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Robert D. Kaplan’s early 2023 book, The Tragic Mind: Fear, Fate, and the Burden of Power, is the latest of his nearly two dozen books over the past 35 years. Like its predecessors, The Tragic Mind features Kaplan’s impressive powers of observation and analysis at the junction of politics, history, and world geography. Unlike his prior prodigious, geographically focused works including Balkan Ghosts (1994), Monsoon (2010), and In Europe’s Shadow (2016), this is a short work. It contains his personal musings unbound by specific geography and focused on both his experiences reporting from war zones since the early 1980s and his reflections about them in the context of great philosopher-thinkers from ancient Greece to modern America.

In The Tragic Mind, Kaplan describes the leader’s historic dilemma about the use of force. That choice is never truly one between good and evil but rather between one good and another or between lesser evils. That choice also is destined to cause suffering. Kaplan observes that leaders—political and military—must keep this in mind and be humble in their decisions and realistic in execution. They must think tragically to avoid tragedy.

Spanning 14 pithy chapters, The Tragic Mind is written with a foreboding tone. Kaplan has reported on Yugoslavia’s fragmentation and collapse into civil war after Josip Broz Tito’s death; Romania’s chaotic plight after the fall of its dictator, Nicolae Ceausescu; and the tumult, turmoil, and suffering that convulsed Iraq, Libya, and Syria when external interventions, military and cyber, wracked long-standing tyrannical regimes. In this book, Kaplan works to make sense of the extraordinary human suffering during these dramatic events by consulting the ancient Greeks and Shakespeare for insights into the frailty of the human condition. He also references the philosophical wisdom from European thinkers like Albert Camus, Fyodor Dostoevsky, and G.W.F. Hegel to chronicle the patterns of human behavior, both noble and flawed, throughout the ages.

Kaplan’s literary journey blends with his personal war-zone tribulations to produce a work with chapter titles like “The Battle of Good Against Good,” “Order and Necessity Must Be Obeyed, Even When They Are Unjust,” “Because War Is Ever-Present, the Burden of Power Is Overwhelming,” and “Imperial Wars Are Decided by Fate.” There are more. All are signposts to Kaplan’s major insights and cautions. He reminds the reader that since the ancient Greeks and Persians, the eternal political struggle for humankind is that of “tyranny against anarchy.” Neither is an absolute good or an absolute evil. But for  Kaplan, 40 years of personal history with human suffering convinced him that the ancient Persian philosopher Abu Hamid al-Ghazali had it mostly right when he argued that 1 year of anarchy is worse than a hundred years of tyranny. And so is Shakespeare, in whose works Kaplan observes, “[O]rder is the first step toward civilization. Only after order is established can the work begin to make order less coercive.” The tragic mind understands this and values order over chaos even while it understands that that order can descend into tyranny. The tragic mind does not wallow in passivity. It acts when necessary and with the humility that comes from the historic understanding that the dangers of hubris, pride, and human ambition are always present and will lead to tragedy if the “terrible power of the irrational” is allowed to drive a choice to use force in pursuit of “grand ambition.”

Kaplan laments Washington’s recent military forays in its pursuit of the “grand ambition” of making the world in America’s image as a liberal democracy. He views America’s last great statesman to be George H.W. Bush—“the last American President to embrace the use of military power while thinking carefully and tragically about it.” Kaplan defines Bush’s humility, prudence, and tempered determination to have exemplified the tragic mind and successfully guided the United States to win the first Gulf War, manage the fall of the Soviet Union, and sustain U.S. relations with China after the Tiananmen Square massacre. He finds Presidents Bill Clinton, George W. Bush, Barack Obama, and Donald Trump wanting in comparison.

Most of The Tragic Mind looks back at examples of unsatisfactory U.S. military interventions to end tyranny. The book’s epilogue looks forward. Kaplan warns modern American politicians, pundits, and intellectuals that a “tragic sensibility” is required today to manage intensifying Great Power rivalry in Europe and the Indo-Pacific region. A tragic mindset is not afraid to take military action but proceeds deliberately. It analyzes rationally and acts with temperance, prudence, and an understanding that action generates counteraction, and leaders who fail to appreciate the worst possible outcomes will only exacerbate human suffering with little to show for it.

In the context of America’s ongoing Great Power competition with Russia and China, the choices made in Washington are consequential. The tragic mind must consider whether pursuit of an absolute defeat of Russia in Ukraine could result in national collapse like that of a century ago when post-czarist Russia descended into anarchy and millions died. The tragic mind must also contemplate whether the prospect of Ukrainian success could lead Moscow to use nuclear weapons—taking the world to a new, dangerous threshold of destruction and encouraging other countries to acquire them. Likewise, would an overt American military engagement of China over its struggle to incorporate Taiwan be worth the impact on the global economy, or could such a clash unleash a series of destructive military, cyber, and space-based exchanges that would permanently shift today’s world of strategic competition into one of persistent war?

Kaplan’s insights urge American politicians and their military advisors to display humility and be mindful of history when evaluating the proper means to challenge China and Russia in this era of Great Power competition. The tragic mind requires “an awareness of the narrow choices we face and however vast the landscape, the knowledge that not everything is possible, regardless of the conditions.” Military planners are used to developing alternative courses of action based on best- and worst-case possibilities and narrowing the options to those that best mitigate risks. The Tragic Mind suggests that America’s most senior civilian and military leaders need to adopt and enhance this military planning technique, seasoning it with an understanding that actions taken to sustain order, however imperfect, are inherently less destined for tragedy than those targeted at ending tyranny without certainty that a better form of order will swiftly follow. JFQ

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The war in Ukraine has been going on for 3 years now, and much has been written about Vladimir Putin’s strategic failures and the valor of the Ukrainian defenders. The conflict has transformed from a poorly executed coup de main into a grinding war of attrition. It is time to take stock of this conflict. Learning from contemporary conflict is harder than it seems, but it is a small investment with big payoffs from crucial insights into the changing character of war.

These three books—War in Ukraine, The War for Ukraine, and A Call to Action—collectively offer wide-ranging perspectives from this violent contest of wills. Learning from this and any war is complicated by limitations in access to battle data, from determining what did or did not work and why, which is often blurred in the fog of war. This set of books provides history’s first cut of the confrontation, and each uses a different analytical lens across all three levels of war. 

At the strategic level, War in Ukraine offers a set of penetrating insights from an all-star cast of commentors. This well-edited anthology provides the reader with a study of the first 2 years of the war. While it is replete with incisive analysis, it contains no Ukrainian or Russia voices.

JFQ readers will find the chapter by Thomas Mahnken and Joshua Baker reveals numerous strategic insights that could be applied beyond Ukraine. Mahnken is a well-recognized defense strategist and leads a Washington-based think tank, the Center for Strategic and Budgetary Assessments. Baker is a recent graduate of the Johns Hopkins School of Advanced International Studies. Their chapter offers an analysis based on several decisionmaking pathologies. These fallacies include the irrationality of war, the irrational adversary, the hyper-rational adversary, overestimation, silver bullets, and the faith of decisive victory. All of these can be seen in this contest by the antagonists or by commentators. It is a great case study for teaching strategy. As Mahnken and Baker note, “an awareness of the pitfalls that soldiers, statesmen, and scholars frequently fall prey to is a useful starting point to formulating and implementing sound strategy” (198). For that reason, this chapter should be mandatory reading in all U.S. professional military educational programs; it offers a diagnostic framework that might be applied in every case study in any policy and strategy department.

The chapter written by Alexander Bick is also noteworthy. It offers an insider’s perspective on National Security Council efforts to anticipate the implications of the alarming crisis in Ukraine. This illuminating chapter shows how the Joseph Biden administration learned from its planning shortfalls that led to the ignominious withdrawal from Kabul in the summer of 2021. This time the staff proposed—and National Security Advisor Jake Sullivan approved—the charter of a “tiger team” that worked full time in late 2021 to assess the likelihood of a Russian invasion and possible U.S. policy responses. Bick details the tabletop exercises that this cross-functional team employed to explore its assumptions and the policy playbook it prepared for the President. The author is honest about the failings of imagination in the team. However, he concludes the team helped. Bick writes, “It enabled us to foresee challenges and requirements that had not yet arisen. And it provided a vehicle to explore and develop ideas that otherwise would have languished as agency leadership prioritized near-term demands” (149). The question that should be asked now is how these processes are institutionalized so that U.S. strategic competency is not subject to a sine wave of costly learning during turnovers in administrations. (See Frank Hoffman, “Risk: A Weak Element in U.S. Strategy Formulation,” JFQ 116, 1^st Quarter 2025).

Critics of the Biden administration’s risk aversion will find much to agree with in the critique of Washington’s strategy in a sharp chapter crafted by Kori Schake, a veteran policy practitioner and scholar at the American Enterprise Institute. She notes a persistent pattern in Washington’s slow responsiveness to Kyiv’s continual requests for advanced arms. While the Ukrainians were in an existential battle, the administration initially denied them requested weapons until other allies stepped in or when public and allied opposition reached a crescendo. Only then would “the Biden Administration bowing to public criticism and inter- national pressure and slowly relenting [provide] the systems months and even years later than when they would have been most effective” (164). History may ultimately find this era’s risk and escalation assessments to have been contradictory to U.S. interests.

