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Pursuing Global Impact

Special Operations Forces’ Vital Role in Achieving Objectives Through Global Health Engagement Initiatives

 

Col. Bert E. Kinkead, PhD, U.S. Army, Retired
Col. Jamie C. Riesberg, MD, U.S. Army, Retired
Lt. Col. Cynthia A. Facciolla, DVM, U.S. Army
Lt. Col. Bobbi S. Snowden, DrPH, U.S. Army*
Master Sgt. Jan M. Krieg, MSL, U.S. Army
Sgt. 1st Class Paul E. Loos, U.S. Army, Retired

 

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Choosing the right tools at the right time and for the right problem to be solved is the most imperative gray matter requirement for SOF [Special Operations Forces] leaders today and for the SOF professionals of tomorrow.

—Dr. Isaiah Wilson III, former president of Joint Special Operations University

 

A December 2022 Congressional Research Service report on Department of Defense (DOD) global health engagement (GHE) raised the idea that Congress should reexamine “the purpose of GHE” and “reevaluate how GHE is used to support military-specific requirements and broader global health objectives.”¹ The report also echoed a Center for Strategic and International Studies that said DOD “strategic thinking about global health and security is evolving very slowly.”² Considering this context, it is appropriate for Army special operations forces (ARSOF) to contribute to posturing the joint force for future conflict. ARSOF’s flexibility, mobility, and indigenous approach roots of working by, with, and through populations, directed at future combat strategies through a GHE lens, is a time-tested method with which there is relatively low risk but significant reward.

GHE tools, when applied appropriately with fiscal backing and proper oversight, promote U.S. national interests between allies and partners, ultimately securing prominence on the large-scale combat operations battlefield. The most significant payoff for the United States and DOD is the long-term relationships that enable a forward posture without a large troop presence, empowering integrated allied- and partner-enabled systems, and establishing infrastructure and personnel that promote a timely capability when necessary. These relationships also promote the timely gathering of critical information, which can be used at all echelons, from policymakers to tactical leaders, before, during, and after crisis and conflict. The current and imminent geostrategic situation demands that ARSOF return to its roots, applying the indigenous approach to medicine and healthcare and every facet of ARSOF to codify and scale their GHE efforts for the joint force. The time is now, without delay, to apply these tools as deterrence measures and to gain an advantage in the future global operational environment.

The Changing Global Operational Environment

Health threats and national interests continue to converge, blending global health, foreign policy, and national security. Global health challenges, including diseases like COVID and influenza, and climate-related disasters—established forces to be reckoned with—have and will adversely impact future operational environments for the DOD’s personnel and national interests. Due to the costly economic, human, and national security implications, correlating strategies have adapted with a deterrence and prevention posture. Convergent strategies collectively demand that commanders and their planners possess dual perspectives and postures toward the future operational environment.³ First, they must think critically, plan for, and employ forces to prevent adverse effects, including health and medically related crises and conflicts. Likewise, they must prepare for and respond to conflict and crisis while supporting future operations, including providing optimal healthcare to forces.

Healthcare delivery in the future operational environment will likely be limited for DOD forces, particularly special operations forces (SOF), due to less than favorable operational environments. The future global ecosystem will likely comprise geographically dispersed landscapes, finite resources, and complex, denied, and uncertain environments limiting the movement of patients and supplies.⁴ During the last two decades, U.S. forces, both conventional and SOF, grew accustomed to a robust and efficient casualty care system, which provided the highest rate of survival from battlefield wounds in the history of warfare. This remarkable feat was attributed to improved point of injury, en route care, and expeditious transportation of casualties to higher echelons of care.⁵ Since the focus of the times was on immediate injury treatment and quick evacuation, many special operations medics, including Special Forces (“Green Berets”), “drifted away from complex, long-duration partnerships toward more linear, short-term, transactional combat operations.”⁶ The future environment though, demands that we reinvest in SOF efforts requiring consistent and sustainable engagements rather than short-lived undertakings.

Historically, U.S. and foreign SOF medics held casualties for long periods and deployed higher medical expertise, such as surgical teams, closer to the point of injury to reduce additional time for resuscitative surgical care.⁷ However, the U.S. military has grown accustomed to the rapid movement of the wounded to forward resuscitative surgery within the “golden hour.” Therefore, customary procedures of the recent past will challenge commanders and planners to rapidly shift their understanding and assumptions of how to deliver, provide, and sustain commonly practiced and understood healthcare to support the future force.

