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Captain Debra D. Buckland-Coffey, USN, is Chief Medical Officer at Walter Reed National Military Medical Center. Colonel Robert P. Gerbracht, USMC, is Special Assistant to the Director and Marine Operational Liaison at the Defense Advanced Research Projects Agency. Commander Kengo Nishida, Japan Maritime Self-Defense Force, is Japan’s Liaison Officer to the U.S. Joint Staff J6/J7. Lieutenant Commander William R. Gureck, USN, is a Logistics Officer at Joint Task Force Civil Support.
Significant gaps in understanding persist across the joint and combined maritime enterprise when it comes to wargaming distributed maritime operations (DMO) and expeditionary advanced base operations (EABO) despite continued campaigns of learning.1 Attempts to wargame future concepts related to DMO remain challenging as a basic premise and become more complicated if warfighters ignore—or “fairy dust”—joint functions like health services during operational planning and exercise design. In the current context, we define fairy dusting as accepting unvalidated assumptions during a planning process, wargame, or exercise—often for simple convenience or to achieve finality in scripted objectives. Since legitimate wargaming rarely offers us final solutions and is instead “best used to investigate processes,” this article focuses on the urgent need to address process limitations in DMO sustainment planning by applying practical wargaming theory to integrated exercise design.2 While the Marine Corps and Navy team continues to take active steps to incorporate accurate health services models throughout its planning activities, much work still needs to be done.3 Accordingly, this article asks a central question: How can refined wargaming efforts support health services integration in DMO exercises, and what tools are available to achieve this integration?
Methodology and Terms of Reference
To explore the question, we conducted qualitative research on recent exercises and wargaming trends by reviewing unclassified Service doctrines, after-action reports, and available data for Service programs of record. To complement these secondary sources, we conducted six expert opinion interviews with Marine Corps and Navy leaders, senior medical planners, logisticians, and program leads (ranging in rank from O-3 to O-9) who have recent experience with U.S. Indo-Pacific Command (USINDOPACOM) and large-scale Service exercises. Additionally, we drew on the international expertise of our research team, considering the risk to bilateral integration as fairy dust drifts across international boundaries. By connecting our research on health services support to our need for better opera- tional relationships with bilateral allies in support of integrated deterrence, we hope to add a sense of urgency and mutual responsibility to solving one of DMO’s central logistical puzzles.
This article uses the term wargaming according to a definition familiar to the field—specifically, “[models] or [simulations] involving actual military forces, and in which the flow of events is affected by and in turn affects decisions made during those events by players representing the opposing sides.”4 This basic definition of wargaming encompasses all elements of gaming, exercising, modeling, and simulation (GEMS), aligning with broader Department of Defense (DOD) guidance included in the fiscal year 2022 National Defense Authorization Act.5
As noted, our initial research identified process limitations in exercise design as an essential consideration, so we focused less on specific games, models, and simulations, as they are most commonly associated with DOD programs of record that are strictly managed according to Federal regulations.6 A focus that was too strong on programs of record alone risked improperly defining our research question as a data analytics or acquisitions challenge rather than one of organizational learning and coordinated understanding. While the former challenges have proved valuable for integrating systems and technologies, we contend that the latter remains necessary.7 More than ever, maritime operations in the Indo-Pacific require shared organizational learning to bridge existing gaps between operational plans and reality.8
Primarily interview data drove our research to focus more on large-scale Service exercises tied to operational planning cycles and influenced by Service-directed organizational processes. In centering our research on exercise de- sign and not on programs of record (that is, process over products), we pursued two primary goals:
- to follow the evidence provided by leadership and duty experts eager to improve health services integration in the joint planning process
- to offer feasible suggestions and areas for improvement, recognizing that changes to practice may be quicker or easier to implement than changes to programs.
As DMO’s ultimate test as an aspirational warfighting concept will be either success or failure in combat, this article first provides an overview of its operational logic and the associated challenges facing health services support.
