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We are applying a late 19th-century to early 20th-century mindset to try to solve 21st-century problems. The future fight and global competition will deliver two predictable outcomes: its nature will be unpredictable, and all domains—land (including subterranean), sea, air, space, and cyberspace—will be contested.¹ Our competitors will create dilemmas in a hyper-enabled, ever-evolving, hyper-adaptive, and supra-chaotic operating environment.² Our competitors will contest time and space as well. The survivability of the joint force requires mitigating these dilemmas by the methodical array and employment of medical offset strategies that will provide the United States with unparalleled and unmatched medical capability.

Figure 1. Levels of Warfare and Medical Support to Warfare (adapted from JP 3-0)

The three proposed medical offset strategies offered here are far-forward intervention, technology and innovation, and allies and partners. These strategies will provide the joint force, its warfighters, and enablers with enhanced medical capabilities to support the attainment of U.S. strategic goals. Medical offset strategies will support combat casualty care in multidomain operations and improve strategic reach to support U.S. objectives. As the joint force prepares for large-scale combat operations (LSCO) and competition in multidomain operations, it is imperative to attain medical overmatch. This proposal for medical offset strategies does not preclude training or clinical judgment, nor does it propose to take the human out of the loop. This concept will serve those the military medical community supports and save lives on the battlefield.

Background: How Did We Get Here?

The United States must employ medical offset strategies to decrease the likelihood of medical capabilities creating a friction point that weakens the military instrument of power.³ During the 20-year war on terror, the United States enjoyed significant medical overmatch that delivered previously unrealized battlefield survivability.⁴ However, the belligerents encountered during the war on terror lacked parity with our current competitors, namely China and Russia. For the first time in U.S. history, our nation faces two nuclear powers that pose an existential threat.⁵ These near-peer competitors possess capabilities and capacity that far outpace any threat that the United States has encountered since World War II. The joint force must possess a sustaining warfighting overmatch to enhance conditions that will ensure the defense of the homeland, deter attack, and prevail across the spectrum of conflict, all while modernizing the force. While the medical force does not engage in combat, it works to defeat the dual threats of preventable casualties and death—raising the question of how the medical support function compels its medical will on the next battlefield to impose order on chaos and save the greatest number of lives.

The casualties in the next war will be far more significant than those seen during the war on terror, likely greater than those seen in any previous U.S. war, and possibly more catastrophic than any previous war in history. Estimates range into the thousands of casualties daily, potentially repeating at similar rates day after day.⁶ Medical overmatch elements enjoyed during the war on terror, such as rapid air evacuation and adequate available medical resources, are not estimated to be feasible or adequate in capacity in any LSCO scenario.⁷ The resources required in future LSCOs will exceed those of World War II, where the Army Medical Department trained 324 hospitals in 24 months from 1943 to 1945.⁸ The current conflict in Ukraine has brought back evacuation by train, a modality not widely employed since the end of World War II.⁹ Finally, Russia’s actions in its war against Ukraine have demonstrated that the medical support function is not considered protected from attack, and therefore its operations must be dispersed.¹⁰ For this reason, capability and capacity at robust, highly capable military treatment facilities, enjoying economies of scale, will not likely be possible.

What Is an Offset?

An offset is an effort to achieve persistent U.S. qualitative superiority as a means of compensating for the limited scale of U.S. forces with respect to global responsibilities.¹¹ Offset strategies are imperative to purposefully gain a competitive advantage for the joint force. Offsets also implement overmatch. Therefore, medical offset strategies require maximizing the end effects of existing medical capabilities when pitted against overwhelming medical requirements to regain overmatch.

Historically, the United States has employed three offset strategies. The United States devised its First Offset Strategy, which focused on nuclear deterrence, in the 1950s. The theory was that the United States would employ tactical and strategic nuclear weapons to offset the Soviet bloc’s quantitative advantage in conventional weapons. In the Second Offset Strategy, from the mid-1970s to the 1980s, the United States used a myriad of technologies, among them battlefield networks; precision-guided strike and stealth munitions; intelligence, surveillance, and reconnaissance platforms; and communication platforms. The purpose was to offset the Warsaw Pact’s numerical superiority, specifically by neutralizing the second echelon of a hypothetical invasion. Countering the former Soviet Union was the focus of the earlier offsets. They did not address U.S. policy toward China.