The United States must glean insight from history while remaining open to the current operational environment and adapt and position for what is likely to ensue. For instance, the present conflict indicates that medical personnel, infrastructure, and transportation, traditionally safeguarded by international law, are now vulnerable to regular attacks. Between February 2022 and July 2024, Russian forces conducted at least 1,474 attacks directed toward Ukraine’s health care system. Of those attacks, 760 resulted in damage to or destruction of hospital and clinic facilities.⁸ Past, present, and probable future conditions demand intentional and critical thinking, planning, and executing of nontraditional medical support solutions. In the future operational environment, healthcare delivery for SOF may be as primitive as a single medic with limited medical supplies in a remote location or as robust as an austere resuscitative surgical team operating in subterranean conditions. In any case, deliberation must include prolonged operations, functioning in nonmedical infrastructure, and nonstandard patient movement and logistical support

The forecasted global competitive environment also consists of traditional warfare and irregular warfare. Irregular warfare can appear under the guise of “gray-zone” competition or hybrid threat activities, favoring indirect, asymmetric, or nonattributable approaches ultimately to influence people.⁹ Competitors may also induce medical challenges unfamiliar to military medical personnel like exposure to novel threats including unconventional weapons or tactics. Therefore, competitors are gaining greater abilities in shaping the international order by operating subtly just below the levels of conflict and crisis, between peace and war, while widening their advantage.¹⁰

Increasing interconnectedness throughout the global system is proliferating mutual impact and reliance. The most obvious example is the COVID-19 pandemic, originating at a distinct location but adversely impacting the global ecosystem. Consequently, strategies have adapted to target and build other nations’ capacity and capabilities to, in turn, protect their own security. Nevertheless, despite growing international interconnectedness, competitors are likely to intentionally disconnect, restrict, and manipulate networks, hindering cooperative information and intelligence sharing. However, the U.S. government further exacerbates this disconnect with many fragmented and siloed platforms that hinder streamlined communications and unity of effort. These limitations lead to challenges in tracking and accurately understanding risks associated with threats and responding appropriately to medical issues, making it difficult to rapidly identify and address broader health challenges to prevent global adverse effects.

A Commander’s Tool to Achieve Optimal Effects

The DOD’s current strategic, and therefore operational and tactical, aim is to apply integrated deterrence—the synchronized, holistic, and deliberate application of an assortment of instruments of national power, including allies and partners, to prevent conflict and keep adversary activities within the desired state of cooperation and competition.¹¹ Security cooperation (SC) is a primary military means, underscored in national policies to achieve strategic ends. SC stresses the use of noncombative methods to build partnerships through foreign engagements.¹² This approach has evolved from addressing problems reactively (postcrisis and postconflict) to proactively preventing, shaping, and cooperating to deter global dangers and enabling partner-nation mitigation and defense against such threats.¹³

DOD geographic combatant commands are responsible for employing collaborative and cooperative approaches with allies and partners throughout their respective regions.¹⁴ Theater special operations commands (TSOC), under the operational control of the geographic combatant commands, serve as a regional operational nucleus of the SOF network.¹⁵ TSOC commanders, aligning with combatant commanders, play an integral role in accomplishing the combatant command’s theater campaign plan. One tool TSOC commanders can utilize is focused activities such as SC to support the combatant command’s theater engagement plan and special operations security challenges. To bolster mutual defenses against various threats, the DOD, through combatant commands and TSOCs, must consider other nations’ capabilities. Health and medical requirements also provide opportunities for dialogue and cooperation, advancing shared interests and building partner health and medical capacity to deter mutual threats.¹⁶ The DOD’s formalized tool, consisting of health-related SC initiatives, entails GHE activities.¹⁷

For centuries, the military has executed GHE activities in different operational environments. Earliest examples include investments in infectious disease research and implementation of measures to protect and mitigate risk to U.S. and foreign forces from vector-borne diseases.¹⁸ Presently, GHE’s spectrum of global health activities is vast. Activities include exercises, training, key leader engagements, subject-matter expert exchanges, capabilities and infrastructure development, and medical support to stability operations. SC, coupled with health and medicine focus areas, has broadened the military’s defense apparatus from focusing primarily on response and conflict aimed at traditional threats to prevention, competition, and asymmetric approaches to address nontraditional challenges.

