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Health Security in the Indo-Pacific

A Modern Approach to Irregular Warfare

 

Lt. Col. Lauren M. Hamlin, U.S. Army

 

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The U.S. Indo-Pacific Command extends over one hundred million square miles of land and ocean territory. It stretches from the west coast of the United States to the eastern coast of Africa, it encompasses vast stretches of ocean, thirty-six countries, 3,200 different languages, and diverse religious, economic, and geopolitical viewpoints. It is home to over half of the world’s population and nearly two-thirds of its economy, along with seven of the world’s largest military forces; therefore, it is a pivotal area for ensuring the security and prosperity of the United States.

Due to the vastness of the Indo-Pacific region, numerous challenges plague the area, posing significant implications for global security. Governments in the Indo-Pacific grapple with natural disasters, resource depletion, internal strife, and governance issues (see figure 1). Furthermore, the People’s Republic of China (PRC) is leveraging its economic, diplomatic, military, and technological prowess to carve out a sphere of influence. This sphere of influence encompasses not only physical territories but also economic, political, and cultural ambitions that would solidify the PRC as a major global power with sway over various aspects of international affairs. At the same time, the Democratic People’s Republic of Korea is persistently expanding its nuclear weapon and missile programs, further compounding the security risks in the region.

The United States’ Indo-Pacific strategy, unveiled in February 2022, articulates a firm commitment to fostering an Indo-Pacific that is free, open, interconnected, prosperous, secure, and resilient.¹ Achieving this end state further necessitates not only bolstering the United States’ own engagement but also strengthening the region to make it unreceptive to competitors’ destructive influence. For instance, numerous states within the Association of Southeast Asian Nations (ASEAN) maintain robust economic relations with China; however, they also strategically hedge against China’s ambitions for territorial expansion by forging defense partnerships with the United States.² Therefore, considering these strategic dynamics, establishing future operations, activities, and investments focused on cooperation will be essential to realizing the U.S. Indo-Pacific’s strategic vision.

The COVID-19 pandemic underscored the potential of health security as a potent geopolitical instrument. Although it spurred unprecedented global cooperation toward a shared objective, it also required international organizations to orchestrate a unified response amidst strained relations. Countries with pharmaceutical industry hubs and robust healthcare systems capitalized on their capabilities to supply vaccines, medical equipment, and effective treatments to partners of their choosing. This strategic allocation of resources allowed them to bolster alliances, strengthen diplomatic ties, and assert their influence on the global stage. Therefore, health diplomacy and health security should be regarded as more than humanitarian aid and knowledge exchange. They are nonkinetic, nonprovocative tools capable of influencing populations and shaping geopolitics. Consequently, as international relation dynamics evolve, the integration of health cooperation efforts will be crucial for nations employing an irregular warfare strategy.

What Is Irregular Warfare?

The recent revision of the U.S. definition of irregular warfare (IW) places primary emphasis on its strategic objective: the erosion or establishment of legitimacy and influence. According to volume 1 of Joint Publication 1, Joint Warfighting:

IW is a form of warfare where states and non-state actors campaign to assure or coerce states or other groups through indirect, non-attributable, or asymmetric activities, either as the primary approach or in concert with conventional warfare. …

… The intent of IW is to erode an adversary’s legitimacy and influence over a population and to exhaust its political will—not necessarily to defeat its armed forces—while supporting the legitimacy, influence, and will of friendly political authorities engaged in the struggle against the adversary.³

In the era of globalization, safeguarding U.S. national security interests requires a comprehensive grasp of IW. Such insight empowers the United States to identify potential collaborative opportunities and adeptly shape operations, activities, and investments that foster mutual benefit and sustainability for partners. However, in the Indo-Pacific region, there exists a notable lack of consensus on the definition of IW among nations. Therefore, to effectively safeguard U.S. national security interests, it is crucial that the entire Department of Defense (DOD) comprehends the foundational definition and meaning of IW as understood by the United States and its allies and partners. Without this shared understanding, divergent perspectives could hinder the integration of health diplomacy and health security within the IW framework.

To facilitate shared language and understanding, the U.S. Irregular Warfare Center released a research report analyzing how IW is understood among U.S. allies and partners in the Indo-Pacific region. The study revealed that many nations predominately define and associate IW with domestic matters and instances of violence.

India: IW is seen as an asymmetric conflict between state and non-state actors (such as insurgents, guerrillas, terrorists, or violent extremists) aiming at challenging the legitimate political structure or overthrowing the government.

