Introduction

There has been a significant change in the types of injuries sustained on the modern battlefield due to the use of improvised explosive devices (IEDs) which are designed to cause severe penetrating injuries to limbs and torso, often resulting in massive haemorrhage in injured soldiers. Massive haemorrhage is the most common preventable cause of death for soldiers wounded in combat1. Hence life saving training techniques and practices are being used by US military medical personnel in an effort to reduce this incidence. ‘Live tissue trauma training’ (LTTT), or ‘combat medic training’2, as it is referred to in the US, involves the use of animals (mostly goats and pigs) for the purposes of direct surgical intervention in which physicians and paramedical personnel (military and civilian) obtain surgical skills by treating severe traumatic injuries. Once animals are deeply anaesthetized, wounds of the type army paramedics and doctors are likely to see in combat situations are inflicted. Such wounds are then appropriately treated in order to gain valuable ‘trauma care’ experience not likely to be offered in any other form. Upon completion of LTTT, animals are humanely euthanased without ever regaining consciousness. Despite the understandable highly emotive and sensitive nature of LTTT, by

providing new combat medics with methods in how to manage critically-injured soldiers within the first few hours post-event, and where there is no local access to doctors or medical facilities, military personnel assert that such realistic training programs are necessary and have facilitated the saving of countless lives of soldiers who have sustained life-threatening injuries on the battlefield.2,7,8,9 In this ‘opinion’ article the author explains how and why animals are used for LTTT and in some areas of military medical research (MMR), as well as why he feels that the continued use of animals for LTTT is justified at this time. He also highlights opinions and recent examples of the animal research/training debate from both the pro- and anti- points of view and provides examples of alternative types of LTTT tuition. He hopes that this article will encourage wider discussion within respective scientific, defence and animal welfare circles, leading to further refinements in the welfare and protection of animals used for these important, although often controversial, purposes.

Why LTTT needs to continue

Jim Hanson2, a former member of a US Special Forces unit, writes in the Washington Times (‘Save people, not pets’), that in his view animal use should continue for LTTT because ‘banning medic training using live animals could kill US troops’. Interestingly, this publication was intentionally timely and was in direct response to a bill before the US Senate at the time. This bill, known as the ‘Battlefield Excellence Through Superior Training Practices Act’3, sought to amend the US Defense Appropriations Act which aimed to phase in human-based training methods and replace the current use of live animals for LTTT. If passed, this bill will require the US Department of Defense, no later than 1st October 2014, ‘to use only human-based methods for training members of the Armed Forces in the treatment of severe combat and chemical and biological injuries’. It will also prohibit the use of animals in such training.3 One of the main groups that are seeking this change is the U.S. Physicians Committee for Responsible Medicine (PCRM), who strongly oppose the use of animals for research and training in any arena. Many believe that this bill (known as the ‘BEST Practices Act’) will likely end up costing the lives of US troops in order to save the lives of some animals simply because US military medics will no longer have access to vital and realistic LTTT.

The PCRM, and other groups that oppose vivisection (surgery used for experimental purposes on living organisms4) such as People for the Ethical Treatment of Animals (PETA) seek an expanded use of simulators and other training aids so as to completely replace LTTT, despite the fact that such simulators and training aids cannot adequately mimic bodily functions or recreate the reality of a wounded living being. In contrast, it is widely accepted in US defence circles that, were it not for training programs such as LTTT, most medics would be sent into combat situations never having had the experience of treating a real traumatic injury. The viewpoint of most medics is that the visceral reaction that a living animal can invoke, being similar to that which each medic must face when a (human) life is in danger, is something that no simulator or training aid can provide. According to the PCRM, the US Department of Defense currently uses approximately 9,000 pigs and goats, and 20 vervet monkeys annually to teach Army medics, Navy corpsmen and Air Force personnel to respond to the most common causes of preventable battlefield fatalities.1 Others claim that these figures are more than fifty-fold higher5, though these claims appear unsupported by any firm evidence. This is put into perspective when one considers that in just one week in the month of February 2009 in the U.S., 2,236,000 hogs were slaughtered for meat consumption.6 In LTTT sessions, military trainees practice procedures including tourniquet application, emergency management of haemorrhage, blocked airway emergency techniques (such as cricothyroidotomy) and chest tube placement. This is because combat medics are ‘trained and prepared to save life, and to keep the casualty alive in austere high-threat conditions for hours on end’. Faces are often destroyed due to blast and burns injuries caused by IEDs used by insurgents, and there is a need to rapidly apply surgical airways.. Hence, ‘the spectrum of care they are expected to provide at any given moment exceeds what an entire civilian trauma centre might encounter in a week or month’.7

