Commentary-A Military Health Care Ethics Framework.

Ethical practice within military health care is a significant topic of professional and academic debate. The term "military health care ethics" enfranchises the entire health care team. Military health care professionals are subject to tension between their duties as military personnel, and their ethical duties as health care professionals, so-called "Dual Loyalty." Some military health care practitioners have suffered moral injury because of the psychological stress associated with ethical challenges on military operations. It is important to define military health care ethics and also to consider how it should be taught. The essence of ethical practice is ethical decision-making. It has become self-evident from our experience of teaching military health care ethics that a simple and agreed framework for analyzing an ethical problem is required. This paper describes the development of the King's Military Healthcare Ethics Framework in support of a military health care ethics policy on behalf of the NATO Military Healthcare Working Group. There is logic to using a stepped approach to analyze an ethical problem in military health care. These steps are: "Identify" the problem, "Analyze" the problem including consideration of perspectives, "Fuse" the analysis, and "Decide". Step 1-Identify-is intended to orientate the decision-making group, and to articulate the problem specifically and clearly in order to determine the exact ethical issue and the secondary issues that arise. Step 2-Analyse-considers the problem from 4 perspectives: patient, clinical, legal, and societal/military. These reflect the breadth of perspectives that impact on health care practice within a military context. Step 3-Fuse-is the culminating step. The conclusions from the analysis of perspectives should be summarized and key references cited. This will determine the exact decision(s) to be made. Step 4-Decide-clearly articulates the decision made and provides the record of the key reasons for making that decision. This may include areas of enduring uncertainly and any planned review of the decision. The King's Military Healthcare Ethics Analytical Framework has been evaluated for content validity through iterative discussion at 4 meetings of the NATO MHCWG and a specific workshop on military health care ethics over 2022/2023. It is included within the draft NATO Standardization Agreement on Military Healthcare Ethics.

History and its relevance to contemporary and future leadership.

BACKGROUND/AIM: This paper argues that an inquisitiveness into the history of medicine and healthcare organisation is an important characteristic of a leader seeking to understand why facts are as they are, before embarking on leading change. I had the privilege of 34 years of service in the UK Defence Medical Services, culminating in the most senior role of Surgeon General. I, and many of my military medical colleagues, are members of the Faculty of Medical Leadership and Management. Through this, I hope that we have been able to add an interesting dimension to the practice of medical leadership in UK health organisations. METHODS: This paper is a reflection on my personal experience suggesting that studying the history of military medicine can provide insights into the collective knowledge of previous generations, the process of organisational development during war, and the clinical and system innovations needed for the next war. RESULTS: This paper summarises my personal experience of the relevance of the history of military medicine in clinical practice and policy development within the UK Defence Medical Services. It has five sections starting with history as a trajectory of knowledge, and how this links to my personal career. I then show how history informed my leadership influence on policy and practice in four topics: the prevention of heat illness, the organisation of medical services, partnerships in military medicine, and organisational learning. The paper is framed around my personal experience over a career that spanned clinical practice, policy development, leadership on military operations, and finally senior strategic roles. CONCLUSION: While I have placed my argument in the context of military medical leadership, I suggest that understanding history is just as important in civilian medical leadership.

"Trust people you've never worked with" - A social network visualization of teamwork, cohesion, social support, and mental health in NHS Covid personnel.

Background: The unprecedented rapid re-deployment of healthcare workers from different care pathways into newly created and fluid COVID-19 teams provides a unique opportunity to examine the interaction of many of the established non-technical factors for successful delivery of clinical care and teamwork in healthcare settings. This research paper therefore aims to address these gaps by qualitatively exploring the impact of COVID work throughout the pandemic on permanent and deployed personnel's experiences, their ability to effectively work together, and the effect of social dynamics (e.g., cohesion, social support) on teamwork and mental health. Methods: Seventy-five interviews were conducted across the UK between March and December 2021 during wave 2 and 3 of COVID-19 with 75 healthcare workers who were either permanent staff on Intensive Care/High Dependency Units used as COVID wards, had been rapidly deployed to such a ward, or had managed such wards. Work Life Balance was measured using the WLB Scale. Interview transcripts were qualitatively coded and thematic codes were compared using network graph modeling. Results: Using thematic network analysis, four overarching thematic clusters were found, (1) teamwork, (2) organizational support and management, (3) cohesion and social support, and (4) psychological strain. The study has three main findings. First, the importance of social factors for teamwork and mental health, whereby team identity may influence perceptions of preparedness, collaboration and communication, and impact on the collective appraisal of stressful events and work stressors. Secondly, it demonstrates the positive and negative impact of professional roles and skills on the development of teamwork and team identity. Lastly the study identifies the more pronounced negative impact of COVID work on deployed personnel's workload, mental health, and career intentions, exacerbated by reduced levels of social support during, and after, their deployment. Conclusion: The thematic network analysis was able to highlight that many of the traditional factors associated with the successful delivery of patient care were impeded by pandemic constraints, markedly influencing personnel's ability to work together and cope with pandemic work stressors. In this environment teamwork, delivery of care and staff well-being appear to depend on relational and organizational context, social group membership, and psycho-social skills related to managing team identity. While results hold lessons for personnel selection, training, co-location, and organizational support during and after a pandemic, further research is needed into the differential impact of pandemic deployment on HCWs mental health and teamwork.