Given the complexities of the future operational environment, SOF should serve a significant role in integrated deterrence through GHE initiatives. Historically, policymakers leveraged SOF assets in competitive or irregular warfare conflicts when facing limitations that prevented them from using conventional forces or other instruments of national power.¹⁹ SOF is a regionally aligned network of personnel and assets (means) employed through SOF activities (ways) in complex, uncertain, and nonpermissive environments to obtain an early understanding of trends, emerging transregional threats, and opportunities to achieve effects (ends).²⁰ Moreover, SOF is appropriately suited for actions requiring an asymmetric approach, with the core concept—irregular warfare—comprising unconventional warfare, foreign internal defense, counterinsurgency, and counterterrorism activities.²¹ Combatant commands and TSOCs employ this broad range of SOF capabilities toward influencing and shaping environments and defending the United States and its allies and partners from malicious gray-zone activities.²² GHE initiatives, employed through SOF assets, could be the optimal and versatile tool to deter and defeat common threats and best position for conflict and crisis in complex and ever-changing environments.

ARSOF’s Value Proposition toward Future Operational Environments

ARSOF, the largest of the SOF service components, is astute in addressing complex challenges and navigating the land domain and “human terrain” through the indigenous approach of by, with, and through populations.²³ In early 2023, Lt. Gen. Jonathan Braga, commander of the U.S. Army Special Operations Command, shared his vision of a “threat informed, strategically driven, operationally focused, and tactically prepared” ARSOF.²⁴ His strategy also asserted that ARSOF’s strategic value is that it is the enabler of the joint force across the competition continuum. SOF services leverage a variety of domains and hardware, such as aircraft and vessels, as their platform. The platform of the U.S. Army Special Operations Command is its networks of people—through units of action on the ground conducting irregular warfare, forward-postured in complex environments. Furthermore, because ARSOF works with partners at the earliest stages of competition, its access to key leaders and austere parts of a country provides unique insight into events unfolding within an area and how U.S. competitors could be influencing those events to achieve effects.²⁵ This by no means suggests that ARSOF should be the only SOF entity employing GHE initiatives to achieve effects; achieving strategic objectives requires a collaborative whole-of-government approach. However, ARSOF’s inherent capabilities, and roles and responsibilities, best position them to lead the way, tactically and operationally, for the joint force on the application of irregular medical support methods across the spectrum of competition, crisis, and conflict to achieve various strategic pursuits.

ARSOF serve as the lead for most SOF core activities.²⁶ SF operational detachment alphas (Green Berets), civil affairs teams, and multifunctional teams are the tactical elements best equipped to conduct irregular warfare through engagements across the competition continuum. One of ARSOF’s core activities, nested within irregular warfare, is unconventional warfare, or support to movements for resisting or countering adversarial activities or advances.²⁷ Fundamental medical training has proven effective in the current conflict in Ukraine against Russian adversaries and reinforces the need for SC at all echelons through a comprehensive defense strategy with a whole-of-society response.²⁸ Commanders apply unconventional warfare before crisis through small footprints and persistent engagements to prevent fires and to prepare the environment if fires ignite.

ARSOF’s primary roles and missions also include support to civil-military operations and stability operations.²⁹ In March 2023, the DOD released a joint statement for a ten-year plan for the U.S. strategy to prevent conflict and promote stability.³⁰ To achieve this policy, the DOD, including SOF, will collaboratively support civil-military engagement, partner training and equipping, defense institutional capacity building, and the professionalization of security forces.³¹ ARSOF civil affairs tactical assets are specially equipped in civil-military operations and stabilization and are most qualified to fulfill this policy for the future operational environment. ARSOF civil affairs have applied medicine and health through civil engagements to identify and mitigate causes of instability. GHE activities include but are not limited to conducting engagements to train and equip local communities to prepare the environment for anticipated conflict (see vignette 1) or leveraging health to partner with local governments by improving veterinary services to counter extremist organizations (see vignette 2). Although ARSOF civil affairs are experts in interacting and solving problems by, with, and through the civil component of the operational environment, their relationship building is more expansive. Civil affairs are master facilitators in coordinating interorganizational approaches, including but not limited to connecting the Department of State, U.S. Agency for International Development, and SOF and conventional assets. ARSOF civil affairs brings inherent capabilities and fosters collaboration with diverse stakeholders, making them essential to the successful implementation and execution of GHE for the joint force. ARSOF is authorized and equipped to conduct certain activities that conventional forces and some other SOF components are not sanctioned to do, like unconventional warfare and civil-military operations.³² These means and ways support both national and military strategies with effectiveness that is unmatched by other assets across the DOD and the U.S. government.

Managing Risk for Maximizing Effects

In his book Risk: A User’s Guide, Gen. (Ret.) Stanley McChrystal, former commander of Joint Special Operations Command, introduced the concept of a “risk immune system.”³³ The concept describes an organization’s ability to identify, remember, and ward off threats, analogous to the body’s immune system. Similarly, a healthy immune system can defend the body from internal and external threats, while a malfunctioning immune system is detrimental to the health of the body. Strengthening the risk immune system can mean the difference between victory and defeat, or life and death. McChrystal also argued that although we may not be able to control the threat or the changing environment, far more lies within our control than outside of it.³⁴ Appropriately identifying threats and reducing vulnerabilities is essential in providing an accurate understanding of risk.

