At the end of July 2010, over 10,000 military medical personnel were deployed to Iraq and Afghanistan, 70 percent of whom were Army servicemembers. Of that number, about 4,000 medical personnel were in Iraq and about 6,000 were in Afghanistan. The United States’ military presence in Iraq is scheduled to end no later than December 31, 2011, and, according to administration estimates, as of September 2010, about 104,000 U.S. military personnel were deployed in Afghanistan. Figure 1 shows the breakdown of all military medical personnel in Iraq and Afghanistan by service at the end of July 2010. DOD has established five levels of medical care to treat injured or sick military personnel, extending from the forward edge of the battle area to the continental United States, with each level providing progressively more intensive treatment. Over the course of operations in Iraq and Afghanistan, the military has integrated more advanced medical care into the first three levels of care, which are typically provided in theater, in order to provide the most comprehensive care possible closest to the point of injury. Figure 2 illustrates the different levels of medical care that may be provided to U.S. servicemembers who become ill or injured while in theater. Level 1 – First responder care. This level provides immediate medical care and stabilization in preparation for evacuation to the next level, and treatment of common acute minor illnesses. Care can be provided by the wounded soldiers, medics or corpsmen, or battalion aid stations. Level 2 – Forward resuscitative care. This level provides advanced emergency medical treatment as close to the point of injury as possible to attain stabilization of the patient. In addition, it can provide postsurgical inpatient services, such as critical care nursing and temporary holding. Examples of level 2 units include forward surgical teams, shock trauma platoons, area support medical companies, and combat stress control units. Level 3 – Theater hospital care. This level provides the most advanced medical care available in Iraq and Afghanistan. Level 3 facilities provide significant preventative and curative health care. Examples include Army combat support hospitals, Air Force theater hospitals, and Navy expeditionary medical facilities. Level 4 – Overseas definitive care. This level provides the full range of preventative, curative, acute, convalescent, restorative and rehabilitative care, most typically outside of the operational area. An example of a level 4 facility is Landstuhl Regional Medical Center in Germany. Level 5 – U.S. definitive care. This level provides the same level of care as a level 4 facility, but most typically is located in the continental United States. Examples include Walter Reed Army Medical Center in Washington, D.C.; National Naval Medical Center in Bethesda, Maryland; and Brooke Army Medical Center at Fort Sam Houston, Texas. Not all patients progress through all five levels of care, and patients being evacuated may skip one or more levels of care as appropriate. In addition, joint and service definitions for each level of care vary marginally due to service-specific support requirements, but they essentially align with one another. For purposes of this report, we focused primarily on level 2 and level 3 facilities and their personnel, which provide the most comprehensive and advanced medical care in Iraq and Afghanistan. The U.S. command structure in Iraq and Afghanistan has evolved over time. In 2009, the designation of U.S. troops in Afghanistan became United States Forces-Afghanistan. In 2010, the designation of U.S. troops in Iraq became United States Forces-Iraq. The commanding generals of United States Forces-Iraq and United States Forces-Afghanistan both are advised by a lead surgeon on medical policy and procedures, according to theater medical officials. Each theater also has a medical task force—the Task Force 1st Medical Brigade and its successor, the Task Force 807th Medical Brigade in Iraq and the Task Force 30th Medical Command and its successor, Task Force 62nd Medical Command in Afghanistan—that, according to theater medical officials, consist of professional staff members who coordinate care in theater and directly command medical- only units in theater, such as forward surgical teams and combat support hospitals. The theater surgeon and medical task forces command mostly Army medical facilities. According to a DOD official, the other services maintain and operate additional medical facilities in theater that may be outside the direct command of the medical task force but under the direction of United States Forces-Iraq and United States Forces- Afghanistan. For example, the Air Force operates a theater hospital in Balad, Iraq but coordinates closely with the task force medical brigade in Iraq. The United States Forces-Iraq Surgeon and staff collaborate closely with the task force medical brigade commander and staff in Iraq to coordinate medical policy and care. The positions of United States Forces-Afghanistan Surgeon and the commander of the task force medical command in Afghanistan are filled by the same individual. According to DOD officials, DOD meets theater medical personnel requirements through its Global Force Management process. DOD designed the Global Force Management process to provide insight into the availability of U.S. military forces to deploy, including medical personnel. Figure 3 depicts the process and the key participants in Global Force Management. Once the Secretary of Defense designates a service to meet a medical requirement, that service