Expanding Global Health Engagement through Multilateral Security Organizations.

INTRODUCTION: Many countries around the world employ defense capabilities in support of global health engagement (GHE) through bilateral and multilateral organizations. Despite this, there does not appear to be a strategic approach and implementation plan for U.S. DoD GHE in support of and through multilateral organizations. The purpose of this research is to identify which security multilateral organizations are engaged in GHE, as well as how and why. These findings could inform an interoperable approach for doing so going forward. METHODS: A systematic review was conducted to develop a list of multilateral security organizations and agreements which engage in GHE, or could potentially play a role in GHE. RESULTS: Of the 3,488 agreements and organizations identified, 15 met the inclusion criteria. Among them, 87% (13/15) of the multilateral organizations are regional and 13% (2/15) are international, all established between 1948 and 2020. The 15 organizations cover all DoD Geographical Combatant Commands. Among them, 20% (3/15) are a legally binding alliance, 73% (11/15) have a treaty, and 7% (1/15) have a diplomatic partnership. Twenty percent (3/15) have an explicit intent to improve health in either their mission statement or as part of their goals, priorities, and/or objectives. Eighty percent (12/15) engage in at least two GHE domains outlined in DoD Policy, 67% in three (10/15), and 47% in all four (7/15). The most common domain is humanitarian assistance and foreign disaster response at 100% (15/15) and least common is Nuclear, Chemical, and Biological Defense Programs at 53% (8/15). CONCLUSIONS: Although there is high demand for GHE, resourcing to enable implementation has not been prioritized. Therefore, multilateral organizations continue to support what is funded (e.g., disaster response) versus prioritizing capacity building or modifying authorities and appropriations to match demand. It is also worth noting most organizations included in this review support the European theater aligning to historical defense priorities, versus emerging threats in the Indo-Pacific region. Identifying a forum within these multilateral institutions to convene GHE policy makers and practitioners is a logical next step. The forums could guide and direct priorities, devise solutions, and implement best practices. Near term efforts could include GHE financing, governance, assurance, and technical assistance within and across multilateral institutions. Recent efforts highlight growth in both interest and action to support the variety of GHE activities regionally and internationally. As the United States seeks to reinforce multilateral institutions and uphold the international and rules-based order, employing GHE through multilateral cooperation could buttress efforts. Now is a perfect time given the sustained interest in global health, amplified value of allies and partners, and renewed emphasis placed on multilateral cooperation for the DoD to design a multilateral GHE strategy and seek Congressional support to resource it accordingly.

The challenges of international collaboration in conflict and health research: experience from the Research for Health in Conflict-Middle East and North Africa (R4HC-MENA) partnership.