The UK Ministry of Defence’s Medical Operating Concept articulates and conceptualizes future environmental challenges and proposes ways to optimize medical capability to achieve effects and reduce risk.³⁵ The document explicitly states,

There are risks and challenges that must be understood and addressed, which will require difficult decisions and resource commitments to be made. … Commanders must understand the medical risk that is associated with every operational activity … The risk appetite of senior leaders to sustain casualties must be clearly articulated.³⁶

In other words, commanders must understand the internal and external threats and vulnerabilities to understand the risk entirely. Once that risk is identified and articulated, decisions to mitigate or accept that risk must occur. Ultimately, it starts with us.

ARSOF capabilities and correlating activities provide commanders with flexible response options with focused precision regardless of operational environments. However, to reduce U.S. risk to forces and operations, future success in battle requires transformation from a unilateral, U.S.-centric support framework infrastructure to a hybrid model, including health service support. This hybrid health service support model utilizes carefully assessed and coordinated partner-nation capability with the capacity to support and ultimately mitigate the loss of life in a future conflict. The hybrid model also emphasizes the indigenous approach through reliance on U.S. partners’ capacity and capability by prepositioning partner-nation supplies and using ARSOF-trained or -validated partner-nation medical providers. This strategy encourages a collaborative approach to deter threats and collectively posture our partner nations and the United States to defend or resist threats cooperatively, ultimately reducing unilateral risk by sharing the risk burden.

The DOD, more specifically U.S. Special Operations Command, must man, train, and equip SOF to employ GHE capability to support theater objectives. As such, there is a need to develop doctrine and training.³⁷ Consulting company Deloitte emphasized similar shortfalls and gaps within GHE strategy and implementation within DOD and in conjunction with interagency and international partners.³⁸ To holistically increase the preparedness and resilience of the target nation or a supported resistance to maximize deterrence, both capability and capacity must be increased for three primary supporting efforts. The first is that of the intervening third party, such as the U.S. government or alliance. Once this intervening entity is adequately trained and capable of training, advising, and assisting, it can then correctly prepare its partner resistance force. Together with and through a properly trained partner force, it can prepare the civilian counterparts, the third and most important effort. This will include all civilian infrastructure, including the host nation’s security services, fire and rescue, emergency medical services, and hospitals. A secondary goal is to efficiently integrate volunteers, nongovernmental organizations, and private contractors to fill gaps that may not be possible for any of the three primary efforts to accomplish (see the figure). Although ARSOF has notable capability to execute and are fortuitously implementing GHE initiatives, explicit and organized guidance from U.S. Special Operations Command to the service components and TSOCs is necessary to suitably prime capabilities for the future operational environment.

DOD has also grown accustomed to antiquated approaches, likely because of their ease and acceptance. For instance, the military continues to conduct medical, veterinary, and dental civil action programs. Although these initiatives may be beneficial toward achieving short-term effects such as access and placement, they are limited in demonstrating the achievement of sustainable change and benefit to U.S. forces in future operational environments.³⁹ Aligned and synchronized engagements need focus and direction to reach strategic ends deliberately. The likely resource-constrained future demands proven medical concepts to increase survivability, mitigate risk, and enable combat power.⁴⁰ Therefore, assessing, monitoring, and evaluating engagements must be at the forefront to capture gaps and measures of effectiveness for initiatives. Likewise, building partner capacity correctly demands multilevel, empirically supported, and synchronized approaches to achieve effective and enduring change.⁴¹

TSOC and SOF planners also focus primarily on critical leader engagements and combined SOF exercises and training for partner SOF development—often unaware of the other available SC and assistance tools, authorities, and processes.⁴² Conversely, embassy SC offices, which balance a country’s diverse SC programs and priorities, may lack expertise in SOF or medical subject matter. SOF, medical, and development principles are often not integrated into theater SC planning.⁴³ The DOD is unlikely to maximize achieving objectives, such as multilevel and sustainable capacity building, because it neglects to recognize and employ critical development planning.⁴⁴