The second book examined in this review, The War for Ukraine, was penned by retired Australian Army Major General Mick Ryan. He is no stranger to these pages (see his article “The Intellectual Edge: A Competitive Advantage for Future War and the Strategic Continuum,” JFQ 96, 1st Quarter 2020). Since his retirement, General Ryan has written three books, including both fiction and nonfiction accounts. (His War Transformed: The Future of Twenty-First-Century Great Power Competition and Conflict was reviewed in JFQ 108, 1^st Quarter 2023.) This third product is the result of several trips to Ukraine and offers two overlapping themes that have shaped the Russo-Ukrainian war: strategy and adaptation. The book is evenly divided by these interactive factors. In his net assessment of the contending strategies, the author uniquely defines Kyiv’s strategy as one of “corrosion,” which presumably fits in the middle of Hans Delbrück’s famous binary set of annihilation and exhaustion. In Ryan’s telling, this form of strategy includes the expanded competitive space of social and informational interaction between societies and the vulnerability of civil society due to cybersecurity weaknesses or the increased reach of long-range strike systems. This concept has utility in this conflict and may be a useful distinction worthy of further case studies and incorporation into military doctrine.

Ryan’s strategy discussions are excellent, particularly his discussion and comparison of Russia and Ukraine’s respective “theories of victory” in his superb dissection of the two countries’ strategies. Strategic scholars including Colin Gray and Williamson Murray put more stock into a larger conception of a theory of success rather than the narrower concept of a theory of victory that may focus on achieving military victory at the expense of attaining the better peace that proper political guidance would frame (see Frank Hoffman, “The Missing Element in Crafting National Strategy: A Theory of Success,” JFQ 97, 2^nd Quarter 2020). General Ryan appreciates the distinction; he declares “postwar prosperity, reintegration, reconstruction, and justice will all be necessary elements of a more enduring ‘victory’ for Ukraine” (65).

Ryan touches on one other enduring constant in war: the human dimension. Though he identifies several critical technologies displayed in the conflict, including Starlink, rocket systems, artillery fires, targeting mesh networks, artificial intelligence, and drones, he underscores the centrality of war as a human endeavor. “While machines and information are vital elements in human competition and war,” Ryan observes, “it is humans who decide how these are used, where, when, and in what organizational constructs that ultimately decide victory and defeat” (11).

The third book, A Call to Action, is an anthology based on a research study conducted by the U.S. Army War College. The project was overseen by John A. Nagl and Colonel Katie Crombe and contains 18 chapters, most penned by students at the Army’s top-level school. The design of the team’s effort is based around battle functions, which generate a comprehensive assessment of the conflict at the operational level. While the project is sponsored by an institution focused principally on land warfare, the book includes chapters on naval operations in the Black Sea and the air war in Ukraine. Every chapter concludes with relevant lessons for application by the Army, with clear and actionable recommendations. The book finds that Ukraine offers lessons similar in importance to those the U.S. Army culled from Israel’s struggles in the Yom Kippur War five decades ago, which were translated into a successful U.S. Army transformation.

The chapter devoted to fires is chockfull of insights on Ukrainian adaptability. The author, Lieutenant Colonel John “Jay” B. Bradley III, also provides a critique of Russian fires systems, including Russia’s “nearly fanatical” reliance on artillery (92). He attributes the Russian Army shortfalls to its poor automated command and control systems and its overly centralized command structures. Conversely, “Ukraine’s ability to make decisions at the lowest level has yielded increased success” (99). Kyiv’s leaders adopted mission command and introduced command and control systems that allowed the Ukrainians to efficiently apply precision munitions and fires against high-value targets. This chapter details the entrepreneurial agility of the Ukrainians.

The author makes explicit the need for the Army to be ready for constant movement and increased force protection. He also recommends adopting systems supported by artificial intelligence (AI) for both dynamic targeting and air space management. Bradley writes, “The targeting process must incorporate AI, autonomous solutions, redundant communication capabilities, and permissive control measures” so that organic fires can match the pace of large-scale and dynamic operations (107). One critical note, however—there is little appreciation for the role of drones as sensors or as a form of fires. Readers will find this topic covered in detail in Ryan’s The War for Ukraine.

Another key chapter, written by U.S. Army Colonel Jamon K. Junius, deals with Mission Command, a leadership philosophy that is central to joint doctrine in the United States. Ukrainian fighting forces are operating far from their major headquarters, which are led by senior officers who may retain too much of the centralized Soviet doctrine they were initially trained with. However, in Ukraine’s prewar training, Ukrainian generals understood the benefits of promoting the trust and initiative that are synonymous with Mission Command. General Valery Zaluzhny, then the head of the Ukrainian defense establishment, sought to promote “a decentralized, empowered, more agile way of warfare than the Russian model” (119). Mission Command has proved itself again in Ukraine, despite the lack of the mutual trust and cohesion normally generated by doctrine, repeated exercises, and extended association.

In toto, War in Ukraine, The War for Ukraine, and A Call to Action represent the best of a growing flood of analyses of the ongoing tragedy in eastern Europe. Brands’s book is especially invaluable on U.S. national security considerations and has exceptional value to top-level schools and civilian security studies curricula. General Ryan’s book is particularly suited for a larger audience, including command and staff colleges, due to its extensive links to foundational literature for students of the profession of arms. A Call to Action will interest anyone who wants to absorb insights from the battlefield and the ever-changing character of warfare.

Further studies about the war in Ukraine will eventually emerge, once the drones and bullets stop flying and historians can interrogate the facts and the fictions. For now, this set is the best collection of insights at each level of war and across all battlefield functions. Understanding the present in context is a requisite step to learning and for preparing for the future. JFQ

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Winning Without Fighting is an excellent new book crafted by four veteran scholar-practitioners that presents a strategic framework for winning the competition between the United States and its allies on the one side and an emerging authoritarian axis that includes China, Russia, Iran, and North Korea on the other. It explores irregular warfare (IW) in the broadest sense, but it makes little reference to insurgency, terrorism, or unconventional combat. Rather, the authors focus on IW as a broad set of competitive activities where “violence and coercion have their place but are unnecessary for an action to be part of an IW campaign.” In this book, irregular warfare is much like George Kennan’s political warfare: “the employment of all the means at a nation’s command, short of war, to achieve its national objectives.” The ends of these competitive efforts are “achieving relative power, influence, and legitimacy in the international system.” The means include information, military, economic, and diplomatic assets. The authors add resilience, both national and alliance-wide, to this set.

Rigorous and systematic in analysis, Winning Without Fighting begins at a key source of policy, the complex issue of strategic cultures. With thorough references to the scholarly literature, the authors conclude that U.S. strategic culture is not well suited to strategic competition in peacetime. Americans tend to see a clear division between war and peace and prefer to use overwhelming force in clear-cut situations. The Departments of Defense and Treasury dominate our coercive approach to deterrence. While the United States is poorly postured for gray zone warfare, “authoritarian regimes . . . prioritize centralized and coordinated IW campaigns as integral to strategic competition.” The authors write, “Unlike the [United States], Chinese strategic culture conceives of a fluid relationship between war and peace; indeed, all statecraft is essential to achieving power in their never-ending struggle.” Russia is less risk averse than China and is currently engaged in trying to restore greater Russia by attacking Ukraine and subverting Moldova and Georgia. The authoritarian nature of Russia and China helps them in some aspects of IW but drives them to excess and frequently alienates foreign clients and neighbors.

To build a bridge to the future, Winning Without Fighting examines the U.S. record of political warfare during the Cold War, an era roughly analogous to the present. During the Cold War, the United States waged political warfare by backing noncommunist parties, funding dissidents, and supporting various anticommunists. It “formed alliances whose purpose was to contain the spread of communism.”

To facilitate a strategy of containment, the United States formed key institutions like the Central Intelligence Agency, the United States Information Agency, and Radio Free Europe. Even the Marshall Plan and Truman Doctrine can be seen as instruments of political warfare. In the 1980s, the Reagan administration—working with allies and friends, like Pope John Paul II—orchestrated a coordinated campaign of rearmament and political warfare to help bring down the Soviet Union. Despite a strategic culture that did not lend itself to this type of conflict, the United States had significant successes in Cold War political warfare. At the same time, the authors argue that it is important to not mythologize the capabilities and limitations of the force in that 50-year era.

The next four chapters of Winning Without Fighting assess the various tools of statecraft: military, economic, information, and resilience. While necessary, these chapters are dense and focused on nonkinetic competition. Each of the chapters ends with strategic recommendations that make perfect sense. Some recommendations, however, like “avoid [economic] protectionism,” are out of fashion among U.S. politicians of both major parties.

The most interesting aspect of the analysis is considering resilience as a tool of statecraft. Nations and systems of governments have long recognized the importance of resilience, but few have set out to cultivate it. In this era, it is essential. Hostile powers will use their assets, particularly in disinformation, to break down trust in governments and prevent nations from adapting effectively to challenges. It is essential to combat disinformation and to plan for natural disasters and pandemics. The authors point out the importance of alliance-wide approaches in furthering resilience. They then turn their attention to the often ignored topic of measuring success in strategy in terms of power, influence, and legitimacy.

The concluding chapter is a worthy summation and set of recommendations. To summarize, the authors believe that:

Conventional military capabilities alone—or even primarily—are as insufficient for the coming era as they proved to be for the last one. American strategic and military culture must expand the aperture and embrace the thinking of Sun Tzu and Kautilya. Their emphasis on winning without fighting, prioritizing non-military tools of statecraft . . . and embracing myriad uses of information and disinformation provide a useful framework (224).

The authors conclude that this will require reinvestment in the assets like regional expertise and language skillshat “bolstered American competitive
statecraft during the Cold War.” More specifically, they recommend a focus on security cooperation, use of trade and economic statecraft, and  increasing collective resilience.

This is a welcome approach. We need better statecraft and integration of all instruments of national power. We need better policy assessment and a greater focus on resilience and restoring trust between the American people and its government. On the other hand, the recommendations here will not replace the importance of more defense spending. In fact, they may add marginally to overall government spending at a time of gargantuan budget deficits. An approach that is less Defense Department–centric will also put more planning and programmatic weight on the State Department.

