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March 20, 2025

Bridging Sky and Sea: Joint Strategies for Medical Evacuation in the Indo-Pacific

Mahdi Al-Husseini, Samuel J. Diehl, and Samuel L. Fricks

ABSTRACT: This article contends that the US Army should coordinate agile and expeditious Joint medical evacuation operations in the Indo-Pacific and develop novel capabilities to do so effectively. There has been limited discussion among scholars and practitioners on modern maritime medical evacuation tactics and techniques inspired by history and informed by contemporary threats. This article introduces three new medical evacuation capabilities and makes six recommendations to advance a Joint maritime medical evacuation operating concept. It provides a framework for medical planners developing evacuation systems in maritime theaters and justifies how and why the US Army should play a substantial role in these systems.

Keywords: medical evacuation, maritime operations, novel capability, World War II, Joint health service

 

The endemic problems that complicated medical evacuation (MEDEVAC) operations in the Pacific theater of World War II warrant professional study and consideration as the US military prepares again for potential conflict in the Indo-Pacific region. In this theater, evacuation systems must overcome vast distances, limitations of transport capacity, an ever-evolving enemy threat, and the complexities of Joint and multinational command structures. Lessons learned in combat and concomitant advances in military medicine and logistics allowed our predecessors to perfect amphibious medical support for a daunting island-hopping campaign against the Imperial Japanese. The strategic coordination of aerial and maritime evacuation and treatment assets enabled the expedient movement and hospitalization of large numbers of casualties across dispersed island chains and clusters. Today, faced with a different adversary and supported by a different inventory, the US Army and US Navy must coordinate as equal partners beginning at the littorals to find ways to do the same. The availability and maturation of rotary-wing aircraft and fast transport ships, the proliferation of networked systems, and advancements in autonomous vehicles and reinforcement and machine learning suggest new and improved Joint approaches to an old, if intensified, problem set.1

At present, the Joint publication on Joint health systems has assigned the Navy the responsibility for coordinating patient movement within the maritime environment. Harkening back to World War II, the Army should also play a critical role in facilitating intra-theater evacuation operations in the Indo-Pacific, thereby freeing up naval resources in a theater where naval capabilities are vital and often overextended. This article has three primary objectives. We first apply history and modern-day threat considerations to identify obstacles to the timely and effective evacuation of wounded, beginning at the littorals. We contextualize these considerations by outlining the Army’s role in maritime evacuation and propose three promising Joint aerial-maritime evacuation capabilities—the overwater ambulance exchange point, the maritime area support MEDEVAC platoon (M-ASMP), and the tail-to-topside transfer to a roaming medical ship. We demonstrate the overwater ambulance exchange point at MEDEVAC Projects Week 2023, a first-of-its-kind training exercise on the Hawaiian Islands organized by the 3-25 Aviation Regiment (as seen in figure 1). We conclude with six recommendations that span DOTMLPF (doctrine, organization, training, materiel, leadership and education, personnel, and facilities), including emphasizing deliberate Joint health service and support training objectives at theater security cooperation exercises and developing a Joint maritime evacuation operating concept. To understand the difficulties ahead, we first review the atolls and archipelagos of the Central Pacific in 1944.

A 25th Infantry Division crew chief in the cabin of an HH-60M medical evacuation Black Hawk helicopter studies Logistics Support Vessel 3 during MEDEVAC Projects Week
Figure 1. A 25th Infantry Division crew chief in the cabin of an HH-60M medical evacuation Black Hawk helicopter studies Logistics Support Vessel 3 during MEDEVAC Projects Week
(Source: Charlie Cook / ©2023 Charlie Cook)

The Island Campaigns

While much has changed in the last 80 years, the Central Pacific World War II campaigns continue to provide insights into amphibious operations in the littorals and evacuation best practices in front of, across, and beyond the reefs. The Allied strategy to invade and secure the Gilbert, Mariana, and Marshall Islands formed the core of three successive and successful Central Pacific campaigns designed to break through Imperial Japan’s outer perimeter. Victory did not come easy, and sustainment was challenged at every turn. Mary E. Condon-Rall and Albert E. Cowdrey write of the capture of the Mariana Islands, “Hardly an aspect of the evacuation story could be cited that did not reveal failures of foresight and unnecessary suffering inflicted on the wounded.” Those operations exposed a taxed evacuation system slow to respond to contingencies related to natural obstacles, destructive weather, and a spontaneous and far-reaching enemy threat. Nonetheless, the Joint Army-Navy medical enterprise performed well in theater. They overcame materiel shortages and manning shortfalls, demonstrated tremendous resolve, and learned the art and science of multimodal evacuation in the littorals while advancing between heavily fortified islands.2

