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NAVAL 

POSTGRADUATE 

SCHOOL 

MONTEREY, CALIFORNIA 

THESIS 


SUCCESS AND FAILURE IN DOCTRINAL INNOVATION: 
A COMPARISON OF THE U.S. ARMY MEDICAL 
DEPARTMENT AND LOGISTICS BRANCH, 1990-2010 

by 

Douglas P. Wekell 
March 2012 

Thesis Advisor: Maiah Jaskoski 

Second Reader: James A. Russell 


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March 2012 


6. AUTHOR(S) Douglas P. Wekell 


11. SUPPLEMENTARY NOTES The views expressed in this thesis are those of the author and do not reflect the official policy 
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13. ABSTRACT (maximum 200 words) 

In the latter half of this decade, the U.S. Army has been engaged in persistent asymmetric warfare. During this period, 
army organizations have varied in the degree to which they have innovated doctrinally and technologically to confront 
this new reality. At the broadest level, the army has innovated considerably. However, at the combat brigade level, we 
observe variation across medical and logistics units, critical for providing support for combat operations. This thesis 
explains this variation. 

Several authors propose that units learn and innovate primarily during wartime or peacetime, and 
they do so from either a top-down or bottom-up methodology. Yet, such methods of learning do not adequately 
explain variations between respective levels of innovation in which logistics forces within combat brigades have 
seemingly adapted more rapidly than their medical counterparts. This thesis suggests that another factor, 
organizational complexity, explains why the brigade support medical company has not adapted as rapidly as its 
logistics counterparts within the support battalion (BSB) structure. 


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111 


14. SUBJECT TERMS logistics, medical, BSB, BSMC, support battalion, military innovation, 
combat brigade, sustainment, military adaptation, doctrine, U.S. Army, ambulance, Stryker 


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Naval Postgraduate School 
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4. TITLE AND SUBTITLE Success and Failure in Doctrinal Innovation: A 
Comparison of the U.S. Army Medical Department and Logistics Branch, 1990- 
2010 


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Approved for public release; distribution is unlimited 


SUCCESS AND FAILURE IN DOCTRINAL INNOVATION: A COMPARISON 
OF THE U.S. ARMY MEDICAL DEPARTMENT AND LOGISTICS BRANCH, 

1990-2010 

Douglas P. Wekell 
Major, United States Army 
B.A., Naval Postgraduate School, 2012 


Submitted in partial fulfillment of the 
requirements for the degree of 


MASTER OF ARTS IN SECURITY STUDIES 
(DEFENSE DECISION-MAKING AND PLANNING) 


from the 


NAVAL POSTGRADUATESCHOOL 
March 2012 


Author; Douglas P. Wekell 


Approved by: Maiah Jaskoski 

Thesis Advisor 


James A. Russell 
Second Reader 


Daniel Moran 

Chair, Department of National Security Affairs 
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IV 



ABSTRACT 


In the latter half of this decade, the U.S. Anny has been engaged in persistent asymmetric 
warfare. During this period, army organizations have varied in the degree to which they 
have innovated doctrinally and technologically to confront this new reality. At the 
broadest level, the army has innovated considerably. However, at the combat brigade 
level, we observe variation across medical and logistics units, critical for providing 
support for combat operations. This thesis explains this variation. 

Several authors propose that units leam and innovate primarily during wartime or 
peacetime, and they do so from either a top-down or bottom-up methodology. Yet, such 
methods of learning do not adequately explain variations between respective levels of 
innovation in which logistics forces within combat brigades have seemingly adapted 
more rapidly than their medical counterparts. This thesis suggests that another factor, 
organizational complexity, explains why the brigade support medical company has not 
adapted as rapidly as its logistics counterparts within the support battalion (BSB) 
structure. 


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vi 



TABLE OF CONTENTS 


I. INTRODUCTION.1 

A. OVERVIEW.1 

B. IMPORTANCE: INCREASING ROLE AND EXPECTATIONS.4 

C. ORGANIZATIONAL COMPLEXITY.6 

D. METHODOLOGY.7 

1. Level of Analysis: Combat Brigade Support Units.7 

2. Time Period.8 

3. Propositions.9 

4. Methodology.10 

E. ORGANIZATION.11 

II. LITERATURE REVIEW.13 

A. OVERVIEW.13 

B. DOCTRINAL AND TECHNOLOGICAL INNOVATION.15 

C. THE FOUR QUADRANTS OF INNOVATION.18 

1. Top-Down Innovation, Peacetime.20 

2. Top Down, Wartime.21 

3. Bottom-Up Innovation, Peacetime.22 

4. Bottom-Up Innovation, Wartime.22 

D. ORGANIZATIONAL COMPLEXITY.24 

III. AMEDD AND LOGISTICS BRANCH: DETAILED DESCRIPTION OF 

OUTCOMES.27 

A. INTRODUCTION.27 

B. TECHNOLOGY.28 

C. DOCTRINE.29 

D. TECHNOLOGICAL INNOVATION AND DOCTRINE.31 

1. Pre-Global War on Terrorism (GWOT) Tracked Ambulances 

(Top-Down/Peacetime).34 

a. AMEV (Armored Medical Evacuation Vehicle) . 35 

b. AMTV (Army Medical Treatment Vehicle) . 36 

2. Pre-GWOT Wheeled Ambulances (Top-Down/Peacetime).37 

3. Post-GWOT Attempts at Innovation.38 

a. Stryker MEV (Top-Down/Peacetime) . 38 

b. MRAP Ambulances (Bottom-Up/Wartime) . 40 

c. Post-GWOT Conventional Methods (Top-Down/Wartime) ..42 

4. Technological Intersection and Disparity (Medical and 

Logistics Companies).43 

E. OPERATIONAL INNOVATION AND DOCTRINE.45 

1. Formal Doctrine.45 

a. AMEDD and Sustainment Doctrine (Top-Down Efforts) . 47 

b. Medical and Logistics Formal Training as Doctrine 

Rehearsal (Top-Down) . 48 

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c. Logistics . 50 

F. CONCLUSION.51 

IV. AMEDD AND LOGISTICS BRANCH: A THREE-PRONGED 

COMPARATIVE ANALYSIS.53 

A. INTRODUCTION.53 

B. KEY INDEPENDENT VARIABLE: ORGANIZATIONAL 

COMPLEXITY.54 

C. SEPARATENESS AND TOP-DOWN DOCTRINAL 

DEVELOPMENT.57 

1. Army Doctrine.59 

2. Logistics Doctrine.60 

3. AMEDD Doctrine.61 

4. AMEDD: Lessons Learned, Lessons Lost (Bottom-Up).64 

5. Logistics.67 

D. CONCLUSION.71 

V. CONCLUSION.73 

A. SUMMARY.73 

B. IMPLICATIONS.76 

1. Facilitate Increased Integration with Logistics Counterparts.77 

2. Prioritization of Ambulance Production.79 

3. A Case of Viable Alternatives (Air MEDEVAC).80 

C. RECOMMENDATIONS FOR FUTURE RESEARCH.81 

LIST OF REFERENCES.83 

INITIAL DISTRIBUTION LIST.91 


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LIST OF FIGURES 


Figure 1. Innovation Axes.19 

Figure 2. Theoretical Framing and Argument.53 

Figure 3. Top-Down Army Doctrinal Information Flow.59 






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LIST OF TABLES 


Table 1. Division of Labor within AMEDD.57 

Table 2. Comparison of Survivability and Mobility Definitions.63 


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LIST OF ACRONYMS AND ABBREVIATIONS 