The concept of the Third Offset Strategy came about in the mid-2010s. It focused on technology and innovation, advanced computing, big data, machine learning (ML), and artificial intelligence (AI) to give the United States a marked advantage against its competitors. Countering China and Russia, two strategic competitors of concern, was the focus of this strategy.¹²

Applying the offset concept to the medical domain will increase the likelihood that medical capabilities will maintain a competitive advantage in sustaining combat power and enhancing power projection. The United States will be able to leverage combat power through improved survivability of the force, with enhanced power projection and improved interoperability with our allies and partners because of the inherent capability overmatch created by the medical offsets.

The medical levels of support for the joint force need to be nested within all levels of war during LSCO. We are familiar with the levels of war: tactical, the use of methods to win the battle; operational, the collective use of tactics to achieve strategic objectives within theaters or other operational areas; and strategic, the collective use of operations to achieve strategic objectives as a nation or multinational force. Broadly defined, the medical levels of support to the joint force are medical tactics, medical operations, and medical strategy. Medical tactics is the use of individuals and equipment to save lives on the battlefield, medical operations are the collective use of medical tactics to support strategic objectives within theaters or other operational areas, and medical strategy is the collective use of medical operations to preserve the U.S. national or multinational force in support of strategic objectives.¹³ Coupling the medical levels of war with cogent medical offset strategies will support combat power.

Figure 2. Medical Offset Strategies

The Importance of a Medical Offset Strategy

Give me a lever long enough and a fulcrum on which to place it, and I shall move the world. —Archimedes

Medical offset strategies provide the joint force with a robust systems approach to counter the unpredictable nature of modern LSCO. Why should the joint force employ a military medical offset strategy? There are two answers, one simple and one conceptual. The simple answer is to make one action exponentially multiply the positive effects for the end user. A medical offset strategy will create additive effects and create asymmetric outcomes and advantages (where the upside or outcome is exponentially greater than the downside) beneficial to the user.14 The current state has limitations—existing medical forces and logistics capabilities cannot support repeated mass casualties or ultra–mass casualty operations. One monitor tracks one patient’s vitals, or one medical provider cares for one patient, leading to one outcome. Often, multiple medical personnel care for one patient, leading to one outcome. This also occurs in the realm of medical logistics. For example, medical resupply assumes freedom of movement and maneuver and occurs on demand using a just-in-time strategy, which results in self-imposed limitations—limitations that can be corrected and unfettered with medical offsets.

The conceptual answer is to create a desired state where the joint medical force retains the ability to deliver effects through medical overmatch to meet the demand for medical capacity and support combat power across the spectrum of conflict. At the tactical level, this desired state will provide the ability to perform one task or action and produce many advantageous outcomes—for example, a single monitor that can track multiple patients, or novel devices that have multiple diagnostic and therapeutic uses. These effects will be multiplied at the operational level, giving the user advantages in time and space and creating momentum, speed, and precision for military operations. These effects will be more profound at the strategic level and will support U.S. national and multinational resolve. Most important, these effects will allow the joint force to operate at the speed of relevance and war.

Proposed Medical Offsets to Create Medical Overmatch

The three distinct medical offset strategies for the joint force are:

• First Medical Offset: Far-Forward Intervention

• Second Medical Offset: Technology and Innovation

• Third Medical Offset: Allies and Partners.

Because of the inherent nature of the medical offsets, the level of partnership and coordination required is balanced against the level of risk and the strategic impact if not employed. They are defined as medical offset strategies, not lines of effort.

First Offset Strategy: Far-Forward Intervention

The First Medical Offset Strategy focuses on having trained medical personnel very far forward with the ability to deliver a live, warm, non-coag-ulopathic (the casualty is still able to activate their own clotting factors), and non-acidotic patient (a casualty with good perfusion that can support and sustain life) to the next level of care.¹⁵

Strategic Survivability Triad.¹⁶ The SST comprises three critical medical concepts that, when combined, would provide the joint force with a sustained capability required in future conflicts to enable power projection, improve survivability, and mitigate risk. The three medical concepts are early medical treatment and intervention, early control of hemorrhage (compressible and noncompressible), and blood far forward (or early blood administration).¹⁷

Austere Medical Care. This collective term represents a constellation of options of care that require longer patient hold and care capacity and capability. To accomplish the SST in austere circumstances, skills usually performed by physicians in hospitals during peacetime will have to be task-transferred to medically trained persons, both noncombatant and combatant. This action increases the size of the force available to deliver medical effects. It offloads more straight-forward tasks from specialized medical resources (such as doctors and nurses), allowing these finite personnel types to perform functions that more generalized care providers or non-healthcare personnel cannot accommodate.