Evacuation in the Central Pacific proved difficult for several reasons. While each invasion was short in duration and constrained in space, the requirement to move patients from the front line to the beachhead and across the reef to the rear required a complex network of unique evacuation assets. Moving patients from the beachhead to beyond the reef involved a dizzying combination of small assault craft and amphibious vehicles, tank landing ships, tank landing craft, transports, and hospital ships. At Saipan, smaller ships transferred patients as many as five times prior to arrival at larger transports and hospital ships. Treacherous coral reefs, inclement weather, and tidal considerations prevented landing craft from approaching the shore. Enemy air and submarine attacks kept transports well offshore after dark, and a threatening Japanese naval fleet forced the transports to withdraw early.3

Although evacuation by fixed-wing aircraft became commonplace as airfields were built, poor planning and synchronization marred early operations. Coordinating Joint evacuation assets was haphazard and sometimes absent, leaving some transports filled to the brim while others sailed empty. Similarly, many wounded left the beachhead without adequate treatment, arriving at transports and hospital ships in critical condition. Overcrowding at key treatment facilities complicated patient regulation, and many servicemembers were returned to the fight prematurely, while others were evacuated too far for their medical disposition.4

The Allies learned many valuable lessons from the island campaigns and, in time, the Allied evacuation system matured into a modular structure that could support atolls and archipelagos. Enhanced command and control of evacuation and treatment assets enabled improved evacuation across and around obstacles, while predictive realignment of assets provided more efficient regulation of patients. Every amphibious operation provided opportunities to standardize and refine medical support concepts. These refinements included an increase in the number of ships and hospitals allotted to assault divisions, additional security for medical facilities near the front lines, and amphibious planes to transport patients near the shore until the military could construct airfields. Medical planners began coordinating aerial and maritime assets for evacuation routing, with a combination of amphibious aircraft and watercraft moving the wounded to secured islands with airstrips, followed by intra- and inter-theater air evacuation by large military transport aircraft.5

New Rules

Although the twin problems of distance and dispersion that plagued our predecessors in the Pacific remain relevant today, America’s ability to overcome both is challenged by China’s burgeoning anti-access / area denial (A2/AD) capabilities. China has spent the last 20 years extending its reach and influence in the South China Sea by building artificial islands and offshore bases. Its unmanned aircraft systems, land-based fighter aircraft, and diesel-electric submarines inhibit freedom of maneuver and power projection in the Western Pacific. With a ballistic missile arsenal capable of striking Guam—well beyond the second island chain—and heavy investment in blue-water naval forces arrayed throughout the Central Pacific, fixed sites and large, predictable movements are especially vulnerable to ballistic missile threats. Any mitigating strategy must involve mobile and distributed forces capable of operating in the Western and Central Pacific.6

While deterring Chinese aggression remains the focus of the National Defense Strategy, Joint medical plans, including medical evacuation concepts, must present strategically acceptable options if deterrence fails. The US Air Force maintains a global fixed-wing aeromedical evacuation presence to facilitate inter-theater patient transport from Guam, Japan, and the Philippines. Nonetheless, evacuation efforts will face opposition when moving patients from the littorals to fixed-wing transfer points. This reality presents an opportunity to develop Army-supported Joint maritime evacuation capabilities that prioritize modularity, adaptability, and speed.7

A Joint State of Mind

While the Navy and Air Force will project substantial sea and airpower in forthcoming maritime conflicts, the Army will also play a significant role. Former Secretary of the Army Christine E. Wormuth outlined a prescient vision involving five combat and support tasks the Army should assume in an Indo-Pacific conflict. One task involves logistical support for the Joint Force, a familiar role the Army dutifully fulfilled during World War II. Logistics, however, is only one of the four elements of the sustainment war-fighting function.8

The Army’s health service should have a central role in coordinating agile and expeditious health service and support operations throughout the Indo-Pacific, with an emphasis on evacuation, for two reasons. First, the Army is the only service branch with a rotary-wing medical evacuation fleet. Joint Health Services, Joint Publication (JP) 4-02, describes medical evacuation as “the movement of wounded, injured, or ill persons to medical treatment facilities on marked medical platforms with en route care provided by medical personnel.” In contrast to medical evacuation, casualty evacuation is unregulated, may occur via nonmedical platforms, and may not provide en route medical care. Additionally, timely and efficient multimodal evacuation, whether medical evacuation or casualty evacuation, will require a high degree of command and control. The sheer magnitude of expected casualties will further complicate the logistics of medical regulation in the Indo-Pacific. Fittingly, another of Wormuth’s five tasks is to provide command-and-control capacity for the Joint Force. The emerging capability of the 18th Medical Command (Deployment Support) in the Indo-Pacific provides the Joint Force the opportunity to codify authorities that will provide clarity and efficiency in future fights.9