4GW 

Fourth Generation Warfare 

AAR 

After Action Review 

AHS 

Army Health Services 

AMEDD 

Army Medical Department 

AMTV 

Armored Medical Treatment Vehicle 

ARFORGEN 

Army Force 

AR 

Army Regulation 

ARTEP 

Army 

AXP 

Ambulance Exchange Point 

BCT 

Brigade Combat Team 

BDE 

Brigade 

BFV 

Bradley Fighting Vehicle 

BSB 

Brigade Support Battalion 

BSMC 

Brigade Support Medical Company 

C2 

Command and Control 

C4ISR 

Communication, Computers, Intelligence, Surveillance, 
Reconnaissance 

CAC 

Combined Arms Center 

CASCOM 

Combined Arms Support Command 

CAT 

Combat Application Tourniquet 

CBRNE 

Chemical, Biological, Radiological, Nuclear, E 

CCMRF 

CBRNE Consequence Management Reaction Force 

CMTC 

Combat Maneuver Training Center 

COIN 

Counter Insurgency 

DART 

Document Assistance Review Team 

DCDD 

Directorate of Combat and Doctrine Development 

DVH 

Double “V” Hull 


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DoD 

Department of Defense 

FBCB2 

Force XXI Battle Command Brigade and Below 

FCS 

Future Combat Systems 

FLA 

Four Litter Ambulance/Front Line Ambulance 

FM 

Field Manual 

FMTV 

Family of Medium Tactical Vehicles 

FOB 

Forward Operating Base 

FORSCOM 

Forces Command 

FSB 

Forward Support Battalion 

GAO 

Government Accounting Office 

GC 

Geneva Convention 

GCV 

Ground Combat Vehicle 

GWOT 

Global War On Terror 

HBCT 

Heavy Brigade Combat Team 

HEMTT 

Heavy Expanded Mobility Tactical Truck 

HIC 

High intensity conflict 

HLZ 

Helicopter Landing Zone 

HMMWV 

High Mobility Multipurpose Wheeled Vehicle 

HSS 

Health Service Support 

IBCT 

Interim brigade combat team 

ICRC 

International Red Cross 

ICV 

Infantry Carr 

IED 

Improvised Explosive Device 

IHL 

International Humanitarian Law 

IPT 

Integrated Product Team 

JCAHO 

Joint Commission on Accreditation Healthcare 

JRTC 

Joint Readiness Training Center 

LSAC 

Low Signature Armored Cab 

LZ 

Landing Zone 


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M113 

(vehicle nomenclature) Tracked Evacuation Ambulance 

M577 

(vehicle nomenclature) Tracked Treatment Platform 

MC4 

Medical Communications for Combat Casualty Care 

MCSC 

Marine Corps Systems Command 

MEV 

Medical Evacuation Variant 

MLRS 

Multiple Rocket Launcher System 

MRAP 

Mine Resistant Ambush Protected 

MTOE 

Modified Table of Organization and Equipment 

NTC 

National Training Center 

ONS 

Operational Needs Statement 

OTSG 

Office of the Surgeon General 

PLS 

Palletized Loading System 

PROFIS 

Professional Filler System 

RFI 

Rapid Fielding Initiative 

TDDD 

Training and Doctrine of Development Directorate 

TJC 

The Joint Commission 

TRADOC 

Training and Doctrine Command 

Up 

Tactics Techniques and Procedures 

USAMMDA 

U.S. Army Medical Materiel Activity 


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ACKNOWLEDGMENTS 


The author wishes to thank the senior leadership of the Army Medical 
Department, specifically Colonel Bruce McVeigh, as the previous 70H Medical 
Operations Officers Branch Consultant, for the honor of being selected as the initial 
Medical Service Corps Branch officer to attend Long Term Health Education & Training 
(LTHET) under the 687 Curriculum, Strategic Decision-making and Planning at Naval 
Post Graduate School. During the last fifteen months, I have had the privilege of 
receiving a first-rate education as a student at Naval Postgraduate School, which has 
simultaneously been one of the most rewarding and challenging educational experiences 
of my life. Such an education was the first chance to think the “why” portion. Due to the 
specific nature of the school it also allowed intellectual exploration among sister services 
and international students. 

Additionally, I wish to thank my thesis advisors for their patience and to help find 
in me the writer within, something I now realize is a process and a journey, rather than a 
destination. In doing so, I thank Professors Jaskoski, Russell, and Moltz for being my 
compass, keeping me on the right course in developing this manuscript. 

Second, the author wishes to thank the individuals who have provided mentorship 
throughout my career. Specifically, Brigadier General Steve Townsend, and, and Colonel 
Michael Oshiki, both of whom I had the honor of serving under during grueling 
operations in Iraq in 3-2 Stryker Brigade Combat Team stationed out of Fort Lewis 
Washington. I similarly thank Colonel Paul Hurley, under whom I served (First Annored 
Division, a legacy heavy armored unit from Baumholder Germany). In both units I had 
the opportunity to serve as a company commander in combat operations in Iraq in 2003 
and 2007, respectively, each providing a different set of experiences extracted a much 
better and well-rounded field grade officer, which at times was both physically and 
mentally painful. I also wish to thank my previous chain of command for allowing me to 
attend an in residence master’s degree program, at the expense of being short a Deputy 
Brigade Operations Officer during their deployment to Operation Enduring Freedom, a 
choice which could have easily been made in the favor of my deploying unit. I know if I 

xvii 



were to make such a decision the choice would have been a difficult one. Finally, it is 
with great gratitude I thank my wife, Tina, and my children for their patience and time 
lost throughout the duration of the crafting of this document in which I was deployed to 
the library. 