While most LTTT tuition involves the infliction of wounds using surgical instruments, some select US special operations units8,9,10 have conducted LTTT using various ‘projectile’ methods such as gunshot wounds, (bayonet) stab wounds, (napalm) burns, and amputations. Such courses, known as ‘Combat Trauma Management’, are ‘designed to test and reinforce the application of knowledge with regard to patient stabilization and treatment on an injured animal-patient. The use of ballistic wounding in these courses is used to create a variation of wounds and environments to complicate patient management and increase training realism’.7 It should be stressed that during such procedures, animals are always deeply anaesthetised (at a surgical plane of anaesthesia) for the entire period, given appropriate analgesia, and humanely euthanased post-training.

The production of extensive injuries in animals used for LTTT is important so that medics, when faced with a real combat situation are unlikely to ‘freeze’ due to emotional shock and they are able to quickly identify what they need to do, and apply it immediately and confidently. Such is the reality of LTTT that even hardened military personnel, when observing a gunshot wound for the first time, cannot remain unaffected by the experience. LTTT training also provides clinical and psychological ‘conditioning for the horrors and chaos of war.’ Indeed there are many medics belonging to Special Forces (elite) units who would gladly provide testimonials in support of the fact that such training, albeit graphic, has saved the lives of their colleagues who had sustained severe wounds in actual combat.2,8,9,10 Despite numerous advances in modern military technology, such as personal body armour and armour-plating of vehicles, it cannot be disputed that a confident and well-trained combat medic is probably the most likely ‘instrument’ to save a wounded soldier on the battlefield. Furthermore, a military spokesman for the US Army in Europe recently announced that effective combat trauma training, such as LTTT, had contributed to the lowest ‘killed-in-action rate in military history’.11 Thus, as LTTT actually saves lives, military personnel believe that this vindicates their position, and that LTTT should continue. The author, who also believes that priority should be given to human life over that of animals, concurs with this view. Indeed, it would seem that others are also of this view. David Hull, in his review of ‘Animal Liberation’,12 wrote that “if a choice has to be made between saving a human being and saving a pig, we would be morally obligated to save the human being because human beings are capable of greater sentience (possession of feelings such as pain and emotional states such as fear) than pigs. One must be careful when drawing such conclusions however as the degree of pain experienced by an organism cannot be assumed to be proportionate to its level of sentience. 13

Military Medical Research

In the area of MMR numerous devices (for example, tourniquets), procedures (damage control surgery) and clinical practice guidelines (use of balanced plasma to packed cell ratios) have been promulgated in the military through initial animal studies and subsequent clinical studies. Subsequently, training procedures employing the use of animals have been modified to reduce the use of animals, refined to maximize their use and where possible, replaced by the introduction of wide and varied techniques including simulators.

