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Some considerations on the medical aspect of the universal national service

Reflection circle G2S - n°21
The Army in society
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Sne area in which the nostalgia generated by the suspension of the National Service in 1997 has led to a near consensus is that of health. What did we hear then about the loss of epidemiological information on young men or the early detection of pathologies hitherto unknown to those concerned? All these regrets were well-founded, even if they only concerned the male half of an age group.

For this population, other sources for collecting medical indications have since been developed, mainly based on statistical samples. Despite this, the lack of an annual health photograph of French youth remains a regret that is regularly mentioned. Here, then, is at least one area of interest, admittedly special, but certainly not anecdotal, which should benefit from the revival of a form of national service, especially since it would also concern young women. However, this epidemiological compendium would represent only a secondary benefit of this service, on condition that it is the occasion for medical examinations, which are necessary for other reasons: the inescapable need to determine unfitness for this new national service and the inevitable medical care of young people called up. Nolens volens, the corollary to the coverage of these needs will be to agree to a suitable organization and sufficient means. Without very precise indications as to what this service will be, the experience of past national service can be used to point out, in absolute terms, avenues for reflection and to put forward cautiously some ideas which are at least of interest, that of being able to be refuted!

1. Determining Unsuitability for the UNS and its Physical Activities

Each age group, for the first ones concerned by the SNU, has approximately

750,000 young people and has a very slight male numerical preponderance (about 51.2%). Targeted surveys have provided statistical data on the health of young people, making it possible, for example, to estimate the proportion of individuals between 10 and 25 years of age who reported at least one disability (5.4%), the incidence of obesity (4%) and ofoverweight (19.1%) in school or the evolution of tobacco, cannabis or alcohol use (19.1%).alcohol for both sexes, with in particular the increasing emergence of " one-time heavy drinking" practices. However, the synthetic elements available do not allow a relevant extrapolation to the probable number of situations representing a medical contraindication to perform the national service. The only indication available could be the exemption rate (this rate does not only include reforms for medical reasons), recorded before 1996, which averaged 20% year after year.

However, some thought will have to be given to defining the scope of this concept of medical unfitness for the new form of compulsory service, partly prior to any experimentation. This analysis could be based on two foundations:

▪ Given the nature of the SNU, it would in no way be a question of defining an ability to withstand physiological constraints specific to particular jobs;

▪ on the other hand, it would be necessary to determine what type or level of pathology, disability or psychological maladjustment would result inThe purpose of this study is to determine the type or level of pathology, disability or psychological maladjustment that would result in the permanent or temporary incapacity of an individual, as the individual would not be able to reap any benefit from the period of national service. Included in this typology would be conditions that could result in a risk to the group.

The most extreme situations will be easily identifiable; in the experience of selection during the former national service, it was not these categories of reformed persons which presented a real difficulty of discernment. The same was not true for those with less frank pathologies, situated "at the limit", and for those who considered, a priori, that the obligation of service was an unacceptable constraint. Today too, the latter will exist and will inevitably be tempted to use all possibilities to escape this subjection. This probability highlights the need for an indisputable and transparent method of assessing incapacity by asking the crucial question of homogeneity. of reform decisions, which implies that these decisions should be based on precise rules that are perfectly codified and applied by doctors trained in this practice.

The question of " when and where" to determine these incapacities and make them official will also arise. There appears to be only one alternative: either during a medical selection organised prior to the appeal, or directly during the "incorporation" of those subject to the rules. The second proposal has a certain number of advantages, in particular that of not multiplying either the number of invitations to attend or the number of dedicated structures, and of not having to make a large number of calls for tenders.The second proposal has a number of advantages, in particular the fact that it does not require a medical examination on arrival at the SNU centre, if only to formalise the medical limitations to carrying out certain physical activities. At the same time, however, the medical selection prior to the call, carried out within the specialized structures, has its own merits, in particular that of providing the certainty of perfect consistency in the decisions taken. Neither of these solutions rules out the possibility that certain serious cases, duly documented, may be settled "on the basis of documents"; this procedure was already in force in the old form of national service.