The process of writing a thesis has been simultaneously one of the most 
challenging endeavors of my career which was not devoid of its personal and 
professional challenges. The experience has also been the most rewarding intellectual 
experiences of my career and my life. I hope this to be yet another stepping stone to 
reach higher levels of education and training so that I may continue to be of service to our 
nation in uncertain times. 


xviii 



I. INTRODUCTION 


A. OVERVIEW 

What explains military adaptation to the complexities of non-linear warfare? 
Such a question has been addressed by an assortment of authors and practitioners who 
have contributed numerous works, particularly in the past decade, in which the United 
States has been engaged in conflict under a variety of demanding conditions in Iraq and 
Afghanistan. However, the vast majority of such literature has been applied to 
specifically address the portions of the U.S. Anny, commonly referred to as maneuver 
units, tasked in the destruction of enemy forces. 1 

This work focuses on the organizations which directly support and sustain such 
efforts, particularly medical units and logistics units within combat brigades, from 1992 
to 2010, providing variation in tenns of the intensity of combat: the 1992-2002 period 
was one of relative peace, in which the U.S. Army took part in limited stability or 
humanitarian relief operations. In contrast, the period from 2003 to 2010 represents an 
extended period in which the Army participated in complex asymmetric warfare. 

The thesis seeks to explain why the U.S. Army Medical Department (AMEDD) 
differs from both its logistics counterpart, and the larger Anny function of Sustainment, 
which includes the medical, logistics, and personnel services sub-functions, and the larger 
Army in innovation. 2 In particular, the thesis focuses on why medical units have failed to 
adapt to combat needs, which has adversely affected their performance both in modern 
linear combat (i.e., generally combat between two or more national militaries), and in 
contemporary counterinsurgency warfare or what the military establishment refers to as 


1 A search revealed that while there are academic works that specifically address innovation at the 
combat brigade level, very few specifically address logistics. The only works with regard to medical 
innovation at the brigade level are found within periodicals. 

2 Headquarters, Department of the Army, Field Manual 4.0, Sustainment (Department of the Army: 
Washington, DC, April 30, 2009), iv. 


1 



“COIN.” 3 In contrast to the anny medical community, the logistics branch and the army 
at large have effectively adapted to combat realities and needs in terms of their vehicles 
and fonnal doctrine. The AMEDD-logistics variation is particularly striking, given that at 
the combat brigade and battalion levels, both organizations are similar in size, 
organizational structure, and functional support mission. 4 

The analysis will address the technological and doctrinal aspects of medical care 
at the lowest respective units of measure in which both medical and logistics 
organizations can be found, specifically within the combat brigade. This level is the only 
place one may find medical, logistics, and combat arms personnel operating within the 
same environment and experiencing the same set of collective demands, constraints, and 
tactical concerns. 

In current conflicts, such as those in Iraq and Afghanistan, where support 
personnel and infantry units are closely intermingled within the areas of combat, we find 
the medical company simultaneously operating in multiple capacities. They provide 
medical support to their brigade as their doctrinal mission dictates. Additionally, they 
provide support to large numbers of military personnel and civilian contractors without 
their own medical units, and treating military personnel and civilians from other nations. 
In order to facilitate such care, these medical companies are routinely called upon to 
conduct operations in multiple locations simultaneously, commonly referred to as “split- 
based operations.” This task is a significant challenge for such medical companies, as 
they are not allocated adequate manpower or medical equipment levels to enable such 


3 Committee on Armed Services. House of Representatives, “Report to the Chairman, Subcommittee 
on Military Personnel and Compensations, Operation Desert Storm: Full Army Medical Capability Not 
Achieved,” Washington, DC: U.S. General Accounting Office, August 1992; Ralph W. Nazzaro, 
“Redefining the role of the BSMC in Operation Iraqi Freedom: brigade support Medical Companies Find 
Themselves Sidelined From Their Doctrinal Roles. What New Roles Can They Adopt To Better Support 
Their BCTs?” Army Logistician 38, no. 2 (April 2006): 19-23. 

4 For the purposes of this study the terms “support battalion” will refer to both the older (legacy) 
Forward Support Battalions (FSB) and modernized Brigade Support Battalions (BSB) found within the new 
modular brigades. Similarly the term medical company will refer to Role II medical units (usually C 
Company, C Med, or BSMC) found within either respective parent organization. 


2 



efforts. 5 Rather, such brigade support medical companies (BSMCs) continue to be 
manned, equipped, and armed as though they were to provide support from a single 
location, in relatively secure areas, and to the rear of combat operations. 

We find leadership routinely attempting to address such capabilities shortfalls 
through innovation by various means in combat. While it seems that medical units do 
learn in the field, the lessons are seemingly not being adequately captured into formal 
doctrine at the institutional levels within the AMEDD. Rather one finds the most valuable 
information composed of informal doctrine scattered throughout a large body of 
periodicals, within online forums, and in informational briefings that are given directly by 
members of outgoing medical units to personnel in the incoming medical units during 
combat rotations. 

Aside from AMEDD’s doctrinal shortcomings, we also note difficulties regarding 
efforts to develop and introduce new equipment. There have been significant challenges 
with regard to larger efforts by coordination through army entities outside of 
AMEDD, such as Army Acquisitions, to update the Anny’s aging fleet of both wheeled 
and tracked ambulances. It has only been within the last five years of a decade-long 
counterinsurgency conflict, that have we seen the development of wheeled mine-resistant 
ambush-protected (MRAP) vehicles which have been modified for interim use in a 
medical evacuation capacity, and only more recently since 2006, have those vehicles for 
such a purpose been fielded in appreciably large numbers. 

In contrast to the BSMC case, we find the U.S. Army logistics community better 
suited to its combat mission based on current manpower allocations, and more suitable 
types and amounts of equipment. Such adaptation has allowed logistics units to more 
effectively provide split-based operations in support of combat operations, a task also 
routinely required of this type of unit during deployments. Comparably, logistics units 
which operate at the same levels on the battlefield have seen advances in manning, 
organizational structure, and equipment, thus allowing such units to support combat 

5 As early as 1994, the surgeon general specifically identified shortfalls in 2001 in the ability to 
conduct either 24-hour or ‘‘split-based” operations. Office of the Surgeon General, U.S. Army, briefing, 
“Medical Reengineering Initiative: Combat Health Support of Force XXI,” April 14, 1999. 


3 



forces more effectively in multiple locations. Vehicles used by logistics units, while also 
somewhat old, are also routinely armored, thus allowing such units to transport supplies 
and repair parts in-between forward operating bases in combat zones. In addition, many 
such innovations can be found in the most recent versions of formal doctrine publications 
pertaining to logistics. In contrast to the AMEDD at this same level, the logistics 
community seems able to effect change more rapidly both in terms of its equipment and 
its doctrine. Why has the AMEDD failed to adapt to full-spectrum conflict at the same 
rate as a similar functional organization, their logistics counterparts? 