Another major factor within the battlefield scenario, is the issue dealing with blood loss. Uncontrolled haemorrhage is by far the major cause of death for wounded soldiers.2,7,8,9,10 Blood loss accounts for 40% of all combat deaths in Iraq and Afghanistan, according to the Army Institute of Surgical Research Joint Trauma System, but 79% of ‘potentially survivable’ deaths.14 Medics in the field are restricted in their ability to maintain blood pressure and to ensure that there is enough circulating blood as possible within the body . Mostly the only tools a medic has in order to achieve these aims include the use of compression bandages, various bandaging techniques, the use of thrombotic drugs to assist in slowing the loss of blood and the knowledge and experience gained from LTTT in dealing with complex traumatic injuries. Through their experience on the battlefield, medics have found that soldiers can often recover relatively well if haemorrhage and potential massive blood loss has been arrested.7,14

The Pentagon has recently invested approximately $10 million dollars in MMR to investigate strategies to increase the survival rate of soldiers through induction of a hibernation-like state.14 The medical research arm of the US military has commissioned Texas A & M University to undertake studies which initially have shown that hydrogen sulphide can put rodents into a state of ‘induced hibernation’. An extension of this work will seek to find scientific solutions that could potentially allow human cells to survive with less oxygen carried in the bloodstream and able to keep soldiers alive for up to six hours despite massive blood loss.14 Essentially, such research is aimed at reducing the body’s requirements at the cellular level regardless of the state of consciousness. If successful, this area of MMR is likely to have applications within the civilian world as well, for example in assisting victims of motor transport accidents.

Another significant part of MMR is the issue of chemical weapons defense research (CWDR; as opposed to chemical weapons offence research – banned in US for decades). This is another area where animals are used for military purposes.1,2,4,5 In order to find cures for soldiers exposed to deadly chemical attacks on the battlefield, vervet monkeys are used as a model for CWDR. In this work, the monkeys are anaesthetized and administered a non-lethal dose of a drug that mimics the symptoms of a chemical weapon, and then given an appropriate treatment. The efficacy and safety of chemical warfare antidotes and vaccines must be screened on animals prior to their use in humans. This methodology has to date become standard practise in this area of MMR.

Combat-experienced soldiers, having first-hand experience with regard to the types of injuries often sustained in modern military conflicts as well as seeing the benefits of LTTT, haemostatic training and CWDR, are strong advocates of LTTT and MMR for the purposes of saving human lives (lives of soldiers sent to war) over animals. They feel that LTTT should not be considered as a ‘callous disregard of animals. It is the careful and thoughtful regard for the survivability of the men and women that are sent to war’ by giving them (medics) all the tools and training that can help them save lives.2

The LTTT situation in Australia

LTTT has been similarly practised in Australia to aid in the training of both civilian doctors and Australian Defence Force (ADF) personnel in the initial assessment and management of the trauma victim. This training essentially concentrates on the first hour of emergency care post-event, and does not include the infliction of firearm/projectile injuries (ie. gunshot, grenade wounds) as is practised by select US military groups conducting LTTT. In Australia, LTTT is known as Early Management of Severe Trauma (EMST)15 and since 1988, training programs have been regularly provided for civilian and ADF medical and paramedical personnel across the country. It is important to note that EMST training, when it is conducted, is carried out in full compliance with National Health & Medical Research Council Guidelines, NHMRC (2009). Guidelines on the use of animals for training interventional medical practitioners and demonstrating medical equipment and techniques.16 The EMST focus is purely on the ‘trauma’ patient, regardless of whether that is within a civilian casualty or a military casualty context. EMST training was essentially ‘imported’ into Australia in the early 1980s when the Royal Australian College of Surgeons (RACS) liaised with its equivalent body in the United States, the American College of Surgeons, to seek support and permission in setting up the Advanced Trauma Life Support (ATLS) training programme for the Australasian region. As a result, the first EMST course, made available by the RACS, was offered to potential trainees in 1988, and has to date been providing this type of training as well as refresher training (normally undertaken if not done within four years of the initial EMST training) ever since.