Philippines: IW is defined as armed rebellion, insurgency, violent extremism, and terrorism, along with the application of measures to prevent and counter them.

Singapore: IW is defined as a range of covert and overt activities conducted by non-state actors to challenge the sovereignty and erode the legitimacy of the state by expanding and deepening their influence and control of a population.⁴

The divergence in perspectives, coupled with the recognition of nonstate actors as participants in IW, underscores how the Indo-Pacific states closely associate insurgency and terrorism with their views of IW. Understanding this regional view is a critical first step as the 2020 Irregular Warfare Annex to the National Defense Strategy states that America will proactively employ IW capabilities as “means to help expand the competitive space, shape the environment, and prepare for escalation to conflict, if required.”⁵ Therefore, it is imperative that our partners grasp our perspective of IW and recognize it as a method to strategically position and create dilemmas without necessarily resorting to kinetic actions. Varying interpretations could lead to misalignment in strategic objectives and potentially hinder effective collaboration when addressing shared security challenges.

In a broader context, the United States must recognize the irregular dimension of great-power competition and counter adversaries through legitimacy and influence rather than solely relying on kinetic capabilities for deterrence. Conventional deterrence, which primarily focuses on matching force capabilities, assesses risk to the nuclear triad and adjusts military posture based on the “belief that the cost of action outweighs the perceived benefits” cannot alone counter the malign influence and predatory lending tactics employed by the PRC and Russia.⁶ For instance, in 2010, China extended substantial loans for the Sri Lanka Hambantota port’s construction, despite doubts regarding its economic viability. When Sri Lanka encountered repayment challenges, China renegotiated the terms, ultimately securing a ninety-nine-year lease on the port in 2017.⁷ This maneuver granted China significant control over a strategically situated port in the Indian Ocean, greatly bolstering its maritime influence in the region. In other words, the PRC strategically gained a significant advantage through irregular means, consistent with its long-term strategic objectives. Therefore, during great-power competition, the United States must consider the fundamental nature of IW, which involves creating dilemmas, escalating risks and expenditures for adversaries, and gaining a strategic advantage, as part of its multifaceted approach to counter adversaries; this includes the strategic domain of global influence.

One of the key means to exert global influence is through health diplomacy. Therefore, it must be integrated as a line of effort within IW campaigning. By addressing global health challenges, the United States and its partners can build goodwill, enhance their reputations, and gain influence among populations worldwide. While our competitors co-opt health diplomacy for malign purposes such as exploiting vulnerabilities, sowing discord, and undermining stability, the United States can leverage the power of health security as a potent tool to build partner legitimacy and garner influence during competition.

While variances in IW definitions presents challenges, recognizing the power of health cooperation to achieve IW objectives transcends regional differences. Adopting a cohesive, multidimensional approach to health security benefits both the United States and partners. Competing without kinetic fighting while simultaneously aiding a host nation in facing insurgency builds legitimacy within the population and ideally reduces the size of the population that joins the insurgency.

Contrasting Health Diplomacy Strategies

The Health Silk Road (HSR) is China’s health diplomacy strategy and a key component of its Belt and Road Initiative (BRI). China’s objectives are to dominate international health collaboration and position itself as the global leader in health. While the HSR has both positive and negative implications, its underlying motives are strategically targeted and closely align with the U.S. definition of IW. The initiative includes a spectrum of interests ranging from economic gains and diplomatic leverage to reputation enhancement, regional stability, and bolstering health security.⁸ The HSR, with its multilayered approach, places a primary emphasis on public health and international cooperation. While the HSR brings recognized benefits to the partner nation—including healthcare services capability and capacity, advancements in infrastructure, and capacity building—significant challenges and limitations persist, particularly in addressing issues of quality and sustainability. Often, initiatives mandate partnerships with Chinese enterprises and reliance on Chinese financial institutions.

This was particularly evident during the COVID-19 pandemic, when China prioritized distributing vaccines to countries within the BRI and those holding strategic economic or political significance, particularly those rich in natural resources. Another illustration is the financing and construction of Friendship Hospitals in Pakistan, Laos, and Cambodia.⁹ While these facilities do enhance partner capacity, they also come with significant partner-nation burdens from loans, sustainability, and maintenance. Despite providing humanitarian assistance, it’s essential to recognize that the primary objective of China’s HSR program, expanding export markets and positioning China as a dominant supplier of medical goods and services, is an IW tactic. Their strategic health pursuits align with China’s broader agenda of exerting influence, coercing, and creating instability to further its interests.

