Military Medical Assets as Counterinsurgency Force Multipliers: A Call to Action

Abstract

The U.S. military is likely to increasingly engage in Counterinsurgency (COIN) warfare.  Despite the successful integration of medical engagements into civil-military COIN operations by Special Operations Forces, such engagements have not been widely pursued by conventional medical assets.  The authors present a rationale for rethinking the role of conventional U.S. deployed medical assets in COIN operations.  Recommendations are made regarding medical engagements in a COIN environment with the aim of turning conventional medical assets into COIN force multipliers.

Introduction

Insurgencies represent the predominant form of state-level conflict encountered in modern times. (Jones 135-8)  Correspondingly, the United States’ Armed Forces are increasingly involved in counterinsurgency (COIN) operations.  In COIN warfare, the popular indigenous support of a legitimate government is the ultimate goal while the restoration of basic services to the contested populace is central to mission success. (Headquarters, Department of the Army, Jones 49-50, Kilcullen 10).  Conventional U.S forces have limited doctrinal guidance in the execution of modern COIN missions, as these forces are designed and trained to fight orthodox kinetic battles.  Both existing military doctrine and the consensus of civilian COIN experts agree on the high priority of civil-military operations in the COIN environment.

Health care is a fundamental societal service which, when properly provided, can lend legitimacy to the agency or individual providing it.  This is especially true in rural areas, which tend to be underserved by the government and are preferred havens for insurgents to foment discontent within the population. (Jones xiii-iv)  It thus stands to reason that health operations should be of vital interest to those forces opposing an insurgency in rural areas.  There is no current conventional U.S. military doctrine for the application of military medical assets in COIN warfare, however further medical involvement in COIN operations has been suggested as having the potential to yield great dividends in the broader COIN battlespace. (Bryan, Jones 100, Keenan). 

U.S. Special Operations Forces (SOF), particularly those of the U.S. Army Special Forces, count civil affairs as one of their core disciplines.  Historically, these elite units have applied their medical assets in support of their civil affairs missions.  They have fielded programs designed not only to provide direct medical care to the population of a contested area but to build indigenous capacity to provide care, meeting a central principle of civil-military operations in COIN.  The medical assets available to SOF units are typically limited to small clinics with one or two physicians and a small number of combat medics.  SOF commanders wishing to utilize medical assets as an integral part of their COIN mission do not have authority over larger medical units deployed in support of conventional forces within the same COIN battlespace.  With the prevalence of U.S. involvement in COIN likely to increase, conventional medical planners should develop doctrine for leveraging conventional medical assets to directly support the COIN mission, reflecting on a larger scale what SOF have historically accomplished.

Where We Are

Conventional U.S. military medical assets are deployed to an operational theater along with combat forces, and remain in place as long as the conflict continues and servicemembers are in harm’s way.  The primary mission of such assets is to treat battle casualties and non-battle injuries and illnesses occurring among friendly force personnel.  The motto of the U.S. Army Medical Department is “To conserve the fighting strength,” and medical operational doctrine is limited to this mission.  COIN conflicts tend to be protracted and relatively akinetic (producing fewer serious casualties than conventional operations) however, resulting in the relative underutilization of considerable medical resources if doctrine is strictly followed. 

When conventional medical forces have engaged in civil-military relations with indigenous populations, it has typically been in the form of Medical Civic Action Programs (MEDCAP’s).  These are a means of humanitarian assistance in which primarily U.S. providers offer direct health care to host nation civilians on a time- and resource-limited basis.  MEDCAP’s as such do not meet the central COIN objective of increasing indigenous health capacity in the name of the legitimate government.  In fact, MEDCAP’s have been suggested to be counterproductive in COIN operations for two reasons; first, the provision of care by U.S. military personnel is transient, creating resentment when we are no longer there to provide care or cannot provide the “miracle cure” that was envisioned by the local patient.  Second, it suggests that local host nation capabilities are lacking, thus undermining popular confidence in the indigenous health system and decreasing government legitimacy as a provider for the population. (Rice)  A U.S. military physician and a few medics can go into a village and hand out a lot of medications over the course of a day, but who will be there in a month to check on blood pressures and what does U.S. medical presence say about the capabilities of the local government clinic to care for the people?