None of these objections should detract from this excellent and original book. As we move into yet another novel security environment, it is essential that we get beyond buying another next-generation system, enlarging the iron mountain, and finding different terminology to describe the need to deter, fight, and win the first battle of the next war. We need to focus on how to succeed in competitive statecraft, which just may be the best way to avoid World War III. The authors of Winning Without Fighting are to be commended for their contribution to the discussion of IW and strategic competition. JFQ

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Air Force military training instructors lead formation of graduates at Air Force Officer Training School class 24-06 graduation parade, in Montgomery, Alabama, March 14, 2024 (U.S. Air Force/Brian Krause)

While the national security community has consistently faced significant unknowns, disruptions, and wicked problems with no known solutions, today’s leaders must operate in a world unlike anything anyone has ever experienced. Joint force senior leaders must clearly see the right direction to move out courageously, even when shrouded in a dense fog of uncertainty. Meeting America’s enormous global challenges requires Department of Defense (DOD), joint force, and defense industry senior leaders and executives who are bold, visionary, and strategic.

America’s Extraordinary Political-Military Challenges

America is facing a seismic shift in the national security environment. Not since the Korean War has the United States faced simultaneous confrontations from multiple formidable adversaries—China, Russia, North Korea, and Iran. Furthermore, the character of war has changed. With precision- strike weapons, the joint force is subject to short- to long-range “zero-miss” guided munitions. Moreover, China, Russia, North Korea, Iran, transnational criminal organizations, and terrorists have developed heightened expertise in cyberspace that can disrupt America’s economy and infrastructure, joint force command and control, and all informational aspects of military activities.¹

While the joint force remains the strongest globally, a realistic view invites pessimism. The challenges to meeting the needs are substantial—outdated or obsolete hardware and software, inadequate funding, disruptive technology (artificial intelligence, machine learning, digital transformation), and difficulties in recruiting skilled personnel. Both allies and adversaries must perceive America’s joint force as credible. Otherwise, there is a potential increase in misunderstandings, missed signals, emboldened challenges, and, ultimately, armed conflict.

The Heritage Foundation’s 2024 Index of Military Strength reports that the current joint force is at significant risk. The Air Force is rated “very weak,” the Navy and Space Force “weak,” and the Army and the nuclear forces “marginal.” The Marine Corps is rated “strong,” but its strength is “not sufficient to compen- sate for the shortfalls of its larger fellow Services.”² Furthermore, support for war efforts in Israel and Ukraine is depleting the joint force’s military equipment and weapons stockpile.

According to the 2018 National Defense Strategy (NDS) and the 2022 NDS, the joint force is moving on from conflicts in Afghanistan and Iraq to focus on China and Russia. Then-Secretary of Defense James Mattis stated, “Without sustained and predictable investment to restore readiness and modernize our military to make it fit for our time, we will rapidly lose our military advantage, resulting in a joint force that has legacy systems irrelevant to the defense of our people.”³

The clarion call to reform is not new. For example, when General Joseph Dunford, then Chairman of the Joint Chiefs of Staff (CJCS), delivered the commencement speech at the National Defense University’s 2016 graduation ceremony, he stated, “We’re already be- hind in adapting to the changed character of war today in so many ways.”⁴ In 2017, then Commandant of the Marine Corps General Robert Neller told Congress that the Marine Corps was not “organized, trained, and equipped to face a peer ad- versary in the year 2025.”⁵

Consequently, each of America’s military Services must focus on top-to- bottom transformation. As then Chief of Staff of the Air Force General C.Q. Brown, Jr., stated in August 2020, “We must accelerate change now! The consequences of failure, and success, are profound.”6 Likewise, General Philippe Lavigne of the French air force stated in 2023 that the North Atlantic Treaty Organization had to reform.⁷

To meet today’s enormous political- military challenges, America needs DOD and joint force senior leaders who can exercise the bold, visionary, and strategic leadership essential for building a robust capability that contributes significantly to America’s survival and success. Making bold decisions is not “shooting from the hip.” Strong strategic leaders analyze available data and information, under- stand the significant risks and uncertainty in their decisionmaking process, and clearly envision where they want to lead the organization.

Seven Factors Stifling Effective Joint Force Senior Leadership

1. Unpreparedness for Strategic Senior Leadership. Regardless of their success at lower levels, many DOD, joint force, and defense industry leaders state that they were unprepared for senior leadership’s unique roles, responsibilities, and strategic challenges. For example, in 2018, McKinsey reported that 74 percent of U.S. senior leaders believed that they were unprepared for their senior-level roles.⁸ In 2021, DDI reported that only 28 percent of human resources professionals believed their organizations had high-quality leadership.⁹ Several joint force and other senior leaders I have talked with echo these results. Though they thought they were prepared, these leaders admitted they were not. This unpreparedness exists despite the plethora of advice at leaders’ fingertips as well as their participation in numerous development, academic, and executive leadership programs in public policy and government and attendance at professional military education (PME) institutions.

2. Insufficient PME Policies and Guidance. While PME programs are excellent in developing operational and tactical warfighting joint officers, most programs undervalue how leadership at the strategic level differs fundamentally from operational and tactical leadership. Furthermore, Secretary Mattis expressed concern in the 2018 NDS that “PME has stagnated, focused more on the accomplishment of mandatory credit at the expense of lethality and ingenuity.”¹⁰ In 2020, the Joint Staff directed PME to develop joint force officers who were competent in five broad areas, three of which were critical elements of strategic leadership—strategic, systems, and critical thinking; superb communication skills; and the ability to anticipate what is around the corner and ensure the joint force maintains strategic competitive advantage.¹¹ It also identified six Desired Leader Attributes—the knowledge and skill to:

• understand the security environment and contributions of all instruments of national power

• respond to surprise and uncertainty • recognize change and lead transitions

• operate on intent through trust, empowerment, and understanding (mission command)

• make ethical decisions based on shared values of the profession of arms

• think critically and strategically in applying joint warfighting principles and concepts to joint operations.

Army Lieutenant Colonel Loron Granthom demonstrates capabilities of Joint Task Force–Civil Support’s Joint Operations Center to General Gregory Guillot, commander, North American Aerospace Defense Command and U.S. Northern Command, at Joint Base Langley-Eustis, May 9, 2024 (U.S. Navy/Ryan Walvoord)

Regrettably, despite the updated guidance, PME for senior and general officers/flag officers often gives short shrift to the essential thinking, reasoning, and intuitive skills and abilities vital to the art and practice of strategic leadership.

3. Incorrect Strategic Leadership Development Mindset. Some on the Joint Staff and some PME faculty believe that proven leaders at the operational level do not require additional leadership development. This view leads to the belief that by taking courses in geopolitical areas and national security strategies and policies, these operational leaders will gain the essential strategic leadership insights through deduction. Individuals with this belief argue that because of their mandate to convey specialized knowledge and skills, they have insufficient time to convey the critical strategic leadership elements to their students.

4. Bureaucracy. DOD and other agency leaders initiating bold proposals must go through a gauntlet of approvals, of which only one “no” can kill the initiative. Moreover, two contributing factors are political appointees’ focus on achieving the administration’s agenda, not making the organization more efficient and effective, and senior executive service (SES) leaders stagnating in their current agency’s leadership positions.

5. Minimum Time Available to Execute Critical Transformational Change. With 4 or fewer years in tenure, DOD and joint force senior leaders must have a bold organizational vision before assuming their leadership positions. Implementing the myriad bold initiatives will take the first year and the next 3 years to sell the vision, get buy-in, and obtain or reprogram the necessary resources.

6. Arduous Acquisition Policies and Processes. Congress’s onerous funding policies and processes make it difficult for DOD and the joint force to maintain pace with, much less exceed, adversarial weapons innovation and modernization—adversaries do not have such obstacles.

7. Potential Backlash. Regardless of the merit, taking bold actions will increase the magnitude of the opposition and naysayers—especially those touting the status quo. Bold senior leaders getting out in front of others can risk receiving arrows in the back. For example, I recently witnessed excellent military senior leaders who took bold action to improve their respective unit’s capability be destroyed on social media.

Why Is Senior Leadership Different?

Operational leaders (lower level leaders) focus primarily on running the organization and achieving the mission through operational excellence and effectiveness. In contrast, senior strategic leaders must ensure their organization remains relevant and viable 3 to 20 years into the future. The senior leaders and executives I talked with spend 50 percent or more of their time looking outside their organization, attempting to make sense of what is happening and trying to see “what’s around the corner.” Even when looking internally, it is for an external purpose.

Internally, effective strategic leaders glide over their organizations like pelicans over the ocean, periodically diving to catch a fish. Successful senior leaders learn the essential things to watch for, and if they think something needs attention, they can dive down into the required level of detail. Unfortunately, many joint force senior leaders enjoy retreating to a previous lower level of leadership they are more comfortable with rather than doing the work needed at the strategic level.

Joint force, DOD, and defense industry senior leaders indirectly influence organizational members through offering directives and policies, shaping climate and culture, and supporting metrics and incentives. Other than direct reports, most of those they seek to influence are outside their authority—for example, peers, stakeholders, media, key constituents, Congress, partners, and others whose influence or actions (for or against) will determine their ability to accomplish desired outcomes. This requires joint force senior leaders to be skilled in person-to-person influence skills. Such social and emotional intelligence abilities are needed to deal persuasively and collegially with others and to negotiate constructively with near-equals who have both personal power and the ability to commit resources to achieve shared objectives.