Moreover, while PRC’s HSR program exemplifies a utilization of health diplomacy for coercive geopolitical ends, Japan, a closely aligned ally, pursues a contrasting approach. Japan’s engagement in global health diplomacy reflects an adaptive response to evolving strategic dynamics. Initially, Japanese aid efforts, dating back to the 1950s, aimed to address the aftermath of World War II, including reparations for war crimes. With the resurgence of its economy in the 1980s, Japan’s foreign aid contributions surged, reflecting its commitment to global health initiatives. Japan prioritized diplomatic objectives through peaceful means, directing resources toward pharmaceutical research, infectious disease surveillance, and public health safety.¹⁰ While these efforts are categorized as soft power strategies, it’s worth noting that Joseph Nye, former U.S. assistant secretary of defense for international security affairs, believes effective foreign policy advocates for the integration of both soft and hard power—commonly referred to as smart power. Nye contends that true global influence stems from the ability to shape the behavior of others to achieve desired outcomes.¹¹ Therefore, the contrasting strategies between Japan’s health diplomacy, rooted in soft power, and China’s more coercive approach underscore the necessity of integrating health diplomacy to achieve effective and sustainable global influence.

In recent years, the United States has strategically invested in smart power initiatives, recognizing the importance of addressing global challenges while strengthening alliances worldwide. This approach aligns with efforts to promote global public goods, address public health challenges linked to climate security, and foster unity among allies. Given the imperatives of addressing climate change, collaboration with hard power remains essential, even amid competition. For example, safeguarding freedom of navigation in the South China Sea through the deployment of the U.S. Navy is crucial to upholding international norms and protecting shared interests. Rather than prioritizing a strategy centered on regime change, our objective should emphasize competitive coexistence within a rules-based international order that safeguards U.S. and allied interests. Sustaining alliances is pivotal for achieving strategic success in the face of evolving geopolitical dynamics. Therefore, as we navigate great-power competition, it is necessary to employ a combination of IW tactics and use health diplomacy to our advantage, reinforcing our commitment to global stability and security.

The U.S. Military Global Health Engagement Strategy

Under the U.S. health diplomacy framework, the Department of Defense plays a pivotal role in executing smart power efforts. Through global health engagements (GHE), the U.S. military advances national security objectives by engaging with international partners on health and medical initiatives. GHE initiatives serve to extend U.S. presence in various countries, cultivate and sustain partnerships, and reinforce mutually beneficial alliances that bolster the Nation’s paramount global strategic interests.¹² Essentially, GHEs diminish adversaries’ legitimacy while strengthening partner interoperability, capacity, and influence—a fundamental element of IW.

GHEs leverage a comprehensive array of health capabilities in military-to-military, military-to-civilian, or multinational operations. These activities aim to establish, revitalize, sustain, or enhance the capabilities of partner nations’ military, civilian health sectors, or pertinent governmental agencies such as the Ministry of Defense or the Ministry of Health. While health engagements constitute just one component of the IW strategy, their potency lies in their nonprovocative nature toward adversaries, rapid enhancement of public opinion, and effectiveness as a conduit for influencing the information domain.

In the Indo-Pacific region, the military landscape poses significant challenges, characterized by the presence of only five regional treaty alliances: Australia, Japan, the Republic of Korea, the Philippines, and Thailand. These challenges are compounded by major transnational issues such as glacier melts, rising sea levels, natural disasters, and governance challenges, which render many nations vulnerable. Health diplomacy and GHEs serve as foundational steps toward fostering trust-based relationships and should be employed to achieve IW objectives. GHEs include four primary categories: humanitarian assistance and foreign disaster relief, encompassing medical staff augmentation and donations of medical supplies through civic assistance programs; force health protection, aimed at advancing public health research and development initiatives; building partner capacity and interoperability, which includes training programs and knowledge exchanges; and nuclear, chemical, biological, and defense programs, focusing on collaborative threat reduction and disaster preparedness in conjunction with interagency partners.¹³ Successful utilization of GHEs necessitates a comprehensive approach that integrates these categories, tailored to the specific needs of partner countries and underpinned by predefined metrics to assess effectiveness in advancing strategic objectives.

A prime example of humanitarian assistance in action is the annual Pacific Partnership mission, a multinational endeavor led by the Navy. During these missions, military and civilian personnel from various nations and services converge to deliver vital medical assistance, facilitate infrastructure development, and provide disaster response training to communities across the Pacific. These efforts not only strengthen existing healthcare infrastructure but also foster interoperability among regional partners and enhance disaster response capabilities. GHEs like this are instrumental in achieving overarching strategic objectives, including the promotion of stability, the fortification of alliances, and the advancement of U.S. influence in the region. These objectives align closely with the core principles of IW, which seek to legitimize nations and address security challenges through collaborative approaches.