The LTTT situation in the United Kingdom

In an article supporting the use of LTTT, Reeds (2010) states that ‘it would be prudent to clarify that the Royal College of Surgeons of England (RCSE) neither supports nor objects to the use of live animals for trauma training’.17 In a document published by the RCSE in 1999, titled ‘Surgical Competence Challenges of Assessment in Training and Practice’, the RCSE remained ‘neutral’ by providing information as to the benefits of LTTT, but also emphasizing the disadvantages relating to animal welfare considerations. Rather than outlining the formal policy of the RCSE on LTTT, this document was simply a discussion of issues relating to surgical training and LTTT, which was collated as a summary of various conference presentations. As such, the document ‘has confirmed that it does not hold any formal opinion or policy (on LTTT) nor has it ever considered the same.’ 18

Anti-vivisectionist groups also oppose civil medical research

Anti-vivisection groups such as PCRM, PETA and the more militant group Animal Liberation Front (ALF) of the UK have traditionally been strongly opposed to the use of animals for research purposes of any kind. Effectively they believe it is ‘inhumane’ and claim that those biomedical research organisations who conduct animal research, do so in a totally unregulated environment which is fraught with animal

cruelty. Recently, these groups have been very active on a world-wide scale by protesting (PETA and ALF, violently)19,20,21,22 against any form of animal-based research or training. PETA, ALF and recently PCRM, seem to have realised that if they can’t force a change to their views of various industry and government bodies, they can certainly be more effective by using official processes to file complaints against major US research institutions . This results in the delay or stopping of research progress, the waste of much-needed resources and results in frustrating delays while complaints are investigated, many of which usually result in ‘non-event’ outcomes. It seems that their collective influence is spreading, for example, one just has to take note of the ever-increasing, official filed complaints to animal welfare regulatory bodies such as the US Department of Agriculture (USDA) and Animal and Plant Health Inspection Service (APHIS). These obstructive tactics have had, at least in some cases, their desired effect, with a few major internationally-respected research institutions very recently having ceased using live animals.23

This has occurred not due to the institutions in question having breached any federal animal welfare laws but rather because it simply was easier for the institutions to avoid the time-consuming nature of such USDA investigations and the associated disruption to research, teaching and training. The two Canadian hospitals in question, namely Hamilton Health Sciences in Ontario and Saint John Regional in New BrunswickCanada, have indeed halted their Advanced Trauma Treatment Courses (ATTC) using live pigs, and have commenced using patient simulators23. Despite being accused of ‘caving in’ to external pressure exerted by the PCRM by some commentators, there was resistance by the Hamilton institution staff to the loss of the ATTC. Surgical residents at Hamilton openly expressed their opposition to the changes, as they considered the new simulators as poor replacements in their training when compared to their previous experience using live pigs. The medical students repeatedly demanded the return of the pigs for this type of training, because they felt that the ‘tissue’ on the mannequins simply was neither lifelike nor realistic.23

Citing stark factual differences, a university veterinarian at Hamilton made it clear that some (anti-vivisectionist) groups often deliberately used misinformation to get their point across.23 For example, in this very situation, the pigs used in ATTC were cared for by well-trained, dedicated staff who would ensure that they were housed in a comfortable environment, were well-fed and treated with the utmost care and respect. Pre-delivery to the institution, the pigs would be transported in an air-conditioned van and given a period in which to acclimatize to their new surroundings. The pigs would be carefully anaesthetized before undergoing the ATTC procedure, and prior to the conclusion of the training, they would be humanely euthanased with an overdose of anaesthetic while still unconscious. This entire protocol certainly does not reflect a portrait of inhumane treatment of animals, as claimed by some anti-vivisectionist groups.

PETA filed a complaint in 2010 to the USDA against the University of Michigan (UM), which conducts Survival Flight Training using animals.24 It claimed that the UM had violated the US Animal Welfare Act because it used cats and pigs in an emergency training course for its Survival Flight nurses (personnel providing emergency air transportation service for patients in critical care). PETA stated that the UM should use human simulators instead of live animals to practise common emergency procedures such as endotracheal intubation, which involves inserting a breathing tube into the trachea to ventilate the lungs.