Opportunistic Casualty Evacuation. This term identifies any multimodal casualty evacuation platform, medium, or method to move patients across the continuum of care.

Second Medical Offset Strategy: Technology and Innovation

The Second Medical Offset Strategy focuses on four areas where technology enhances the ability to transfer human actions and tasks to nonhumans to accomplish across the continuum of care (for example, drone air or ground evacuation with en route monitoring/intervention).

1. Next-generation medical regulating and patient tracking:

• AI-assisted evacuation prioritization and routing will provide the ability to optimally triage all casualties to the most appropriate and available care location, overcoming limitations on operationally dispersed forces and already limited medical capabilities.

• AI will minimize time lost from repeat evacuations, help spread the burden of care across all available medical resources, and ensure capacity exists at the receiving facility while conserving select resources such as damage control surgery and damage control resuscitation to the casualties best suited for these types of emergency care.

2. Contested logistics defeat:

• Forward medical supply supported by additive manufacturing using common input requirements decreases resupply volume and frequency requirements.

• Predictive analysis of medical logistics and precision delivery simplify resupply coordination.

• Drone air or ground supply and evacuation coupling increase each movement’s efficiency and relieve the force risk by decreasing unnecessary movements.

3. Novel medical technology:

• Novel forward medication production through additive printing, programmable bacteria to produce drugs, whole blood analogs, or blood farming can expand operational and strategic reach.

• Unmanned systems: Remotely controlled or autonomous air or ground evacuation and sustainment platforms with en route, real-time monitoring and

intervention capability could be used.

• AI- and ML-assisted decisionmaking would mitigate cognitive overload. While machine-enabled medical decision assistance is not new (for example, intensive care unit monitor alarms), deployment to an austere battlespace to assist single personnel in treating, monitoring, and re-triaging multiple casualties is novel.

• Cross-industry leveraged technology would allow advanced hospital-based technologies to be deployed far forward with minimal operator training (austere point-of-care ultrasound imaging enabled by AI, intravenous fluid generators, and technologies borrowed from deep space travel).

• Novel therapies (nanoparticles, nano- technology, and phage therapy) that are on the horizon of development with military-funded research and co-development could be delivered to the battlefield of the future faster.

4. Next-generation medical patient registry for performance improvement:

• The Joint Trauma System developed the Joint Trauma Registry as part of a more extensive system to collate data that informed best medical practices across the continuum of battlefield care. However, the current process requires generating records, often on paper, and later transcribing those records. Rather than a multi-step process, seek a singular solution network that captures crucial data.

Digitizing the medical battlespace, with data interoperability between military and civilian systems and interoperability between nations, would decrease the time from data collection to analysis and ultimately lead to marked performance improvement measures for operational and battlefield medicine.

Third Medical Offset Strategy: Allies and Partners

The Third Medical Offset Strategy focuses on five areas that develop expansion treatment and evacuation resources through allies’ and partners’ interoperability, cooperation, and synchronization.

Unlock or Unfetter Cooperative Potential Between Our Allies and Partners. All nations’ medical systems function within the framework of their respective systems. Interoperability of these independent systems between two nations remains challenging, particularly in the prehospital space where much of military medicine delivers effects. The magnitude of this challenge increases when multiple nations are involved, as with our North Atlantic Treaty Organization (NATO) partners.

Create a Shared Understanding, Vision, Intent, and Trust Among Our Allies and Partners. This would ensure that we collectively understand our weaknesses, opportunities, threats, and shared interests.

Create Multinational Medical Interoperability. Why has interoperability been accomplished with fuel and ammunition but not medical functions?

• Commonly used capability terms lack defined common understanding (for example, medic is not an agreed-on capability in NATO).

• Commonly accepted and agreed-on standards for blood are lacking between the United States and NATO Allies and partners.

Create Opportunities for Shared or Joint Logistics and Sustainment Platforms. This could come from a common manufacturing base, common manufacturing standards, transportation and storage platforms, and energy access.

Understand How Our Allies and Partners Conduct the Defense of the Homeland, especially those partners whose primary mission before they joined NATO was the defense of the homeland (how did they plan and coordinate those activities?).