DMO and Wargaming Aspirational Concepts
DMO can best be described as a warfighting concept that involves “a combination of distributed forces, integration of effects, and maneuver” that will “enhance battlespace awareness and influence” and “generate opportunities for naval forces to achieve surprise” by imposing operational dilemmas on our adversaries.9 Fully embraced by Marine Corps and Navy leadership as a cornerstone of integrated all-domain naval power and force design efforts, DMO promises the “virtues of mass without the vulnerabilities of concentration.”10 As an essential element of maritime strategy, DMO proposes tackling the “tyranny of distance” across the physical and electromagnetic domains through investment in command and control, fires, and sustainment technologies— many of which are either theoretical or still in development.11 Broad acceptance of these nascent warfighting capabilities can make even the most detailed sustainment planning estimates seem aspirational and, absent historical precedents, risk becoming counterfactual.12
As a 2018 RAND study illustrated, “[m]edical and other combat service support functions face a . . . daunting paradigm shift” in near-peer competition.13 Such a shift to large-scale naval combat operations and DMO will likely entail significant efforts in health services, particularly under the threat of antiaccess/area-denial tactics from near- peer adversaries.14 This environment challenges the traditional “golden hour” for medical evacuation, predicting significantly higher casualty rates and logistical hurdles that could overwhelm existing medical systems. The necessity for innovative evacuation methods, the logistical complexity of transporting medical units and supplies, and the high potential for interdiction by adversaries underscore the need for flexible and resilient health services support systems.15 Added to these challenges are the historically proven realities of nonbattle injuries and ongoing medical care at scale, which are incredibly taxing even to unstressed medical networks.16
More recent research has addressed these challenges by identifying the importance of host-nation partnerships and the exploitation of expeditionary advanced bases. Using the Falklands War as a historical case study, a group of researchers adroitly notes that EABO employment in support of health services support networks “may become [necessary in] large-scale conventional warfare in [USINDOPACOM],” and include “host-nation facility interoperability with allied forces, trauma systems development, and coordination of allied casualty movement through the host-nation hospital system.”17 The research group further argues that “doctrinal changes in treatment strategies, logistics planning, and personnel requirements should consider and address” the challenges posed by health services support to DMO.18
Challenges of Modeling Naval Medical Logistics
Accurately modeling health services sustainment to DMO in the Indo-Pacific region is inherently a feat based on mastering distance and time. When we consider a potential conflict with a regional peer adversary, logistics and the ability to sustain forces in a contested environment will be the keys to successful operations. As put succinctly in another RAND report, “It is critical that the logistics underpinning a credible military deterrent be figured out now and not wait any longer.”19 For Navy units to operate in the USINDOPACOM area of operations, vessels must rely on receiving stores and fuel from Military Sealift Command supply ships, known as combat logistics force vessels, or these vessels must replenish via ports in hub locations such as Australia, Guam, Japan, Korea, and the Philippines.20 While there may be some opportunities for Navy ships to replenish at smaller Pacific ports, supplies are limited and usually transported from these primary logistical hubs.
After a ship receives supplies and fuel, its typical operating endurance at sea can range from 45 to 60 days, depending on crew size and available cargo space. The most problematic aspect of the Indo-Pacific maritime environment is that logistics is neither quick nor convenient, and replenishment orders often take months to plan and execute, mainly due to moving desired stores from the continental United States via air and sea methods.21 Ships not only have to store food and supply parts selectively, but also, in the case of health services, they must consider the proper storage of Class 8 (medical) supplies. Generally, ships have enough medical supplies on hand to operate for 7 to 10 days in a contested environment before needing replenishment.22 Modeling challenges increase by orders of magnitude when we consider other significant variables—such as damage to storerooms and unexpected casualties—that can significantly affect a ship’s operating endurance in a contested environment. Also, medical casualties jeopardize a ship’s ability to remain on station by affecting its need to offload patients or by rendering it incapable of receiving additional necessary medical supplies from combat logistics force ships due to an increased combat risk to these vessels.
Habituated patient care expectations further challenge the accurate modeling of health services sustainment. During the wars in Iraq and Afghanistan, combat injuries were typically smaller in scale relative to combat action, primarily originating from small arms, mortars, and improvised explosive devices that affected numbers of Servicemembers in the tens of thousands. Given operational overmatch and relative air superiority, most casualties could immediately be treated at a Role 1 facility with transfer to a Role 2 or Role 3 facility within an hour.23 After stabilization, injured Servicemembers were transferred to a standing military treatment facility, most commonly Landstuhl, Germany, and then back to the United States for definitive management at a Role 4 facility. This evacuation pathway was standardized, practiced, and timely.24
In a near-peer maritime battle with contested maneuver across every physical domain, the expected golden-hour standard of surgical care will be unrealistic.25 Injuries will likely be of larger scale from advanced munitions that may potentially cause casualties in the hundreds.26 While many injuries will be immediately lethal, those that are not will require point-of-injury management until evacuation can safely be executed to a Role 1 facility. Patient movement is not likely to progress smoothly or sequentially. In a contested maritime environment, it is more likely that patients will spend prolonged periods at initial Role 1 facilities and move in a leapfrog fashion through various care locations until opportunistic lift can evacuate them to Role 3 care. Movement to a hardened medical treatment facility or stateside care may take several days or even weeks.
