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Interview the with the Surgeon General of the French armed forces, Médecin Général des Armées Prof. Dr. Bernard Lafont
The quality of our medical care focuses on the concept of “best practice”, even in foreign deployments
Which targets exist here, what are the core points of this project?
Médecin Général Prof. Dr. Lafont: I would like to begin by referring to our 300 years of history. Even if today's climate means we must restructure and develop the system, our military medical services are based on an extremely long tradition. The turbulence of history and the many challenges posed by it enabled us to consolidate a sound structure with equally solid organisation.
The military medical service is part of the overall public service offered by the state, and in keeping with this, its changes also reflect the overall transformations and developments of our state.
As time passed, we had to admit that in some areas, our military medical services had reached their limits.
Here, two points are of particular importance:
• on the one hand, the abolishment of compulsory military service in France and
• on the other hand, the change in the type of activities carried out in foreign missions had a significant effect on medical services and their integration into the military structures.
Changes in the field of military command, both within the administration and the national army as a whole, made it necessary for us to adapt the military medical services accordingly.
In order to develop the military medical service further, we have implemented a comprehensive system to identify shortcomings and pinpoint areas in which the military medical service requires consolidation, whilst establishing its future tasks and goals.
Here, I would like to address two points:
Firstly, it goes without saying that medical care must be guaranteed for our soldiers, particularly those who are deployed abroad. After all, we are a military medical service!
Secondly, our tasks also involve the population as a whole, in areas which correspond to us as a military service, and which are generally not available in the civil sphere. An example of this is medical ABC protection, especially nuclear defence and to a lesser extent, biological threats, followed by chemical threats.
When establishing our targets, we focus the quality of care on the concept of “best practice”. This obviously presents a considerable challenge in terms of our foreign operations, and we must make sure that our code of professional conduct is observed within the military field.
The military medical service is made up of several integrated areas which are key to its proper functioning. These include hospitals, troop medical care at the corresponding locations, military medicine research units, the provision of medical materials and much more.
All of these areas obviously need to be established and integrated within the new system. If just one of these were missing, the whole task and its completion could be jeopardised, which certainly does not correspond to the concept of further development.
In addition to this, we also have to keep a close eye on the financial framework, or rather the budget funds made available for development processes. In light of the ever-increasing multinational character of foreign deployment operations, interoperability is also of upmost importance. This not only applies to bilateral collaborative projects and the joint engagement of two nations, but also the consequences of France’s reincorporation in NATO structures.
With careful consideration of these points, the further development of our system aims to achieve the creation of an area which is as independent as possible. It needn’t always be completely independent, but in the current conditions, it must be able to react as autonomously as possible.
MCIF: Within all national armies around the globe, practically no area is more connected to civil guidelines, laws, expectations and developments than the medical service. How do you see the overlaps with the civil health system?
Médecin Général Prof. Dr. Lafont: This is an extremely important point. After all, only one type of medicine exists, as the specific medical fundaments are the same, whether we are talking about the civil health system or the military medical services.
There is no part of military medicine which contrasts completely to the care administered to civil patients in civil hospitals.
Rather, it is the framework conditions, the various practical constraints concerning the implementation of the specialist basis, which ultimately make the difference.
Of course, it is extremely important to ensure that the interfaces between these two areas are precisely established by contract. And this is something which distinguishes the French military medical services: the extremely detailed contracts we have signed with the Ministry of Health, for instance concerning the integration of our military hospitals in the public health care system.
Accepting civil patients from the area at our clinical facilities ensures that our medical officers and specialists can keep their skills up-to-date. And of course there is no point denying that such measures also enable us to gain a corresponding part of our budget.
The military medical service is a key protagonist within France’s public health system, and this is clearly evident from the variety of contracts, contractual relationships and collaborative partnerships we have with the public system.
Apart from the points I have already mentioned, we also cooperate closely with civil research centres.
In the area of material supplies, we maintain close contact with the so-called “Direction Général Santé”, which is ultimately responsible for ensuring the provision health care in France.
For instance, if we required strategically significant medicines for a particular emergency within the framework of national healthcare, we could produce them on our premises and store them accordingly.
Furthermore, cooperative collaboration in the fields of education and training is of huge significance. In relation to this, we can offer a range of interesting and attractive points for the civil market, such as surgical measures under special conditions.
MCIF: France boasts a long tradition of tropical medicine. In today’s multinational missions, many military medical services come face to face with the challenges of tropical medicine. As a result of this, the topic has gained global relevance. This is just one example of how necessary it is for nations to exchange their specialist experience and knowledge – which is of course one of the main aims of MCIF.
What significance does tropical medicine have within the military medical services in your country? To what extent and through which measures can the expertise of your medical services be drawn upon internationally?
Médecin Général Prof. Dr. Lafont: If we speak in terms of tradition here, we are referring to the tradition based on experience gathered over several decades of multi-faceted missions. Naturally, this is reflected in our corresponding facilities and is also preserved if such facilities require relocation within our future structure.
We were able to identify reasonably early that tropical medicine and tropical medical pathology represents an extremely strategic interest in both military and medical terms. The immediate effects on the strength and operational readiness of deployed troops are obvious.