Risk: The Enemy of Good Is Perfect

In his writings, a wise Italian says that the best is the enemy of the good. —Voltaire

The concept of medical offset is simple, but the implementation may not be easy because novel innovation is required. Implementation of medical offset strategies has challenges, risks, and rewards. Some of these challenges lie in the time it takes to create a cogent plan and then effect wide-scale adoption. Policymakers staff and write policy, which in turn drives doctrine. Sometimes, a much-needed capability or concept, such as medical offset, will require a policy to ensure the members of the joint force can perform their assigned roles.¹⁸ The Commission on Defense Innovation Adoption presented 10 recommendations in a 2024 report to help the Department of Defense improve innovation efforts.¹⁹ The report submits that current U.S. defense acquisition practices do not and were not designed to keep pace with the rapid pace of innovation. Incorporating some of the solutions presented in the report would create opportunities to drive medical offset strategies and leverage the attainment of national objectives.

Medical offset strategies have risks. Risk is defined as the “probability and consequence of an event causing harm to something valued.”²⁰ The continuum of qualifiable and quantifiable risk spans from military strategic risk (risk to national interest) and military risk (risk to executing the National Military Strategy) to risk to the commander and force. The most critical risk in attaining medical offset strategies is the application of resources and the prioritization of time spent training for the First Medical Offset, developing capabilities for the Second Medical Offset, and building cooperative and cohesive efforts to pursue the Third Medical Offset. There are only a finite number of resources that the Department of Defense can expend in the pursuit of medical offsets. Pursuing the offsets needs to be done in a deliberate yet timely manner. Inversely, the time spent not pursuing medical offsets equates to potentially more lives lost, an inherent contributor to strategic risk. The dynamic application of a medical offset strategy over time would mitigate strategic and operational risk. Still, the United States needs to initiate these strategies to achieve overmatch sooner rather than later.

A simplistic way to frame the risk in the context of medical offset strategies is the risk of action versus the risk of inaction. Both choices have consequences (good and bad). The choices must be calculated and weighed to preserve the force and attain strategic objectives. In some cases, the risk of inaction may outweigh the risk of action. Sometimes it is more dangerous to do nothing than to act. A simple example of nonaction is the nonemployment of a medical device or solution that can potentially prevent battlefield deaths or preserve the force that meets 80 percent of requirements across the joint force but is not transi- tioned for use due to a minor parameter that is not met. An example is the Israel Defense Forces Medical Corps in Israel’s war against Hamas, which successfully decided to send whole blood forward “all the way to the frontline medical units on the battlefield” with positive outcomes.²¹ In these cases, inaction may bring catastrophic risk to the force and mission, while action brings merit and survival to its enterprise.

Overall, the benefit of medical offsets far outweighs the risks while supporting combat power and the joint force. Unequivocally, far-forward intervention equates to more lives saved achieved through the careful array of medical assets throughout the continuum of care coupled with agile resuscitation and surgical teams. Technology and innovation as a medical offset will keep pace with the speed of war. Deliberate and coordinated efforts with our allies and partners while employing the First and Second Medical Offsets will secure the force with an unmatched capability. The power of monopsony through international partnerships realized in the Third Medical Offset will spur industry to help solve some of the most complex military medical problems and mitigate gaps. In sum, the rewards of medical offsets far outweigh the risks, and often overmatch favors inaction.

Conclusion

To operate at the speed of warfare and the relevance of saving lives in the current and future battlespace, the joint force must employ three medical offset strategies: far-forward intervention, technology and innovation, and allies and partners. The sum of the effects of these offsets will save lives on the battlefield throughout the spectrum of conflict while supporting combat power. In the current global climate, competition is palpable, and hybrid warfare is the course of action that competitors use to delegitimize and undermine U.S. strategic resolve. During this seemingly interwar period, the United States is at an inflection point where strategic opportunity exists to set conditions to charter the next century. The United States and its allies and partners must seek and create opportunities to bring medical overmatch to fruition. These opportunities will arise if they are actively pursued, the right questions are asked and answered, and conditions that promote adaptive problem-solving approaches are genuinely enabled. JFQ

Thanks to Chaplain (Colonel) Christopher J. Guadiz, USA, who reviewed this manuscript and provided much thought- ful advice as well as to Colonel Jeffrey Oliver, USA (Ret.), Colonel William D. Thompson, USA (Ret.), and MajorJennifer Farley, USA.