decades during missions in Afghanistan and Iraq, among others. Take the ratio between the number of wounded who – almost – immediately die and the number who survive. We assume one direct death in four to five injuries. Of the ten injured, one is so badly injured that it requires surgery within an hour; the other nine can wait. This also appears to be the case in Ukraine. My Ukrainian colleague Tetyana Ostashchenko shared these public figures in a confidential meeting with the surgeon generals [hoogste militaire medici] of the NATO countries.”
Wouldn’t you expect relatively more deaths with the continued shelling by Russia?
“Yeah, I was surprised too. In an absolute sense there are of course a lot of deaths [naar schatting komen dagelijks ongeveer 200 Oekraïense militairen om]. The type of injury there is different from what we are used to. In Afghanistan people suffered a lot of damage to the lower body – legs, pelvis – from explosives next to and under the road. In Ukraine, doctors see many head and neck injuries. This may be because there is a lot of fighting in cities. If a little big bullet hits a brick, you’ll get hard flying rock splinters – just as dangerous as shrapnel.
“The majority are not seriously injured. You can’t fight on with a single shrapnel in the arm or a broken collarbone. Then a few weeks of rest are needed. Of the previously mentioned nine wounded who do not require immediate surgery, five will return to the front within six weeks.”
Is that happening in Ukraine?
“Yes, the whole system is designed for that,” said Ostashchenko. After the outbreak of war in February, Western NATO countries prepared themselves to receive a flood of Ukrainian wounded. It never came. Only for long-term rehabilitation or for multiple operations, as in the case of severe burns, Ukrainian wounded go west. The vast majority of the wounded are being treated in Ukraine, with great success, as more than half are able to return to the front to fight. That is also the task of the Dutch medical service in a possible fight elsewhere in Europe: to ensure that the armed forces do not run out because people have to return to the Netherlands for relatively light treatments.”
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Why do military personnel have their own health care system?
“Because military medicine is not just about people’s health, but also about ensuring combat power. So we provide soldiers with excellent healthcare in accordance with Dutch standards and we ensure that they are deployable. This means, for example, that the military general practitioner often also acts as a company doctor. If a soldier has a backache, we might say: you can do your job, but you can’t carry a backpack – and hand over a note for the commander. This also means that the soldier is obliged to see a doctor in the event of illness; that’s not a choice. If that doctor prescribes something, you have to stick to it; because you have to be employable. You just can’t be forced to have surgery. Vaccinations are mandatory; you give up the right to refuse it when you sign for the armed forces – unless the soldier invokes conscientious objection.”
Does this vaccination obligation cause problems, for example with the corona jab?
“For years, soldiers have been vaccinated as standard when they go on deployment. If they go to an area where there is yellow fever, they get a yellow fever shot before leaving. In thirty years with the medical service, I once saw someone refuse a vaccination on principle. With Covid there were many dozens of soldiers who did not want a vaccine. They didn’t trust the vaccine because of “information” on social media. That is really something of this time. I don’t know how many soldiers have been vaccinated. At one point we didn’t have enough vaccines. Then we said: you can get vaccinated at the GGD. We did ask to have it registered with us, but we don’t know how many soldiers did that. Our incomplete figures show that in some units only 80 percent were vaccinated, in a few only 60 percent. It has been decided not to keep military personnel to the vaccination obligation, except for deployments.”
Back to the extra money for medical support. What would you do if you were to become a commander doctor now?
“I would make sure that I would get a big finger in the pie when distributing the money. Then I would take care of those special operations units; that helps to retain staff, because people like to work with beautiful equipment – with which they can make the difference between life and death. Then I would continue to build our network with civilian hospitals, also internationally with military partners. We can make hospitals attractive as employers because doctors and nurses can do adventurous things with us some of the time. Conversely, we can get places in hospitals for wounded soldiers – Dutch, but also, for example, Polish and German soldiers. Because if we participate in a war like the one in Ukraine, we will need a lot of hospital capacity.”
A version of this article also appeared in the newspaper of August 8, 2022