BACKGROUND: Healthcare is a basic human right extending across all humanitarian contexts, including conflict. Globally, two billion people are living under conditions of insecurity and violent armed conflict with a consequent impact on public health. Health research in conflict-affected regions has been recognised as important to gain more understanding of the actual needs of such populations, to optimise healthcare delivery, as well as to inform advocacy and policy change. International collaborative research maximises the resources and skills available for dealing with global health issues, builds capacity and endeavours to ensure the research reflects real needs of the populations. Under the UK's Global Challenge Research Fund in 2017 a number of such international programs were created including the Research for Health in Conflict-Middle East and North Africa (R4HC-MENA) partnership to build capacity in conflict and health research as well as study specific areas, namely noncommunicable diseases in conflict (cancer & mental health) and the political economy of health in conflict. METHODS: A qualitative study using semi-structured online interviews was conducted to explore researchers' and stakeholders' perspectives on the R4HC-MENA programme over its lifetime from 2017 to 2021. It aimed to understand the factors that influenced and accelerated international collaboration within the R4HC-MENA programme on conflict and health research, and to provide deeper insights into the implementation of the programme. Data collection was conducted from March 2022 to June 2022. Purposive and snowball sampling techniques were used for participant recruitment. Thematic analysis was applied for data analysis. RESULTS: Twelve researchers/stakeholders participated in this study: four men and eight women. Four main themes were generated: Theme 1: Network building (personal and institutional levels); Theme 2: Hierarchies and power dynamics (power imbalance between different academic status, genders and institutions); Theme 3: Communication challenges; Theme 4: Career development (management, leadership, research, and teaching skills). CONCLUSIONS: This study provided preliminary insights into perspectives on international collaboration in a major international programme of research on conflict and health. Several key challenges and outputs were generated by the researchers in this study. The findings are important for further developing effective strategies to tackle the challenge of power imbalance and ineffective communication in international research collaborations.

Delivering effective Defence Engagement (Health): lessons from Operation TRENTON (South Sudan).

This paper describes the Defence Engagement (Health) (DE(H)) component of the medical mission within the UK deployment to South Sudan under Op TRENTON, the UK troop contribution to the United Nations Mission in South Sudan (UNMISS). The DE(H) activities provided advice and mentoring to the Vietnamese military medical services to support the predeployment preparation and training of their medical contingent that would undertake a relief in place of the UK personnel providing a Level 2 hospital in Bentiu, South Sudan. The paper describes these UK DE(H) activities at the strategic, operational and tactical levels to show the integration across these levels from January 2017 until the handover of command in South Sudan on 26 October 2018. The UK worked alongside personnel from the US and Australian military medical services to deliver a Field Training Exercise and other capability-building events for personnel from the Vietnamese 175 Military Hospital. The paper shows how a DE(H) programme can have strategic effects by bringing another nation into a United Nations mission, increasing UK diplomatic activity with a partner country, and by ensuring continuity of medical cover to a key UNMISS location after the withdrawal of the UK medical contingent. This paper forms part of a special issue of BMJ Military Health dedicated to DE(H).

Ethical tensions in delivering Defence Engagement (Health).

This paper considers the potential ethical tensions in the conduct of Defence Engagement (Health) (DE(H)) activities. Multiple academic papers have described the ethical dimensions of topics such as 'medical rules of eligibility', cultural differences in clinical behaviour when providing mentoring support to military health professions, MEDCAPS (non-emergency primary care clinics by international military medical personnel direct to the indigenous civilian population) and military medical collaboration with the civilian public health system and humanitarian organisations. After a short summary of principles and perspectives in military healthcare ethics (MHE), this paper considers the ethical risks of DE(H) activities at the strategic, operational and tactical level. The paper closes by discussing how to prepare military healthcare personnel for ethical challenges during DE(H) tasks. This includes considering the wider legal, professional, societal and public health perspectives alongside clinical perspectives in the analysis of an MHE issue. In conclusion, potential MHE issues during DE(H) activities are predictable and personnel should be trained to identify and address them. This paper forms part of a special issue of BMJ Military Health dedicated to Defence Healthcare Engagement.

Personal view: security sector health systems and global health.

In many countries the security sector is a major contributor to the healthcare system. The role and transformation of a state's security health system within the universal health coverage is important, in that it sits at the interface of the United Nations Sustainable Development Goals 3 (ensure healthy lives and promote well-being) and 16 (promote just, peaceful and inclusive societies). The paper describes the breadth of the security sector and outlines the potential beneficiaries, clinical services and macro-organisation of a security sector health system from the perspective of its contribution to wider government health services and crisis response. It examines the characteristics of the security sector compared with other providers of health services, including those generic to the sector and unique to a given service. Understanding civil-security relationships is a critical facet of effective Defence Healthcare Engagement (DHE), which includes the use of defence medical assets in support of capacity-building overseas. The analytical process described may form the basis of DHE planning. It may have even greater importance in the near future as countries review national resilience and global health diplomacy after the COVID-19 crisis.

Military Healthcare Ethics: Making It Relevant to the Whole Military Care Team.