Responding to the PETA complaint, the UM veterinarian and director for laboratory animal medicine stated that ‘the work of the Survival Flight nurses required that such procedures were performed on living tissue’, and that there was no substitute for this type of training, claiming that both simulators and associated teaching aids simply weren’t adequate.24 This training was designed for practising various essential life- saving techniques, which ultimately would be used for helping young children. The clinicians felt that because of the anatomical similarities between some animals and humans, they were simply the best learning models available for this training, 24 and importantly, the animals were under anaesthesia when such training was being conducted.

In another separate animal welfare complaint, filed by the PCRM to the USDAs APHIS against the University of Washington (UW) School of Paediatrics,25 the PCRM claimed that this institution was breaking federal animal welfare laws because it used live (anaesthetized) ferrets as a model to train paediatric medical residents to insert breathing tubes, as would be used for emergency procedures in premature babies. Responding to the complaint, a UW Medical Director and Professor of paediatrics stated that up to ten ferrets (maximum) were used for paediatric training sessions per year. He reported the species was a good model for such training as they were a hardy animal which, when anaesthetized, could easily tolerate between six to eight intubation attempts with minimal airway irritation. Recovery is rapid and they could be used again within a few weeks.25 The Professor said that this training was important as it helped train medical students to insert breathing tubes in very low birth weight babies, where medical simulators (mostly plastic models which contain semi-realistic anatomical features, and unable to adequately duplicate the airway passage in extremely small infants) simply weren’t at the level of sophistication required for these tiny infants.

Anatomical and physiological differences

Anti-vivisection groups often cite the anatomical and physiological differences between animals and humans as one of their main arguments in opposing LTTT. In a brief prepared by the PCRM for consideration by the US Senate in relation to the BEST Practices Act30 the PCRM states that ‘the use of pigs and goats for combat casualty care training (another name for LTTT) is suboptimal due to, among other issues, the animals’ anatomical and physiological differences from humans. Compared with humans, pigs and goats have smaller torsos and limbs, thicker skin, different responses to anaesthesia and analgesia, and important differences in anatomy of the head and neck, internal organs, limbs, blood vessels and airway’.

The same report also seems to recognise however that the most important elements of LTTT for practitioners is realism, human-specific injuries and treatments, volume of trauma exposure and ‘team-building’.30 In essence, they recommend combined use of simulators, human cadaver use and access to civilian trauma centres. While in theory this combination of training elements does sound ideal for LTTT, and in fact they are used by the military wherever and whenever possible, all of these separate elements do have their own inherent problems.

In addressing the first argument above, it needs to be stated that it is the reaction or response of living tissue to injury or irritation, rather than the anatomical or physiological species differences which is the main issue in question. Live tissue appears to be the most suitable element in training combat medics. ‘Most patient simulators do not bleed, and those that can, do not respond in the same biological way that bleeding patients do in clinical practice’.31 Using the example of physician training, real vascular injuries allow trainees opportunities to perform various techniques that respond authentically to injuries that they realistically encounter during clinical practice; this is a distinct advantage of the Advanced Trauma Operative Management course (or LTTT) that uses the live tissue porcine model and which has been shown to be of great benefit to trainees.32,33 ‘An additional benefit is the pathophysiological response to traumatic injuries that live tissue provides and the appropriate physiologic response of the patient that is observed to the trainees interventions/clinical management’.17,31 Simulators and human cadavers cannot produce this same effect. Endoscopy and other associated training techniques have also been used as part of LTTT. Some operators, Barthet et al (2007), also have ‘demonstrated significantly increased competence using live liver tissue in performing diagnostic procedures with regard to visualizing anatomic structures, performance of fine needle aspiration, and, to a lesser extent, endoscopic ultrasound-guided celiac neurolysis (endoluminal ultrasound)’.34