Strategic decisions are often based on incomplete information, the ramifications of which may not be realized for many years. Consequently, both unknown factors and the factor of time are weighted more heavily in decisionmaking at the senior level. For example, the Secretary of the Navy decides to build an aircraft carrier that takes 8 to 10 years to build and costs billions of dollars. By the time it is built, the joint force must live with the decisions made a decade earlier.

Thus, while logical and analytical reasoning skills often work well in the structured, routine decisionmaking at the lower levels, joint force senior leaders’ judgments are usually made by informed intuition or gut instincts. As former CJCS General Richard Myers told me, “That’s why, when it comes down to it, most decisions at the senior level are made by informed intuition.”¹² In addition to critical warfighting knowledge and skills, effective joint force senior leaders require the following two competencies.

1. Skill in the Art and Practice of Strategic Leadership, Emphasizing Strategic and Systems Thinking. Recent CJCS direction and guidance underscore the importance of strategic leadership and its critical components of strategic and systems thinking. Joint force leaders and PME curriculum developers need help developing joint force strategic leaders. A key factor is that strategic thinking has become a buzzword. To assist decision- makers and curriculum developers, I offer the following eight-step strategic thinking framework to assist in understanding the involved factors.¹³

Step 1: Have an Open Mindset. This step is a prerequisite. Being open-minded means being willing to receive and consider new information and ideas. Joint force leaders will not maximize the other seven steps if they do not have an open mindset. Without an open mind, leaders will fall prey to the status quo. Being open-minded allows leaders to change their views based on new information and facts.

Step 2: Get Information. Scan and evaluate external and internal environments. In today’s volatile environment, the ability to anticipate the future and have that sixth sense that enables leaders to see around corners or have peripheral vision is crucial for the Nation, national security organizations, and suppliers to be viable. Gaining a cue from the external environment can alert leaders that something is amiss or surprising or is something to further explore.

Step 3: Connect the Dots. This step involves identifying patterns and sense-making. Yet, as demonstrated by the terrorist attacks on 9/11, the dramatic fall of the Afghan government to the Taliban, and the Hamas attack on Israel, a key challenge is to find the dots in the first place.

Step 4: Create Ideas. Creativity opens the thought process to new ideas. It is not simply looking for solutions to a challenge, opportunity, or problem—it is divergent thinking.

Step 5: Engage Intuition. Intuition is using mental models and frames of reference without thinking about them when seeking a solution or making a decision. In some cases, it provides immediate understanding without conscious rational processes. In other cases, it may be a slower process that can emerge as “aha!” revelations. Intuition usually occurs without any conscious analysis or supporting evidence. It is essential to joint force leader thinking and decisionmaking processes. Therefore, reflecting and taking steps to learn and grow will enhance the intuitive decisionmaking capacity by making it more informed.

Step 6: See the Whole. Systems thinking is essential. Joint force leaders must see the interconnected and interrelated whole, not just the parts. Such thinking enables leaders to synthesize seemingly disparate elements into a unified whole. Seeing the system’s interrelationships, linkages, patterns, and interactions enhances joint force leaders’ ability to solve vexing issues and problems. It allows them to identify potential unintended consequences and leverage points to influence the system in the desired direction.

Step 7: Perform Analysis—Critical Thinking and Developing Foresight. Through critical thinking, leaders bring the scanning and sense-making process to closure—it is convergent thinking. Using critical thinking, joint force leaders systematically analyze all the relevant information from their scanning, sense-making, and intuitive insights and reframe challenges and opportunities. Translating their sense-making judgment into fore- sight, joint force leaders can envision the problem, develop a range of options, prioritize, strategize, and make decisions.

Step 8: Make Decisions. After re- viewing the facts and conclusions of the strategic thinking process, leaders must challenge their assumptions and decide (or make a series of decisions). They ask questions such as, “How do the decisions we make today set us up for long-term success? Is this the correct approach to get where we need to go? Are we missing something?”

While the first step—having an open mindset—is critical, leaders will likely use the other seven steps in the strategic thinking process at various times. Acknowledging the critical necessity for joint force senior leaders to be adept at strategic and systems thinking is insufficient. New CJCS policy and guidance require PME students to know the mate- rial and demonstrate proficiency in using the knowledge and skills. Considering this guidance, curriculum developers and faculty should cover the above eight steps in depth with exercises, gaming, or simulations, enabling students to learn and employ these crucial thinking and practical action skills.

2. Essential Competencies for Joint Force Senior Leader. The list of leadership styles, behaviors, skills, and attributes associated with outstanding visionary leadership is extensive. The following seven competencies are vital for a leader’s quest to be bold, visionary, and strategic—especially when leading across boundaries.

• Leveraging Power and Politics: A senior leader’s competency in power and politics either enhances or detracts from his or her ability to influence others and perform the work required at the senior level. While the connotation of “playing politics” is usually pejorative, political skill can be essential to forging consensus or resolving competing values and propositions within strategy or decisionmaking processes. One DOD executive remarked, “If you do not understand power and are not politically savvy, you are dead as a senior leader. I see both power and politics as essential assets.”

• Building Coalitions, Selling Ideas, and Reducing Naysayer Influence: Critical elements of these skills are the ability to negotiate and communicate strategically. Most senior-level decisions result from some form of negotiation. Furthermore, buy-in and support for the leader’s decisions require consistent and effective strategic communications.

• Building and Nurturing Strategic Networks: Joint Force senior leaders must interface with and influence many constituents and stakeholders. Building and nurturing such networks will help inform leaders about what is happening in the external and internal environments. Leaders will hear various viewpoints and action plans that may be useful in developing strategies and objectives, identifying potential resources, and sorting out the political and power relationships and interests involved. A robust and effective strategic network is essential.

• Projecting Executive Presence: Through executive presence, joint force leaders exude self-confidence, communicate persuasively, and project a certain gravitas that instills confidence in others that they are reliable, capable leaders who can deliver.

• Having In-Depth Self-Awareness: Arguably the most essential ability and skill needed is in-depth self-awareness. It is the core of authenticity and enables joint force senior leaders to be comfortable with their strengths and not be crippled by their shortcomings. Self-awareness allows them to learn from mistakes and successes, facilitating continued learning and growth. Furthermore, leaders must have clarity about how their behaviors affect others.

• Being Tech-Savvy: Joint forces leaders do not have to be experts in the field. However, they must have sufficient knowledge and the ability to ask the right, in-depth questions to make excellent technological decisions.

• Nurturing Mind, Body, and Spirit: Dead joint force senior leaders are not in great demand. Senior-level leadership is very demanding, requiring great physical and emotional stamina. Former Army Chief of Staff General George Casey stated, “One of the toughest challenges for senior leaders is to sustain their physical, mental, and emotional fitness at levels that allow them to deal with the hugely complex challenges confronting them.” Moreover, managing personal time and energy and reflecting are the key to senior leaders’ resilience and mental toughness.

Ensign Damiyan Caldwell, left, and Commander James Koffi, right, commanding officer of guided-missile destroyer USS Truxtun, scan the horizon for aircraft or maritime craft in proximity to ship, January 26, 2025 (U.S. Navy/Sierra Bryant)

Making It Happen

The following recommendations have the power to help develop a bold, visionary, and strategic joint force senior leader. Current strategic leaders must:

• Create an organizational culture supporting and nurturing strategic and systems thinking processes. They should evaluate and improve processes for gathering information and connecting the dots to obtain reliable information.

• Make developing subordinate joint force senior leaders and aspiring senior leaders a top priority. Provide ongoing oversight to ensure PME efforts to develop joint force officers meet expected outcomes (that is, students are strategic and know what to do).

• Beware of biases and limitations, solicit other perspectives in thinking and decisionmaking, and expand exposure to other perspectives.

• Ensure that aspiring strategic leaders are afforded an educational system and dedicated strategic leadership curriculum and are incentivized to self-develop.

• Mandate that Federal Government SES members rotate positions every 3 to 4 years—preferably to different agencies as was envisioned when the SES program was initiated. Doing so expands SES members’ mindsets, encourages learning and growth, and prevents stagnation (being stuck in their comfort zones).

• Encourage high-potential joint force leaders’ self-development. Encourage attending a nonmilitary master’s program (in business administration, executive business administration, or government affairs) and a war college. Attending a nonmilitary institution opens the participants’ minds to different perspectives and enhances learning and growth.

• Institute effective screening and senior-level competency assessment processes at each war college to ensure that faculty and students live up to the words “proven elite leaders and faculties.” Attending a war college, the Foreign Service Institute, an executive MBA pro- gram, or a similar educational program significantly broadens a leader’s mindset and enhances cognitive and social capacity. What is needed is dedicated learning focused on the following:

• Leading at the senior level, which differs fundamentally from leading at the operational level.

• Being adept at strategic leadership and strengthening students’ capacity to think strategically and systematically.

• Building the climate and culture that support and nurture the scanning and sense-making processes.

• Developing strategies to avoid settling for the status quo—continually transforming the organization to be viable and effective and sustain competitive advantage in war and peace both today and in the future.

• Gaining in-depth self-awareness. Programs should include implementing an actionable personal leadership development plan for each participant. Faculty should periodically meet with each student to evaluate progress and provide necessary coaching.

• Integrating virtual reality and artificial intelligence–enhanced simulations and gaming into leadership development programs. Doing so allows participants to touch, taste, and feel experiences in a safe environment and practice different behaviors and approaches to decisionmaking.

• Becoming tech-savvy. PME faculty should help students dig deep into the latest and potential high-tech technologies that students must soon become advocates for.

• Asking guest senior leaders and executives to discuss candidly their views on strategic leadership, with particular emphasis on:

» the challenges of being strategic leaders » the extraordinary issues they face

» what they wish they had learned earlier in their career to prepare them for their current assignment » recommendations to help aspiring senior leaders prepare for the job.