This article notes the significant increase in academic papers and policy guidance on the subject of ethical practice in military healthcare over the past two decades. This is usually within the domain of "military medical ethics," linking medical ethics as applied to the medical profession (doctors) with ethics as applied within the military (primarily from the perspective of officers). This article argues that this, highly elitist, perspective disenfranchises the majority of the military healthcare team who are nurses and allied health professionals and serve across the entire rank spectrum. We suggest that the subject should be reframed under the banner "military healthcare ethics" to include the concepts within military medical ethics but to emphasize the obligations of all military health professionals to comply with legal, regulatory, and ethical guidance for the practice of healthcare in the military environment. We recommend that the subject should be included in the curricula for education and training for all military health professions across their whole career.

Observations from the Korean War for Modern Military Medicine.

This paper reviews developments in military medicine during the Korean War and places them in the evolution of military medical lessons from the Second World War and the subsequent development of military medicine through the Vietnam War to the present day. The analysis is structured according to the '10 Instruments of Military Healthcare.' Whilst there were incremental developments in military medicine in all these areas, several innovations are specifically attributed to the Korean War. The introduction of helicopters to the battlefield led to the establishment of dedicated medical evacuation helicopters crewed with medical personnel and the evolution into the DUSTOFF system during the Vietnam War. Helicopter evacuation was the primary medical evacuation system in the wars in Iraq and Afghanistan. The establishment of the Mobile Army Surgical Hospital during the Korean War were founded upon the US Auxiliary Surgical Groups or the UK Casualty Clearing Stations of World War II. The requirement for resuscitation and surgical teams close to the battlefield has endured through the development of mobile hospitals of varying sizes from Field Surgical Teams to the current 'modular' Hospital Centre and other international equivalents. There were many innovations in the clinical care of battle casualties covering wound shock, surgical techniques, preventive medicine, and acute psychiatric care that refreshed or advanced knowledge from the Second World War. These were enabled through the establishment of medical research programs that were managed within the theatre of operations. Further advances in all these clinical topics can be observed through the Vietnam War to the wars in Iraq and Afghanistan - all of which were underpinned by institutional directed research programs. Finally, collaboration between international military medical services and the development of Korean military medical services is a major theme of this review. This 'military-tomilitary' and 'civil-military' medical engagement was also a major activity during the Vietnam War and more recently in Iraq and Afghanistan. Overall, the topics and themes in military medicine that were important during the Korean War can be considered to be part of trajectory of innovation in military medicine have been replicated in many subsequent wars. The paper also highlights some 'lessons' from World War II that had to be relearned in the Korean War, and some observations from the Korean War that had to be relearned in subsequent wars.

Understanding teamwork in rapidly deployed interprofessional teams in intensive and acute care: A systematic review of reviews.

The rapid increase of acute and intensive care capacities in hospitals needed during the response to COVID-19 created an urgent demand for skilled healthcare staff across the globe. To upscale capacity, many hospitals chose to increase their teams in these departments with rapidly re-deployed inter-professional healthcare personnel, many of whom had no prior experience of working in a high-risk environment and were neither prepared nor trained for work on such wards. This systematic review of reviews examines the current evidence base for successful teamwork in rapidly deployed interprofessional teams in intensive and acute care settings, by assessing systematic reviews of empirical studies to inform future deployments and support of rapidly formed clinical teams. This study identified 18 systematic reviews for further analysis. Utilising an integrative narrative synthesis process supported by thematic coding and graphical network analysis, 13 themes were found to dominate the literature on teams and teamwork in inter-professional and inter-disciplinary teams. This approach was chosen to make the selection process more transparent and enable the thematic clusters in the reviewed papers to be presented visually and codifying four factors that structure the literature on inter-professional teams (i.e., team-internal procedures and dynamics, communicative processes, organisational and team extrinsic influences on teams, and lastly patient and staff outcomes). Practically, the findings suggest that managers and team leaders in fluid and ad-hoc inter-professional healthcare teams in an intensive care environment need to pay attention to reducing pre-existing occupational identities and power-dynamics by emphasizing skill mix, establishing combined workspaces and break areas, clarifying roles and responsibilities, facilitating formal information exchange and developing informal opportunities for communication. The results may guide the further analysis of factors that affect the performance of inter-professional teams in emergency and crisis deployment.

How Should Access to Military Health Care Facilities Be Controlled in Conflict?