The biannual Indo-Pacific Military Health Exchange is a force health protection engagement that serves as a crucial platform for fostering collaboration and information sharing among military medical professionals in the region. Through this exchange, participating nations enhance their medical capabilities, share best practices, and build enduring relationships. This exchange not only promotes regional stability and security but also reinforces the collective capacity of Indo-Pacific nations to address health threats and humanitarian crises collaboratively. With over six hundred participants from twenty-six countries, this engagement provides an ideal environment for conducting bilateral discussions, establishing future partnership initiatives, and influencing future posture objectives.

In 2023, an innovative GHE initiative unfolded in Papua New Guinea, spotlighting efforts to bolster partner capacity and promote interoperability. A U.S. Army forward resuscitative and surgical detachment was dispatched to Papua New Guinea, seamlessly integrating into the operations of Port Moresby General Hospital alongside civilian physicians. This collaborative endeavor in the emergency department and operating room facilitated reciprocal learning and skill refinement. U.S. Army providers encountered complex polytrauma cases rarely seen in the United States, significantly enhancing their proficiency. Moreover, when viewed strategically, this engagement closely aligns with IW objectives, as the engagement effectively shaped public opinion within the information domain. Such GHEs not only offer invaluable training opportunities for providers but also underscore U.S. goodwill and dedication to supporting the local community. This engenders trust and fortifies resilience while counteracting potential adversary influence, culminating in a mutually advantageous outcome from both tactical and strategic standpoints.

The COVID-19 pandemic, the Ebola epidemic, and the rising malaria risk worldwide all underscore the profound impact infectious diseases have on society, highlighting the importance of biosurveillance and vaccine development. The United States maintains military medical research laboratories and satellite facilities across the Indo-Pacific in Australia, Thailand, Nepal, Singapore, Japan, the Republic of Korea, and the Philippines. These facilities collaborate closely with host nations to support GHE efforts, particularly focusing on nuclear, chemical, biological, and defense programs and emerging infections surveillance. For instance, many infectious disease vaccines trace their roots back to research conducted by Army medical research programs. Notably, the U.S. Military HIV Research Program continues to lead the global fight against HIV, with breakthroughs such as the RV144 vaccine trial, also known as the Thai Study, marking significant milestones in HIV prevention efforts.¹⁴ Similarly, research conducted at other U.S. military labs has contributed to the development of the RTS,S/AS01 malaria vaccine, now recommended by the World Health Organization for widespread use. These biological advancements serve as a form of health diplomacy, fostering goodwill and shaping military relationships, even amidst competition. Therefore, these laboratories are powerful soft-power tools that can be used to achieve IW objectives.

Importance of Assessment, Monitoring, and Evaluation

All security cooperation activities require robust monitoring and evaluation mechanisms, encompassing both qualitative and quantitative assessments. A 2018 RAND study emphasizes the significance of partner nations’ feedback, particularly regarding the quantity and consistency of aid. However, achieving true effectiveness necessitates first establishing a baseline assessment to understand partner capabilities, vulnerabilities, and preferences thoroughly.¹⁵ Furthermore, a comprehensive plan must be devised to outline how engagements will achieve specified outcomes, particularly if they are to be used in support of building legitimacy and furthering IW objectives. The DOD policy for assessment, monitoring, and evaluation, as outlined in DOD Instruction 5132.14, Assessment, Monitoring, and Evaluation Policy for the Security Cooperation Enterprise, underscores the imperative of monitoring and evaluating all security cooperation efforts as this practice fosters accurate and transparent reporting to key stakeholders on the outcomes and sustainability of cooperation initiatives.¹⁶

Given the inherent rigor in quantitatively defining metrics for assessing improvements in combined joint medical readiness, capacity building, and improving public opinion, the Indo-Pacific military health community has devised specific outputs for monitoring and evaluating health engagements. These outputs include blood sharing agreements, medical logistics posture, established health facility credentialing processes, and improved global health partnerships like the ASEAN Expert Working Group on Military Medicine (for example, see figure 2). The overarching strategic objectives are to facilitate trust building, enhance interoperability, and deter adversaries from transitioning to conflict. However, many policy documents lack guidance on effective implementation. Therefore, the Army in the Pacific has developed both quantitative and qualitative approaches to evaluate success. Though not flawless, these methods serve as a critical starting point and will hopefully guide future investment decisions and help evaluate how health security is supporting IW objectives.