• Creating incentives for current and aspiring senior leaders to continue self-development.

Promulgating policy statements such as “We must consistently prioritize continuous learning and professional development” becomes another cliché if not backed up with guidance and resources to make it happen.

Summarizing the need for dedicated focus and resources, Mike Harris, retired U.S. Army colonel and former National War College faculty member, states:

We need to accept that developing bold, strategic leaders requires a deliberate investment strategy of time, education, experience, and mentorship to influence, shape, and prepare leaders to succeed at the upper levels. Nominated senior leaders want to succeed. The people they lead want a competent leader. But I’m not seeing current government, business, and joint force executives matching their rhetoric for senior leader development to their policies, dedicated resources, and the assignment of top-notch faculty required to prepare aspiring and help current senior leaders succeed.

Marines with Bravo Company, Basic Officer Course 2-24, bow heads for final invocation during graduation at Little Hall on Marine Corps Base Quantico, Virginia, June 28, 2024 (U.S. Marine Corps/Darien Wright)

The AWC Approach

During my March 2024 presentations with Air War College (AWC) faculty and later to the AWC class of 2024, I became intrigued by and impressed with the AWC’s revamping of its strategic leadership curriculum. While the curriculum had introduced the importance of strategic thinking earlier in the academic year, students built on their experiences and expertise during the remaining 60 days. In addition to my presentation and readings on vision and leading change, some of the program elements included assessing and shaping organizational culture; advice, dissent, and the profession of arms; ethical leadership; senior leader responsibility and accountability; mission command; strategic communication; influence and negotiations; and crisis leadership.

What I found intriguing was the students’ required tasks. Because strategic leadership is emphasized at the end of the year, most already know their next assignment after graduation. With almost all military organizations undergoing reorganization and modernization, AWC tasked students to identify and analyze two significant challenges they believe their new organizations will face during their tenure and use strategic leadership course concepts to frame their analyses. The students must reach out to their future organizations and actively collaborate with their predecessors, future bosses, and other relevant personnel to identify their new organizations’ significant challenges. Less than 2 weeks later, they used their learned approaches for solving highly complex problems (including associated risks) to create a plan, strategy, and approach that enables their new organization to overcome the identified significant challenges. They provide their solutions orally and in writing, with their target audience being their new boss’s boss.

I suggest that AWC’s approach takes the concepts beyond the theoretical to the practical—that is, students can touch, taste, and feel what they learn. Students can see how warfighting and organizational leadership come together strategically. Such an educational practicum helps to set these students up for success in their postgraduation assignments. They can hit the ground running in their new leadership positions. Joint Staff J7 and AWC’s sister colleges should consider benchmarking the revamped curriculum and approach to maximizing the art and science of the student’s strategic leadership capacity.

All Military Services Must Transform

Beginning with the change in the 2018 NDS, each U.S. military Service recognized that major reorganization and weapons modernizations were required to sustain joint force competitive advantage. In February 2024, when announcing its Aviation Investment Rebalance, the Army stated that it “remains committed to its most ambitious modernization effort in more than 40 years.”¹⁴

On February 12, 2024, Secretary of the Air Force Frank Kendall III announced sweeping changes for “reshaping, refocusing, and reoptimizing the Air Force and Space Force.” Secretary Kendall announced 24 key changes that feature both near- and longer term initiatives that focus on four core groupings—Develop People, Generate Readiness, Project Power, and Develop Capabilities.¹⁵ Included are the creation of a new Air Force Integrated Capabilities Command and a new Space Force Space Futures Command. Despite these strategic objectives, Congress has intervened, stating that “the Department of the Air Force has not provided thorough justification for this reorganization.” In response, retired Lieutenant General David Deptula, dean of the Mitchell Institute for Aerospace Studies, stated, “Congress is effectively meddling, which is likely to slow down needed changes and could add costs.”¹⁶ In 2021, the Navy Aviation 2030–2035 Vision stated, “Leadership must take bold action and make difficult choices to generate the change required to win across the spectrum of conflict. This will require a renewed focus on the capabilities, capacity, readiness, and training the Navy needs to improve and sustain our warfighting advantage.”¹⁷

Then National Defense University President Lieutenant General Michael Plehn congratulates graduate from Dwight D. Eisenhower School for National Security and Resource Strategy during graduation ceremony on parade grounds in front of National War College, Fort Lesley J. McNair, Washington, DC, June 8, 2022 (NDU Audio Visual)

What Does Bold, Visionary, and Strategic Leadership Look Like?

General David Berger, Commandant of the Marine Corps from 2019 to 2023, is a shining example. For years there was talk that the Corps needed to change, but action was negligible. Because of 20 years of combat in Iraq and Afghanistan, Berger recognized the Corps had migrated to being like the Army and would become irrelevant if it stayed the same. Berger decided to do something about it.

He had to hit the ground running because he had only 4 years to sell his vision and execute massive transformational change. He articulated his bold vision and planning guidance in Force Design 2030, which was released in March 2020.18 In the document he argued, “We cannot accept or accede to recommendations for incremental change or better versions of legacy capabilities but must pursue transformational capabilities that will provide naval fleets and Joint Force commanders with a competitive advantage in the gray zone and during contingency.”

Berger knew that DOD did not have the billions needed to begin the transformation and modernization process. He knew that if he did not start immediately upon becoming commandant that the Corps would not have the required military capability by 2030. Consequently, he boldly decided to “divest to invest”—that is, eliminate or reduce current structures and systems to fund future ones (3 to 7 years into the future). His bold plan received approval from DOD and many congressional members to divest $15 billion of current assets toward modernizing the Corps. Examples included:

• eliminating all Corps tank battalions and transferring the Corps’ 500 tanks to the Army

• reducing aircraft per squadron from 18 to 10 (obtaining newer F-35s complemented by unmanned aircraft)

• reducing the number of cannon artillery batteries from 21 to 5

• reducing forces by 12,000 personnel by 2030.

Berger made his decisions based on his experience in the Pacific region, participation in war games and exercises, and experimentation. He sought advice from Corps senior leaders, which was bolstered by data, analytics, and seasoned judgment.

Serious pushback and debate raged from highly respected retired Marine Corps generals. They argued that the plan posed a significant risk to national security and that the Corps would become a hollow shell of its former self. Two retired generals, former Commandant General Charles Krulak and General Anthony Zinni, went public with their Vision 2035, which they argued would ensure the Marine Corps remained the Nation’s “911 force” today while modernizing and transforming it to meet the Nation’s needs in the future.¹⁹

General Berger kept to his vision and strategic objectives until his retirement in 2023. Upon confirmation as the 39th commandant on September 21, 2023, General Eric Smith made it clear he would continue Berger’s transformation initiatives and attempt to accelerate them. Doing so will require appropriate budgeting and acquisition funding support by DOD and Congress. General Berger and General Smith (supported by DOD and the combatant commanders) believe the risks of doing nothing outweighed the risks associated with the sweeping changes.

Conclusion

Today’s dangerous world demands joint force, DOD, and industrial-based leaders capable of shaping events rather than reacting to them. An effective visionary strategic joint force leader and thinker requires continuous learning, growth, and enhanced cognitive and social horsepower. Being driven, demonstrating grit, and working hard are not enough. Developing and executing robust PME curricula and learning programs incorporating these recommendations will prepare joint force leaders to lead effectively at the senior level and have the courage and confidence to make the bold decisions that America needs. These leaders will demonstrate personal confidence, courage, and the firm belief that their bold decisions are appropriate and will move forward with determination. JFQ