This commentary on a case analysis examines the principles that govern decisions about which patients might be admitted to an international military hospital during humanitarian or combat operations. It explores the balance between duties under the Geneva Conventions and other international humanitarian laws, the requirement to be able to provide medical support to the military mission, and the obligation of clinicians to coordinate with other health care practitioners (local civilian, local military, and nongovernment organizations). Finally, this commentary considers the practical aspects of implementing these arrangements.

Comprehensive Medical Support in Complex Emergencies (CMSCE): pilot course review.

Global threats to health and health security are growing. Fragile and failed states, armed groups, ungoverned spaces, outbreaks and potential unknown "Disease X" threats, antimicrobial resistance (AMR), hybrid and gray zone conflict all exacerbate complex medical emergencies. These growing threats increase preventable morbidity and mortality of the most vulnerable populations. In an effort to promote best practices, standardize responses, and prevent excess death and disability in these contexts, The Kofi Annan International Peacekeeping Training Centre (KAIPTC), with support from multiple international partners and a volunteer facilitator faculty, administered the pilot course for military and civilian health officers involved in U.N. peacekeeping missions entitled, "Comprehensive Medical Support in Complex Emergencies (CMSCE 19)." This brief review paper provides a description of the process in designing and delivering an interdisciplinary course for providers and decision makers responding to complex emergencies. We conclude with best practices and next steps for course evolution.

Thematic Analysis of Military Medical Ethics Publications From 2000 to 2020-A Bibliometric Approach.

INTRODUCTION: There has been external criticism of the compliance of military health personnel with internationally agreed principles in military medical ethics (MME). In response, a number of authors have called for clarity on the principles and topics within the domain of MME. This complements an increased acknowledgment of the need for education in MME for military health personnel. Our paper utilizes bibliometric techniques to identify key themes in MME to inform the development of a curriculum for this subject. MATERIALS AND METHODS: We designed a search strategy to find publications over the period January 1, 2000-December 31, 2020 in the domain of MME from the three databases, PubMed, Web of Science, and Scopus, using the search string (ethic* OR bioethics* OR moral*) AND military AND (medic* OR health*). We obtained a total of 1,115 publications after duplication removal. After exclusion based on topic, year, and study design, we analyzed a total of 633 publications using Scopus's embedded analysis tool and the software VOSViewer. We generated a co-occurrence word map from the abstracts of each of the publications. We deduced themes of MME based on the clusters shown in the word map, and we categorized each publication into one of these themes to analyze the change of themes over time. RESULTS: We observed a 10-fold increase in annual publications on MME between 2000 and 2020. The majority of papers were written by U.S. (72%) and UK (13%) authors, although a total of 15 countries were represented. After using VOSViewer to identify co-occurring keywords in titles and abstracts from these publications, nine themes were identified: biomedical research, care to detained populations, disaster/triage, mental health, patient-focused foundations, technology, dual loyalty, education/training, and frameworks. The relative proportion of each of these themes changed over the study period, with mental health being dominant by the end. CONCLUSIONS: This study has identified key themes that might inform the development of a curriculum for teaching MME. It is noticeable that the majority of themes cover MME from the perspective of professional practice on military operations; noting, the research and technology themes also pertain to the generation of knowledge for military operations. There were a limited number of publications covering practice in the non-deployed or garrison settings, and these were codified under the themes of "framework" and "dual loyalty". The results are skewed toward English-speaking countries and exclude non-academic publications. Further work will search for other open-source information and non-English publications. To our knowledge, this exploratory bibliometric analysis on MME in the academic literature is the first of its kind. This article has demonstrated the use of bibliometric techniques to evaluate the evolution of knowledge in MME, including the identification of key themes. These will be used to support further work to develop a curriculum for the teaching of MME to military medical audiences.

Evolution of First Aid Training in the British Army.