Means and Ways

Medical planners in the Central Pacific theater of World War II demonstrated tremendous ingenuity and resourcefulness by developing evacuation capabilities befitting their inventory, manning, and training. Consider the Joint Capabilities Integration and Development System definition of capability: “the ability to achieve a desired effect under specified standards and conditions through combinations of means and ways to perform a set of tasks.” The “combination of means and ways” suggests that evacuation capability is a function of the assets used and the manner of their employment, especially in tandem with other assets. Similarly, we find that novel maritime evacuation capabilities arise from combining strategic multimodal dispatching with capable aerial and maritime evacuation platforms. Those platforms include existing and future long-range rotary-wing aircraft and dedicated medical watercraft. Emerging platforms of note include the Future Long-Range Assault Aircraft (FLRAA) and the Expeditionary Medical Ship (EMS). The FLRAA, to be fielded in 2030, is a tilt-rotor utility aircraft with roughly twice the range and speed of the UH-60 Black Hawk. The EMS, the first of which will be fielded in late 2026, is a medical variant of the Expeditionary Fast Transport ship and enables prolonged care of onboard patients while cruising at up to 43 knots.10

Drawing inspiration from existing doctrinal tactics and techniques, we introduce three multimodal medical evacuation capabilities designed to support distributed operations in a maritime theater, primarily in the littorals:

  1. the overwater ambulance exchange point,
  2. the maritime area support MEDEVAC platoon (M-ASMP), and
  3. the tail-to-topside transfer to a roaming medical ship.

While each capability supports a different problem set, the three capabilities are linked and collectively comprise a modular tactical evacuation system best enabled by a combination of Joint platforms.

Ambulance exchange points are pre-identified locations, typically fixed in space, where patients are transferred between two evacuation platforms en route to a higher echelon of care. The overwater ambulance exchange point uses watercraft as transfer sites for evacuation aircraft transporting patients between distant islands, should at least one island lack a runway to facilitate fixed-wing transport, or between an island and a hospital. The location and movement of intermediary watercraft, sometimes underway in support of their own mission requirements, can complicate ambulance exchange point selection. If the intermediary watercraft does not possess a helicopter landing pad, hoist operations from the evacuation aircraft are necessary to move patients to and from the deck. Consecutive overwater ambulance exchange points with two or more evacuation aircraft form an evacuation chain, enabling longer transfer distances. While few operational scenarios would necessitate such distances without an opportunity for fixed-wing transport, hypersonic weapons may prevent fixed-wing airfield accessibility into the third or fourth island chains. Simulations suggest a high density of nonmedical watercraft between two islands is a sufficient substitute for a single controllable medical watercraft, with minimal impact on patient transfer times. A dense network of watercraft supporting air evacuation between echelons of care forms a dynamic evacuation opportunity zone.11

The new maritime area support MEDEVAC platoon (M-ASMP) is based on the traditional area support MEDEVAC platoon (ASMP), which moves patients between treatment facilities on an area support basis on land. Area support relationships are determined by the geographic location of units requesting support. The maritime area support MEDEVAC platoon postures one or more MEDEVAC aircraft and supporting crew on an offshore EMS, larger hospital ship, or other medical aviation-capable watercraft for an extended duration. Much like its counterpart, the maritime area support MEDEVAC platoon serves as a centralized node within an established area of operations rearward of one or more forward support MEDEVAC platoons (FSMP). The maritime area support MEDEVAC platoon can support a large island or archipelago, while the forward support MEDEVAC platoons (FSMP) service smaller individual islands. The maritime area support MEDEVAC platoon may transfer patients from its host ship to a larger medical treatment facility. Using supplemental aircraft fuel systems can further extend the operational reach of the maritime area support MEDEVAC platoon.12

The expeditious nature of the forthcoming EMS, combined with its onboard medical capabilities, makes it uniquely relevant to the Indo-Pacific operating environment. Rather than be relegated to an overwater exchange point between air ambulances, the EMS and similar fast-moving medical ships can replace the delivering or receiving air ambulance in ferrying patients to a hospital ship or multidisciplinary general hospital on land. This process, which we call the tail-to-topside transfer, resembles the tail-to-tail transfer between air ambulances conducting patient handovers at ground ambulance exchange points. The tail-to-topside transfer may overcome limitations in evacuation throughput. For example, the ship can simultaneously transport more than 100 patients while facilitating tail-to-topside transfers continuously en route to its next destination. Each ship can be restricted to operating within defined zones or, alternatively, may sequence into a circuit after delivering patients to a hospital ship via ship-to-ship transfer. The watercraft zone boundaries and circuit routing may then be optimized to reflect the evolving tactical environment. There are several combinations of forward and area-based medical evacuation aircraft and medical ships that may be adopted to support a campaign’s geography and casualty estimates.13

An HH-60M MEDEVAC Black Hawk helicopter executes hoist iterations to Army Logistics Support Vessel 3, which is traversing the open ocean south of Honolulu, Hawaii, at 5 knots
Figure 2. An HH-60M MEDEVAC Black Hawk helicopter executes hoist iterations to Army Logistics Support Vessel 3, which is traversing the open ocean south of Honolulu, Hawaii, at 5 knots
(Source: Mahdi Al-Husseini / ©2024 Mahdi Al-Husseini)

