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In the recent wars in Iraq and Afghanistan, the U.S. military medical enterprise achieved historical highs for saving lives and treating extreme injuries. Indeed, the enterprise was so successful that a precedent of the Golden Hour was established, where medical providers could get to the point of injury and transport injured warfighters out of the battle and to a hospital within 1 hour.¹ Air supremacy combined with in-country medical centers and short transport distances facilitated this success. The speed at which providers could load and transport patients to advanced care was unparalleled.² In a conflict with the People’s Republic of China, however, this picture would change drastically, as the Golden Hour aspiration is likely untenable in a U.S. Indo-Pacific Command (USINDOPACOM) fight. Here, the paradigm will be distributed maritime operations (DMO), air superiority will be severely challenged, and vast distances exist between treatment locations. With patients being held for hours or days, updated medical treatment strategies and capabilities are required to meet the requirements of a major war.³

Relatedly, the transport of medical materials throughout the Pacific theater, and especially the “last tactical mile” to maritime combatants, is extremely challenging in this scenario.⁴ Whereas a land-based hub-and-spoke logistics model for just-in-time delivery was successfully executed in recent conflicts, a new maritime approach with different methodologies will be required in DMO. Here, the Navy, using the Military Sealift Command (MSC), will need to execute the five “Rs” of logistics:

• resupply (general ship supplies for the crew)
• rearm (replenishing ordnance following firing of ship payloads)
• refuel (fueling ships at sea or close to the fight)
• repair (ship repair at sea or in theater)
• revive (replenishing shipboard medical supplies) in the distributed maritime domain to keep forces going in the USINDOPACOM theater.⁵

To transport medical experts and capabilities to combatant ships in remote locations with casualties onboard, and then transport patients away from the conflict zone and eventually to safety, planners should think about leveraging platforms carrying out the five Rs. Therefore, Pacific Fleet should request MSC to have vessels executing the five Rs of contested logistics configured to support the transport of medical supplies to warfighting ships in theater, along with the transport of injured patients from those ships to uncontested areas. Such patient movement in contested logistics scenarios requires proper training and equipment at the point of need. Years of experience have demonstrated that a centralized acquisition authority structure, exemplified by Program Management System (PMS) 408 within Naval Sea Systems Command, enables the rapid development, evaluation, and sustainment of naval expeditionary medical systems, increasing responsiveness, and overall fleet readiness. This concept is explored in this article.

Medical Challenges in DMO

The challenges that Navy medicine will face during DMO are many. The naval force will use tempo and maneuver to project seapower by dispersing friendly forces across large distances, thereby complicating targeting attempts by the adversary while covering more area to apply fires to the enemy. In this context, the risk of mass fires being levied by the enemy on a concentrated friendly force, producing immediately decisive effects, is mitigated. However, DMO will require commanders to manage risk across all domains during execution given the complicated time, space, and force challenges in coordinating multiple forces to act harmoniously across vast distances.⁶ From a medical and logistics perspective, this could leave individual platforms vulnerable if they experience combat damage or run out of supplies prematurely. While the force is less likely to be dealt a decisive blow at a decisive point, individual platforms may be at greater risk if compromised. For instance, a high-value asset may be acting alone when an adverse event happens to it, compounding the time/force/space challenges of expeditiously rendering it assistance.⁷

Extensive war-gaming efforts have highlighted the challenges U.S. forces will face in a USINDOPACOM fight with China. While extremely costly for both sides, results suggest that within 3 weeks, approximately 5,000 U.S. personnel would be wounded or killed, while dozens of ships and hundreds of aircraft are lost. If accurate, the United States would lose half of what it lost in 20 years in Iraq and Afghanistan in just weeks. Eerily, including U.S. allies in this equation more than doubles the friendly force loss totals.⁸ Further analysis suggests a greater than 50 percent casualty rate in future large-scale combat operations, leaving the military health system overwhelmed.⁹ Cumulatively, prognostications suggest tremendously high numbers of casualties in this scenario. To minimize these potentially staggering losses, Navy medicine must be at its best from both a positioning and logistics perspective.