The comparison challenges the literature on military innovation, which centers in 
important ways on two debates: first, whether militaries innovate primarily from a top- 
down or bottom-up dynamic; and second, whether peacetime or wartime is more 
conducive to military innovation. This study finds that, across the same period of shifts 
between peacetime and wartime, Logistics has primarily “learned” through both bottom- 
up mechanisms during wartime, using its doctrine as a baseline from which it can modify 
as needed. In contrast, the AMEDD has seemingly not captured learned lessons from the 
bottom-up into its formal doctrine, and such innovation is being transferred informally 
between units during wartime. These observations push us to move beyond existing 
approaches to military innovation. 

B. IMPORTANCE: INCREASING ROLE AND EXPECTATIONS 

Strategy is to war what the plot is to the play; Tactics is represented by the role 
of the players; Logistics furnishes the stage management, accessories, and 
maintenance. The audience, thrilled by the action of the play and the art of the 
performers, overlooks all of the cleverly hidden details of stage management. 

— Lt. Col George C. Thorpe: Pure Logistics (1917)6 

A study on adaptation—and the failure of—within AMEDD is timely, given 
radical shifts in combat needs and therefore in the need for the AMEDD to adapt. 
Following Operation Desert Stonn, and the end of the Cold War, the anned forces of the 
United States found itself drawn into a broad array of smaller regional crises such as 

6 George C. Thorpe, Lt. Col: Pure Logistics: The Science of War Preparation (Washington, DC: U.S. 
Government Printing Office, 1917), 4. 


4 



Somalia, Bosnia, and Kosovo, in part due to bipolar destabilization, in which 
deployments for medical personnel increased by 60 percent between the final year of the 
Cold War and 1998. 7 In addition to more frequent deployments, such intrastate conflicts 
produced their own implicit suggestions for adaptation, in part by the blurring of what 
was war and what was “something else.” Such new efforts suggested a wider variety of 
skills were required in conducting humanitarian relief missions, and other complexities 
associated with failed states and ungovemed spaces. 

Following the tragic attacks on the World Trade Center on September 11, 2001, 
scholars have continued to provide copious literature amounts of analysis on the topic of 
innovations associated with the complexities of application of ground forces in 
information age warfare. Such missions necessitated that the Army as a whole become 
proficient in less traditional roles in which they provided relief supplies, assisted with 
reestablishment of institutions and infrastructure, and provided medical care to 
indigenous civilians. These efforts were required in addition to more traditional logistical 
and medical support requirements, an increased workload which further stretched support 
resources. 

Accordingly, there has been a renaissance in publications in both scholarly texts 
as well as by practitioners within periodicals. Such introspection is of particular 
relevance given the current convergences associated with the uncertainties of the world as 
noted by the most recent 2010 Quadrennial Defense Review, the 2010 National Security 
Strategy, and the 2011 Army Posture Statement A Each of these documents stresses the 
critical need for the military to be able to respond to a broad array of environments. Such 
a gradient of environments is known as a “full-spectrum” of threats. At one end of such a 
spectrum we find conventional or “linear” combat, which may be conceptualized as 
traditional interstate conflict. At the opposite end of the spectrum there is asymmetric, or 

7 General Accounting Office, Military Personnel: Perspectives of Surveyed Servicemembers in 
Retention of Critical Specialties, report to congressional requesters, GAO/NSAID-99-197BR (Washington, 
D.C: GAO, August 1999). 

^ 2010 Quadrennial Defense Review, February 2010. 5; 2010 National Security Strategy May 2010; 

The Honorable John M. McHugh and General George Casey, Jr., A Statement on the Posture of the United 
States Army 2011, submitted to the Committees and Subcommittees of the United States Senate and the 
House of Representatives, 1st Session, 112th Congress, March 2011, respectively. 


5 



non-linear warfare, in which an enemy may not wear a uniform, and uses 
counterinsurgency or asymmetric warfare to sidestep the advanced firepower and 
technologies of the United States. 

If indeed the AMEDD has not been able to challenge its own paradigms or 
facilitate innovation through the larger Army or Department of Defense (DoD), this 
raises some troubling issues, as the result may be that the lives of injured or sick soldiers 
and civilians may be jeopardized. The role of the medical personnel in combat is such 
that there is little margin for error, perhaps even more so than in peacetime, when 
medical procedures are largely planned events rather than crisis management in the midst 
of hostilities. Only by understanding three interrelated questions can one then address 
such concerns: How the AMEDD is equipped, manned, and trained; what is the nature of 
such shortfalls if found; and what is the causal nature of such deficiencies? Only then 
would it be possible for the AMEDD to better support a broader variation of combat 
operations, and ultimately saving more lives in the process. 

C. ORGANIZATIONAL COMPLEXITY 

This thesis argues that in order to explain the disparity in innovation levels 
between the AMEDD and its logistics counterparts within the context of the larger U.S. 
Army organization over the last two decades, in addition to examining how the 
organization learns, we should also focus on the exceptionally complex nature of the 
AMEDD as an organization. In addition to its expanding wartime roles, the Army 
Medical Department is still responsible for its much larger and sometime disparate role of 
maintaining a large fixed-facility healthcare system for members of the military, their 
families, in addition to a growing population of retirees. This healthcare system is spread 
across the globe, with major facilities throughout the United States, as well as in Europe 
and Asia. In its providing of medical care it falls under the same purview as its civilian 


6 



counterparts to include a three-year validation cycle by civilian agencies such as The 
Joint Commission (TJC), formerly known as the Joint Commission on Accreditation of 
Healthcare Organizations (JCAHO). 9 

In particular, the analysis focuses on how organizational complexity has led to a 
high degree of separateness or relative autonomy from the larger Army organization. In 
addition, being a less-complex organization, leadership in the logistics branch can focus 
centrally on the question of supplying combat personnel, both while training and, when 
those personnel go overseas, in real combat situations. 

The complexity of the AMEDD has meant that the area of focus of this study, that 
of providing medical support at the brigade combat team is only a small portion of the 
overall Anny Health Support (AHS) mission and respective focus. In addition, limited 
numbers of personnel in comparison to the larger AMEDD spend time within combat 
brigades, and for a relatively limited portion of their careers. This limited experience, in 
turn, has implications for AMEDD’s learning and adaptation process. First, areas in 
which doctrine is produced within the AMEDD are somewhat separate from the larger 
Anny-wide doctrinal institutions and are manned by individuals with no experience in 
combat brigades. In addition, bottom-up innovation is limited not only by the fact that 
there are few AMEDD personnel in the field to express their needs through the 
appropriate chains of command, but also that that very chain of command is interrupted: 
at the battalion levels medical personnel respond to a logistics commanding officer. In 
this context, “lessons learned” by medical personnel tend to be transferred informally 
between medical leaders as their units are replaced in combat, and are published in 
journals read by the logistics community, rather than the AMEDD. 