MEDEVAC Projects Week

The C/3-25 Aviation Regiment “Lightning DUSTOFF” planned and executed the inaugural MEDEVAC Projects Week exercise in October 2023. An ambitious first for the Army, this exercise demonstrated how the military can use underway watercraft as overwater ambulance exchange points to facilitate patient transfers between medical helicopters over long maritime distances. Exercise partners included 8th Theater Sustainment Command, Army Futures Command, and 18th Theater Medical Command. After months of preparation, and as seen in figure 2, Lightning DUSTOFF crews executed mock litter patient handovers between two HH-60M MEDEVAC Black Hawk helicopters conducting dynamic hoist operations over Army Logistics Support Vessel (LSV-3) General B. Somervell, which was underway approximately 10 miles south of Honolulu, Hawaii.

The combination of deliberate and progressive aircrew training and mission-enhancing equipment helped minimize risk and enable safe initial deployment of the overwater ambulance exchange point capability. The logistics support vehicle initiated the exercise by routing a nine-line medical evacuation request through Starlink commercial satellite Internet to the DUSTOFF command post. Upon arrival to the ship, the first aircrew used a load stabilization system during delivery and pickup to preclude oscillation of the hoist load. Subsequently, they transferred all patient data digitally using a battlefield-assisted, trauma-distributed operation kit and transport telemedicine tablets sourced from the Air Force. After the overwater ambulance exchange point transfer was completed, the second aircrew delivered the patient to Tripler Army Medical Center for follow-up care. Both aircraft were dispatched in accordance with an artificially intelligent dispatching algorithm designed by Stanford University researchers specifically for overwater patient transfers. The use of underway watercraft to facilitate the flow of casualties to the rear significantly expands aeromedical evacuation reach and flexibility.14

The United States Development Command Army Research Laboratory has agreed to pursue two patent applications related to MEDEVAC Projects Week. They are titled “Systems and Methods for Optimally Facilitating Patient Transfers in Non-Contiguous Maritime Environments” and “System and Method for Continuously Reallocating Heterogeneous Evacuation Assets Across Dispatching Subsystems.” The Lightning DUSTOFF team also submitted a paragraph on the demonstrated value of the overwater ambulance exchange point for addition to Medical Evacuation, Army Techniques Publication (ATP) 4-02.2. Lessons learned from MEDEVAC Projects Week are further informing an active cooperative research and development agreement between the Army Research Laboratory and Stanford University titled “Hierarchical Framework for the Dynamic Resource Allocation of Heterogeneous Medical Evacuation Assets.”

Distributed medical evacuation operations in a theater as vast and complex as the Indo-Pacific can be challenging. Developing and deploying a diverse repertoire of maritime tactics and techniques for the Joint evacuation enterprise provides medical planners flexibility in operations. The ongoing research at Stanford University and the Army Research Lab involves developing novel models and planning and reinforcement learning algorithms to help identify promising means for conducting evacuation operations in noncontiguous environments. Outcomes include matching evacuation requests to evacuation platforms, selecting and placing land and overwater ambulance exchange points, and allocating and organizing evacuation platforms on a dispersed battlefield in a manner befitting the maneuver commander’s tactical plan. Exercises like MEDEVAC Projects Week help shape evacuation operations in unique environments and demonstrate how analyzing and evaluating new capabilities can have an outsized and lasting influence on an entire theater.15

Recommendations

Coordinating effective multimodal evacuations across large swaths of the Indo-Pacific in a heavily contested environment will require a return to form. The Joint operating concept for health services must continue to evolve with an eye toward evacuation in a maritime environment, especially the littorals. Although the military has made significant strides in developing new platforms like the EMS and FLRAA, it still needs to improve how they are employed to overcome the challenges of distance and dispersion that characterize maritime theaters. The remainder of this section proposes six ways the Army can address these challenges and enhance medical evacuation operations in the Indo-Pacific. First, the Army should integrate deliberate Joint health service and support training objectives into theater security cooperation exercises. Joint multimodal evacuation is challenging, but opportunities to train abound. The 25th Infantry Division MEDEVAC aircraft in Hawaii regularly conduct deck-landing qualifications with Navy vessels, and capability demonstrations like MEDEVAC Projects Week have explored novel methods for integrating non-medical assets like Army watercraft into the concept of health service and support. We encourage additional capability demonstrations, such as posturing a MEDEVAC aircraft and crew on an aviation-capable Navy vessel for an extended period during Rim of the Pacific and other Joint exercises. In support of future Joint integration, the Joint Force should develop an understanding of how MEDEVAC aircraft can operate in tandem with ships like the EMS before they are fielded.