Notes

¹ Joint Concept for Operating in the Information Environment (Washington, DC: The Joint Staff, July 25, 2018), viii, https://www.jcs.mil/Portals/36/Documents/Doctrine/concepts/joint_concepts_jcoie.pdf.
² Dakota L. Wood, ed., 2024 Index of U.S. Military Strength (Washington, DC: The Heritage Foundation, 2024), 24, https://www.heritage.org/
sites/default/files/2024-01/2024_IndexOfUSMilitaryStrength_0.pdf.
³ Summary of the 2018 National Defense Strategy of the United States of America (Washington, DC: Department of Defense,
2018), 1, https://dod.defense.gov/Portals/1/Documents/pubs/2018-National-Defense-Strategy-Summary.pdf.
⁴ Jim Garamone, “Dunford to NDU Grads: Embrace Change and Innovation,” DOD News, June 9, 2016, https://www.jcs.mil/Media/News/News-Display/Article/796366/dunford-to-ndu-grads-embrace-change-and-innovation/.
⁵ Jeff Schogol, “The Next Fight: The Commandant Is Pushing the Corps to Be Ready for a ‘Violent, Violent Fight,’” Marine Corps Times, September 18, 2017, https://www.marinecorpstimes.com/news/your-marine-corps/2017/09/18/the-next-fight-the-commandant-is-pushing-the-corps-to-be-
ready-for-a-violent-violent-fight/.
⁶ Charles Q. Brown, Jr., Accelerate Change or Lose, CSAF Action Orders (Washington, DC: Headquarters Department of the Air Force, August 2020), https://www.af.mil/Portals/1/ documents/2020SAF/ACOL_booklet_FINAL_13_Nov_1006_WEB.pdf.
⁷ Philippe Lavigne, “Embracing Change: A Sense of Urgency,” Joint Force Quarterly (4th Quarter 2023), 25–31, https://ndupress.ndu.edu/Media/News/News-Article-View/Article/3569539/embracing-change-a-sense-of-urgency/.
⁸ Scott Keller and Mary Meaney, “Successfully Transitioning to New Leadership Roles,” McKinsey, May 2018, https://www.mckinsey.com/business-functions/organization/our-insights/successfully-transitioning-to-new-leadership-roles.
⁹ Global Leadership Forecast 2021(Bridgeville, PA: Development Dimensions International, Inc., 2021), 8, 10, https://www.ddiworld.com/glf.
¹⁰ Summary of the 2018 National Defense Strategy.
¹¹ CJCSI 1800.01, Officer Professional Military Education Policy (Washington, DC: The Joint Staff, May 15, 2020), A-2, https://web.archive.org/web/20240928015811/ https://www.jcs.mil/Portals/36/Documents/Doctrine/education/cjcsi_1800_01f.pdf.
¹² Unless otherwise cited in the notes, all senior leader quotations are from personal interviews and discussions with the leader named.
¹³ James W. Browning, Embracing Senior Leadership: Three Critical Factors Needed to Reach the C-Suite and Thrive (Irvine, CA: Universal Publishers, 2022), 18–28.
¹⁴ U.S. Army Public Affairs, “Army Announces Aviation Investment Rebalance,” February 8, 2024, https://www.army.mil/
article/273594/army_announces_aviation_investment_rebalance.
¹⁵ Air Force Public Affairs, “Air Force, Space Force Announce Sweeping Changes to Maintain Superiority Amid Great Power Competition,” Spaceforce.mil, February 12, 2024, https://www.spaceforce.mil/News/Article-Display/Article/3674633/air-force-space-force-announce-sweeping-changes-to-maintain-superiority-amid-gr/.
¹⁶ Greg Hadley and Chris Gordon, “Congress to USAF: Not So Fast on Your Reorg Plans,” Air & Space Forces Magazine, March 23, 2024, https://www.airandspaceforces.com/congress-more-info-air-force-reoptimization/.
¹⁷ Navy Aviation 2030–35 Vision, October 27, 2021, https://media.defense.gov/2021/oct/27/2002881262/-1/-1/0/navy%20
aviation%20vision%202030-2035_fnl.pdf.
¹⁸ David H. Berger, “Force Design,” U.S. Marine Corps, 2020, https://www.hqmc.marines.mil/portals/142/docs/cmc38%20
force%20design%202030%20report%20phase%20i%20and%20ii.pdf.
¹⁹ Charles Krulak and Anthony Zinni, “Vision 2035: Global Response in the Age of Precision Munitions,” The National Interest, December 16, 2022, https://nationalinterest.org/feature/vision-2035-global-response-age-precision-munitions-205995.

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Wounded Marine gets injection of blood plasma from Navy Hospital Corpsman during battle for Okinawa, May 1945 (U.S. Marine Corps)

At 0530, the gunfire support started, and over the next 3 hours 100,000 projectiles hammered inland. There would be 25 rounds for each 100-yard square under bombardment. At 0745, air attacks hit with bombs, napalm, and machine gun fire. At 0830, the initial waves of landing craft crunched ashore, and within an hour 16,000 men were fanning out.

It was L-day (landing day), April 1, 1945, and the United States had massed 1,300 ships to cover the initial landing of four divisions and seize Okinawa as another stepping stone toward Japan. Forces had converged from many bases, and supply convoys were already in motion to sustain momentum.¹ Operation Iceberg was underway.

The invasion of Okinawa was an example of joint forcible entry in an anti-access/area denial environment. Ground, maritime, and air forces played their roles, with supply lines stretching back to the United States and Australia. Support also went front to back, as medical care involved evacuation as well as support flowing forward. It was long before joint operations had anything like their current meaning, but the successes and challenges can still enlighten us about best practices in medical support and command.²

Army nurses, left to right, Lieutenant Margaret J. Whitton, Lieutenant Ruth Anderson, Lieutenant Marjorie Dulain, and Lieutenant Eleanor Kennedy, wash out of steel helmets, on Okinawa, May 7, 1945 (National Archives and Records Administration/U.S. Army Signal Corps)

Planning

Planning for Operation Iceberg had started in the autumn of 1944. Fifth Fleet would handle maritime operations, but there was no land component headquarters of sufficient size to handle the ground forces that would be needed to secure a large island against fierce resistance. Thus, the Joint Chiefs of Staff ordered the activation of Tenth Army headquarters to provide dedicated planners for the land operation. Initially, Tenth Army planned Operation Causeway—the invasion of Taiwan—but when the target changed to Okinawa, its experience allowed for quick adjustment. The land fighting would include III Amphibious Corps (the 1st, 2nd, and 6th Marine divisions) and XXIV Corps (the 7th, 27th, 77th, and 96th Infantry divisions).

Tenth Army surgeon was Colonel Frederick Westervelt, U.S. Medical Corps, who had recently served on Admiral Chester Nimitz’s staff and thus had experience in both Army and Navy medicine.³ Westervelt and his small staff were based in Hawaii but had to coordinate with the two corps headquarters; XXIV Corps was in action in the Philippines, while the III Amphibious Corps was forward-deployed and had units engaged in the Mariana and Palau Islands campaign and also commanded ground operations at Iwo Jima. Fifth Fleet staff were based at Ulithi (an atoll in the Pacific Ocean), over 4,000 miles away from Hawaii, and were concurrently in operations or planning them. For Tenth Army to focus on the battle, an Island Command (ISCOM) was created to handle the buildup of logistical units on Okinawa for its role in the intended invasion of Japan. ISCOM was also headquartered in Hawaii, allowing close coordination. But with none of the other headquarters nearby and all engaged in operations, there was limited bandwidth for planning Iceberg.

That seems to have affected the planning. There were joint aspects, but there were also substantial elements that each Service handled for itself. Some responsibilities were handed to one Service to provide for both. This caused aspects of medical care to differ substantially. Starting at the plan, there was limited medical intelligence about Okinawa, which was something of a backwater within the Japanese Empire. Apparently, the existence of poisonous snakes was the only data point, and the planners could do little more than recommend checking vaccinations and being prepared for malaria and tropical diseases with insecticide and other countermeasures.⁴ (Both of these assumptions proved to be faulty but with no negative consequences—the lack of snakes and malaria was hardly a problem.)

At a lower level, the surgeon for 1st Marine Division looked at both Army and Navy experience in island fighting in making his plans.⁵ Intelligence on enemy forces was hard to pin down, and since enemy resistance would drive the friendly casualty estimates and thus the medical plans, it was hard to be sure whether the plans for hospitalization and evacuation were adequate. Unfortunately, the estimates of enemy strength kept rising as L-day grew closer. It turned out that the final prediction was roughly correct, and the rising numbers were largely Okinawan natives who were being conscripted into the Japanese forces. They contributed more numbers than combat power. An unknown was the substantial artillery strength of the Japanese 32nd Army, which affected casualty patterns.

Flight Nurse Jo Nabors secures Okinawa casualty into stretcher on transport plane, which has been converted into hospital plane after bringing in mail and supplies, April 7, 1945 (National Archives and Records Administration/U.S. Army Signal Corps)

Colonel Westervelt seems to have been limited in his ability to coordinate some medical aspects. Army and Marine divisions had their own organic medical support, and the Tenth Army did not try to dictate medical support within the two corps. Both the Army and Navy provided hospitals to support Operation Iceberg, and it is unclear how much control the Tenth Army had over those. Army doctrine of the period would have given Westervelt control over all hospitals, which he could then attach to corps but still retain control over.

In the joint situation, he assigned Navy hospitals to support the Marines and Army hospitals to support the Army. Perhaps he believed neither Service would be more flexible and “joint.” Other medical responsibilities were assigned to the Army or Navy. For instance, the Army was supposed to handle all medical supplies, including the subtask of supplying fresh whole blood and the time-sensitive cold supply chain that it entailed (since blood must be kept cold and has a shelf life).⁶ On the other hand, the Navy had responsibility to provide medical support to the civil affairs/military government personnel on the island. Evacuation off Okinawa was coordinated by Tenth Army’s 96th Medical Battalion but was executed by Army or Navy sea or air assets, with the 645th Medical Company handling all patients at airfields.⁷

There were also elements that were substantially different between the two corps. During World War II, the Army created portable surgical hospitals (PSHs), with 4 physicians and about 30 personnel total. These performed a role like today’s Forward Resuscitative Surgical Detachment (Army) or Forward Resuscitation Surgical Team (Navy), but at the time the Navy formally had nothing similar. However, both 1st and 6th Marine divisions had procured some leftover equipment (trailers and amphibious tractors), fitted these with operating room equipment, and improvised staff for forward surgery.⁸

The Army did not have enough PSHs even to support the divisions of XXIV Corps (some regiments had PSHs attached, and others had to make do with less mobile surgical support), so III Amphibious Corps units had none attached and thus entirely lacked forward surgical capability.⁹ Similar, the Army organized auxiliary surgical groups, with a variety of specialty surgical teams to augment hospitals. The few teams that were available were attached to the Army hospitals.¹⁰ Moreover, the Army found a few psychiatrists and attached one per Army hospital, and some Army divisions conducted short courses for their medical personnel (and in one case, for line unit commanders) on psychiatric reactions to combat. At least one Navy psychiatrist arrived during the battle.¹¹ The Navy, in contrast, found enough corpsmen to provide two per platoon in the Marine infantry battalions, and the 1st Marine Division trained some troops as litter bearers.¹²

Outside Tenth Army, both the Army and Navy undertook some similar medical preparations. The obvious base to sup- port Operation Iceberg was the Mariana Islands, and both Services expanded their hospitals there to a combined 16,000 beds. Also, both cleared patients from the existing hospitals in the Marianas back to hospitals in Hawaii and the continental United States so that maximum beds would be available on L-day.