Medical Logistics Challenges

Medical supply and coverage operations will need to transcend systems of the past, which are incapable of supporting DMO, littoral operations in contested environments (LOCE), and expeditionary advanced basing operations (EABO). The Navy needs to execute uninterrupted operations in the contested maritime environment; therefore, it must be able to conduct the five Rs of logistics, including revive, to be successful in this endeavor.¹⁰ The expectation is for medical care to be in the right location at the right time.¹¹ However, in DMO, geographic isolation would likely force individual ship medical providers to execute prolonged stabilization combined with temporally longer than typical treatment of patients before further movement could occur. This could result in resources being drained much faster than usual.¹² Treating patients in this environment requires a robust supply/resupply system, but the current “pull system” and procurement process will not be sufficient in this environment.¹³

Lessons learned from the Marine Corps suggest that logistics supporting distributed operations must include greater logistics capability along with autonomy and requires decentralization to support operations over vast distances.¹⁴ Similarly, Vice Admiral Ricky Williamson (Ret.), Deputy Chief of Naval Operations for Fleet Readiness and Logistics, N4, stated in his 2021 remarks to Congress, “The Navy must transform its logistics enterprise to be more agile and resilient to ensure combat effective sustainment in a contested environment. Shifting to a ‘push logistics’ model via an intra-theater distribution network will enable warfighters to remain in the fight in support of DMO, LOCE, and EABO.”¹⁵ This was an adamant recognition that naval logistics, including revive, needs to be radically different than in recent conflicts.

Additionally, the enemy can do things to complicate logistics further. In May of 2023, the Department of Defense (DOD) discovered a vast cyber-espionage campaign conducted by Chinese actors targeted at critical transportation and communication infrastructure. This raised concerns that the DOD logistics enterprise could be severely disrupted through effective hacking attempts by an adversary.16 Should there be a major conflict, the challenge of DMO logistics in a cyber-challenged environment would be compounded by physical constraints, such as severely limited air superiority. In this context, lessons can be taken from the Falklands War between Argentina and the United Kingdom in 1982.

In this case, Argentina failed miserably to supply its force despite having the advantage of a much shorter maritime distance to cover. Why? According to the Argentine war college in a postconflict analysis, “Although the elements were available at harbors or air terminals, most of the time the question was how to deliver them to the users.”¹⁷ The authors then go on to state that “terrain conditions made transport difficult, and the British had eliminated our air assets as well as our naval assets.”¹⁸ Observably, getting supplies the last tactical mile to the end user in island warfare during tough conditions, and when the enemy is challenging air and naval assets, is extremely difficult. The authors go on to note that “consequently when it was time to engage in combat, the [Argentinian] troops had run out of supplies and were in poor health. Their fighting capability was therefore undermined.”¹⁹ Argentina stopped short partly due to logistical incoherence.

For the United States, which would be wise not to repeat these mistakes, the tyranny of distance encountered in DMO, amplified by enemy-caused logistics disruption across multiple domains, will make maintaining a sufficiently supplied fighting force extremely challenging. For revive, the need to get to the location of resupply urgently is of extra importance because it likely means there are already wounded patients there, draining supplies and in need of transport. So what is the best solution given these multifaceted challenges? This is the topic for the remainder of this article.

World War II Medical

Medical operations and logistics during World War II offer a salient example to inform present strategies for DMO. In the Pacific theater, quick health care was almost nonexistent due to the character of island warfare and extreme distances of dispersion.20 Medical providers had to provide health-care procedures in atypical environments. Exacerbating the problem were difficult supply methodologies to support ships that had to maneuver; supplies were hard to get and treating the wounded required difficult operations.21 Simultaneously, ashore hospitals were not ideal places for patients due to the hot, rainy climate facilitating mosquito-vectored illnesses. This led to hospital ships and slightly smaller evacuation ships playing prominent roles in patient care. Unmarked with red crosses, evacuation ships could transport patients, fully armed, out of the theater and then return to the battle loaded with more warfighters and supplies. Evacuation ships were configurable for their mission based on which way they were going, and whether they had injured or healthy warfighters onboard.22

Landing Ships, Tank (LSTs), were crucial platforms for health care during World War II as well, responsible for getting injured warfighters from close to the shore of islands to the assets for further transport.23 Perhaps limiting their applicability to a China conflict scenario, ship-to-shore and shore-to-ship movement of personnel and supplies would likely be extremely difficult. Nonetheless, the LST model offers an initial concept to consider for tactical medical transport and supply.