The Army should introduce maritime and littoral evacuation operations into doctrine and curricula. The Army last updated Medical Evacuation, ATP 4-02.2, in July 2019, and it features only a brief mention of maritime operations. Currently, a small subsection on “Shore-to-Ship Evacuation Operations” is delegated to Section XI: “Other Types of Medical Evacuation Support Missions.” The Medical Center of Excellence Doctrine Literature Division’s recent efforts to add maritime considerations to ATP 4-02.2 are commendable, and we suggest that future additions include overwater evacuation capabilities such as the overwater ambulance exchange point, physical characteristics of maritime environments that influence medical evacuation, planning considerations for the littorals, and common illnesses and injuries in the Indo-Pacific. Additionally, professional medical military education, including the Army Medical Department Captains Career Course and the Medical Evacuation Doctrine Course, must emphasize maritime evacuation operations and the Indo-Pacific in lesson plans and practical exercises.16

The military should enlarge the inventory of logistics watercraft and medical and hospital ships with an emphasis on expeditious and expeditionary operations. The number of logistics vessels and hospital ships in the current inventory is inadequate for sustaining the Joint Force during a future war in the Indo-Pacific. Currently, the Army’s fleet of 132 watercraft is about three orders of magnitude smaller than the World War II fleet. At the height of World War II there were a combined 34 Army and Navy hospital ships; today there are only two Navy hospital ships—the Mercy and the Comfort. While the Army and Navy have recently undertaken laudable watercraft-building initiatives, doing so independently and in a manner that does not support the Joint logistics concept is perilous. The Navy’s EMS is a high-quality addition to the fleet, but only three were approved in the 2023 military budget, and none have been fielded; more will likely be required for a sprawling maritime conflict. In contrast to the EMS, Army watercraft move at 8 to 12 knots, making them easy prey for Chinese air, naval, and rocket attacks. Additionally, any requirement to operate at a functioning port will be a nonstarter in a contested environment where ports and airfields are likely be high-value targets.17

The military should build on existing research agreements with academic partners to develop and assess new evacuation capabilities at scale in noncontiguous theaters. Capability is complicated; multimodal patient movements between Joint assets will require a high degree of command and control and an informed approach to sequential decision making. The adoption and deployment of operationally informed data analytics and AI tools enable military leaders to make rapid and well-informed decisions. The partnership between Stanford University and the Army Research Laboratory, partially in support of the 25th Infantry Division, is developing decision support structures and their underlying models and algorithms for maritime evacuation planning. Existing software systems, like the Medical Planners’ Toolkit (MPTk) and Joint Medical Planning Tool (JMPT), have also been used to determine how emerging platforms and treatment facilities can improve operations in a given health system.

The feasibility of evacuation decision support structures is related to their performance in a denied, degraded, and disrupted communications environment. Reinforcement learning is an interdisciplinary subfield in AI that is concerned with how an intelligent agent should make decisions in an evolving environment. In the language of reinforcement learning, an inability to communicate results in partial observability and decentralized control. Partial observability indicates limited knowledge of the system state; for example, the surgeon cell not knowing the location of all friendly evacuation platforms during a wide area jamming event. Decentralized control means agents decide on actions based on local observations, such as a jammed evacuation platform making evacuation decisions with only the operational environment knowledge it possesses, independent of a higher-echelon medical planner or centralized controller. The robustness of a decision-making support structure for an evacuation system is tied to how it performs when the Medical Common Operating Picture is temporarily, or even permanently, degraded or when the operating environment suddenly and substantially changes.18

The military should pursue mature autonomous evacuation solutions and develop the policies to guide and constrain their employment. Technology outpaces policy. It is, therefore, crucial that military leaders facilitate the difficult conversations that result in policies enabling technologies that provide an asymmetric advantage over our adversaries. Trust in autonomous platforms does not, and should not, come easy. This trust is especially true in the case of evacuation aircraft that tend to the sick and wounded. Still, the upside is too great to sidestep the role autonomous evacuation platforms will soon play in facilitating patient movement, especially from high-risk areas and across long distances. Consider that many autonomous evacuation solutions, while incipient, already exist. The Aircrew Labor in-Cockpit Automation System is a drop-in kit for existing aircraft that enables multiple levels of autonomy to minimize pilot workload, improve mission performance, and enhance aircraft safety. A Black Hawk helicopter equipped with this drop-in kit completed its first uninhabited flight in 2022 and continues to be flight-tested in support of diverse mission sets, including medical evacuation. The Army Medical Robotics and Autonomous Systems Division has a portfolio of modernization efforts organized under “RAS Transport” designed to augment medical evacuation and resupply efforts. Such efforts should be expanded to support operations in maritime environments. Shaping enabling requirements and policies and educating military leaders across the force can accelerate the Army’s adoption of autonomous evacuation solutions in the Indo-Pacific.19