Lack of synchronization of military medical missions and objectives with other agencies charged with civil affairs in COIN operations is another current problem.  Provincial Reconstruction Teams (PRT’s) arose from the evolving COIN missions in Afghanistan and Iraq, but these teams had little or no intrinsic medical role applicable to their reconstruction missions and little to no coordination with (often co-located) military medical assets. (Thompson)  Additionally, the U.S. military has been slow to synchronize its medical diplomacy efforts with those of Non-Governmental Organizations (NGO’s) in modern COIN operations.  This discrepancy exists despite increasing security, considered a prerequisite for the broader application of NGO’s in COIN. (Jones 130-1)  NGO participation can ensure the sustainability of military medical assistance, even after U.S. forces redeploy.  The U.S. military can deliver the generator to power the hospital, but who will ensure that it has fuel and remains in good repair when the host nation stands alone?

Where We Should Be

U.S. military participation in foreign COIN campaigns is likely to continue into the foreseeable future.  It is time to rethink the role of conventional military medical assets in COIN operations while simultaneously allowing them to maintain continuous readiness to support their primary mission of caring for friendly force casualties, injuries, and disease.  Using SOF medical engagements as a model, we advocate for the development of doctrine that turns conventional medical assets into COIN force multipliers by leveraging physical plant, materiel resources, knowledge, and skills to perform medical engagements within the indigenous health care system.  Such engagements should consistently and solely be geared towards increasing the legitimacy of the supported government by promoting increases in indigenous health care capacity.  We present four critical themes that have guided such engagements and have proven successful in SOF COIN medical operations.

Civic engagement with indigenous health resources and key leaders

Placing “locals in the lead” is key to the success of any civil-military operation in COIN. (Jones 88)  Close collaboration between host nation and U.S. military medical providers allows for the development of the relationships and interactions that characterize COIN success. (Kilcullen 37)  For medical COIN missions to succeed, early and frequent interaction with personnel within the indigenous health sector must occur.  Any medical operations should address specific health needs identified by local community members during a cooperative needs assessment process.  Planners should take care to ensure that popular expectations are reasonable, as a broken promise can be worse than no promise at all in COIN. (Kilcullen,47) 

By proactively engaging local leaders, SOF medical teams have successfully leveraged their assets using the above model.  One example is an indigenously-led targeted community education program known as the Medical Seminar (MEDSEM). (Alderman, Irizarry)  Additionally, the authors have participated in frequent medical key leader engagements at the district and provincial levels in Tarin Kowt, the capital of Uruzgan province Afghanistan.  Normalizing of leader relationships allows the targeting of training and aid programs to needs that can be most sustainably met in the community.  

Recommendation: Conventional military medical personnel must engage leaders from the indigenous healthcare sector and establish relationships to guide planning and execution of civic medical interventions.

Development of training programs for local healthcare providers

Knowledge and skills are the most powerful assets that conventional military medical units can leverage to become COIN force multipliers.  Training should be tailored to the conditions in which indigenous providers will practice to impart skills and techniques that will result in progressive local capacity increases.  Whenever possible, only indigenously available equipment should be used to train local providers.  Direct medical humanitarian assistance, even when provided on a large scale, is rarely sustainable – donated medications run out, treatment supplies are exhausted, and equipment breaks or requires specialized technical maintenance unavailable locally.  Training providers from the local health sector in response to specific knowledge and skills deficits assessed through civic engagements is also the most sustainable method of increasing indigenous healthcare capacity in COIN.  Properly designed and executed medical training programs allow for increases in the capacity of the civilian and military healthcare sectors, lending legitimacy to both the civilian government and its armed forces. 

SOF-led training programs for civilian healthcare providers have used the MEDSEM model in a rural area of the Philippines, where medical self-reliance was promoted by educating large numbers of indigenous healthcare providers in primary care. (Alderman)  In Tarin Kowt, Afghanistan, the authors’ unit hosts a program in which a rotating group of physicians, nurses, and anesthetists from the local provincial hospital live and work at our small facility learning to care for and acutely ill and injured patients from Uruzgan and nearby heavily medically underserved districts.  The providers are paid by the U.S. military for their participation in exchange for a commitment to remain working in the local hospital following their graduation from the three-year program.