The future of GHE initiatives among ARSOF directly requires a shift in thinking at the TSOC level. TSOCs must embrace their role in what Rauen coined an “operational integrator.”⁴⁵ The operational integrator connects, consults, and facilitates communication from tactical to strategic on how the tactical leader affects the strategic outcome and understands how the strategic-level plans and policies affect the tactical leader to achieve GHE initiative objectives. Operational integrators must be well versed in irregular warfare, SOF core activities, national and military strategy, authorities for GHE activities, operations, mission analysis, and planning. They must also decipher and connect to the interorganizational network to joint, intergovernmental, interagency, multinational, and commercial stakeholders. However, this role is not exclusive to TSOCs. Representation at the combatant command level (geographic and functional—e.g., U.S. Indo-Pacific Command and U.S. Special Operations Command, respectively), service component command (e.g., U.S. Army Special Operations Command and U.S. Air Force Special Operations Command), and their respective subordinate commands would best “integrate” plans into operations. A medical operational integrator should be a planner with fluency in systems, global health, foreign policy, and the qualifications like Will Chu and his team proposed for health security advisors.⁴⁶ TSOCs provide the best vantage point to identify, synchronize, and deconflict the numerous GHE activities and efforts occurring in respective areas of responsibility to achieve effects and support special operations objectives.

The ubiquity in demand for healthcare globally means that effective GHE initiatives involve several stakeholders. Unfortunately, the historical trademarks of GHE are well-intentioned activities that lack coherence and unity of effort.⁴⁷ The U.S. government complicates communication and coordination with the necessary actors who often have the appropriate authorities, resources, or policy backing to support the initiatives. Conversely, fostering effective communication can lead to reducing redundancies, improving mission efficiencies and effectiveness, and strengthening resilience of partnerships and the “risk immune system.”

Conclusion

In March 2023, the assistant secretary of defense for special operations and low-intensity conflict published a concept paper on nonstandard medical support. The report identifies the lack of an existing framework for medical support to operations in contested or nonpermissive environments.⁴⁸ Proposed solutions, executed through GHE activities, consist of three pillars: shaping the operational environment, building ally and partner medical capability, and enhancing U.S. operational flexibility through increasing nontraditional medical care, nonstandard evacuation, and nonstandard equipment and supplies. The author states that U.S. Special Operations Command is best suited to serve as the proponent for building a nonstandard medical support construct for the DOD. Similarly, ARSOF is ideally suited to lead the joint force in executing the three lines of effort. ARSOF’s unique ability to understand and influence the human domain and establish and maintain enduring partnerships sets it apart as a crucial asset for the future global security environment. Failing to engage (or compete) in this space creates accessible opportunities for our strongest competitor to engage potential partners with limited competition or at a low cost. We are making strong progress in competing with a legislative proposal, that if approved, would allow DOD to offer nonlethal medical training and equipment to allied and partner civilians.⁴⁹ Gen. Mark A. Milley, former chairman of the Joint Chiefs of Staff, emphasized in the Joint Concept for Competing, in the absence of contending, the U.S. joint force will “lose without fighting.”⁵⁰ Instead, the United States must “tilt the competitive balance” in its favor toward respective strengths. To contend against a sophisticated and critical competitor, the DOD must both draw on strengths and commit and transform now. Our approach must change from U.S.-centric to partner-centric for this transformation to work. Policy and decision-makers, commanders, and planners must also radically shift their mindsets from exclusively preparedness and response to an emphasis on prevention, and they must shift from focusing on materiel platforms to people. The DOD, specifically ARSOF, must remain confident in its abilities and recognize that success will require allies’ and partners’ expertise and synchronization of interorganizational stakeholders. Lastly, achieving effectively integrated deterrence requires admittance, acceptance, and the desire to change for the better—which will not be easy. Nonetheless, ARSOF can lead the way for the joint force to serve as a global leader and preferred partner for GHE activities and, with joint, interagency, and allies and partners, prepare for and overcome the challenges that lie ahead.

We extend our sincere appreciation to Maj. Gen. Gil Ferguson, commanding general, 1st Special Forces Command (Airborne), for his review of this manuscript. We would also like to thank Lt. Col. Regan Lyon, formerly the deputy director, Irregular Warfare Strategic Design, Office of the Assistant Secretary of Defense for Special Operations and Low Intensity Conflict/Irregular Warfare and Counterterrorism, for her insightful feedback and constructive suggestions. We are truly grateful for their time, effort, and dedication to shaping the final version of this work.

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Notes

• Epigraph. Isaiah Wilson III, “Rediscovering the Value of Special Operations,” Joint Force Quarterly 105 (2nd Quarter, 2022): 37–43, https://ndupress.ndu.edu/Media/News/News-Article-View/Article/2999171/rediscovering-the-value-of-special-operations/.