These layers of logistical complexity are daunting and, therefore, tempting to disregard. Accordingly, accurate health services modeling is often fairy dusted in exercises, training evolutions, and wargames, since combat-centric scenario designers fail to devote needed attention to the intricacies of patient care, casualty movement, and logistics. As one senior officer told our research team, even naval medical and logistical planning personnel may fail to contribute thoroughly to wargames or exercises because their goals conflict with those defined by the simulation designers.27 Practical wargaming should instead facilitate shared understanding among warfighters, medical personnel, and logisticians to effectively model and forecast requirements, which will help maximize operating endurance while minimizing potential risk.
Given the criticality of multilateral operations in the Indo-Pacific region, the need to sweep away fairy dust must begin in our own house, lest it settle with our allies and partners and further challenge our interoperability. Increased multilateral coordination and integration should be a foregone conclusion to realize DMO, as the joint force will require allies and partners to maximize sustainment across the Indo-Pacific region if organic supplies from the United States or other major hubs are threatened. Unfortunately, security clearances and national caveats often constrain our ability to interact fully with international partners, leading to uneven insights, split understanding, and uneven coordination during exercises.
While formidable, the intellectual challenge of accurate health services modeling is nevertheless worth the reward. Theater medical and logistics communities should predict and prepare for armed conflict in a legitimately integrated fashion by pursuing more interaction through international partners and avoiding logistical fairy dusting in exercises.
Findings and Considerations
Our research illustrates three central points when building wargaming, exercise, and modeling approaches for DMO. First, we should be informed by historical examples without overreliance on them. While the most obvious analog to a future distributed naval war in the Pacific is our last distributed maritime war in the region, times and technologies have changed. The lethality and reach of modern weapons systems, coupled with nearly a century’s advances in intelligence, surveillance, and reconnaissance, change the potential injury patterns that naval medical services are likely to treat.28 Second, our efforts should inherently account for multilateral approaches that will require the involvement of allies and partners. While EABO can provide critical nodes in a more extensive theater network of care, host-nation medical capabilities remain a potential center of gravity. Finally, naval medical professionals must develop a wargaming mindset to address the challenges of near-peer DMO and be willing to challenge the status quo of existing exercises. While many of these professionals may see wargaming only as an adjunct to the military planning process, it should be seen more as the professional obligation of anyone charged with supporting a nascent warfighting concept like DMO. Not only does wargaming promote creative thinking and dialogue among professionals, but it also provides fail-safe environments where they can challenge concepts (like DMO and EABO) with an eye toward critical improvement.29
Interview data we gathered on recent trends in DMO planning and exercise design highlighted the importance of these three points. While in Japan on a recent visit to support the Joint Inspectors General Office, a senior Navy medical officer interviewed by us met with local Navy hospital and Marine Corps leadership to assess their units’ respective readiness in support of theater contingency plans. What this officer experienced was both enlightening and concerning. While Marines had high expectations of available health services supporting theater plans, Navy hospital staff expressed little or no awareness of their involvement in such plans and sometimes even ambivalence about their responsibilities. One officer replied, “What’s an O-Plan?” when pressed about their participation in theater contingencies.30 Ostensibly, this officer may have lacked a wargaming mindset.
However, surmounting such educational limitations can prove tricky, as obstacles to effective integration abound. During a recent large-scale Marine Corps exercise, a medical battalion’s casualty assessment was sidelined to advance the programmed pace of the event.31 When attempting to model patient movement and Role 2 care based on a scripted mass-casualty event, Marines fairy dusted their casualty assessments, while the medical battalion assessed more realistic injuries. As a result, notional casualties were “resurrected” and put back in the fight, undercutting the training value to medical planners and practitioners.
