Mason H. Remondelli
This piece was selected as a finalist in an essay contest co-sponsored by IWI and the Joint Staff J7 Office of Irregular Warfare and Competition (OIWC). Due to the nature of the contest, this piece is published with only minimal inputs from our editorial team. The views expressed do not represent the position of IWI or the US Government, including the Joint Staff J7 OIWC.
For the past twenty years, the US military has been performing counterinsurgency operations in the Middle East against an ambiguous, evasive, yet enduring adversary. The global war on terror was distinguished by its reliance on small-scale, unconventional warfare in which the United States wielded full spectrum dominance in all domains. The military adapted its doctrinal capabilities to defeat the enemy within this dispersed operational context, which also included changes to medical trauma systems that provide combat casualty care. Specialized medical teams’ ability to provide advanced surgical support in this battlespace was enabled by the unopposed aeromedical and tactical evacuation of wounded service members within the golden hour—the period of time after a traumatic injury during which medical intervention is most critical. Unfortunately, this relative luxury is unlikely to endure.
As policymakers shift their attention toward great power competition, however, this luxury likely will not be obtainable in a large-scale, conventional force-on-force fight due to the anti-access/area denial (A2AD) capabilities of Russia and China. A conventional large-scale combat operation against a technologically comparable adversary will also generate substantial combat casualties for US service members and create the need for prolonged-casualty care in a denied, hostile operational context.
To address the challenges in combat casualty care elucidated by a theater-wide distributed multi-domain environment, policymakers and military leaders should establish irregular warfare trauma systems and covert medical intelligence networks to increase the US medical sphere of influence. Asymmetric approaches to combat casualty care and medical intelligence would facilitate military force regeneration and adversarial combatant deterioration, and it would enable the United States to compete and prevail in a prolonged contest against revisionist powers.
Guerrilla Trauma Systems as a Tool of Irregular Warfare
During a period of great power competition and, potentially, conflict, military force sustainment and combat casualty return-to-duty will be paramount to erode adversarial warfighting functions, decrease revisionist global influence, and diminish the enemy’s motivation to fight. Even as the robust A2AD capabilities of competitors such as Russia and China exacerbate the challenges of casualty care and medical evacuations, the United States can establish irregular warfare trauma systems within potential areas of geostrategic contest as a framework for proactive national defense.
The creation of guerilla trauma systems within austere, expeditionary areas key to operational success would need to involve special mission units and special operations forces augmented by special operations medical teams. Such irregular warfare groups, explicitly trained in these mission sets, must locate, evaluate, and influence indigenous populations to assist the United States in its medical care objectives. The selection of indigenous guerilla trauma networks should comprise diffuse, decentralized localization of overlapping battlespaces to provide optimal casualty care at dynamic medical decisive points throughout the constantly changing multidomain environment. Once these indigenous medical groups are identified and assessed, irregular warfare units would emphasize the doctrinal teaching of battlefield medicine, including tactical combat casualty care, damage control surgery, medical evacuation, and trauma systems communication.
Constructing a network of guerrilla trauma systems will allow for pre-hospital treatment of combat casualties far forward on the battlefield by providing life-saving surgical and resuscitative care. Having guerrilla trauma systems installed antecedent to denied, hostile environments will enable continuous on-the-ground medical situational awareness, prolonged-casualty care, and the expeditious movement of casualties, resources, supplies, and personnel through underground resistance support structures. The development of guerilla trauma systems through irregular warfare activities likely will decrease combat casualty mortality, which is vital to force regeneration in the context of large-scale, perpetual strategic competition with states such as China and Russia.
Clandestine Medical Intelligence Networks
To maintain control of the operational environment, the United States should expand its clandestine and irregular warfare medical intelligence networks in areas of geostrategic importance. The implementation of irregular warfare medical intelligence lattices within indigenous and foreign countries will facilitate the gathering, analysis, and assessment of revisionist military medical capabilities. Irregular warfare and clandestine medical intelligence networks will provide key information to understand adversaries’ trauma care clinical practice guidelines, casualty and tactical evacuation protocols, medical resupply logistics, and medical personnel training. By acquiring, integrating, and examining adversarial medical protocols, the US military can exploit weaknesses within enemy medical capabilities and technology.