D. METHODOLOGY 

1. Level of Analysis: Combat Brigade Support Units 

This study focuses specifically on organizational innovation and the transfer of 
such knowledge within self-contained functional medical and logistics support 

9 Tricare Media Center, “The Joint Commission Confirms Your Health Care Is Top-Notch,’’ 
http://www.tricare.mil/pressroom/doctor is in.aspx?fid=48 (accessed February 22, 2012). 


7 



organizations at the lowest level on the battlefield, or what is referred to within military 
as the “company” level within the formalized Army hierarchical structure. These 
companies are nested within their parent BSB, which provides a variety of logistical 
support, or what is referred to as multifunctional logistics, to the combat brigade it 
routinely sustains on the battlefield. 10 It is only at this level within the U.S. Army 
hierarchy that we find both such functional support units, the medical and logistics 
companies operating within the same tactical environment, and with the respective tasks 
of supporting the larger combat brigade either medically or logistically under conditions 
identical to combat forces. 

A comparison between civilian medical organizations, or medical units of other 
branches of service such as Air Force or Navy medical units would seemingly present a 
cogent study of interest. However, such a correlation was examined and ruled out as 
being too dissimilar for two reasons. First, Army medical units within combat brigades 
routinely support complex ground operations, requiring their personnel to be incorporated 
into the overall tactical plan of ground combat operations on the battlefield. Conversely, 
Navy and Air Force medical units at this same level do not typically require such 
competencies, and are routinely implemented in support of a larger strategic goal and 
operate from static locations. Equally, the operating environments of the civilian medical 
community are normatively very different. Organizationally their structure is less rigidly 
hierarchical, and civilian medical personnel do not require armored ambulances used 
under the duress of combat in the direct role of supporting the overarching mission of 
destruction of an enemy force. 

2. Time Period 

This study was deliberate in selecting a two-decade period from 1990 to 2010. 
This period contains alternating periods of both peace (1991-2000) and war (2001- 
2010), allowing careful analysis of which period medical personnel to do the majority of 
their doctrinal learning. In looking to the past, such a timeframe also represents the end of 

10 This study will refer to identified organizations in their respective generic terms rather than parsing 
them into older forward support battalions (FSB) within heavy brigades, or the newer and more robust 
brigade support battalion (BSB) found within the new modular brigade combat team (BCT). 

8 



Cold War stasis and subsequent global destabilization. Such geopolitical change 
precipitated a period of deployments within failed or failing states, such as Bosnia, 
Kosovo, and Somalia. The middle of this timeframe presents an abrupt transition from 
emphasis on large-scale mechanized warfare (conceptualized in Operation Desert Storm), 
to an ambiguous post-September 11, 2001, “war on terror.” Such a change was 
exemplified by adversaries who were able to rapidly exploit the tenets of asymmetric 
warfare to offset the technological overmatch and firepower of U.S ground forces. In 
echoing the recent 2011 Anny Posture Statement, this two-decade period implies a 
strategy of risk mitigation by the ability to operate across the full-spectrum operations 
(FSO). 11 Full spectrum operations according to the latest version of Anny Field Manual 
3-0, Operations , are defined as “the range of operations Anny forces conduct in war and 
military operations other than war.” 12 

3. Propositions 

In order to develop a common conceptual framework, there are three intenelated 
propositions to be used in the analysis which follows in this research study: 

Proposition #1. The current environment of low-level conflict is likely to persist 
for the foreseeable future. In addition, medical companies have been directed to 
operate in a variety of future environments across a “full-spectrum of conflicts.” 
Accordingly, medical personnel must be able to perform a wider variety of tasks 
and have greater capabilities than previously required. 

Proposition #2. There are a number of inherent conditions within the AMEDD 
which do not exist within other Army organizations. These conditions can be 
conceptualized as complexity. Such forms of complexity include the 


11 Department of the Army, Army Posture Statement 2011 (Washington, DC: Department of Defense, 
2010 ). 

12 United States Army, Operations, Field Manual (FM) 3-0 (Washington, DC: Department of the 
Army, February 2008), viii. 


9 



broad mission scope of the AMEDD in relation to its size, its broad array of 
highly technically-oriented subspecialties, and its separateness from the larger 
Army. 

Proposition #3. Institutions over the last two decades have identifies shortfalls 
within the AMEDD in terms of adequate battlefield capabilities (the ability to 
mirror the maneuverability and survivability of supported combat forces). Over a 
decade of efforts to rectify these issues only interim solutions when assisted by 
outside agencies such as the larger Army. 

4. Methodology 

The thesis engages research on military innovation, which generally discusses 
methods of institutional learning by two methods, either “top-down,” or “bottom-up.” 
This comparative analysis will do so from both of these perspectives. First, to understand 
how doctrinal innovation has occurred from the top down in Logistics but not in 
AMEDD, the thesis will examine AMEDD and Logistics doctrinal development at the 
highest levels. 

This study will then isolate and examine both AMEDD and logistics in addition to 
Sustainment doctrine, from a “bottom-up” perspective. It will examine current 
publications, at lower levels such as periodicals published by the AMEDD and the 
logistics communities. It will suggest that the majority of infonnation which is detailed 
enough for the purposes of planning medical operations is primarily found within in 
logistics journals, and will suggest a causal relationship regarding disparity of lessons- 
leamed ultimately being codified within respective fonnal doctrines. 

Lastly, this thesis will isolate the study’s key variable, organizational complexity. 
Specifically, it will address mission scope as well as the highly technical nature of 
AMEDD’s missions. It will also trace the implications of that complexity, focusing on 
the distribution of AMEDD personnel across different functions, AMEDD’s separateness 


10 



when compared the larger Army, and how the AMEDD’s organizational complexity has 
influenced the command and communication structures at the combat brigade and 
battalion levels. 

E. ORGANIZATION 

Chapter II provides a review of the literature on military innovation. In particular, 
it addresses different ways to measure military innovation and analyzes two central 
debates: whether military learning occurs in a bottom-up versus top-down manner, and 
whether peacetime or wartime is more conducive to learning. The chapter also introduces 
the importance of organizational complexity for understanding military innovation, 
focusing on one piece of scholarship that grounds the thesis’ causal argument: Chris 
Demchak’s (1991) Military Organizations, Complex Machines: Modernization in the 
U.S. Armed Sendees. 

Chapter III serves as a detailed presentation of the varied outcomes—i.e., 
AMEDD’s failure to innovate in contrast to substantial innovation in the logistics branch. 
Chapter IV, the core of the thesis, explains the variation between AMEDD and logistics, 
within the context of the larger U.S. Anny organization, focusing on the exceptional 
complexity of the AMEDD relative to the logistics branch. In closing, Chapter V 
highlights the future implications with regard to the AMEDD as a complex and 
technically-oriented organization, and the prognosis for its efforts if it is to innovate 
battlefield medical care. 