Overall, during World War II the Navy operated 15 hospital ships and 3 ambulance ships, while the Army operated 24 hospital ships with a combined capacity of approximately 17,000 patients.24 Their primary duties included the evacuation of patients from the combat zone, transport of patients from advanced bases out of the theater, acting as floating hospitals for fleet units, and providing emergency supplies for other ships.²⁵ Contrastingly, whereas 39 hospital ships were operated in World War II, today the U.S. military has only two Navy hospital ships, the USNS Mercy and USNS Comfort.²⁶ Hospital ship capacity has been greatly diminished since the World War II era. However, even though World War II hospital ships provided a greater capacity, it is important to note that 74 to 97 percent of patients evacuated between 1943 and 1945 were done so using troop transports and not hospital ships.²⁷ Again, the need for configurable multimission vessels is highlighted. This should be replicated in the present day to provide robust medical coverage in DMO.

Military Sealift Command: The DMO Solution

Reconfiguration of MSC vessels to meet dual missions—one going to supply combatants, the other transporting patients out of contested zones—is the most viable solution. In 2018, Chief of Naval Operations Admiral John Richardson called for a logistics posture that supports DMO and sustains the fleet globally. This was in response to the ever-increasing competition for access to markets, strategic partnerships, and sea lines of communication.²⁸ MSC, as the naval component of U.S. Transportation Command, is responsible for supplying the joint force at sea. To do this, it mans, trains, and equips to support a fleet of approximately 130 vessels, roughly 70 percent of which are expected to be ready for use at any given time. These vessels are collectively responsible for the 5Rs of maritime logistics. According to MSC, vessel capability will be just as important as capacity for these ships, and single-mission ships are of little use.²⁹ One MSC platform highlighted for its versatility, able to be equipped with different adaptive force packages for different missions, is the Expeditionary Fast Transport (EPF) program.³⁰ In fact, EPF can be configured to support transports of multiple varieties, including parts, munitions, food, and fuel.³¹

Plans are being executed to have EPFs support revive. In January of 2022, the keel was laid for the USNS Cody (EPF 14). This is the inaugural Spearhead-class EPF Flight II configuration that will be able to carry stowed medical equipment to outfit configured spaces on ship when deployed for a medical mission.³² The ship was delivered to the Fleet on January 11, 2024.³³ As put by Vice Admiral Williamson, “The Navy is developing the EPF Flight II, which will expand the logistics capability of these vessels to embark enhanced medical capability in support of DMO, LOCE, and EABO.”³⁴ Here we see the concept of leveraging certain Rs to support other Rs, specifically to the benefit of revive.

This is tremendous progress toward supporting effective health care in DMO, but more is needed. We suggest that in a “push” logistics model spanning vast contested areas, logistics vessels should be configured to support as many logistics missions as possible, without sacrificing support for its primary mission. Theoretically, this would provide more options and opportunities for warfighter logistics. Without this mentality, friendly forces may not have enough revive coverage, potentially exposing them to unnecessary risk. Therefore, as many logistics vessels as possible should be configurable to support revive. Notably, there is an especially ripe opportunity for revive and repair to start working together.