Covert pursuance of enemy medical intelligence—including tracking the movement of blood products, construction of field hospitals, and tactical evacuation and transportation routes—will allow for the penetration, exploitation, and disintegration of enemy troops in a denied, contested battlespace. Understanding where the enemy will build field hospitals, concentrate medical supplies, and array battlegroups before such actions occur will permit the United States and its allies to preposition long-range precision fires, mass conventional ground forces, and disrupt enemy resupply and evacuation lines. Employing irregular warfare capabilities to increase medical intelligence assets will subvert enemy combat power, dampen logistical resupply capacity, and diminish force-strength sustainment, while simultaneously enhancing combat casualty care, reducing friendly casualty numbers, and increasing the force recovery of the US military.
Psychological and Information Operations
Psychological operations and covert medical information campaigns will be critical tools in the campaign to destabilize revisionist powers. Subverting behaviors of adversarial combatants and foreign civilians through medical psychological and irregular warfare will diminish morale and reduce the will to fight. To accomplish this, the US military should create irregular warfare medical psychological processes that select tangible areas of enemy and foreign citizen vulnerabilities. These medical psychological domains can include broadcasting enemy combat casualties to target the cognitive and emotional systems of adversarial warfighters and sharing casualty totals on Russian and Chinese social media platforms to undermine civilian trust. Controlling the narrative of medical psychological operations throughout the battlespace will enable the United States to shape and influence the motives, behaviors, and reasoning of enemy combatants and civilians toward a favorable US outcome. Reducing adversarial motivation to fight would give the US military opportunity to gain a physical and psychological advantage, which in turn would reduce friendly combat casualties and increase force sustainment for an elongated conflict.
Covert medical and asymmetric warfare information campaigns will play an important role in the concealment of friendly medical logistics, casualty evacuation, and resupply missions. These efforts will be crucial to deceive Chinese and Russian military intelligence agencies from acquiring data that could be used by A2AD technology to destroy US or partner medical supply lines and to disrupt casualty evacuation processes. The ability to feign movement of medical supplies and casualty transportation will be critical for the force sustainment strategy of the United States in a prolonged force-on-force fight. Medical information operations will also be key in decreasing enemy knowledge of friendly blood product transfers and austere medical personnel activity, which are typically nested under and co-located with conventional ground forces. Psychological operations and medical information campaigns will allow the United States to overcome challenges of military force sustainment and combat casualty regeneration caused by Russia and China in the context of great power competition.
Strengthening the Global Medical Sphere of Influence
As US policymakers shift focus toward strategic competition with revisionist powers, increasing the global medical sphere of influence will be essential. To do this, the United States should develop irregular warfare guerilla trauma systems in geostrategic areas of operations that will be decisive in future conflicts. This will enable far-forward pre-hospital and prolonged trauma care to injured service members that will be necessary to overcome the casualty evacuation obstacles posed by the A2AD capabilities of Russia and China. The installation of covert or clandestine medical intelligence and information methodologies will be crucial to control the flow of information and to shape the operational context in a dispersed, irregular, and multidomain environment.
The future of warfare is assumed to be a conventional force-on-force theatre-wide combat operation with the use of land, air, naval, space, and cyber assets. Nested within this large-scale combat operation will be small, modular special operations forces and special mission units employed to undermine enemy command and control, degrade decision-making capabilities, and dampen adversarial motivation to conduct further combat operations. Thus, the US military’s ability to sustain combat effectiveness through personnel force sustainment and recovery will be paramount. Strengthening irregular warfare combat casualty systems and enhancing medical intelligence networks, while simultaneously deteriorating adversarial medical logistical support through clandestine psychological operations and medical disinformation processes, will be crucial for overall mission success.
Second Lieutenant Mason H. Remondelli is an active-duty US Army officer and second-year medical student at the Uniformed Services University of the Health Sciences (USUHS) in Bethesda, Maryland. He graduated Magna Cum Laude from the United States Military Academy at West Point in 2021, earning a B.S. in Life Sciences with Honors and a Minor in Nuclear Science. As a medical student, 2LT Remondelli conducts research within the USU-Department of Surgery focusing on the advancement of austere battlefield medicine, medical intelligence, and prehospital combat casualty care for the future multi-domain environment. In addition to his medical education, 2LT Remondelli is pursuing a graduate degree in International Security through the Harvard University Extension School to bridge the gap between military medicine and security policy studies.
The views expressed are those of the author and do not reflect the official position of the United States Military Academy, Uniformed Services University of the Health Sciences, Department of the Army, or Department of Defense.
Image: US Army Reserve photo by Master Sgt. Michel Sauret.