With all traditions, however, we have to think about modernisation and further development.
We do this through a range of initiatives, such as the epidemiological monitoring programme “ASTER”, which is currently in the testing phase. We aim to incorporate this into a ”Disease-Surveillance Centre”, which we hope to be able to operate in the future with the German Armed Forces Medical Office in Munich. I think this serves as an excellent example of supranational participation in a specific area of expertise.
MCIF: For military medical professionals, post-traumatic battle stress syndrome is a well-known clinical condition. What is the experience of your medical services concerning the acceptance of this condition within society and amongst military leaders? How does the French medical service react to this development?
Médecin Général Prof. Dr. Lafont: Nowadays, we have much more knowledge on this subject. This applies to all levels, including military leaders, the medical services, and also the patients concerned. This has enabled everyone involved to deal with such situations in a more effective way.
This development was undoubtedly triggered by the first Gulf War in 1989/1990, coupled with Israeli experiences.
As a result of this, the last decade has witnessed the creation of a large association spanning all levels and all relevant areas, from military leaders and medical services right through to politics. The topic now receives wide-spread attention. Through the synergy effects of this collaboration, coupled with collective perception and support, we are attaining increasingly better results.
All of our deployed forces contain trained personnel on site. Such staff members are trained to identify early signs of traumatism, and any soldiers affected are quickly filtered out of the unit. It goes without saying that the medical staff members are also trained accordingly and know how to deal with such situations.
In all of our operational areas, one or more trained psychiatrists are present to advise and support unit commanders and medical staff.
Psychological crisis teams have also been formed to offer on-site services if required.
We also have the specialist medical units available in hospitals and medical centres, which can also be used for treatment if necessary.
In collaboration with military leaders, we plan to organise a type of decompression or briefing, which is not concerned with psychological monitoring by supervisors, but rather with offering soldiers the possibility to come to terms with what they have experienced, during or after the mission and before returning to their families.
Nevertheless, what we still need in order to cover this complex of problems is a long-term monitoring or follow-up system for affected soldiers, even those who have left the force in the meantime. We already know that it is entirely possible for no problem to manifest for a particular period of time, and then suddenly develop later.
In light of this, advances still need to be made. Approaches have been made, but we are still lacking an established concept to assure an effective follow-up.
MCIF: Let’s come back to the 300th anniversary of the French Armed Forces Medical Services. In the book on the history of medicine, France takes up several important pages, especially concerning military medicine.
At MCIF, we created an author prize and named it after the French military surgeon, Ambroise Paré. Our question is how do the French military medical services honour his legendary tradition and what influence does this have on the next generation?
Médecin Général Prof. Dr. Lafont: Paré is, without doubt, the founding father of our military medicine. We have a picture of him in our meeting room.
Indeed, 1708 was the year in which our medical services were founded as an institution.
Without wishing to become philosophical or jinxing things, I am convinced that today’s generation of students at the medical service school also feel bound by this tradition, and - I mean this in an extremely positive way - often feel more committed to this tradition than some other generations.
However, tradition not only comes from a few outstanding personalities who crop up time and again in history books. One factor must not be overlooked: these figures were not the creators of a medical service, but rather simply helped to bring the facilities already in existence a few steps forward. Nevertheless, these were extremely important innovators, who had the courage to make significant changes and strive for further development.
Accordingly, we do not teach students to learn history off by heart as a catechism, but rather attempt to convey the spirit of these innovators and developers, some of whom were even Nobel Prize winners.
We use such historical examples to form, nurture and train young, prospective medical officers. And this is offered within an extremely attractive framework, not only in terms of knowledge and material, but also within the context of this tradition and the vast amount of experience gained.
But I always say they are special, they are medical officers, they will soon become doctors who will eventually be confronted with a completely unique working environment with special challenges, which must also be tackled. This is what these young people have to internalise, spontaneously and absolutely unconditionally.
That is one of the reasons why the military medical training schools are particularly significant for us.
One could argue: why are there medical faculties in universities? Why can’t medical officers be trained there?
My answer is: we need medical schools which offer the possibility to reflect the unique working environment and particular challenges faced by a military doctor. We need to shape the next generation accordingly and let them experience something that simply does not exist in other areas. We give them the possibility to develop corps morale, whilst trying to understanding their tasks and integrating themselves into the community of perspective medical officers. This applies to both male and female members of the medical services. Currently, 55% of our students are women. And they have certainly proven themselves.
In contrast to other countries, France does not have any legal basis for the definition of quotas. Decisions are made exclusively on the qualifications of each individual applicant.
MCIF:
Finally, we would like to ask whether you could give us any suggestions for the MCIF as an international professional forum.
Médecin Général Prof. Dr. Lafont: Something that immediately attracts my attention is the presentation, which makes you want to open the magazine and take a closer look.
The value of such a magazine is to show the particularities of the medical services within the armed forces:
• Organizational structures of a technical domain tailored to produce results;
• Management procedures adapted to the operational environment;
• Capability of reactivity to cope with crisis’ or complex situations.
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