The final medical plan anticipated 30,000 casualties, with 6,600 dead. (Disease cases were expected to be 41,000 in the first 60 days, but far more of them would return to duty as long as there were enough hospital beds for them to recover.¹³) In case the landing was opposed on the beaches, the landing forces would have their unit medical support, with casualties evacuated as soon as possible by landing craft back to a landing ship, tank (hospital) (LST[H]), an ordinary landing ship, tank that had been augmented with medical personnel (some Army, some Navy) and equipment to provide blood transfusion and emergency surgery capabilities. (The Navy provided four to each landing corps.) As the landing forces pushed inland, medical support would increase in capacity and capabilities. If all went well, by the end of L-day there would be slices of every medical function ashore. Medical companies would provide low-acuity care, surgical teams would be ashore along with medical supply elements, and a medical illustration detachment would document patient care.

Meanwhile, offshore the LST(H) not only could treat urgent patients but was also seaworthy enough to ferry all patients out to the hospital ships steaming farther away from Okinawa. Both the Army and Navy sent hospital ships to provide adequate capacity. Both also had hospital transports, which were ordinary transport ships with modest augmentations of medical personnel to transport lower-acuity patients. Scarcer hospital ships could then provide more complex care to higher-acuity patients. This was part of a shift from using hospital ships mainly as highly capable medical evacuation platforms to using them as mobile medical treatment platforms. A shortage of Navy surgeons meant another joint requirement: some Army surgical teams were provided to expand capability and capacity on Navy hospital ships.¹⁴

Air evacuation was also used, but it was for less acute patients (hospital ships and even hospital transports had far more capabilities than cargo aircraft with one nurse and one medical technician on board) and of course required having a working airfield. The planners were cautious and did not expect to have an airfield operational before L+11. Correlating that with casualty estimates, some 7,000 casualties might be wholly reliant on waterborne evacuation. Thus, the hospital transports were required, and patients who could usually return to duty in only a few days would likely be evacuated much farther, and their return to units would be substantially delayed. Hospital ships would be needed to both treat and evacuate patients, but hospitals would be landed early and were expected to be operational after about a week. Westervelt had wanted 8,000 hospital beds (total of Army and Navy) to get patients stable for evacuation (not only stabilized, as modern high-acuity en route care can handle, but also fully stable) and to heal many so they could return to duty.15 Replacement troops were scarce in the Pacific theater, and having combat-ex- perienced troops returning to duty close to the fight would sustain combat power. However, only 4,500 beds were available, including some new special augmented hospitals from the Navy.¹⁶ The final plan had Navy hospitals supporting III Amphibious Corps while Army hospitals were behind XXIV Corps. This approach also aligned with the operational plan: the Marines landed on the left and were to turn north, while the Army landed on the right and turned south. Each force would have its own support rather than intermingled or joint support.

Operations

The landing was unopposed. Scuttlebutt had been that landing units might take 80 percent casualties (projections were for only 300, rising to 600 per day), but there was so little opposition on L-day that troops were spooked and scouted cautiously.¹⁷ Gaining confidence the next few days, troops quickly moved across the island to the east coast. Then the Marines headed north and the Army moved south. While there was resistance in the north, the main Japanese forces were in the south, and Tenth Army reorganized. After clearing the north, the Marines took the western flank and the Army the eastern. Again, Service hospitals supported their own troops. It took until June 22, 92 days of action, to secure the island.

Captain James R. Barron, with Company F, 382nd Infantry Regiment, 96th Infantry Division, receives plasma by frontline aid men after being wounded by Japanese sniper on Okinawa, April 4, 1945 (National Archives and Records Administration/U.S. Army Signal Corps)

Total battle casualties were close to predictions, but there were problems. The Japanese had substantially more artillery on Okinawa than U.S. forces had faced in the Pacific. This gave the Japanese the ability to at least harass U.S. forces at greater depth. The duration of the campaign, likely exacerbated by the Japanese artillery, also led to substantial numbers of psychological casualties, which were not documented if they responded to treatment at an aid station and did not go to a hospital.¹⁸ The reasonably accurate prediction camouflaged problems, however: instead of a smooth slope of casualties, there were days of fierce fighting (battalions might take more than 350 casualties in a day) that briefly overwhelmed the medical system, at least locally. Taking a single hill might cost almost 4,000 casualties.¹⁹

The fleet also took unexpected casualties resulting in Okinawa becoming the Navy’s bloodiest battle of World War II.²⁰ The Imperial Japanese Navy had no ability to drive the Fifth Fleet away from Okinawa, but the prolonged ground campaign meant the fleet had to stay around Okinawa for months. That exposed the ships—and their Sailors—to relentless air attack, both conventional and kamikaze. Thousands of air sorties caused heavy losses in the Fifth Fleet, with about 250 ships and more smaller craft hit. Most of the ships hit were small, and even a few casualties could overwhelm the limited medical support aboard. Without helicopters to move casualties to care, the damaged ship had to come alongside another ship, and thus there could be several hours’ delay before patients could get more than rudimentary care. The length of the campaign and repeated attacks also caused psychological casualties afloat, something for which the Navy had not prepared.

Medical support on land was generally good. Elements of every medical function were ashore on L-day, and the lack of early opposition meant that hospitals could easily be landed and be ready by L+5, before there was much fighting. (The period without much fighting also allowed air spraying against insects, which reduced disease incidence.²¹) Air evacuation was also available sooner than anticipated, with both Army Air Forces and Navy aircraft ferrying casualties back to the Marianas by L+6. It is not clear whether the Services would not cooper- ate, or whether, since both would be flying cargo forward, it made sense for both to evacuate as well.

Hospital ships were effective, although the USS Comfort was hit by a kamikaze that plunged into an operating room be- fore exploding, killing patients and Army surgical personnel who were augmenting their Navy colleagues. The hospital transport USS Pinkney was hit the same day, after it had unloaded the combat troops that it brought forward. Total casualties on the two ships were 65 dead and 60 wounded. After that, hospital ships turned off their lights at night, relying on concealment rather than the protections of the Geneva Convention. Ultimately, about half the patients were evacuated by air and half by water. Just as the Army and Navy worked together to evacuate patients from Okinawa, movement around the island was sometimes joint: heavy rains made ground evacuation dangerously slow for several days, and LST(H) and other amphibious craft were used to move patients to hospitals and clear those hospitals to others in the rear.²²

Meanwhile, ground forces pushed aggressively, and there was not enough hospital support available on Okinawa when heavy fighting started. The wounded took priority over psychiatric casualties for hospital beds, which meant combat fatigue patients were evacuated off the island.²³ That was known to cause worse outcomes to the patients (“fixing” their symptoms before therapy could ameliorate them) and meant that troops who would have been likely to return to combat if they received prompt care could not do so. Thus, lack of hospital capacity cost combat power. Some lightly wounded were also evacuated without any hospitalization. Had more convalescent facilities been available, those 5,175 patients might have been returned to combat.²⁴ Later, more hospitals and other medical units were repurposed to care for psychiatric casualties, which provided adequate capacity if little more capability. Even with few psychiatrists available, forward treatment proved extremely effective, with approximately 73 percent of patients returning to frontline duty, and a further 7 percent returning to rear-area duty.²⁵

There was some joint support, with Army ambulance units attached to III Amphibious Corps and some Marine patients treated at Army hospitals. Two Army hospitals were temporarily subordinated to III Amphibious Corps.²⁶ Some improvements to care were implemented. Fresh whole blood was widely available— first, flown to the Marianas and then shipped forward, and later, flown straight to Okinawa. With iceboxes available, blood was pushed forward to regimental and even battalion level, an echelon or two closer to the front than previously.²⁷ Quantities were also greater than earlier in World War II, forecasting 1 pint per casualty as opposed to 1 pint for every 3 casualties in 1943, and about 41,000 units of blood were used, slightly more than 1 unit per surgical patient.²⁸ (A unit of blood is roughly equivalent to a pint.)

Oxygen apparata were apparently provided to regiments and on ambulances, but no reports of use have been found, and training may not have been synchronized with issue.29 The Army’s auxiliary surgical teams were effective in augmenting hospitals designed for low-acuity care, so they could handle battle casualties. The Army reported a rate for “died of wounds”—patients who arrived alive at a hospital and subsequently expired—of 3.4 percent, which was below the World War II average of 4.5 percent. (Surgeons still thought more could be done if more hospitals with more surgical capacity were available, and they were probably right; perhaps more surgical teams should have been improvised from units in the rear.³⁰) The hospitals also proved their value not just in treating patients to get them stable for evacuation but also in returning troops to duty, and both the Army and Navy improvised convalescent centers.³¹ The Army suffered 34,500 casualties on Okinawa, of whom about 15,000 returned to duty before the battle was over. More Soldiers were returned to duty than were evacuated from Okinawa. Considering this was counting only inpatients, the medical system was truly supporting the fight.

There was a potential problem with command of the medical effort. The Tenth Army was supposed to secure Okinawa, while ISCOM would establish and run the logistical base that would support the invasion of Japan. ISCOM units would be coming ashore while the fighting was continuing (although none of ISCOM’s 10,800 hospital beds would be functional during the fighting), creating potential tension between the headquarters. The Tenth Army surgeon’s office was understaffed to handle operations, while the ISCOM surgeon, Brigadier General Earl Maxwell, and his staff came ashore on L+10. Colonel Westervelt recognized he was not going to pull personnel from Maxwell and sensibly merged his staff into Maxwell’s.³² Maxwell oversaw medical support for the fighting and building the ISCOM medical infrastructure. These two functions might well be dual-hatted today, but in 1945 they had to adjust on the fly.