Finally, and most critically, the military should develop a Joint maritime medical evacuation operating concept. Lieutenant Colonel Ian Natkin observed, “Even the current concentration on Joint service efforts has not generated the needed written guidance” in his 1989 US Army War College study project on the role of health service in support of theater campaign planning. Natkin’s concerns ring true today, although progress has been made since his paper was published. JP 4-02, updated in August 2023, enables the planning, preparation, and execution of health service operations across the Joint Force. Only minimal written guidance for facilitating operations in maritime environments exists. JP 4-02 introduces a general framework whereby a Joint movement center defines evacuation requirements and passes them to service transportation control centers for scheduling, tasking, and monitoring. At its most detailed, JP 4-02 compels the Navy to facilitate patient movement “within the maritime environment.” This stipulation belies the critical role the Army, especially its MEDEVAC aircraft and substantial capacity for planning and synchronization of theater operations, should play in any maritime evacuation system that begins at the littorals.20

The three novel maritime evacuation capabilities introduced will require extensive collaboration between the Army and Navy, as shown during the World War II Pacific campaigns. A more in-depth intra-theater maritime evacuation operating concept should be developed that reflects this Joint integration, accompanied by defined service authorities for patient operations and regulation across echelons in noncontiguous environments. Just as there is a section on operations in chemical, biological, radiological, and nuclear environments, there should similarly be a section on operations in maritime environments.

Conclusion

Maritime medical evacuation planning is an old game with new rules. Many challenges our World War II predecessors faced in the Pacific remain relevant today, namely, maneuver-inhibiting coral reefs and tides, destructive weather, a pervasive enemy threat, and the need to evacuate dispersed assets across vast distances. Yet, much has changed. The enemy air, naval, and long-range fires threaten the Western Pacific and beyond, forcing a transition from fixed sites and consolidated movements to mobile and expeditionary platforms, facilities, and operations. The modern-day inventory is complete with long-range rotary-wing platforms and fast transport ships, which, when coordinated strategically, can form a modular and adaptable intra-theater evacuation system. The three evacuation capabilities (overwater ambulance exchange point, the maritime area support MEDEVAC platoon (M-ASMP), and tail-to-topside transfer) introduced here are analogous to existing capabilities (ambulance exchange points, area support MEDEVAC platoon (ASMP), and tail-to-tail transfers) but applied to a maritime environment and enhanced by emerging evacuation platforms.

Revitalizing Joint maritime evacuation operations begins with the deliberate development of a comprehensive Joint maritime medical evacuation operating concept. Army and Navy medical planners, research partners at academic institutions and military research laboratories, and military capability developers must coordinate their diverse efforts and objectives to advance any such operating concept successfully. Key institutions to be brought together include the 18th Medical Command (Deployment Support), Stanford University, the Army and Naval Research Labs, the Medical Evacuation Concepts and Capabilities Division, and the Defense Medical Readiness Training Institute. Supporting the Joint maritime medical evacuation operating concept must be a multifaceted approach to implementation that integrates Joint health service training into theater security cooperation exercises, introduces maritime evacuation into doctrine and curricula, expands the inventory of watercraft and medical ships, develops relationships with academic partners to explore novel evacuation capabilities, and matures and guides the employment of autonomous evacuation platforms. Now is the time to bring the Joint health service enterprise together to develop, demonstrate, and train capabilities that bridge the sky and the sea. Our servicemembers—and the outcome of the next conflict—depend on it.

 
 

Mahdi Al-Husseini
Captain Mahdi Al-Husseini directs the Medical Evacuation Doctrine Course for the Department of Aviation Medicine. He recently served as the operations officer for C/3-25 Lightning DUSTOFF and as the deputy director of the 25th Infantry Division’s Modernization Office. He has a master’s degree in computer science with a specialty in AI from the Georgia Institute of Technology and is a PhD student at Stanford University studying multi-agent reinforcement learning and planning.

Samuel J. Diehl
Lieutenant Colonel Samuel J. Diehl is the commander of the 3rd Battalion, 25th Aviation Regiment. He is an aeromedical evacuation officer, senior aviator, and Black Hawk UH-60L/M instructor pilot. Diehl is an honors graduate of the Aviation Captain’s Career Course and the US Army Command and General Staff College and a distinguished graduate of the Advanced Military Studies Program at the School of Advanced Military Studies. He holds graduate degrees from the University of Kansas and the US Army Command and General Staff College.

Samuel L. Fricks
Colonel Samuel L. Fricks serves as the chief of the Medical Evacuation Concepts and Capabilities Division and is responsible for air and ground evacuation modernization. He has served as an aeromedical evacuation officer for more than 24 years and has recently participated in multiple Ukraine lessons learned collection events. Fricks holds multiple advanced degrees and is a 2023 graduate of the US Army War College.