11 



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12 



II. LITERATURE REVIEW 


A. OVERVIEW 

Very little scholarship examines innovation of the U.S. army medical community, 
in general and more specifically within the support battalion which provides sustainment 
to its larger combat brigade. Similarly, at this level, logistics units also receive highly 
limited attention. Instead, analysis of innovation within the United States Army and more 
broadly the Department of Defense almost exclusively deals units specifically tasked 
with destruction of the enemy’s forces, rather than the forces designed to facilitate or 
sustain the ability to conduct such operations. 

Strategic level documents addressing transfonnation within the U.S. Army 
illustrate this apparent marginalization of the medical community when compared to its 
logistics counterpart. If one examines Elements of Transformation 2004, Fire, Maneuver, 
Protection, Communications (C4ISR), and Logistics are all separately addressed in detail, 
yet medical transfonnation is not even addressed as a sub-category of either logistics, or 
sustainment as it is refened to at higher levels. 13 The trend continues within a 
Congressional Budget Office Study, An Analysis of the Army’s Transformation Programs 
and Alternatives 2009, only specifically addresses medical transformation in passing by a 
mere mentioning of a cancelled ambulance design. 14 Earlier reports have noted the lack 
of an Army-wide, armored vehicle for medical evacuation, yet such a deficiency 
continues to be postponed. 15 

Beyond these strategy documents, the little work that has addressed battlefield 
logistics and medicine can be parsed into three categories. First we find that of general 
historical narrative in relation to a larger conflict, such as the strategic levels of logistics 

13 Office of Force Transformation, Elements of Defense Transformation (Washington, DC: Office of 
the Secretary of Defense, October 2004), 12-13. 

14 United States Congress. A CBO Study: Army’s Transformation Programs and Possible 
Alternatives, June 2009 (Congressional Budget Office, Publication 3193. 2009), xv, 13. 

15 Office of the Deputy Chief of Staff, U.S. 2004 Army Transformation Roadmap, July 2004 
(Washington, DC: Army Operations, Army Transformation Office, 2004), 5-11. 


13 



during the Korean War or medical planning during World War II. 16 In addition, we also 
find discourse relating to either the purely technical aspects of logistics, or similarly a 
discussion of the clinical medical skills of the era. 17 Finally, a third category provides 
limited writings evaluating logistics and anny medical efforts either from external 
organizations such as the RAND Corporation or assessments by government 
organizations. 18 

Examples of historical works reflecting the work of practitioners at the strategic 
level is that of Lieutenant General Frank F. Ledford, Jr. His article in Journal of the 
Army Medical Department, titled “Medical Support for Operation Desert Storm,” 
provides a narrative from the perspective of the Surgeon GeneraFs Office, of the pre-war 
buildup of medical forces who supported the short duration conflict which followed. 19 
Such contemporary works at combat brigade levels or lower are mirrored in the 2010 
article by Lieutenant Colonels’ Matthew Rice and Omar Jones in Medical Operations in 
Counterinsurgency Warfare: Desired Effects and Unintended Consequences . 20 

The body of information which addresses operations at the brigade level consists 
of formally published military doctrine to be found in Anny Field Manuals (FMs); 
articles within periodicals authored by junior military leadership; and finally a broad 
array of multimedia presentations by practitioners posted within web-based forums 


111 An example of such historical logistics work at the strategic level is by Gouge, Terrence J. U.S. 
Anny Mobilization and Logistics During the Korean War, A Research Approach. Center of Military 
History, United States Anny: Washington D.C: 1987; Similarly, strategic level medical concerns are 
addressed by Wolfe, Edwin P. Colonel, Medical Department of the United States Army in the World War 
Volume III, Finance and Supply (U.S. Government Printing Office Washington, DC, 1928). 

17 Andre J. Onibene, Brigadier General, and O’Neill Barrett, Jr., Colonel, USA (Ret.) eds. Internal 
Medicine in Vietnam, Army Medical Department, Volume II: General Medicine and Infectious Diseases 
Office of the Surgeon General and the Center of Military History (Washington, D.C: 1982), available at 
http://history.amedd.army.mil/booksdocsMetnam/GenMedVN/default.html. 

18 Gary Cecchine and David Johnson et al., Army Medical Strategy: Issues for the Future (RAND: 
Santa Monica CA, 2000). 

19 Frank F. Ledford Jr., Lieutenant General, and Matthew W. Lewis, et al., “From The Surgeon 
General of the Army: Medical Support for Operation Desert Storm.” The Journal of the U.S. Army Medical 
Department (January-February 1992): 3. 

Rice, Matthew S., and Omar J. Jones. “Medical Operations In Counterinsurgency Warfare: Desired 
Effects and Unintended Consequences.” Military’ Review (June 2010): 47-57. 


14 



formally created within the last five years. 21 The omission of medical operations at the 
combat brigade level in literature is disconcerting, especially given that in the last two 
decades the U.S. army has been heavily engaged in combat, in non-linear warfare: the 
brigade combat team is the building block level of the Army, and the brigade relies 
heavily upon responsive support from both the logistics and the medical communities 
during conflict. 

This chapter will now examine each respective area of prurient interest to this 
study. First it will begin by providing the framework in discussing the role of innovation 
and doctrine in the Anny. A portion of this focus on doctrine will address where the 
Anny sees itself in the future in its examination of strategic level documents which guide 
its transfonnation efforts and ultimately its doctrine. Next, it will examine works 
produced by the practitioner within both the Army medical and logistics communities. 
Finally, it will examine the works of the larger body of authors who provide analysis on 
the topic of innovation itself. 

B. DOCTRINAL AND TECHNOLOGICAL INNOVATION 

What is the role of innovation within the context of military organizations? 
Professor Rosabeth Kanter advocates that rather than being solitary event, innovation is a 
complex and disruptive process within organizations which involves resources from 
outside agencies in the form of time, funding and manpower. Such a process ultimately 
demands the innovator to cross organizational boundaries in order to be successful. 22 In 
order to evaluate innovation within this military context, this thesis will provide clear 
metrics to facilitate such a task. Appropriate metrics are derived from Andrew W. 
Marshall director of the United States Department of Defense’s Office of Net 
Assessment, who suggests there are subcomponents to innovation, to include the simplest 


21 SustainNet, and Medical Warfighter Army Medical Warfighter Forum (MedWfF) forums. 
https://www.us.army.mil/suite/page/131414. accessed October 18 . 2011. 

22 Rosabeth Moss Kanter,”The Middle Manager as Innovator,” Harvard Business Review 82 (July- 
August 2004): 153. 


15 



form, technological in addition to doctrinal innovation. 23 These facets of innovation may 
be considered complimentary, building upon one other and overlapping in varying levels. 