Standing up indigenous partner forces is typically the rate-limiting step in planning withdrawal from a COIN theater of operations.  SOF military medical assets successfully increased the capacity of host nation military medical units to care for their own casualties, contributing to overall COIN mission success.  A MEDSEM-type program instituted in Kabul, Afghanistan to educate Afghan National Army (ANA) medical personnel resulted in sustainable improvements in capacity. (Irizarry)  The authors’ unit participates in weekly didactic and practical casualty care training with ANA conventional and special operations forces.  This has resulted in greater partner force casualty care autonomy, hastening the transfer of care to partner force providers and reducing reliance on coalition medical assets.

Recommendation: Training programs for indigenous healthcare providers should be instituted by conventional medical units deployed in COIN operations.  Programs should maximize use of local resources and tailor to local healthcare conditions.

Agreements for transfer of patients between local and military medical facilities

In medically underserved rural areas in the COIN environment, a deployed U.S. military medical unit’s resources and capabilities may far exceed those of the host nation.  Directly providing medical care to the indigenous population can be advantageous, though enthusiasm should be tempered with the limitations of MEDCAP’s outlined above.  The direct provision of medical care has been demonstrated to be a very effective method of gaining the support of the contested populace and developing actionable intelligence. (Jones 100, Keenan)  It does not lead to the goal of sustainable increases in indigenous healthcare capacity, however.  Sustainability can be produced through patient care training programs offered by the U.S. medical unit as described above and by collaborative, progressive patient transfer agreements allowing for maximal participation of local healthcare assets.  Such agreements should be flexible to allow for increasing local national care as indigenous capabilities increase.  Over time, reliance on U.S. military medical assets must decrease.

The author’s small forward-deployed surgical unit has a strong relationship with the medical director and the medical staff of the Tarin Kowt (provincial) hospital.  We accept patients in transfer with needs that exceed the available resources at the local hospital and provide acute care for (typically surgical) disease at our facility.  These patients provide training experiences for our resident local medical providers and are transferred back to the local hospital as soon as feasible.  Over time, we have noted fewer and fewer transfer requests from the local hospital and increased confidence and ability to care for serious injury and illness there.  Additionally, there has been increasing participation of local providers not affiliated directly with the training program, multiplying its impact on the healthcare in the community.

Recommendation: Conventional military medical assets should develop relationships with indigenous healthcare facilities for reasonable patient transfers when local capabilities are exceeded.  The care of such patients should be part of a training program for local providers and overall reliance should decrease over time as indigenous capabilities increase.

Coordination with PRT’s, NGO’s, and other government agencies

U.S. military medical units will likely not be deployed for the entire duration of COIN conflicts, which typically last for decades. (Jones 10)  Whatever participation these units have in the COIN civil-military programs will therefore be transient in view of the entire conflict.  Civilian NGO’s and other U.S. governmental agencies will likely have longer-term involvement with indigenous health system reconstruction than will the military.  For this reason, military programs should be synchronized at the strategic level with the activities of these other actors to best facilitate seamless transition of reconstruction efforts.  PRT’s, NGO’s, and other actors may be performing community healthcare interventions in the same area and at the same time as military assets.  Synchronization is required to address this issue at the tactical level to avoid duplication of effort and to present a unified front to the effort as viewed by the local population.

Coordination and communication with key medical leaders from the Uruzgan multinational military team and the PRT have been critical to the success of COIN medical engagements performed by the authors’ unit and the local PRT.  The PRT in our area is responsible for provincial midwifery and children’s health initiatives while our military unit is responsible for hospital and trauma care.  Regular meetings of key leaders from both groups have avoided unnecessary duplication of effort and have provided additional medical intelligence to enhance independent needs assessments of indigenous capacity.

Recommendation: Military medical interventions in COIN should be performed in concert with NGO’s, PRT’s, and other agencies operating in the same area.  Operations should be synchronized at the strategic and tactical levels.

Conclusion

It is time to rethink the role of conventional U.S. military medical assets in COIN operations. These assets are currently underutilized, but by following the model of successful SOF medical engagements they can become COIN force multipliers; simultaneously maintaining readiness to care for friendly force elements.  We make the following recommendations for operational planning:

·       Engage with key leaders of the indigenous health sector

·       Establish tailored training programs for local healthcare providers

·       Develop patient transfer relationships with local facilities

·       Coordinate at all levels with nonmilitary agencies

Acknowledgements

The authors wish to acknowledge the operational support and editorial assistance of Commander Mike Hayes.  This paper and our efforts to get deployed medicine involved in COIN are dedicated to everyone in the armed forces who have tried to help those in need.