A potential symbiotic relationship between repair and revive is worth close examination for two reasons. The first reason is one of practicality. If a ship requires repair due to inflicted damage, such as by a missile strike or striking a mine, there is also a strong likelihood that there are also injured patients in the same place. If support from one of those Rs is required in the DMO environment, there is a decent chance support is also needed from the other. The second reason is one of opportunity. Like revive, repair has not had to focus its efforts on expeditionary repairs in recent conflicts and is realigning its capabilities and operations to meet the new demands. Succinctly put, both repair and revive are amid rapid adjustment to a more difficult mission set while facing similar challenges, and their operational missions will likely often require both support functions in the same location at the same time.

A recent U.S. Government Accountability Office (GAO) report examined this repair situation in depth. It notes that the Navy has not had to repair multiple damaged ships concurrently since World War II and that since the Cold War, the repair mission has been to support peacetime maintenance requirements.³⁵ Consequently, due to divestitures, today any kinetically damaged ship would likely fall into the regular maintenance cycle with status quo capabilities rather than a robust expeditionary repair strategy.³⁶

In the DMO environment, however, emerging repairs may require damage control and salvage operations not covered by regular maintenance.³⁷ Indeed, the GAO authors note the Navy will likely suffer significant damage to its ships in the DMO environment, requiring expeditionary repair capabilities and strategies to provide effective support.³⁸ Adding to the urgency, at-sea repair was not war-gamed until 2019 when the Naval War College hosted a logistics-focused game (subsequent games were hosted in 2020 and 2021), highlighting the early stages for fleshing out expeditionary repair strategies. Similarly, revive was not included until the May 2022 Contested Logistics Wargame, showcasing even later infancy.³⁹ The GAO report goes on to explain that the Navy is in the early stages of developing battle damage repair concepts and requirements to support DMO and notes that only in April 2021 did Pacific Fleet finalize its Ship Wartime Repair and Maintenance concept, including expeditionary repair of ships at sea along with expeditionary ports that may get damaged.⁴⁰ To enhance communication among vital stakeholders across the enterprise, OPNAV N4 established a repair cross-functional team in 2020 to enhance awareness, coordination, and rigor in the developmental process^.41 The same happened for revive shortly thereafter.⁴²

Cumulatively, this suggests that repair and revive are in similar stages of the reorientation process, making it reasonable for both vectors to immediately coordinate the potential of a combined DMO response. Testing has already been performed that could serve as a catalyst for this relationship to be formally established. Specifically, in September 2020, the USNS Burlington (EPF-10) carried out proof-of-concept testing in which it transferred a Maintenance Expeditionary Team to various ships for scheduled maintenance.⁴³ Here we see a platform whose newer variants are being configured for revive support, proving that this platform can also support repair in an expeditionary fashion. The possibility for MSC platforms to be leveraged to support both revive and repair is ripe and should be exploited to the maximum extent. The figure provides the concept for a repair and revive combined mission.

Figure. REPAIR and REVIVE Paired Concept of Operations

Acquisition Authorities

Until recently, a missing piece of the ecosystem to make this idea actionable was an acquisition program office with the authority and expertise to design, integrate, and sustain medical payloads onto MSC ships. As of 2021, the office with that resident expertise has been stood up and is fully functional. Acquisition authorities, often housed within a specific program office, are critical for fielding new capabilities within DOD. The program manager oversees budget management, solution testing/evaluation, risk mitigation, full Navy capability delivery, cybersecurity compliance, and sustainment. These duties ensure the safe and efficient implementation of critical systems.

Within Naval Sea Systems Command, the Assistant Secretary for Research Development and Acquisition (ASN RDA) holds primary responsibility for these functions. PMS 408 Expeditionary Missions—a program office under the ASN RDA and the Program Executive Office Unmanned and Small Combatants—manages expeditionary medical capabilities for the Navy. PMS 408 has distinct authority as a Milestone Decision Authority, allowing rapid delivery of crucial capabilities to the Navy. This process and oversight have been recently demonstrated with the delivery of expeditionary medical capabilities deployable in expeditionary and on-ship settings, specifically the Emergency Resuscitative Care System and the Emergency Resuscitative Surgical System that provide essential stabilization for patients before reaching advanced medical facilities.