Implications

Planning was difficult in a low-band- width environment. Current operations rely on rapid and reliable communica- tions to compensate for distances and to coordinate among Services and forces. One mitigation for operating in a denied, disrupted, intermittent, and limited bandwidth environment could be the sort of deconfliction and setting up parallel operations that the Tenth Army did rather than operating fully joint operations. It took 6 months to plan the invasion of Okinawa, with many of the (highly experienced) headquarters involved in the planning also executing other operations. Keeping a plan simple could speed the operational tempo.

Private W.D. Fuhlrodt is removed from tank that carried him from front lines because Japanese artillery and small arms fire made it impossible for ambulances to carry wounded to safety, Okinawa, 1945 (Alpha Stock/Alamy)

Medical support in Operation Iceberg was good despite not meeting modern concepts of jointness. Despite effective medical support, it was a bloody battle: 43 percent of the combat strength were casualties, with roughly equal numbers of battle and nonbattle casualties.³³ Medical support in future operations with even 10 percent of the casualties suffered at Okinawa would challenge medical sup- port at every step—forward surgery and hospitalization, evacuation to the United States, and care in military hospitals in Marble 79 the United States.³⁴ Better command and coordination to use theater assets can mitigate some of the problems, and theater medical commands should help in the future. Current doctrine is certainly more joint than that of 1945, and our capabilities are far greater, but our capacity is far less. Let us hope deterrence works and the enemy does not get a vote. JFQ

¹ On the battle, see Roy E. Appleman et al., Okinawa: The Last Battle (Washington, DC: U.S. Army Center of Military History, 1948), https://web.archive.org/web/20241212210948/https://www.history.army.mil/html/books/005/5-11-1/index.html.

² Joseph Caravalho, Jr., and Enrique Ortiz, Jr., “The Future Joint Medical Force Through the Lens of Operational Art: A Case for Clinical Interchangeability,” Joint Force Quarterly 101 2nd Quarter 2021), 55–8, https://ndupress.ndu.edu/Portals/68/Documents/jfq/jfq-101/jfq-101_55-58_Caravalho-Ortiz.pdf.

³ Main sources on medical support are Mary Ellen Condon-Rall and Albert Cowdrey, Medical Service in the War Against Japan (Washington, DC: U.S. Army Center of Military History, 1998), chap. 12, https://web.archive.org/web/20241207064919/https://www.history.army.mil/html/books/010/10-24/CMH_Pub_10-24-1.pdf; “Medical Service in the Asiatic-Pacific,” chap. XIV, unpublished draft, U.S. Army Medical Service Historical Unit, ca. 1965, U.S. Army Heritage and Education Center; U.S. Navy Bureau of Medicine and Surgery, The History of the Medical Department of the U.S. Navy in World War II—A Narrative and Pictorial Volume, vol. I (Washington, DC: U.S. Government Printing Office, 1953), https://archive.org/details/HistoryOfTheMedicalDeptInWWIIV1/mode/2up.

⁴ United States Navy Medical Department at War, 1941–1945, vol. 2, Organization and Administration (draft) (Washington, DC: Bureau of Medicine and Surgery, Navy Department, 1946), 29–30, https://digirepo.nlm.nih.gov/ext/dw/14321920RX4/PDF/14321920RX4.pdf.

⁵ United States Navy Medical Department at War, 1941–1945, 3.

⁶ Office of the Surgeon, Headquarters U.S. Army Forces Middle Pacific (HUSAFMIDPAC), Administrative History of Medical Activities in the Middle Pacific (Washington, DC: U.S. Army Heritage and Education Center, 1946), 110. This Army subtask did not work well, although medical supplies were interchanged among the Army, Marine Corps, and Navy.

⁷ Office of the Surgeon, HUSAFMIDPAC, Administrative History of Medical Activities in the Middle Pacific, 16; Condon-Rall and Cowdrey, Medical Service in the War Against Japan, 408.

⁸ U.S. Navy Bureau of Medicine and Surgery, The History of the Medical Department of the U.S. Navy in World War II, 106, 110.

⁹ Office of the Surgeon, HUSAFMIDPAC, Administrative History of Medical Activities in the Middle Pacific, 14.

¹⁰ See John W. Devine, Jr., and Hollon W. Farr, “The Neurosurgical Management of Wounded in the Okinawa Campaign,” Military Surgeon 103, no. 3 (September 1948): 202–7.

¹¹ On psychiatric aspects, see Oscar B. Markey, “Tenth U.S. Army,” chap. XVIII in Neuropsychiatry in World War II, vol. II, Overseas Theaters, ed. William Mullins and Albert Glass (Washington, DC: Office of the Surgeon General, 1973), 639–80, https://apps.dtic.mil/sti/pdfs/ADA295201.pdf; United States Navy Medical Department at War, 1941–1945, 26.

¹² U.S. Navy Bureau of Medicine and Surgery, History of the Medical Department of the U.S. Navy in World War II, 106–7. The First Marine Division alone would have 478 casualties among Hospital Corps personnel, with 49 killed, 226 wounded, 17 injured, and 186 sick.

¹³ Office of the Surgeon General, “Medical Aspects of the Ryukyus Campaign: Noneffective Rates,” in Health (Washington, DC: Headquarters, Army Service Forces, War Department, September 30, 1945), 2–10, 18, https://collections.nlm.nih.gov/pdf/nlm:nlmuid-22310600RX32-leaf.

¹⁴ David A. Lane, “Hospital Ship Doctrine in the U.S. Navy: The Halsey Effect on Scoop-and-Sail Tactics,” Military Medicine 162, no. 6 (June 1997): 388–95.

¹⁵ Office of the Surgeon, HUSAFMIDPAC, Administrative History of Medical Activities in the Middle Pacific, 24.

¹⁶ U.S. Navy Bureau of Medicine and Surgery, The History of the Medical Department of the U.S. Navy in World War II, 37.

¹⁷ Office of the Surgeon, HUSAFMIDPAC, Administrative History of Medical Activities in the Middle Pacific, 35–36.

¹⁸ Office of the Surgeon General, “Medical Aspects of the Ryukyus Campaign,” 6.

¹⁹ Condon-Rall and Cowdrey, Medical Service in the War Against Japan, 394–95.

²⁰ U.S. Navy Bureau of Medicine and Surgery, The History of the Medical Department of the U.S. Navy in World War II, 107–9.

²¹ Tenth Army Surgeon, Essential Medical Technical Data for the Okinawa Campaign, August 29 1945, on file at the Army Medical Department Center of History and Heritage, San Antonio, TX; National Archives, Record Group 319, entry A1-145, box 4.

²² Tenth Army Action Report: Report of Operations in the Ryukyus Campaign (Washington, DC: Tenth Army, September 80 Recall / Medical Support at Okinawa 3, 1945), chap. 11, “Staff Section Reports,” 11-XV-13, https://cgsc.contentdm.oclc.org/digital/collection/p4013coll8/id/600/rec/1.

²³ Office of the Surgeon, HUSAFMIDPAC, Administrative History of Medical Activities in the Middle Pacific, 93.

²⁴ Office of the Surgeon, HUSAFMIDPAC, Administrative History of Medical Activities in the Middle Pacific, 126.

²⁵ Historical Sub-Section G-2 HUSAFMIDPAC, History of United States Army Forces Middle Pacific and Predecessor Commands During World War II, vol. XII., ca. 1946, 2708.

²⁶ United States Navy Medical Department at War, 1941–1945, 14; Tenth Army Action Report, II-XV-12.

²⁷ United States Navy Medical Department at War, 1941–1945, 27.

²⁸ Historical Sub-Section G-2 HUSAFMIDPAC, History of United States Army Forces Middle Pacific and Predecessor Commands During World War II, vol. XII, ca. 1946, 2704; Edward D. Churchill, Surgeon to Soldiers: Diary and Records of the Surgical Consultant, Allied Force Headquarters, World War II (Philadelphia: Lippincott, 1972); Office of the Surgeon General, “Medical Aspects of the Ryukyus Campaign,” 10.

²⁹ Historical Sub-Section G-2 HUSAFMIDPAC, History of United States Army Forces Middle Pacific and Predecessor Commands During World War II, vol. XII, ca. 1946, 2709.

³⁰ John Flick, Forrester Raine, and Robert Robertson, “Pacific Ocean Areas,” in Surgery in World War II, vol. II, Activities of Surgical Consultants, ed. B. Noland Carter (Washington, DC: U.S. Government Printing Office, 1964), 645–50, 675–82, https://apps.dtic.mil/sti/tr/pdf/ADA286769.pdf.

³¹ Office of the Surgeon, HUSAFMIDPAC, Administrative History of Medical Activities in the Middle Pacific, 78; Appleman et al., Okinawa, 414; U.S. Navy Bureau of Medicine and Surgery, History of the Medical Department of the U.S. Navy in World War II, 110.

³² Office of the Surgeon, HUSAFMIDPAC, Administrative History of Medical Activities in the Middle Pacific, 71–72.

³³ This source apparently includes combat exhaustion and other psychiatric casualties with noncombat losses.

³⁴ Matthew Fandre, “Medical Changes Needed for Large-Scale Combat Operations: Observations From Mission Command Training Program Warfighter Exercises,” Military Review, May-June 2020, 36–45, https://www.armyupress.army.mil/Portals/7/military-review/Archives/English/MJ-20/Fandre-Medical-Changes.pdf; F. Cameron Jackson,“Don’t Get Wounded: Military Health System Consolidation and the Risk to Readiness,” Military Review, September-October 2019, 141–51, https://www.armyupress.army.mil/Portals/7/military-review/Archives/English/SO-19/Jackson-Military-Health.pdf.