References

Alderman S, Christensen J, Crawford I. Medical Seminars: A New Paradigm for SOF Counterinsurgency Medical Programs. Journal of Special Operations Medicine Vol 10, Issue 1, Winter 2010.

Becker T, Link M. Medical Rules of Engagement Negative Patients: the Dilemma of Forward Surgical Teams in Counterinsurgency Operations. Journal of Special Operations Medicine Vol 11, Issue 2, Spring 2011.

Bryan AR, Field Hospital Support for Civilians in Counterinsurgency Operations. Military Review July-August 2009.

Irizarry D, Tate C, Wey PF, Batjom E, Nicholas TA, Boedecker BH. Advanced Medical Technology Capacity Building and the Medical Mentoring Event: A Unique Application of SOF Counterinsurgency Medical Engagement Strategies. Journal of Special Operations Medicine Vol 12, Issue 1, Spring 2012.

Headquarters, Department of the Army. Counterinsurgency (Field Manual 3-24). Boulder, CO: Paladin Press, 2006.

Jones S. Counterinsurgency in Afghanistan. Arlington, VA: RAND Corporation, 2008.

Keenan S. Role of Medicine in Supporting Special Forces Counter-Insurgency Operations in Southern Afghanistan. Journal of Special Operations Medicine Vol 7, Issue 1, Winter 2007.

Kilcullen D. Counterinsurgency. New York, NY: Oxford University Press, 2010.

Rice MS, Jones OJ. Medical Operations in Counterinsurgency Warfare: Desired Effects and Unintended Consequences. Military Review May-June 2010.

Thompson DF. The Role of Medical Diplomacy in Stabilizing Afghanistan. Defense Horizons No. 63, May 2008.

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Comments

Gentlemen,
Thank you for your outstanding article. I thoroughly appreciated your emphasis on relationship development, because that is where the rubber meets the road in counterinsurgency medical engagements. A relationship denotes commitment. Indigenous communities and their host nation health systems are looking for that commitment and they are keenly aware when it is absent. Given this, any force (conventional or SOF) must first evaluate their operational and temporal ability to commit to relationship development. If they are unable to commit, alternative, non-medical means of engagement should be considered. Fortunately, relationship development aligns with command lines of effort during counterinsurgency operations, so unit medical advisors should be able to promote health improvement through relationship development.

The first step in building a committed relationship is earning confidence. You might capture a few “hearts and minds” with a traditional MEDCAP, but you won’t earn their confidence. My previous Battalion Commander, LTC(P) Brian Petit once told me: “The key to victory in COIN is not about winning hearts and minds. They are short-sighted and easily swayed. The key is winning the confidence of the people. Confidence in their own government to provide, govern and secure its people.” The MEDSEM concept works because it promotes confidence through a long term, relationship developing strategy. During the MEDSEM process, relationships are also nurtured with the host nation medical officials and NGOs who will ultimately provide real longevity to the health improvements. Again, I enjoyed the article and appreciate your efforts to spread the word.

MAJ Shawn Alderman
These comments represent my own opinion and do not represent the views of the US Army or any organization/unit.

Excellent article! The USAF Medical Service has been utilizing conventional military medical assets, Active, Reserve and Guard, to conduct international health engagements via 2 programs: The International Health Specialist (IHS) program and the Defense Institute for Medical Operations (DIMO). These programs embrace 3 of the 4 critical themes you mention to various extents, with the exception of theme 3, and have supported SOCOM on various initiatives. IHS is primarily involved with relationship building and highly effective humanitarian assistance programs such as PACIFIC ANGEL. IHS has teams that directly support each geographic command and SOCOM fulltime. DIMO's mission is to support the Defense Security Cooperation Assistance (DSCA) capacity building programs by engaging international partners with trainer-of-trainers (TOT) programs on trauma surgery, first responder, mass casualty, etcetera. While their target audience is not specifically indigenous populations, they have on many occasions engaged them and have done so since at least 2002.

Gentlemen,

Thanks for the article and the update on the medical training program in Tarin Kwot. When I arrived at TK in the summer of 09 as the Special Operations Surgeon, I found the CJSOTF FST essentially providing direct trauma and surgical care for the Provincial hospital without any training or development of the indigenous systems. Over the next several months, and with the support of the FST Surgeons, we transformed it into a teaching laboratory that trained the local physicians and provided care to the civilian populace in support of our VSO operations. It is great to get some feedback on the continuation of the program; thanks for the feedback and for your hard work.