When required, PMS 408 is well-positioned to rapidly modify and customize medical solutions during crises while maintaining critical safety and efficacy standards. PMS 408 oversees sustainment requirements (roughly 75 percent of life-cycle cost), cost estimations, and budgeting to ensure the operational readiness of expeditionary medical systems. Configuration control and management are executed in coordination with in-service engineering agents. Together, they maintain system modifications and updates, document all changes, and ensure compliance with laws, regulations, and standards governing military operations and resource management. Having an acquisition program office leading expeditionary medical capability development and delivery has overwhelmingly helped advance the Navy’s REVIVE efforts.

Counterargument and Rebuttal

It may be argued that the focus of the joint force efforts in the above scenario will be lethality, and so in an atmosphere where trade-offs are required, all budgetary and operational trade-offs should be tilted toward enhanced lethality. Therefore, from a medical perspective, we should rely on what is already present in our platform organic capabilities, fixed land medical facilities, hospital ships, and host-nation medical facilities, but little to nothing more, as this would distract from the primary objective. Furthermore, from a logistics perspective, this line of thinking suggests, we should prioritize “lethality-enhancing” support functions such as rearm and refuel. This attitude is reflected in recent budget justifications where Vice Admiral Sara Joyner, Director of Force Structure, J8, described the budget in the following manner: “All together, our historical investments in platforms and systems across the air, sea, and land domains will increase the lethality of our joint force, and enhance our ability to deter threats well into the future.”⁴⁴

While we agree that lethality should be prioritized, we also believe that survivability of friendly forces results in greater overall lethality potential. Lethality and medical care are not mutually exclusive trade-offs, and in fact, preserving both helps maintain force lethality.

The reality is that current medical capabilities are severely deficient to maximally protect the joint force in a contested maritime domain. There are not enough organic capabilities on warships to treat multiple casualties for extended periods. Additionally, host-nation care may be limited depending on agreements in place, the lack of dedicated medical connectors for transport from the point of injury, and the number of fixed medical facilities in theater spread across vast distances and relatively low in number for expected casualties. Therefore, we believe that lethality can be enhanced by protecting the health of the fighting force, and medical supply and patient transport should not be deprioritized. After all, the intangible benefit of force morale is increased when Marines and Sailors expect to receive treatment for any wound and not become just another burial at sea statistic.

Alternatively, some could argue that we should have many more medically designated ships, including both hospital ships and smaller transport ships, to provide sufficient healthcare during DMO. For instance, a Center for Strategic Budgetary Assessments report suggests that a fleet of small hospital ships could be used to receive or recover wounded warfighters and then transport them to larger hospital ships or aircraft that would then take them to a transportation hub where they would be ferried to a major a medical facility.⁴⁵

We agree that this would be the ideal state. However, as mentioned, the current inventory of hospital ships is 2, compared to 39 in World War II. This will not change significantly in the short term, rendering the “many new ships as a strategy” unviable for the foreseeable future. Furthermore, we encourage the reader to hearken back to World War II lessons, where even with approximately 20 times more hospital ships as the current inventory holds, the majority of patient transport took place aboard ships configured to transport supplies and warfighters into theater and injured
warfighters out while receiving health-care support.46 Therefore, while this is a noble ambition to shoot for in a 10- to 20-year plan, the best way to support warfighters in the DMO environment in the short-term is to ensure logistics ships are configurable to also support revive.

There are many challenges facing revive as it transitions to a DMO coverage strategy. Delivering medical supplies to maritime forces over the last tactical mile, and subsequently moving patients across vast maritime distances to safety will be the greatest challenge that Navy medicine has faced since World War II. MSC vessels offer a potential solution to this difficulty by ensuring U.S. supply ships are configurable not only to deliver supplies in contested environments but also to move patients out of combat and to uncontested zones. Currently, repair vessels are the best situated to start this process, although the ultimate objective should be to leverage all 5 Rs to meet this valiant goal. Therefore, Pacific Fleet should work with MSC to ensure maritime logistics platforms supporting all 5 Rs are configurable to transport patients in addition to their primary mission set. JFQ

Notes

¹ Janet A. Aker, “Military Medicine Is Preparing for the Next Conflict,” U.S. Indo-Pacific Command, June 15, 2022, https://www.pacom.mil/Media/News/News-Article-View/Article/3064657/military-medicine-is-preparing-for-the-next-conflict/.