1. Bryce H. P. Mendez, Global Health Engagement in the Department of Defense, CRS Report R47326 (Washington, DC: Congressional Research Service [CRS], 6 December 2022), 12, https://crsreports.congress.gov/product/pdf/R/R47326.
2. Eugene V. Bonventre, Kathleen H. Hicks, and Stacy M. Okutani, U.S. National Security and Global Health: An Analysis of Global Health Engagement by the U.S. Department of Defense (Washington, DC: Center for Strategic and International Studies, April 2009), 4, https://csis-website-prod.s3.amazonaws.com/s3fs-public/legacy_files/files/publication/090421_Bonventre_USNationalSecurity_Rev.pdf.
3. The White House, National Security Strategy of the United States of America (Washington, DC: The White House, October 2022), https://www.whitehouse.gov/wp-content/uploads/2022/10/Biden-Harris-Administrations-National-Security-Strategy-10.2022.pdf; Office of the Secretary of Defense, 2022 National Defense Strategy (Washington, DC: Department of Defense, 2022), https://uploads.mwp.mprod.getusinfo.com/uploads/sites/23/2022/11/2022-NATIONAL-DEFENSE-STRATEGY-NPR-MDR.pdf.
4. Joint Chiefs of Staff, Joint Operating Environment (JOE) 2035: The Joint Force in a Contested and Disordered World (Washington, DC: Joint Chiefs of Staff, 14 July 2016), 4–14, https://www.jcs.mil/Portals/36/Documents/Doctrine/concepts/joe_2035_july16.pdf?ver=2017-12-28-162059-917.
5. Robert L. Mabry and Robert DeLorenzo, “Challenges to Improving Combat Casualty Survival on the Battlefield,” Military Medicine 179, no. 5 (2014): 477–82, https://doi.org/10.7205/milmed-d-13-00417; Todd E. Rasmussen et al., “In the ‘Golden Hour’: Combat Casualty Care Research Drives Innovation to Improve Survivability and Reimagine Future Combat Care,” Army AL&T (January-March 2015): 80–85, https://asc.army.mil/web/access-st-in-the-golden-hour/.
6. Edward C. Croot, “There Is an Identity Crisis in Special Forces: Who Are the Green Berets Supposed to Be?” (Carlisle, PA: U.S. Army War College, 2020), 6, https://cttp.sanford.duke.edu/wp-content/uploads/sites/16/2020/04/Ed-Croot-Final-Paper.pdf.
7. Warner D. Farr, The Death of the Golden Hour and the Return of the Future Guerilla Hospital (MacDill Air Force Base, FL: Joint Special Operations University Press, 2017).
8. Attacks on Health Care in Ukraine, accessed 9 August 2024, https://www.attacksonhealthukraine.org/.
9. Joseph L. Votel et al., “Unconventional Warfare in the Gray Zone,” Joint Force Quarterly 80 (1st Quarter, 2016): 6–12; Training Circular 7-100, Hybrid Threat (Washington, DC: U.S. Government Printing Office, 2010).
10. Lyle J. Morris et al., Gaining Competitive Advantage in the Gray Zone: Response Options for Coercive Aggression Below the Threshold of Major War (Santa Monica, CA: RAND Corporation, 2019), https://www.rand.org/pubs/research_reports/RR2942.html.
11. White House, National Security Strategy, 22.
12. Joint Publication (JP) 3-20, Security Cooperation (Washington, DC: U.S. Government Publishing Office [GPO], 5 July 2024 [CAC required]), xi–xii, https://jdeis.js.mil/jdeis/new_pubs/jp3_20ch1.pdf.
13. Nina M. Serafino, Security Assistance and Cooperation: Shared Responsibility of the Departments of State and Defense, CRS Report R44444 (Washington, DC: CRS, 26 May 2016), https://crsreports.congress.gov/product/pdf/R/R44444; Bolko J. Skorupski and Nina M. Serafino, DOD Security Cooperation: An Overview of Authorities and Issues, CRS Report R44602 (Washington, DC: CRS, 23 August 2016), https://crsreports.congress.gov/product/pdf/R/R44602; Derek S. Reveron, Exporting Security: International Engagement, Security Cooperation, and the Changing Face of the U.S. Military (Washington, DC: Georgetown University Press, 2016).