The teaching program using the FST was built upon the principle that effective security forces require competent, reliable and capable medical support to support security operations. What security officer, military or police, is going to provide effective patrolling and risk-taking if there is no medical back-up or support? The teaching program focused on developing trauma resuscitation teams (one physician, one anesthetist, one nurse) that would train side-by-side our FST to develop the skills of doing this for themselves.

While I agree with the general call for the use of the larger military medical forces as technical units that can facilitate medical training, I propose that those interventions should be tied to security development. As you know, the medical needs in stability/COIN environments can be overwhelming. Focusing military health development on security supports the larger COIN strategy and will have spill-over effects for the civilian populace. For police or constabulary forces who receive their care through the civilian health sector (similar to the U.S.), this also provides the justification for engaging with the civilian health sector that will be providing initial care, evacuation and stabilizing care.

Teaching and training, in my opinion, are the path to success. When direct care to civilians by U.S. military is needed, it needs to be accompanied by concurrent development of indigenous capability. Medical professionals in host countries understand the value of education, and we can leverage our medical education and training. If we can improve the care to those injured while performing their security duties, our medical efforts can support the security development effort.

One more question for the group:

What have studies shown in terms of how counterinsurgents (NATO and ISAF) view the efficacy of such activity? Anecdotally - I am not in the military - I've heard positive and negative reviews of medical missions, the negatives along the lines of "it was nice but handing out medicine didn't do anything." Just curious how such activity is viewed by returning military and veterans? I suppose each individual experience is different.

While I agree with the general call for the use of the larger military medical forces as technical units that can facilitate medical training, I propose that those interventions should be tied to security development. As you know, the medical needs in stability/COIN environments can be overwhelming.

What an interesting comment. I was wondering how various medical programs "tied up" with larger objectives. I suppose in each case it's different. How to support a mission with medical objectives without becoming overly diffuse and allowing mission creep to set in? (In the counterinsurgency literature, it seems to me that larger claims about various activities increasing stability veer into overconfidence in the ability of outsiders to socially engineer away security issues....)

In counterinsurgency, what are the potential settings within which such missions take place? Something like the following?:

1. Micro level - intelligence, bonding with local people and leaders, countering insurgent propaganda
2. Macro "countrywide" level - part of creating or strengthening a security force, if that is a reasonable part of a larger strategy

Outside counterinsurgency:

1. Humanitarian assistance
2. One aspect of military-to-military relationships

And so on.

The development of military medicine this past decade or so has been stunning. The few lectures I've attended on the topic have blown me away, frankly.

Nice read. Thanks to the authors.

The topic has been discussed in the following Council thread:

http://council.smallwarsjournal.com/showthread.php?t=15619

Ever the skeptic, I note in the thread that the literature (at least from my haphazard review) seems mixed and that medical operations seem to run the gamut from helpful to possibly harmful to the local population and that such operations may or may not contribute to the overall goal of creating a connection between the people and the government.

I also found a lot of papers that were essentially "case reports" of a particular medical operation but few that put the medical work within the larger context.

Anyone reading able to provide such references? I had a librarian do a search for the previous thread but we didn't come up with much. I'm not sure why?

This is an interesting area of study. Really enjoyed the paper. Again, thanks to the authors.

Update to comment: I forgot to mention this, but before a "call to action" what does the history of medical operations within a military stabilizing environment show? This is the part that confuses me, I can't get a good sense from the literature. I'm sure the fault is mine, this is a new area to me.

David/Tucker: request permission to reprint and use with the course we teach here: Maritime Civil Affairs. Would incorporate with professional readings program. Selected students would read and report on this article in open forum during classroom time.

tomkinton at g mail dot com

thanks

Tom,

If you return to this thread: it would be interesting to see what your students do with the topic (and some of the questions I posed above in my second comment.)

Tom,

If you check the Creative Commons Licence it states: 'You are free: to Share — to copy, distribute and transmit the work'.

Link:http://creativecommons.org/licenses/by-nc-sa/3.0/

I am not a copyright lawyer, but understand that SWJ owns the copyright under the Licence; so as long as the source is made clear you can use this in class.