INTRODUCTION: This article describes the evolution of first aid in the British Army from the Crimean War to the present day in order to interpret the processes of innovation, implementation, and diffusion of ideas to improve the clinical outcomes for military casualties. MATERIALS AND METHODS: The article is an analysis of policy and practice for training in first aid published in King's/Queen's Regulations for the Army, the Field Service Pocket Book, or generic military training policy. This is complimented by a review of medical training manuals and a search of articles in the Journal of the Royal Army Medical Corps (RAMC). Most sources have been accessed from the Museum of Military of Medicine and the Wellcome RAMC Muniments Collection. RESULTS: The narrative summarizes the evolution of clinical concepts in first aid and their translation for Army personnel; starting with RAMC stretcher bearers, extended to soldiers assigned to medical duties at unit level, and finally simplified into first aid training to be taught to all soldiers. Alongside this story of training is a secondary story of the development of field first aid equipment, principally dressings, tourniquets, and analgesia. The final part of the story is the transfer of knowledge from military first aid training into the civilian, community setting. The following themes were identified: the reality of conflict wounds, battlefield first aid is different from civilian first aid, progressive transfer of training from medics to soldiers, transfer of knowledge to civilian sector and internationally, and specific clinical innovations: first field dressings, tourniquets, and prehospital analgesia. DISCUSSION: The current generation of soldiers are at the highest ever standard of first aid training and equipment. This must be maintained through gathering of evidence in effectiveness and outcomes in prehospital emergency care in both military and civilian settings.

Understanding the structure of a country's health service providers for defence health engagement.

There are a variety of structural and systems frameworks for describing the building blocks of country's public health and health systems. In this paper, we propose a conceptual framework for a holistic view of a country's health service providers in order to inform the plan for Defence Health Engagement activities with partner countries. This includes all potential government ministries involved in healthcare provision, the independent, private sector and the non-government organisation/charity sector. The framework provides a visualisation to support the analysis of a country's health services providers. We propose that recognising and analysing the different contributions of all these national health providers is essential for understanding the wider political economy of a nation's health systems. This can inform a plan of Defence Health Engagement for capacity building in crisis response, development and health systems strengthening.

MIlitary Combat Mental Health Framework.

This paper describes a framework for understanding military combat mental health based on the possible mental ill-health consequences of exposure to 'potential trauma events' for members of the armed forces and after their military service as veterans. It uses a life course approach that maps an individual's mental well-being against four 'states': fit, reacting, injured and ill. It then considers five categories of factors that influence the risk of mental illness from this exposure based on research evidence; prejoining vulnerability, resilience, precipitating, treatment and recovery. This framework offers a structure to debate current knowledge, inform policy and therapeutic interventions, provide education and to guide future research into the subject.

An Analysis of International Military Health Systems Using the Military Medical Corps Worldwide Almanac.

INTRODUCTION: A number of organizations publish comparisons of civilian health systems between countries. However, the authors were unable to find a global, systematic, and contemporary analysis of military healthcare systems. Although many databases exist for comparing national healthcare systems, the only such compilation of information for military medical systems is the Military Medical Almanac. A thorough review of the Almanac was conducted to understand the quality of information provided in each country's profile and to develop a framework for comparing between countries. This information is valuable because it can facilitate collaboration and lesson sharing between nations while providing a structured source of information about a nation's military medical capabilities for internal use. MATERIALS AND METHODS: Each of the 142 profiles (submitted by 132 countries) published in the Almanac were reviewed. The information provided was extracted and aggregated into a spreadsheet that covered the broader categories of country background, force demographics, beneficiary populations, administration and oversight, physical structures and capabilities, research capabilities, and culture and artifacts. An initial sample of 20 countries was evaluated to test these categories and their subsections before the rest of the submissions were reviewed. Clear definitions were revised and established for each of the 69 subcategories. Qualitative and quantitative data were compiled in the spreadsheet to enable comparisons between entries. RESULTS: Significant variation was found in how information was presented in country profiles and to what extent this was comparable between submissions. The most consistently provided information was in the country background, where the categories ranged from 90.15% to 100% completion across submissions. There was inconsistency in reporting of the numbers and types of healthcare workers employed within military medical services. Nearly 25% of nations reported providing medical care to family members of service members, but retirees, veterans, reservists, and law enforcement personnel were also mentioned. Some countries described organizational structures, military medical education institutions, and humanitarian operations. A few reported military medical research capabilities, though each research domain was present in 25% or less of all submissions. Interestingly, cultural identities such as emblems were present in nearly 90% of profiles, with many countries also having badges, symbols, and mottos. CONCLUSIONS: The Military Medical Almanac is potentially a highly valuable collection of publicly available baseline information on military medical services across the world. However, the quality of this collection is highly dependent on the submission provided by each country. It is recommended that the template for collecting information on each health system be refined, alongside an effort to increase awareness of the value of the Almanac as an opportunity to raise the international profile of each country's military medical system. This will ensure that the Almanac can better serve the international military medical community.