14. National Security Challenges and U.S. Military Activity in North and South America Before the House Armed Services Committee, 117th Cong. (8 March 2022) (statement of Gen. Laura J. Richardson, Commander, United States Southern Command), https://www.southcom.mil/Portals/7/Documents/Posture%20Statements/SOUTHCOM%20Posture%20Final%202022.pdf?ver=tkjkieaC2RQMhk5L9cM_3Q%3D%3D; National Security Challenges and U.S. Military Activities in the Greater Middle East and Africa Before the House Armed Services Committee, 117th Cong. (17 March 2022) (statement of Gen. Kenneth F. McKenzie, Commander, United States Central Command), https://docs.house.gov/meetings/AS/AS00/20220317/114523/HHRG-117-AS00-Wstate-McKenzieK-20220317.pdf; To Receive Testimony on the Posture of United States European Command and United States Transportation Command Before the Senate Armed Services Committee, 117th Cong. (29 March 2022) (statement of Gen. Tod D. Wolters, United States Air Force, Commander, United States European Command), https://www.armed-services.senate.gov/imo/media/doc/SASC%2029%20MAR%202022%20EUCOM%20Statement%20(Gen%20Wolters).pdf; To Receive Testimony on the Posture of United States Indo-Pacific Command and United States Forces Korea Before the Senate Armed Services Committee, 117th Cong. (10 March 2022) (statement of Adm. John C. Aquilino, United States Navy, Commander, United States Indo-Pacific Command), https://www.armed-services.senate.gov/imo/media/doc/INDOPACOM%20Statement%20(ADM%20Aquilino)%20_SASC2.PDF; To Receive Testimony on the Posture of United States Central Command and United States Africa Command Before the Senate Armed Services Committee, 117th Cong. (15 March 2022) (statement of Gen. Stephen J. Townsend, United States Army, Commander, United States Africa Command), https://www.armed-services.senate.gov/imo/media/doc/AFRICOM%20FY23%20Posture%20Statement%20%20ISO%20SASC%2015%20MAR%20Cleared.pdf.
15. Charles T. Cleveland and Liam Collins, “Theater Special Operations Command: The Operational Employment of U.S. Special Operations Forces,” chap. 31 in Routledge Handbook of U.S. Counterterrorism and Irregular Warfare Operations, ed. Michael A. Sheehan, Erich Marquardt, and Liam Collins, 1st ed. (New York: Routledge, 2021), https://doi.org/10.4324/9781003164500.
16. R. L. Wilson et al., “Preparing for Large Scale Combat Operations through Global Health Engagement: Medical Interoperability & Medical Support to Resistance” (PowerPoint presentation, Association of Military Surgeons of the United States Conference, Gaithersburg, MD, 2020).
17. Department of Defense Instruction 2000.30, Global Health Engagement (GHE) Activities (Washington, DC: Department of Defense, 12 July 2017), https://www.esd.whs.mil/Portals/54/Documents/DD/issuances/dodi/200030_dodi_2017.pdf.
18. Eugene V. Bonventre and Valérie Denux, “Military Health Diplomacy,” in 21st Century Global Health Diplomacy, ed. Thomas E. Novotny, Ilona Kickbusch, and Michaela Told, vol. 3 (Singapore: World Scientific, 2013), 191–213, https://doi.org/10.1142/8178.
19. I. Chustek, Unconventionally Irregular: SOF’s Role in the Great Power Competition through History (Washington, DC: College of International Security Affairs, National Defense University, 2021).
20. JP 3-05, Joint Doctrine for Special Operations (Washington, DC: U.S. GPO, 2020 [CAC required]), chap. 1 and 2, https://jdeis.js.mil/jdeis/index.jsp?pindex=27&pubId=707.
21. Ibid., II-3, fig. II-2.
22. Clifford Lucas, “In the Gray Zone, This Much Is Black and White: SOF Must Develop Partner and Ally Nation Capabilities,” Modern War Institute at West Point, 13 December 2022, https://mwi.westpoint.edu/in-the-gray-zone-this-much-is-black-and-white-sof-must-develop-partner-and-ally-nation-capabilities/.
23. “Pillars of ARSOF Capability,” USASOC 2035 (Fort Liberty, NC: U.S. Army Special Operations Command [USASOC], 2017), 4, https://www.soc.mil/AssortedPages/USASOCOverview2035.pdf.
24. Jonathan P. Braga, Army Special Operations Forces Strategy 2030 (Fort Liberty, NC: USASOC, 2023), 4, https://www.soc.mil/temp-pages/strategy/ARSOF_STRATEGY_2030.pdf.
25. G. McIntire, Jedburghs: Path to Competition through Historic Understanding (Washington, DC: College of International Security Affairs, National Defense University, 2021).
26. Braga, Army Special Operations Forces Strategy, 15; JP 3-05, Joint Doctrine for Special Operations, II-4, fig. II-3.