 
 

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Endnotes

  1. Anthony W. Gray Jr., “Joint Logistics in the Pacific Theater,” in The Big L: American Logistics in World War II, ed. Alan Gropman (National Defense University Press, 1997), 293–337; and Worrall Reed Carter, Beans, Bullets, and Black Oil: The Story of Fleet Logistics Afloat in the Pacific During World War II (Department of the Navy, 1953). Return to text.
  2. Philip A. Crowl and Edmund G. Love, Seizure of the Gilberts and Marshalls, Center of Military History (CMH) Publication 5-6-1, United States Army in World War II: The War in the Pacific, ed. Kent Roberts Greenfield (1955; repr., CMH, 1993); and Mary Ellen Condon-Rall and Albert E. Cowdrey, The Medical Department: Medical Service in the War Against Japan (CMH / United States Army, 1998). Return to text.
  3. Holman D. Hoover, “Comparison of Evacuation Policies in the Various Theaters of Operation During World War II” (student paper, Command General Staff College, 1949); and Condon-Rall and Cowdrey, Medical Department. Return to text.
  4. Condon-Rall and Cowdrey, Medical Department; and James Robert Pruitt, “PB2Y Coronado Flying Boat Archaeology and Site Formation Studies, Tanapag Lagoon, Saipan” (thesis, East Carolina University, 2015). Return to text.
  5. Hoover, “Comparison of Evacuation Policies”; and Condon-Rall and Cowdrey, Medical Department. Return to text.
  6. Sam J. Tangredi, “Anti-Access Strategies in the Pacific: The United States and China,” Parameters 49, no. 1 (Spring 2019): 5–20, https://press.armywarcollege.edu/parameters/vol49/iss1/3/; Adam W. Kohl, “China’s Artificial Island Building Campaign in the South China Sea: Implications for the Reform of the United Nations Convention on the Law of the Sea,” Dickinson Law Review 122, no. 3 (Spring 2018): 917–37; and Mike Sweeney, “Challenges to Chinese Blue-Water Operations,” Defense Priorities, April 30, 2024, https://www.defensepriorities.org/explainers/challenges-to-chinese-blue-water-operations/. Return to text.
  7. Thomas A. Julian, A History of Aeromedical Evacuation in the U.S. Air Force (Air Force History and Museums Program, 2015), 81, 148–49, 164. Return to text.
  8. Christine E. Wormuth, “China’s Power: Up for Debate 2021—Keynote Remarks by Secretary Christine Wormuth on the U.S. Army’s View of the China Challenge” (speech, Washington, DC, December 1, 2021), Center for Strategic & International Studies, https://www.csis.org/events/chinas-power-debate-2021-keynote-remarks-secretary-christine-wormuth-us-armys-view-china. Return to text.
  9. Christine E. Wormuth, “China’s Power”; On the Posture of the United States Army: Hearings Before the Subcommittee on Defense, House Appropriations Committee, United States House of Representatives, 117th Cong. (2021) (statement of John E. Whitley, acting Secretary of the Army, and James P. McConville, Chief of Staff of the United States Army); C. Todd Lopez, “For Contingencies in Indo-Pacom, Army Will Serve as ‘Linchpin’ for Joint Force,” U.S. Department of Defense (DoD), December 1, 2021, https://www.defense.gov/News/News-Stories/Article/Article/2858596/for-contingencies-in-indo-pacom-army-will-serve-as-linchpin-for-joint-force/; Headquarters, Department of the Army (HQDA), Sustainment, Army Doctrine Publication (ADP) 4-0 (HQDA, July 2019), https://armypubs.army.mil/ProductMaps/PubForm/Details.aspx?PUB_ID=1007565; Joint Chiefs of Staff (JCS), Joint Health Services, Joint Publication (JP) 4-02 (JCS, 2023); and HQDA, Casualty Evacuation, Army Training Publication (ATP) 4-02.13 (HQDA, June 2021), https://armypubs.army.mil/epubs/DR_pubs/DR_a/ARN32888-ATP_4-02.13-000-WEB-1.pdf. Return to text.
  10. Chairman of the Joint Chiefs of Staff Instruction (CJCSI), Joint Capabilities Integration and Development System, CJCSI 3170.01F (CJCSI, May 2007), https://dml.armywarcollege.edu/wp-content/uploads/2023/01/CJCSI-3170.01F-Joint-Capabilities-Integration-and-Development-System-2009.pdf; Rebekah Brandes, “US Navy Building First New Hospital Ships in 35 Years – See What They’ll Look Like,” Nice News, January 10, 2024, https://nicenews.com/innovation/us-navy-building-new-hospital-ships/; and PEO Aviation, “FLRAA Achieves Milestone B, Enters Next Phase of Development,” U.S. Army, August 2, 2024, https://www.army.mil/article/278591/flraa_achieves_milestone_b_enters_next_phase_of_development. Return to text.