With respect to the use of human cadavers and simulators as an alternative to LTTT, another distinct advantage of live tissue is that organ texture and tissue handling characteristics are optimal, both of which are limited in cadavers and simulators. Although cadavers and simulators have their uses in certain applications, neither respond authentically to surgical procedures and other medical interventions in the same way that living patients do in everyday trauma practice.31 There are various (human) simulators on the market, most of which have been developed to meet certain requirements for training. One of them, ‘Trauma Man’ (Simulab Corporation) was constructed specifically for advanced trauma surgical skills training. According to the Surgeon General of the US Army, Major General Gale S. Pollock, ‘use of this simulator is not applicable for haemorrhage control, the largest, preventable killer of our Service members on the battlefield’.7 Furthermore, in a study done at the US Army Base at Fort Lewis, a haemorrhage simulator was used to training military medics. However the control group had received no exposure to the simulator. There was no comparison with live animal haemorrhage training. 35 It should be remembered that simulation is a training step; it is not the end of the training process.7

The use of civilian trauma centres, as an alternative to LTTT and on the scale that the military requires it, is also unrealistic and naïve. Hospital emergency rooms simply do not have the capacity or the resources to accommodate the needs of the military. As a rough guide, their programmes can only provide training for approximately 24 men (only) every 6-8 weeks.7 To put the US military’s requirements into some perspective, Major General Pollock made the following statement in 2007, “On any given day more than 12,000 Army medics – physicians, dentists, veterinarians, nurses, allied health professionals, administrators, and combat medics – are deployed around the world supporting the (US) Army in combat, participating in humanitarian assistance missionsand training throughout the world”.36 Furthermore, he added that “to date, more than 17,800 Combat Medics have received training in Medical Simulation Training Centers which use computerized mannequins that stimulate human response to trauma. (Only) use of live tissue best simulates the challenges and stress inherent in stopping actual bleeding”.36 From the above statements, it should be obvious to the reader that LTTT is the optimal method of training delivery and that the ‘through-put’ of hospital trauma centres cannot provide pre-deployment training requirements for combat medics,, especially in adequate emergency case management experience. Other problems with the use of civilian trauma centres for combat medics is that the types of injury encountered in hospital trauma centres are quite different to the spectrum of injuries that service members often encounter on the battlefield. Lastly, putting combat medics in civilian trauma centres for the purposes of training also removes them from their daily duties and thus reduces their capacity to provide healthcare for other military personnel.

In terms of military medical preparation for the treatment of combat casualties, advocates strongly believe that LTTT is the current solution because it is effective (it saves lives) and is the most advanced kind of training available. I It trains its participants to observe, assess, triage and treat based on the severity of the penetrating trauma presented, and all set within a ‘battlefield scenario’ where the need for rapid decision- making in a ‘high-stress’ environment is a constant challenge for the course participants.7 Participants in LTTT build an individual proficiency and a level of confidence in their ability to treat real combat casualties.37

The US military already uses a range of simulators including Trauma Man, the Combat Trauma Patient Simulation System, and other training modalities as described by Cherry and Ali.38 While these simulators are used where appropriate, and although they can enhance the experience of learning trauma training, they are only at best a progression towards, rather than a replacement for, LTTT, as they cannot replace all of the procedures used in training combat medics. So, effectively, the use of live animals cannot be eliminated altogether and this remains the reason that the US military uses the LTTT model for its troops pre-deployment.39 However, ‘ ‘hybrid’ courses have been developed by military training providers which offer a combination of LTTT, use of simulators, human cadavers and civilian trauma centres to aid in the training of military medical personnel. Though the success of some of these programmes has been variable, 40,41,42 the use of live tissue has remained an essential component of such training.

