Small Wars Journal

Security and Defense Medicine in a New Age of Policy

Wed, 07/19/2023 - 10:43am

Security and Defense Medicine in a New Age of Policy


By Michael R. Hetzler


Security and defense medicine is about to shift into high gear, or instead, it should. Two new and identified security policies are now past the conceptual phase and are being implemented across Western nations, democracies, and alliances.1 Strategic competition (SC) and irregular warfare (IW) will now shape international affairs, diplomatic engagement, and crisis management for at least two decades. Both policies are based on principles of competition, influence, and deterrence below the threshold of war while still preparing for war.


With these policies, guidance has been directed to change our fundamental perspectives of engagement. These approaches are employed as “an enduring condition to be managed, not a problem to be solved.”2 To be successful, these policies require integration of all actors on the world stage, national, allied, partner, and even non-state actors such as nongovernmental organizations (NGOs) and even multi-national corporations.3,4


So what? Operational medicine requires an identical change in its approach, application, and execution. All traditional and doctrinal military norms are being upended, not just by peer or near-peer adversaries but by the technology that can now be used as tools of warfare. The ‘Age of Technology’ has changed every aspect and environment of diplomacy, warfare, and social interaction. While those disciplines redesign and reconstruct to remain instruments of value, so must the support services to them.


The value of medicine and the mitigation of death and loss in our recent low-intensity conflict against terrorism and counterinsurgency is unequaled in history. That success is also likely to be unequaled in the future. Every analysis, every perspective, and every realistic conclusion finds that the support structure, resources, and reactivity of medical care in the last twenty years will likely never be replicated again. Future control of the battlefield, superiority, risk balance, and tolerance will be unfeasible and unrealistic in comparison. Ukraine, although an enigma, has proven that assessment beyond doubt.5


History repeats itself. After another transitional period of stability and security, the dynamics and contest have changed “in the great game.”6 Just as peace was won in 1945, another struggle emerged. Moving past our relative victories over extremism, we now find consequences on the world stage after being so narrowly focused for so long. Strategies of competition and irregular warfare, or irregular activities, will now mirror the Cold War policies of nuclear deterrence and containment of communism. The duration of this global struggle in values and norms may very well replicate the five decades of the Cold War.


With the re-emergence of geopolitics and the age of technology, the conflict continuum can be traversed and undermined, with the present nature of warfare remaining under the threshold of conflict.  Our adversaries already see themselves in conflict with the West and are waging campaigns to achieve their national goals.


Strategic competition is the most recent, and likely the primary, policy to be educated and directed. Late in evolution, compared to IW, its primacy for execution and potential in intent demands its priority in consideration. A “persistent and long-term struggle that occurs between two or more adversaries seeking to pursue incompatible interests without necessarily engaging in armed conflict with each other.”


In strategic competition, medicine must begin considering new and novel health service support approaches, such as applying near abroad medical strategy instead of expeditionary medicine. Coordinating and advocating for medical development in nations and partners of benefit and potential and utilizing assets outside of governmental control for a community benefit of effect. We must do this while the global healthcare working force is decreasing and confidence in medicine is challenged. In fact, medicine is actually identified as a sub-arena of strategic competition, although further buildout for our professional function has yet to be achieved.


Irregular warfare requires the legitimate impact of relevant actors through indirect, non-attributable, or asymmetric activities.7 Other international organizations, such as NATO, maybe describe this more accurately as irregular activities. Arguably a natural platform for hard power such as military activities or the employment of special operations.8 For medicine, we must look at the policy verbiage for the potential medical impact.


In irregular warfare, begin considering the potential, and not our presumption of, medical relationships with international and nongovernmental organizations, nonprofit efforts, and even non-state actors to find efficiency, economy, and synergy of effect. Using all tools in collaboration and coordination to the best potential reduces the workload and waste of all. Allied interaction and learning, the creation of new associations and avenues of partnerships, is where medicine finds its most significant economic and efficient potential.9


To remain entrenched in our comfort zone while gripping the crown of recent casualty success negates our value to policymakers, diplomats, commanders, and ultimately, to our citizens and their future. The scope, scale, and depth of medicine must meet the scope, scale, and depth of security and defense. To provide medicine in pace with strategy and policy instead of keeping up with operations. Otherwise, civilians and the military may suffer and perish due to idleness and disregard.


We must look at more than just the concept of medical operations in security and defense. We must consider, evolve, and embrace an idea of strategic medicine to support strategic goals. We must be able to think and campaign strategically to effectively deploy medical force multipliers in support of established strategic objectives. Educate yourself and the force in this scope and at this level for these concepts – inarguably uncommon for our profession.10 Understand the strategic environment and begin to develop and add structure for the future. Engage with every medical actor on the global scale and change how you see them both in their efforts and how combined efforts can find synergy and effect. Contract medicine, allied medicine, nongovernmental medicine, host nation medicine, and offset medicine all must be assessed and developed for needed battlefield effects. Force multipliers in civil-military relationships and partner nation development must all work to provide more accessible options and solutions to the greater cause.


These new security policies, ultimately, can be described as the human domain. For most nations on earth medicine is part of their social structure; for most nations on earth, medicine is in deficit, and the new generation of most nations sees medicine as a fundamental human right. These all may sound like, but are opportunities for universal security and civil benefit. Medicine is a celebrated soft power; let’s yield it with strategic and human effects.


The views expressed are those of the author(s) and do not reflect the official position of the Department of Defense, NATO, or the views of the University College Cork.


  3. Crafting Strategy for Irregular Warfare: A Framework for Analysis and Action (2nd Edition) > National Defense University Press > News Article View



About the Author(s)

SGM (R) Michael R. Hetzler served honorably for over thirty years in the United States Army, retiring in 2016.  He presently lectures for the University College Cork, Security and Defense Medicine department in Ireland and serves as the program manager for NSHQ medical education efforts.