  11. Mahdi Al-Husseini et al., “Watercraft as Overwater Ambulance Exchange Points to Enhance Air Medical Evacuation,” Air Medical Journal (October 7, 2024); Mahdi Al-Husseini et al., “Semi-Markovian Planning to Coordinate Aerial and Maritime Medical Evacuation Platforms,” arXiv no. 2410.04523, https://arxiv.org/abs/2410.04523; and HQDA, Medical Evacuation, ATP 4-02.2 (HQDA, July 2019), https://armypubs.army.mil/epubs/DR_pubs/DR_a/pdf/web/ARN17834_ATP%204-02x2%20FINAL%20WEB.pdf. Return to text.
  12. HQDA, Medical Evacuation. Return to text.
  13. “Bethesda-Class Expeditionary Medical Ship, US,” Naval Technology, January 16, 2024, https://www.naval-technology.com/projects/bethesda-class-expeditionary-medical-ship-us/?cf-view. Return to text.
  14. Al-Husseini et al., “Watercraft as Overwater Ambulance Exchange Points”; and Al-Husseini et al., “Semi-Markovian Planning.” Return to text.
  15. Hierarchical Framework for the Dynamic Resource Allocation of Heterogeneous Medical Evacuation Assets, ARL CRADA 20-017-002 (Stanford University, Army Research Laboratory, 2023). Return to text.
  16. HQDA, Medical Evacuation; and Jim Mattis, Summary of the 2018 National Defense Strategy of the United States of America (DoD, 2018), https://apps.dtic.mil/sti/pdfs/AD1045785.pdf. Return to text.
  17. Hoover, “Comparison of Evacuation Policies”; Gabriel W. Pryor, “Logistics in the Indo-Pacific: Setting the Theater for a Conflict over Taiwan,” Army Sustainment 56, no. 1 (Winter 2024), https://alu.army.mil/alog/ARCHIVE/PB7002401FULL.pdf; Quintin M. Sanger, “U.S. Naval Hospital Ships in World War II and Korean Action,” Military Medicine 131, no. 1 (January 1966): 36–43; Sebastian Kevany et al., “In Support of Hospital Ships: A Need for Reform, Not Rejection,” Security Nexus 23 (March 22, 2022), https://dkiapcss.edu/nexus_articles/in-support-of-hospital-ships-a-need-for-reform-not-rejection/; JCS, Joint Logistics, JP 4-0 (JCS, 2023); Chris Bernotavicius et al., “You Go to War with the Watercraft You Have,” War on the Rocks, July 26, 2022, https://warontherocks.com/2022/07/you-go-to-war-with-the-watercraft-you-have/; Hope Hodge Seck, “These Speedy New Navy Medical Ships Are Designed with the Pacific in Mind,” Military.com, January 17, 2023, https://www.military.com/daily-news/2023/01/17/these-speedy-new-navy-medical-ships-are-designed-pacific-mind.html; and Garrett Chandler and Matthew Carstensen, “Lots to Be Desired: Why the US Army Needs to Invest in Logistics Over-the-Shore,” Modern War Institute, April 28, 2022, https://mwi.westpoint.edu/lots-to-be-desired-why-the-us-army-needs-to-invest-in-logistics-over-the-shore/. Return to text.
  18. DoD, Data, Analytics, and Artificial Intelligence Adoption Strategy: Accelerating Decision Advantage (DoD, 2023), https://media.defense.gov/2023/Nov/02/2003333300/-1/-1/1/DOD_DATA_ANALYTICS_AI_ADOPTION_STRATEGY.PDF; Mykel J. Kochenderfer et al., Decision Making Under Uncertainty: Theory and Application (MIT Press, 2015); William S. Lovejoy, “A Survey of Algorithmic Methods for Partially Observed Markov Decision Processes,” Annals of Operations Research 28 (December 1991): 47–65; and Francisco S. Melo and Manuela Veloso, “Decentralized MDPs with Sparse Interactions,” Artificial Intelligence 175, no. 11 (July 2011): 1757–89. Return to text.
  19. Army Futures Command Concept for Medical 2028, Army Futures Command (AFC) Pamphlet 71-20-21 (AFC, March 2022); Nathan T. Fisher and Gary R. Gilbert, “Medical Robotic and Autonomous System Technology Enablers for the Multi-Domain Battle 2030–2050,” Small Wars Journal, July 22, 2017, https://archive.smallwarsjournal.com/index.php/jrnl/art/medical-robotic-and-autonomous-system-technology-enablers-for-the-multi-domain-battle-2030-; “Safe, Reliable, and Uninhabited: First Autonomous BLACK HAWK® Helicopter Flight,” Lockheed Martin, February 8, 2022, https://www.lockheedmartin.com/en-us/news/features/2022/safe-reliable-and-uninhabited-first-autonomous-black-hawk-flight.html; “ALIAS Equipped Black Hawk Helicopter Completes First Uninhabited Flight,” DARPA, February 8, 2022, https://www.darpa.mil/news-events/2022-02-08; and Nathan Fisher, “Multidomain Medicine,” Army AL&T, April-June 2017, 61–65, https://asc.army.mil/docs/pubs/alt/archives/2017/Apr-Jun-2017.pdf. Return to text.
  20. Ian L. Natkin, “The Role of Health Services in Support of the Theater Campaign Plan” (individual study project, US Army War College, 1989), https://apps.dtic.mil/sti/pdfs/ADA208619.pdf. Return to text.