² Haraz Ghanbari, “Medical Professionals in Afghanistan Strive to Treat Wounded Within ‘Golden Hour,’” U.S. Army, June 24, 2011,
https://www.army.mil/article/60226/medical_professionals_in_afghanistan_strive_to_treated_wounded_within_golden_hour#.

³ Aker, “Military Medicine Is Preparing for the Next Conflict.”

⁴ The Defense Acquisition University (DAU) defines last tactical mile as “the perceived gap between national intelligence systems and battlefield operations,” or “the three-dimensional segment of the global battlespace closest to the fight.” See “Supply Chain and the ‘Last Tactical Mile,’” CLL037 DOD Supply Chain Fundamentals (Fort Belvoir, VA: DAU, n.d.), https://icatalog.dau.edu/mobile/CLL037/DAU_Supply_Chain_Atlas/010125/010125000060.html.

⁵ Minding the Gap: How Operational Energy Can Help Us Address Logistics Challenges, Hearing Before the Subcommittee on Readiness of the Committee on Armed Services House of Representatives, 107th Cong., 1st sess., 1 (2021) (testimony of Vice Admiral Rick L. Williamson, Deputy of Naval Operations for Fleet Readiness and Logistics, N-4, Office of the Chief of Naval Operations), https://www.proquest.com/printviewfile?accountid=322.

⁶ Brian Seymour, “A Modern Acceptable Level of Risk Model for the Operational Commander in the Great Power Competition Era,” Naval War College, April 16, 2021, 8–9, https://apps.dtic.mil/sti/pdfs/AD1152827.pdf.

⁷ Seymour, 3.

⁸ Nathan Baca et al., “DC Group’s Wargame Predicts How China vs. U.S. War Would End,” WUSA 9 Investigations, March 28, 2023, https://www.wusa9.com/article/news/investigations/china-us-war-simulation-csis-wargame/65-37844d34-ab1f-49a2-ad2e-09a7c8ff94c4.

⁹ Michael Wissemann, “Large-Scale Combat Operations Will Bring New Medical Ethics Challenges,” War on the Rocks, December 8, 2023, https://warontherocks.com/2023/12/large-scale-combat-operations-will-bring-new-medical-ethics-challenges/.

¹⁰ Minding the Gap, 2.

¹¹ Andrew P. Kettner, “21st-Century Medical Readiness,” Marine Corps Gazette, March 2023.

¹² William G. Day et al., “Prolonged Stabilization During a Mass Casualty Incident at Sea in the Era of Distributed Maritime Operations,” Military Medicine 185, no. 11–12 (November/December 2020), 2195, https://doi.org/10.1093/milmed/usaa147.

¹³ Kettner, “21st-Century Medical Readiness,” 44.

¹⁴ Justin A. Hooker, “Logistics in Distributed Operations,” Marine Corps Gazette 95, no. 3 (March 2011), 27.

¹⁵ Minding the Gap, 4.

¹⁶ Jason Wolff, “The Department of Defense’s Digital Logistics Are Under Attack,” Brookings, July 2023, https://www.brookings.edu/articles/the-department-of-defenses-digital-logistics-are-under-attack/.

¹⁷ Argentine Naval War College, Department of Logistics, “Argentine Logistics in the Malvinas Conflict,” paper presented to U.S. Naval War College, Newport, RI, October 1996, 16.

¹⁸ Argentine Naval War College, Department of Logistics, “Argentine Logistics,” 16–7.

¹⁹ Argentine Naval War College, Department of Logistics, “Argentine Logistics,” 17.