2. Medical care for conscripts

Every month, about 60,000 young people will be called up. Even for a form of national service without military activity, the number of accidents and therefore serious or minor traumas, seasonal or intercurrent diseases cannot be underestimated. It is hard to see how we can fail to provide for daily medical support as possible consequences of a pathology for all these young men and women gathered in an as yet undecided number of dedicated centres. However, this number will be a determining factor in organising this daily medical care for conscripts. For small groups, it might be possible to subcontract this care in the local civilian or military environment. However, this solution will very quickly come up against limits both in terms of implementation and profitability from a level of concentration which, although still to be assessed, will inevitably be quite low, given the medical demographics in France.

Moreover, subcontracting would be unsuited to the need to carry out a reference medical examination in order to have an enforceable record when the State is held liable for pathologies occurring as a result of or in connection with the service. It should be recalled that the National Service Code, which is currently dormant, granted conscripts the presumption of origin in respect of disability pensions. It was therefore up to the State to prove that the illness pre-existed or was not related to service. This was one of the purposes of the incorporation visit, the conclusions of which were reached on the 90th day of service. Tomorrow, as this consolidation period does not exist, the importance of a medical examination on arrival at the service in the event of a dispute would be all the greater, unless, of course, this exceptional framework of compensation for physical injury granted to conscripts was abolished and reduced to ordinary law only.

3. The organization and means of medical support

Many arguments seem to converge in favour of the choice to set up a medical structure directly integrated into the SNU centres. This raises the question of the human, material and infrastructural resources to be devoted to these medical services.

For the sole purpose of carrying out a serious medical check-up when the young people arrive at the SNU centre, it is necessary to envisage mobilizing one doctor and one paramedical staff for every half-day for about 25 individuals. In addition, operational staff, particularly secretarial staff, whose activities are shared for the benefit of the entire technical team. From the outset, it is obvious that, from planing to deflation, the Armed Forces Health Service no longer has the active and reserve personnel needed to arm such structures.

Additional technical resources must be found. The most obvious solution is to use part of the pool of students called upon to carry out a three-month medical service devoted to prevention. Indeed, the health check-up that would be carried out during the United Nations system would clearly contribute to the "prevention programme" desired by the Government . These students would then carry out this health service under the SNU, either on a voluntary basis or by geographical designation, because of their proximity to the SNU centres.

Since these students would have to be supervised by senior doctors, the latter could then be set up by the Armed Forces Health Service, whose practitioners, both active and reserve, have experience in organizing and carrying out this type of medical check-up for large groups.

Such an orientation would provide sufficient technical resources to cover all the needs of the UNS centres, including its day-to-day medical support component. This is an interesting solution, perhaps the most relevant one, although no time should be wasted in studying its contours, as the medical service is scheduled to begin as early as September 2018. However, for the time being, it does not seem that any consideration has been given to dedicating a share of the 40,000 health students to any SNU mission.

With regard to infrastructure, the issue will be simpler once the nature of the UNS centres is known. However, when choosing locations, it will be necessary to bear in mind the need to have premises for a medical service for consultations and the creation of a biomedical chain and an emergency reception structure.

With regard to equipment, the services of the Directorate for the Supply of Health Products to the Armed Forces have a high level of expertise that makes it possible to equip the medical facilities that would be dedicated to the SNU centre at the best possible price.

Setting up human resources, building infrastructure and supplying health equipment are obviously subject to an essential prerequisite: the allocation of the necessary budgetary resources. But this is another matter!

Here, hastily put on paper, are some thoughts on the medical aspect of the future universal national service. In writing these lines, the author has made the deliberate choice to consider that this service will actually be implemented with a contribution from the armies. For the time being, the information available on the subject is so fragmentary that it only allows us to open up, blindly, avenues for reflection, while hoping that the commissions responsible for studying the various aspects have not waited to look resolutely at its important medical and health aspects. Indeed, the experiments announced for 2019, with a presentation of the recommendations in the spring of 2018, leave little time to measure the implications of the choices in this field of health and to stop the generic economy.One of the objectives assigned to the future national service by the President of the Republic is to carry out a systematic health check-up for the 18 to 21 age group.

Title : Some considerations on the medical aspect of the universal national service
Author (s) : MGI (2S) Raymond WEY