One of the better developed hybrid courses is the US Army’s ‘Tactical Combat Casualty Course’ which consists of didactic sessions, interactive human surgical simulators, triage scenarios, use of animal tissues and LTTT. It would be interesting to see how changing the relative proportions of such hybrid training may affect overall tuition, hence further research in this area is needed. Currently, until a simulation technique is developed that is documented to equal the benefit of live tissue training in preparing medics to manage combat trauma, appropriately conducted LTTT should be supported as an essential component of combat medic training.7,43

There are a number of simulators available for generic training which, although improved in their ability to provide useful training, they do not yet have the full capability of encompassing all aspects of live tissue training.44 It is for this reason that the American College of Surgeons (ACS) “supports the use and humane care and treatment of laboratory animals used in research, education, teaching and product safety testing in accordance with applicable local, state, and federal animal welfare laws”. The ACS also states that “wherever feasible, alternatives to the use of live animals should be developed and employed” but “believes that now and in the foreseeable future it is not possible to completely replace the use of animals and that the study of whole living organisms, tissues and cells is an indispensible element of biomedical research, education and teaching”.45

The benefits and controls of animal-based research and training

Military medical personnel and researchers across most institutions acknowledge the use and usefulness of alternative approaches as being very important. They do not use animals unnecessarily or uncaringly. All personnel consider it a privilege to use animals in research or training, and demonstrate this by treating them with the utmost level of care and respect.

Military research groups often support their argument by reminding us as to the many lives of soldiers saved directly, both in the past and currently, as a consequence of LTTT, CWDR and MMR. This has similarly been the case in the civilian arena of medical research as well, where the life-saving benefits to human health have been enormous, as has the reduction of human suffering caused by widespread, global infectious diseases.26 This has only been possible, because of the far-reaching implications of animal-based research and training. Interestingly, recent figures from the US National Academy of Science confirm that world rankings on average life expectancy have shown that they have increased over the last 25 years, due mostly to the advances in medical research and training.27 There have also been immense direct benefits to veterinary medicine as a result of animal-based biomedical research. Unfortunately, many anti-vivisection groups continually dismiss these enormous advances in human and animal medicine and continue to incorrectly propagate the view that these advances have been achieved at the expense of ‘humane’ care of animals.

Surely the ‘common denominator’ on both sides of this debate must primarily be the increased protection and safety of service personnel, together with enhanced humane welfare and protection of animals used for LTTT, CWDR and MMR purposes. It should be noted that the US Animal Welfare Act28 does permit the use of live animals for research and training purposes in both the civil and military arenas. However, it is the role of this Act to regulate whether animals are treated humanely. Violations of the Act are promptly investigated. Routine monitoring of conduct often involves unannounced visits to research and training establishments, aiming to ensure that animals are being treated humanely and with the utmost care. Actions taken for non-compliance can be severe and range from official warnings to fines being imposed on the institution, with the possibility of suspension of work or the revocation of research licenses .

The majority, if not all, research and training institutions both military and civil, operate within a rigid environment of internal and external controls governing their use of animals. This environment is highly regulated by the federal government, overseen by federal agencies which mandate several layers of review and involve a dedicated staff of caretakers and research animal veterinarians.26 Additionally, each institution has effective animal care and use committees set up to provide internal controls. A requirement of these committees mandates that a lay-person (an ordinary member of the community) serve as a member of its quorum. Indeed, the system on which this model is based is in place in many western countries today. Taking all of these factors into account, it should be evident that claims such as ‘inhumane treatment’, ‘fraught with animal cruelty’ and the like, appear to be without foundation. Nonetheless, there is no room for complacency as it is important that regulatory authorities continue to monitor the welfare of animals used for military and civil research and training activities, and continue to maintain the high standards expected of such institutions. Those ‘high standards’ have long been a tradition in the military services as ‘military medicine has always been at the forefront of research. It spans everything from disease prevention to rehabilitation’.29

Summary

This article highlights the importance of military training in life saving techniques and treatments developed through clinical research and now used by physicians and combat medics operating in the emergency arena of warfare. To this end, it should be remembered that such protocols have been refined to minimise pain and distress to animals, that the number of animals used is always reduced to the absolute minimum possible and that where effective non-animal alternatives exist, every effort is made to promptly implement or adapt them for current use. And although military and civil researchers will make use of new alternate technology and training methodologies wherever possible, at this point in time, animals (along with other types of tuition) remain vital in advancing medicine and for use in life-saving training techniques.