Doctrine may be conceptualized as both the culmination and continuation of an 
organization’s current body of knowledge. For purposes of this research, we can look to 
the latest edition of the Anny’s Field Manual (FM) 3-0, Operations, for a definition of 
doctrine: “Army Doctrine is a body of thought on how Army forces intend to operate as 
an integral part of joint force.” 24 Doctrine establishes how the Army views the nature of 
its own operations and should ultimately affect the training, manning, and equipping of 
medical personnel during peacetime as well as during combat. Mirroring higher U.S. 
Army doctrine, logistics and medical support doctrinal innovation must experiment with 
the best applications of incorporating new technologies such as vehicles and equipment 
into military operations to exploit new capabilities and to adapt to changes on the 
battlefield. It does so through the lenses of its historical past, its current body of theory, 
and the most importantly, best assumptions about potential future operating 
environments. Doctrine should constitute guiding principles, creating the necessary 
conditions within an organization from which leaders can engage in innovative thinking 
in order to solve problems. 25 

Barry Posen provides a great deal of valuable insight in his analysis of military 
doctrine and ultimately proposes two central questions with regard to doctrine, what will 
be employed and how exactly is it to be employed? 26 Such insight regarding doctrine is 
equally perceptive with regard its interrelated nature with innovation. Posen advocates 
that both doctrinal and technological innovation impose costs in the form of time and 
disruption to an organization. In some cases, he suggests units may choose to change 


23 William S. Lind, et al., “The Changing Face of War: Unto the Fourth Generation,” Military’ Review 
(October 1989) : 2-11. 

24 U.S. Department of the Army, Change 1 (Feb 2011) to Field Manual M 3-0 Operations 
(Washington, DC: Department of the Army, February 2008), D-l. 

25 Ibid. 

26 Barry Posen, 1984. The Sources of Military Doctrine: France, Britain, and Germany Between the 
World Wars (Ithaca, NY: Cornell University Press, 1984), 13. 


16 



their doctrine during peacetime in an attempt to minimize such disruption. 27 However, 
such a statement can be problematic during a time of persistent conflict in which we find 
added complexity in battlefield conditions that has increased the tasks U.S. Army forces 
must be adept at, thus implicitly suggesting the need for both combat and support forces 
to innovate their formal doctrine within a relatively short period in order to ensure 
success. 

Time plays a critical role when evaluating innovation. Innovation should be a 
continuous and cyclical process in which new technologies are developed, efforts are 
determined as to how best utilize the capability, and in which the enemy is continuously 
adapting, thus necessitating further adaptation. 28 Both technological and doctrinal 
innovation must all occur in the proper levels and at the proper rate in order to exploit 
their effectiveness within an organization. In addition, such change must also be 
intentionally synchronized in order to minimize disruption and to facilitate purposeful 
organizational adaptation, as rapid implementation may be seen as disruptive or intrusive, 
especially if directed externally. 29 

However, military leadership may become frustrated by such continuous needs. 
As suggested by Thomas K. Adams in The Army After Next, “the real world seldom 
accommodates itself to doctrine.” Such a poignant portrayal of such a frustration is the 
large-scale armored combat of World War II which was codified into doctrine, and the 
neither of the subsequent conflicts of Korea nor Vietnam required the use of such 
doctrine. Finally, the anomaly of Desert Stonn seemingly vindicated such a concept and 
suggested the “right” way to fight once again, albeit with information warfare technology 
and providing an ill-defined “new way” of fighting wars, or what is commonly referred to 
as a revolution in military affairs (RMA) by suggesting technology married with 3 


27 Posen, The Sources of Military Doctrine, 30. 

28 Derrick Neal, Henrick Friman, Ralph Doughty, and Linton Wells, Crosscutting Issues in 
International Transformation: Interactions and Innovations among People, Organizations, Processes and 
Technology’ (Washington, D.C: National Defense University) edited by Derrick Neal, Henrik Friman, 
Ralph Doughty, and Linton Wells II. 2009), 16. 

29 James R. Fitzsimonds and Jan M. Van Tol, “Revolutions In Military Affairs,” Joint Forces 
Quarterly, (Spring 1994): 25-26. 


17 



generation industrial age formations constituted an RMA. 30 It is this continuous cycle of 
innovation which prompts some military scholars to question whether the United States 
repeatedly fights using the doctrinal tenets learned and internalized from the last war. 31 

C. THE FOUR QUADRANTS OF INNOVATION 

What Drives Innovation? Some authors suggest external factors may constrain 
innovation efforts, such as peacetime reductions in manpower, the pace of wartime 
operations, as well as funding allocations for new equipment. 32 In addition, some may 
advocate that innovation may be hindered internally in which organizational learning and 
adaptation may be constrained by units themselves, specifically due to the methods in 
which they leam and transfer infonnation into military doctrine, or formal institutional 
knowledge. 

In order to provide adequate framework, one must first choose how to parse the 
disparate findings found within relevant scholarly works on how innovation takes place. 
Clearly, such study may be examined from a variety of historical contexts and 
perspectives. For the purposes of this study such analysis as will address drivers of 
innovation as represented by the four such quadrants in Figure 1. 


311 Douglas A. Macgregor, Breaking the Phalanx: A New Design for Landpower in the 21 st Century’ 
(Westport, CT: Praeger, 1997), 230-231. 

31 Stephen P. Rosen, Winning the Next War: Innovation and the Modern Military’ (New York: Cornell 
University Press, 1991), 1. 

32 Stephen P. Rosen, “New Ways of War: Understanding Military Innovation,” International Security, 
vol 13, no.l (Summer, 1988): 167. 


18 



Top-down 


Internally/ 

Externally 

Driven 


Bottom-up 


Stephen Rosen, 
"Winning the Next 
War" 1991 and Paul 
Hebert “Deciding 
What Has to Be 
Done., 1988." 

General David 
Petraeus (COIN) 
and Dr. Kilcullen ,"28 
Articles "2006. 

Douglas MacGregor 
"Breaking the 
Phalanx," 1997. 