Other interview data from large-scale exercises bore out similar disconnects. While supporting a large-scale exercise in USINDOPACOM, another senior medical officer warned a joint planning team against fairy dusting critical aspects of health services support. He was told, “If we allow you to exercise your problems, they’re so complicated they will grind our exercise to a halt.”32 Unfortunately, this sentiment was a common trend in our interviews. Still, among those we spoke to, the consensus was clear—the challenge of fairy dusting medical support occurs less from acts of willful commission than acts of omission. In short, available resources, time constraints, and a desire to “just get through the exercise” often limit efforts to truly build understanding about the inherent difficulties of health services support to DMO. Even the best use of wargaming cannot address these unless design and schedules allow.
Conclusions and Recommendations
Two decades of war in Iraq and Afghanistan have contributed to unconscious biases or even unrealistic expectations of combat casualty care, causing planners to assume uncovered risk during wargaming and exercise design. Senior Service leaders are clearly aware of and concerned about this and are spearheading a comprehensive approach to bridge the gap between GEMS tools and organizational insights.33 In a significant step, the Marine Corps is addressing this challenge head-on with the opening of the General Robert B. Neller Center for Wargaming and Analysis. This 100,000-square-foot location “will employ artificial intelligence, machine learning, data analytics, and modeling and simulation processes to enable the Marine Corps to conduct wargaming and analysis across multiple domains and levels of classification.”34 While this facility will go a long way toward addressing concerns about fairy dusting the medical and logistical aspects of DMO, it may also present opportunities to address similar issues across the joint force.
Our research also revealed some positive exercise design trends, but more must be done. Bilateral exercises, includ- ing the U.S.-Japan exercise Keen Sword, represent critical first steps to address multilateral health services wargaming as a “baked-in” element of their design. As one interviewee noted, while these training opportunities effectively capitalize on realistic (and partnered) health services support, they must be more explicitly codified in multiyear training exercise and employment plans, or they risk becoming add-ons to exercises designed to focus on other joint functions.35 Plans that deliberately account for health services integration in exercises would provide medical planners with the time and space to develop supplemental wargames at the tactical level and habituate subordinate medical support units to the realities of DMO. Intuitively, a recommended first step in addressing health services gaps in exercise design is explicitly including them in exercise design plans.
On the GEMS front, our research indicated that Service-level efforts are already being made to improve virtual modeling and simulation tools such as the Joint Medical Planning Tool, the Medical Planner’s Toolkit, and the Enterprise Estimating Supplies Program to refine health services planning estimates.36 Although these programs of record require attention, one interviewee noted that even the most effective GEMS tools can be ineffective without insightful use.37 Accordingly, as a primary recommendation, we contend that both the Marine Corps and Navy must not only increase investments in programs of re- cord related to health services wargaming but also expand educational initiatives that expose the realities of naval medicine in a DMO context. Simple and low-cost approaches like matrix-style wargames, which optimize dialogue and stochastic (or randomized) narratives, are particularly effective at encouraging this type of organizational learning.38
We neither contend that DMO is unachievable nor ignore the attention that theater sustainment limitations have already received in the USINDOPACOM theater from vocal logisticians and leaders alike.39 Instead, we seek to add to an existing body of knowledge that explores how practical wargaming, across the full spectrum of GEMS, is both necessary and often critically undervalued in developing operational art.40 Furthermore, we argue that of all the joint functions that suffer from fairy dusting in the planning and exercise cycle, sustainment poses the most significant risk, with health services support being the most acute example. We contend that—because of challenges posed by planning timelines, exercise design, and multinational interoperability—wargaming health services in support of planning and exercises can benefit from deliberate, long-term exercise plans in addition to investments in systems and tools that are already being made across the sustainment enterprise.41
As a tentative answer to our research question, we argue that realistic and deliberate exercise design (the E in GEMS) remains essential to integrating health services sustainment into DMO. Furthermore, wargaming through large-scale exercises cannot be seen simply as a process step in the joint planning cycle. If health services are as frequently fairy dusted as our research indicates, it is more than likely that gaps in other joint functions are hiding just below the surface. Although a significant amount of legislative, joint, and Navy interest has been focused on advancing GEMS capabilities in support of health services planning, concerns about gaps between DOD vision and the operational realities of DMO remain warranted. JFQ