identifies and selects units and personnel to fill the requirement. While the procedures and systems used by each service to select medical personnel vary, the services’ processes for filling requirements all result in units and personnel deploying to an operational theater to carry out a mission. Identifying and selecting medical personnel and units to fill requirements can often be challenging due to shortages of medical personnel, but DOD officials told us they have been able to fill almost all medical personnel requirements since the Global Force Management process was established in 2005. More information on the Global Force Management process and the services’ personnel filling processes can be found in appendix II. Medical officials in theater continually assess the number and the types of military medical personnel they need to support ongoing contingency operations in Iraq and Afghanistan. Theater officials also analyze gaps in medical care and the associated risks given different potential scenarios. However, it is unclear what level of care deployed DOD civilian employees can expect in theater because a DOD directive governing medical care for DOD deployed civilians is inconsistent with in-theater guidance with regard to eligibility for routine medical care for deployed DOD civilian employees. In response to congressional interest about deployed civilians, the Secretary of Defense reported to Congress in April 2010 that with each new mission, the need for new civilian skills have resulted in an increase in the number of deployed civilians and that these civilians are not immune to the dangers associated with contingency operations. Although we did not learn of any DOD deployed civilians turned away for care in theater during the period of our review, officials in theater did say this could be a concern if the number of civilians increased, and at that time they would assess the impact of a civilian increase on the need for more medical personnel. At the conclusion of our audit, an Army official agreed that if there is an inconsistency between departmental guidance and theater guidance, it should be clarified. Thus, by examining inconsistencies in departmental guidance compared to theater guidance on the level of routine medical care, DOD could reduce the uncertainty about the level of routine care these deployed civilians can expect in theater. In response to a draft of this report, DOD mentioned to us that its operating units have sufficient organic medical support and the medical needs of deployed civilians are being met. DOD also agreed that the Commander of U.S. Central Command should revise its guidance to clarify the level of care that deployed civilians should receive. Theater operational and medical officials determine how many and the types of medical personnel needed to support operations in Iraq and Afghanistan through an ongoing assessment, which includes an evaluation of the operational mission and other planning factors, such as historical injury statistics and medical workload data. In their assessment, theater officials also analyze gaps in medical care given different potential scenarios and the associated risks. This ongoing assessment takes place in theater and allows theater officials to identify new medical personnel requirements and regularly reevaluate existing medical personnel requirements. Further, theater operational and medical officials also consider operational limitations when developing their medical personnel requirements, including the limit on the total number of forces in theater and shortages of and high demand for certain medical personnel. In determining the number of military medical personnel and the medical specialties needed, theater operational and medical officials told us that they begin by evaluating various mission planning factors, such as the number and dispersion of U.S. forces, the expected intensity of combat, capabilities of the adversary to inflict harm, geography, and climate. Officials said that this information allows them to determine the level and structure of medical care they expect to need to support missions throughout the theater of operations. For example, in planning for the increase of U.S. forces in Afghanistan beginning in early 2010, officials with the U.S. Central Command requested additional medical personnel to provide medical care to the increased number of U.S. military personnel in theater, including a theater hospital and a preventative medicine unit. In addition, during the offensive in Bastion, Afghanistan, officials with the Task Force 30th Medical Command told us that they relocated some mental health providers in Afghanistan to Bastion for the duration of the heightened operational tempo so this type of care could be better provided in the area experiencing hostilities. To further assess the need for specific types of medical specialists in a given unit and across the theater, medical officials analyze data from the Joint Theater Trauma Registry, the Joint Medical Work Station, and service and joint data on disease and non-battle injuries to determine trends in medical workload. Officials use this information to increase or decrease the number of medical personnel in line with demand for medical services. For example, DOD medical officials conducted an analysis to determine the need for cardiovascular specialists in Iraq and Afghanistan based on, among other variables, the volume of cardiovascular-related medical evacuations in theater. Officials also analyze gaps and risks in the medical care structure under different possible scenarios.