Medical support sustains the warfighter, and for years, the Army has struggled with handling the command and control of medical units. At times medical functions have had a separate command chain, while at other times they have been under logistics, or medical officers have been dual hatted as both staff officers to the commander and functional commanders. The question needs to be re-examined: potential large-scale combat operations in chemical, biological, radiological, nuclear, and high-yield explosives (CBRNE) environments increase the complexity for force health protection and health service support. Is a separate functional command needed, or should it be a more robust functional section in a headquarters with all the transportation and sustainment assets needed for the health service support and force health protection functions? A similar problem set was utilized in the Medical Reengineering Initiative (MRI), which started in the 1990s and was the forerunner to the modular hospital center/field hospital concept and the medical command (deployment support). Today’s argument for a theater medical command is the argument for fully implementing the MRI command and control structure, thus having a functional command.
What has worked in the past?
In 1944, Army leadership was concerned about the tooth-to-tail ratio and how many soldiers were absorbed in geographic support commands. Over several years, the concept for a logistical command (LOGCOM) was developed in three sizes—to support a corps, a field army, or a theater (All were titled LOGCOM, but there were types A, B, and C). Medical support was apparently to be subordinated to LOGCOMs, at some date in the future. This was a major change since medical support had been run by corps, Army, and theater surgeons, who were both staff officers and functioned as medical commanders.
In the Korean War, initial events developed too quickly to implement the LOGCOM framework. The officers in charge implemented a World War II-style system of command from the surgeon’s office until 1952, when the Korean Communications Zone (KCOMZ) was created. Then rear-area medical units and functions were transferred to KCOMZ, while the 30th Medical Group handled medical support in forward areas.
After the Korean War, the doctrine for the LOGCOM became more detailed, and the LOGCOM clearly had responsibility for medical support, including in tactical areas. The task force sent to Lebanon in 1958 had a LOGCOM that oversaw all medical support beyond organic medical detachments in units. In the late 1950s and early 1960s, studies tried to delineate what was a command function versus a staff responsibility; this had not been necessary in World War II when the surgeon was responsible for everything. The LOGCOM structure was intended for peacetime and operations, and medical functions were put under logistics commanders around the world.
In Vietnam, the medical force structure evolved as U.S. presence increased from an advisory role to the fielding of combat forces after 1965. The initial structure of medical support was modeled after the doctrinal theories of a study on combat supply and service activities, combat support to the Army, which directed that a field Army should have all logistical support provided by a field Army support command. In Vietnam, this was 1st Logistics Command, with 44th Medical Brigade under it. There was a surgeon for U.S. Army Vietnam (USARV), a surgeon for 1st LOGCOM, and a commander for the 44th Medical Brigade, plus medical groups in each of the corps tactical zones. The system created what was identified at the time as duplicative, overlapping, and confusing channels of communication. This self-inflicted wound handicapped any comprehensive and responsive medical system.
In 1967, the 1st LOGCOM was taken out of the loop, with the 44th Medical Brigade reporting to headquarters, USARV, and the commander double-hatted as USARV surgeon, although with two staffs. In 1970, the staffs were amalgamated, and U.S. Army Medical Command, Vietnam was created as a single ‘bellybutton’ for medical command in Vietnam. That economized technical personnel (saving 15% of medical headquarter spaces) and provided a responsive medical system for the commander and the soldier while engaging with military allies and the host nation.
Where are we now?
Since the end of the Cold War, the medical system has been repeatedly slimmed, meaning there is extra pressure on moving patients through the system to the right treatment facility: the capacity to treat the next patient depends on evacuating current patients. In the mid-1990s, the Army Medical Department (AMEDD) began the MRI to redesign its force structure and reduce the medical footprint in theater through lighter and more flexible units. To make medical units easier to deploy and more responsive, a modular construct was used to redesign both hospitals and the medical command and control infrastructure. The initiation of Army Modularity in 2004 provided further clarification of MRI initiatives. Under MRI, medical command and control architecture had two types of medical commands, theater and corps, and two types of medical brigades, echelon above corps (EAC) and corps. The AMEDD was still in the process of transforming medical units upon the initiation of Operation Iraqi Freedom (OIF).
For OIF, no MEDCOM deployed into the Iraqi theater. Three medical brigades, all commanded by colonels, were deployed in support of initial combat operations. The 30th Medical Brigade was assigned to V Corps as an EAC medical brigade, with the 1st Medical Brigade subordinated to it as a reinforcing corps medical brigade. The 62nd Medical Brigade was originally attached to Task Force Iron Horse (4th Infantry Division). When Task Force Iron Horse was diverted from Turkey to enter Iraq through Kuwait, the 62nd Medical Brigade was detached and subordinated under the 30th Medical Brigade before being assigned to support the 101st Airborne Division (Air Assault) as it covered northern Iraq.
However, what is more important is what the medical footprint became at the end of initial combat operations in May 2003. As the force structure in Iraq stabilized, the Army became the lead component for medical support with the command and control structure for medical elements. In stability operations, a single medical brigade provided command and control for all echelon above division medical units. There were three to four combat support hospitals and two multi-functional medical battalions, plus Air Force and Navy units. Although units rotated in and out of Iraq, the scope and responsibilities of the medical brigade changed very little. With no air or cyber threat, command and control was relatively easy.
Where do we need to be?
The Army needs a medical system that is responsive to commanders and capable for patients. Although there are dedicated medical evacuation platforms, high-intensity conflict, especially in a multi-domain operations environment, the use of casualty evacuation (CASEVAC) will be required to effectively clear patients in an unpredictable environment. There may no longer be a golden hour on the future battlefield, but golden windows that will rely on effective communication about evacuation requirements and the command and control of CASEVAC assets that are likely not controlled by an officer wearing a caduceus.
For the medical system to be responsive and maintain the unity of effort, it must be well integrated across the movement and maneuver, sustainment, and protection warfighting functions. Two questions need answering:
- Is a functional medical command that relies heavily on external coordination for transportation assets and sustainment adequate in the future environment?
- What is the correct balance between separate surgeons for staff advice and medical unit commanders?
For the first, the answer is yes. Medical support is effectively partnered with the sustainment community, from the medical brigade in the corps area/division rear down to the lowest echelons. Combat generates an uneven flow of casualties, each with different needs. The future battlefield will require synchronized movement of patients and resupply to effectively maximize golden opportunities. Moreover, the past 18 months have shown the importance of force health protection testing and monitoring, which will be important not just against disease in garrison but potentially against CBRNE in operations. Since most testing and monitoring assets are held at the operational/strategic levels, it reinforces the need to be under the command and control of a medical element.
Answering the second question is more complex. A separate theater-level medical headquarters (whatever the terminology for it) brings a general officer, and the access they have, and commensurately senior staff officers, but risks—as in Vietnam, and more recently in Central Command— having confusion about policy and authority between the command surgeon and that medical headquarters. That argument is being worked at the Medical Center of Excellence. Still, history has shown the command and control of medical assets at the theater level remains most effective when led by an AMEDD officer reporting directly to the theater Army commander.
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Col. Jason Sepanic most recently served as the commander of the 528th Hospital Center, 1st Medical Brigade at Fort Bliss, Texas. He is a graduate of the School of Advanced Military Studies and the U.S. Army War College.
Sanders Marble has worked as a historian for the Army Medical Department since 2003. He received his undergraduate degree from the College of William and Mary and graduate degrees from the University of London, and he deployed as a field historian to Afghanistan in 2014.
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This content is published online in conjunction with the Spring 2022 issue of Army Sustainment.
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