27. Braga, Army Special Operations Forces Strategy, 15; JP 3-05, Joint Doctrine for Special Operations, II-3, fig. II-2, B-1.
28. Tanisha M. Fazal, “Ukraine’s Military Medicine Is a Critical Advantage against Russia,” Foreign Policy (website), 31 October 2022, https://foreignpolicy.com/2022/10/31/ukraine-military-medicine-russia-war/; Hanna Shelest, “Defend. Resist. Repeat: Ukraine’s Lessons for European Defence,” European Council on Foreign Relations, 9 November 2022, https://ecfr.eu/publication/defend-resist-repeat-ukraines-lessons-for-european-defence/.
29. Braga, Army Special Operations Forces Strategy; JP 3-57, Civil-Military Operations (Washington, DC: U.S. GPO, 2018), https://www.jcs.mil/Portals/36/Documents/Doctrine/pubs/jp3_57.pdf; JP 3-07, Stability (Washington, DC: U.S. GPO, 2022), https://jdeis.js.mil/jdeis/index.jsp?pindex=27&pubId=729.
30. Office of the Spokesperson Media Note, “Joint 10-Year Plans for the U.S. Strategy to Prevent Conflict and Promote Stability,” U.S. Department of State, 27 March 2023, https://www.state.gov/joint-10-year-plans-for-the-u-s-strategy-to-prevent-conflict-and-promote-stability/.
31. Ibid.
32. Kimberly Jackson, Authorities and Permissions to Conduct Army Special Operations Activities Abroad (Santa Monica, CA: RAND Corporation, 2022), 2, https://www.rand.org/pubs/research_reports/RRA412-4.html.
33. Stanley A. McChrystal and Anna Butrico, Risk: A User’s Guide (New York: Penguin, 2021), xvii.
34. Ibid., 9–10, 34.
35. Ministry of Defence, Medical Operating Concept (London: Ministry of Defense, 2022), https://www.gov.uk/government/publications/medical-operating-concept.
36. Ibid., iii, 48.
37. USASOC, Doctrine, Organization, Training, Materiel, Leadership & Education, Personnel, Facilities – Policy (DOTMLPF-P) for ARSOF and Global Health Engagements (Fort Liberty, NC: USASOC, 2022).
38. Mark Ediger, Derek Licina, and Emily LaMarsh, “Enhancing the US Military Health System’s Global Health Engagement Strategy” (Washington, DC: Deloitte 2022), https://www2.deloitte.com/content/dam/Deloitte/global/Documents/Public-Sector/gx-gps-global-health-engagement-stratege-white-paper-thought-leadership.pdf.
39. Bonventre and Denux, “Military Health Diplomacy.”
40. George A. Barbee, “The Strategic Survivability Triad: The Future of Military Medicine in Support of Combat Power,” Joint Force Quarterly 107 (4th Quarter, 2022): 102–15, https://ndupress.ndu.edu/Portals/68/Documents/jfq/jfq-107/jfq-107_102-115_Barbee.pdf?ver=5qAgHXAOvsfAKCoaYRdheQ%3d%3d.
41. Bobbi Snowden, “Enhancing Security Cooperation: Achieving and Sustaining Change through Health Train-the-Trainer Capacity Building Initiatives” (PhD diss., George Washington University, 2021), 14, 22–24, 60, https://scholarspace.library.gwu.edu/concern/gw_etds/rr171z20s.
42. Special Operations Course (SOC) 3210 Student Manual, Special Operations Forces–Security Cooperation, ver. 22 (Tampa, FL: Joint Special Operations University, 2021).
43. Ibid.
44. Snowden, Enhancing Security Cooperation.
45. Brian Rauen, Terri Erisman, and Edward Ballanco, “More Is Not Better: Fixing Security Cooperation,” War Room, U.S. Army War College, 22 June 2018, https://warroom.armywarcollege.edu/articles/more-is-not-better-fixing-security-cooperation/.
46. Will Chu et al., “On Protection of U.S. Forces from Global Health Threats: The Role of Health Security Advisors,” Military Medicine 187, no. 11-12 (November-December 2022): 297–8, https://doi.org/10.1093/milmed/usac085.
47. Rauen, More Is Not Better.
48. Assistant Secretary of Defense for Special Operations and Low-Intensity Conflict, “Non-Standard Medical Support,” Concept Paper (Unclassified), 17 March 2023.
49. Jack Reed and Roger F. Wicker, United States Senate Committee on Armed Services: Fiscal Year 2025 National Defense Authorization Act: Executive Summary (Washington, DC: U.S. Senate Committee on Armed Services, June 2024), 8.
50. Joint Chiefs of Staff, Joint Concept for Competing (Washington, DC: U.S. GPO, 2023 [CAC required]), https://jdeis.js.mil/jdeis/jel/concepts/jcc.pdf.

 

 

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November-December 2024