Conclusion

The Indo-Pacific region, given its vast expanse and strategic significance, stands as a critical theater for ensuring the security and prosperity of the United States. Amidst numerous challenges and evolving geopolitical dynamics, the U.S. Indo-Pacific Command is tasked with navigating a complex landscape fraught with both conventional and emerging threats. As articulated in the Indo-Pacific strategy, fostering a region that is free, open, interconnected, prosperous, secure, and resilient requires a multifaceted approach that prioritizes collaboration with like-minded partners. In this endeavor, health cooperation emerges as a powerful tool, capable of exerting influence and shaping geopolitical dynamics without resorting to kinetic or provocative measures.

Health cooperation, which has traditionally served as an avenue for humanitarian assistance, knowledge exchange, and partnership, has since demonstrated its potential as a nonkinetic, nonprovocative instrument capable of influencing public opinion and shaping geopolitics. Within the broader context of IW, health diplomacy and GHEs play an important strategic role. By addressing global health challenges, the United States and its allies can build goodwill, enhance their reputation, build legitimacy in partner nations, and influence populations worldwide.

As the United States navigates great-power competition in the Indo-Pacific, it must be prepared to confront the irregular challenges posed by adversaries and respond through a comprehensive government strategy of integrated deterrence. This means incorporating health diplomacy within the IW framework to enhance the strategy as a holistic security approach. By leveraging health cooperation initiatives, the United States can reinforce its commitment to global stability and security while advancing its interests. Through concerted collaboration with allies and partners, the United States must seize the initiative and harness the power of health diplomacy to shape the geopolitical landscape in the most consequential theater at the most consequential time.

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Notes

1. U.S. Department of State, Indo-Pacific Strategy of the United States (Washington, DC: U.S. Department of State, February 2022), 6.
2. Koh Ewe, “Is Southeast Asia Leaning More towards China? New Survey Shows Mixed Results,” Time (website), 2 April 2024, https://time.com/6962557/china-us-asean-southeast-asia-rivalry-survey/.
3. Joint Publication (JP) 1, Joint Warfighting, vol. 1 (Washington, DC: U.S. Government Publishing Office [GPO], 2023), II-7.
4. Sandor Fabian and Gabrielle Kennedy, The Conceptualization of Irregular Warfare in the Indo-Pacific Region (Washington, DC: Irregular Warfare Center, 13 February 2024), https://irregularwarfarecenter.org/publications/research-reports/the-conceptualization-of-irregular-warfare-in-the-indo-pacific-region/.
5. U.S. Department of Defense (DOD), Irregular Warfare Annex to the National Defense Strategy (Washington, DC: DOD, 2020), 7.
6. JP 3-0, Joint Campaigns and Operations (Washington, DC: U.S. GPO, June 2022), GL-9.
7. Shaoyu Yuan, “The Health Silk Road: A Double-Edged Sword? Assessing the Implications of China’s Health Diplomacy,” World 4, no. 2 (2023): 333–46, https://doi.org/10.3390/world4020021.
8. Ibid.
9. Ibid.
10. Hisashi Kato, Tim K. Mackey, and Yee K. Heng, “Japan’s Health Diplomacy: Projecting Soft Power in the Era of Global Health,” Global Health Governance 13, no. 1 (June 2019): 5–22.
11. Joseph Nye, Soft Power and Great-Power Competition: Shifting Sands in the Balance of Power between the United States and China (New York: Springer, 2023).
12. DOD Instruction 2000.30, Global Health Engagement (GHE) Activities (Washington, DC: DOD, 2017), https://www.esd.whs.mil/Portals/54/Documents/DD/issuances/dodi/200030_dodi_2017.pdf.
13. Ibid
14. Monica Vaccari, Poonam Poonham, and Genoveffa Franchini, “Phase III HIV Vaccine Trial in Thailand: A Step Toward a Protective Vaccine for HIV,” Expert Review of Vaccines 9, no. 9 (September 2010): 997–1005, https://doi.org/10.1586%2Ferv.10.104.
15. Angela O’Mahony et al., Assessing, Monitoring and Evaluating Army Security Cooperation: A Framework for Implementation (Santa Monica, CA: RAND Corporation, 2018), xviii.
16. DOD Instruction 5132.14, Assessment, Monitoring, and Evaluation Policy for the Security Cooperation Enterprise (Washington, DC: DOD, 2017), https://www.esd.whs.mil/Portals/54/Documents/DD/issuances/dodi/513214_dodi_2017.pdf.

 

 

 

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November-December 2024