²⁰ “Bringing Them Home: The Navy’s Hospital Evacuation Transports of WWII,” SOFREP, August 24, 2022, https://sofrep.com/news/evacuation-ships-during-second-world-war/.

²¹ Veronique R. Falciola and David B. Waisel, “Surgical Challenges Aboard Non-Hospital Ships in the Pacific During WWII,” Journal of Anesthesia History 4, no. 1 (January 2018), https://doi.org/10.1016/j.janh.2017.11.058.

²² “Bringing Them Home.”

²³ “LST(H) Landing Ship, Tank (Casualty Evacuation),” Global Security, n.d., https://www.globalsecurity.org/military/systems/ship/lst-h.htm.

²⁴ “WW2 Hospital Ships,” WW2 US Medical Research Centre, n.d., https://www.med-dept.com/articles/ww2-hospital-ships/.

²⁵ Quintin M. Sanger, “U.S. Naval Hospital Ships in World War II and Korean Action,” Military Medicine 131, no. 1 (January 1966), 36, https://doi.org/10.1093/milmed/131.1.36.

²⁶ Bureau of Medicine and Surgery, Department of the Navy, Almanac, 2023, 25, https://www.med.navy.mil/Portals/62/Documents/BUMED/Almanac%202023%20EDIT-compressed.pdf?ver=8TZfoq3Of7fYhzHQCXhehg%3D%3D.

²⁷ “WW2 Hospital Ships.”

²⁸ Edward Lundquist, “Being in More Places at Once Calls for Both Large and Small Platforms,” Defense Transportation Journal 75, no. 5 (October 2019), 20, https://issuu.com/defensetransportationjournal/docs/dtj164_web.

²⁹ David Bassett and James Regan, “Military Sealift Command: Joint Maritime Mobility,” Joint Force Quarterly 107 (4th Quarter 2022), 68, 71–2, https://ndupress.ndu.edu/Portals/68/Documents/jfq/jfq-107/jfq-107.pdf.

³⁰ Lundquist, “Being in More Places at Once Calls for Both Large and Small Platforms,” 22.

³¹ Lundquist, 24.

³² “Keel Laid For ‘Hospital Ship’ Version of Expeditionary Fast Transport Ship,” Warship Technology, March 2022, 20, https://www.jstor.org/stable/10.2307/48652028.

³³ “Navy Accepts Delivery of USNS Cody,” U.S. Navy, January 17, 2024, https://www.navy.mil/Press-Office/News-Stories/Article/3647805/navy-accepts-delivery-of-usns-cody/.

³⁴ Minding the Gap, 2.

³⁵ Diana Maurer et al., Navy Ships: Timely Actions Needed to Improve Planning and Develop Capabilities for Battle Damage Repair, GAO-21-246 (Washington, DC: Government Accountability Office, June 2021), https://www.gao.gov/products/gao-21-246.

³⁶ Maurer et al., 4.

³⁷ Maurer et al., 9.

³⁸ Maurer et al., 12.

³⁹ Maurer et al., 17; 2022 Naval Contested Logistics Wargame, US Naval War College, Newport, RI, Author’s Personal Knowledge.

⁴⁰ Maurer et al., Navy Ships, 19, 22.

⁴¹ Maurer et al., 23.

⁴² Revive Cross-Functional Team. Author’s Personal Knowledge.

⁴³ LaShawn Sykes, “USNS Burlington Carries out Proof-of-Concept Testing,” Military Sealift Command, September 27, 2020, https://www.msc.usff.navy.mil/Press-Room/News-Stories/Article/2380426/usns-burlington-carries-out-proof-of-concept-testing/.

⁴⁴ Jim Garamone, “Lethal, Resilient, Agile Joint Force Basis for Defense Budget Request,” DOD News, March 13, 2023, https://www.defense.gov/News/News-Stories/Article/Article/3327644/lethal-resilient-agile-joint-force-basis-for-defense-budget-request/.

⁴⁵ Lundquist, “Being in More Places at Once Calls for Both Large and Small Platforms,” 22–24.

⁴⁶ “WW2 Hospital Ships.”