James A. Russell, 
“Innovation, 
Transformation and 
War" 2011 


Peace 


Peacetime/Wartime 


War 


Figure 1. Innovation Axes 


Advocates of varying perspectives of institutional learning can be identified by 
the method in its proponents ultimately propose that military organizations learn and 
innovate. Some suggest senior leadership or external organizations direct adaptation to 
affect change to subordinate organizations, or what shall be called the “top-down” 
method. Conversely, we find proponents of the “bottom-up” method, who advocate 
military units learn lessons at the user level, with adaptation beginning there in attempts 
to overcome battlefield challenges. Advocates of this methodology suggest lessons are 
captured at the user level and transferred to the institution, and subsequently incorporated 
into fonnal doctrine. In addition, we find a second axis to differentiate between schools 
of thought who also propose that combat units adapt primarily during either wartime or 
peacetime. As there is little academic treatment with regard to either logistics or medical 
care on the battlefield, such treatment will include non-academic sources in the analysis 
from the perspective of the Army leader as the practitioner, specifically within the 
bottom-up camp. The discussion will show how none of the perspectives in the literature 
can fully explain the variation between AMEDD, which consistently across peace- and 
wartime from the early 1990s to 2010 has failed to innovate, and the anny logistics 
branch, which across the same period has succeeded in innovating, both through top- 


19 



down and bottom-up mechanisms. As a preliminary note, although the present study 
seeks to measure innovation in terms of technological and doctrinal changes, as will be 
demonstrated below, some authors have measured innovation by other means—e.g., in 
tenns of temporary adjustments to optimize success of in the field during wartime. 
Proponents of such a perspective suggest that formal doctrine plays a lesser role in 
providing a toolbox of sorts from which to use if needed. 33 

1. Top-Down Innovation, Peacetime 

According to the top-down model of military innovation, one would expect to 
find major innovations emanating from the upper levels of leadership within the Army, to 
include leadership within the AMEDD and the logistics communities. Stephen Rosen 
takes a top-down perspective to doctrinal innovation in Winning the Next War in his 
addressing his three types of innovation: peacetime, wartime, and technological 
innovation. 34 As to the origins of doctrine, Rosen takes the position that units do not 
normally make large changes in doctrine other than in peacetime, and that when they do 
make doctrinal changes under combat conditions, those shifts are incremental. 35 Of 
relevance to this study is Rosen’s suggestion that the most successful innovations have 
resulted from calculated attempts to manage risk itself. While Rosen suggests that 
organizations are capable of adapting during both wartime and peacetime, he suggests 
that successful innovation during wartime is more inconsistent, varying in units 
depending on the competence of individual leaders. Conversely, he suggests that during 
peacetime, the military as an organization creates optimal solutions when it has adequate 
time to do so. 36 

Major Paul Herbert’s article “Deciding What Has to Be Done,” provides 
additional insight in his focuses on formal doctrine created by army leaders as a critical 
instrument of change within the Army bureaucratic structure. In doing so, Hebert 

33 Russell, Innovation, Transformation, and War, 33. 

34 Rosen, “New Ways of War,” 143. 

35 Rosen, Winning the Next War, 52. 

36 Ibid., 253. 


20 



provides a narrative of the peacetime process in which General William DePuy 
personally developed the new U.S. Army Field Manual 100-5: Operations, and how such 
an effort was certainly a top-down effort upon taking over Army Training and Doctrine 
Command (TRADOC) in 1973. 37 Neither Rosen nor Herbert explain why, across peace- 
and wartime in the 1990s and 2000s the U.S. anny in general and logistics have 
innovated substantially during this period, whereas AMEDD has to a much lesser extent. 

2. Top Down, Wartime 

Since military operations commenced in Afghanistan and Iraq, there have been 
internal and external expectations for a paradigm shift within the military as a whole, as 
echoed in the previous administration’s issuing Department of Defense Directive 3000.05 
in November of 2005, which placed nation-building on the same priority as combat 
operations. 38 In echoing such a paradigm shift, in his quintessential work on 27 Points, 
David Kilcullen addresses the tenet of logistics or sustainment and stresses its criticality 
in its contribution to the overall fight within counterinsurgency operations. Kilcullen also 
advocates that support forces such as logistics and medical personnel may be required to 
fight more than their counterparts due to the frequent and sometimes regularity of supply 
convoys. While anecdotal, this claim can be supported by the author after experiencing 
two rotations in Iraq. 39 He also suggests that such forces must be much more responsive 
than in linear combat operations, noting the enemy may perceive logistics convoys as soft 
targets when compared to their combat arms counterparts. Kilcullen offers evidence to 


37 Paul A. Herbert, “Deciding What Has to be Done: General William E,. DePuy and the 1976 Edition 
of FM 100-5,” Leavenworth Papers, No. 16 (Leavenworth, KS: Army Command and General Staff 
College), 58. 

38 Center for Strategic and International Studies, “DoD Directive 3000.05, One Year Later,” 
December 11, 2006, http://csis.org/event/dod-directive-300005-mdash-one-year-later (accessed June 7, 
2011 ). 

39 Authors personal experiences from Iraq rotations in 2003 and 2006-07 as a support battalion 
medical company commander within 2 nd Brigade 1AD, and 3 rd Brigade 2ID, respectively. 


21 



support such claims in that, during a one-year period, most attacks when parsed from 
larger combat operations were against either logistics personnel or bases. 40 

While both authors provide insight into institutional learning, these two top-down 
approaches to military learning cannot account for the variation across the logistics and 
medical communities in their capacity to innovate. In the case of the logistics community 
it has seemingly appeared to follow the lead of the “top”—i.e., the larger army—in that it 
has innovated, whereas the AMEDD has not innovated as well. 

3. Bottom-Up Innovation, Peacetime 

In the words of Colonel Douglas MacGregor’s 1997 work, Breaking the Phalanx, 
we see yet another peacetime perspective with regard to military innovation in terms of 
doctrine. MacGregor is a rare example of a military author who provided candid insight 
on the need for reforms while serving on active duty. His work provides prescriptive 
treatment in addressing top-down shortcomings in his analysis of current unit structures. 
His is perhaps the most authoritative analysis in practical attempts to address a failure to 
innovate within current Army hierarchical structure. He suggests that Desert Storm 
created an overemphasis among senior leadership on technology, without addressing the 
archaic organizational makeup of the military, to include its logistics forces which he 
suggests contributed more to decisive strategic victories in the last hundred years than 
tactical competence. 41 MacGregor’s work, too, does not offer insight into the variation in 
innovation when contrasting AMEDD to logistics or the U.S. army at large. 

4. Bottom-Up Innovation, Wartime 

James A. Russell also proposes a bottom-up model of military innovation, but 
amid conflict. His Innovation, Transformation, and War presents a “bottom-up” analysis 
of the U.S. combat unit as a learning organization, suggesting that while doctrine created 
by military leadership does play a part in organizational innovation, it is not necessarily 


40 David Kilcullen Twenty -Eight Articles: Fundamentals of Company-level Counterinsurgency 
Edition 1 (Washington, D.C: Written from field notes compiled in Baghdad, Taji and Kuwait City, March 
2006). 

41 Mac Macgregor, Breaking the Phalanx, 230. 


22 



the primary driver of change. 42 He illustrates this using a detailed case study of the 
technologically advanced 172nd Stryker Brigade Combat Team (SBCT) operations in 
Mosul, Iraq, between 2005 and 2006. 43 Russell notes such bottom-up changes are 
complex, involving both vertical and horizontal communication among individuals 
seeking optimal, rather than merely tolerable, solutions 44 Though Russell focuses 
almost entirely on wartime innovation within the combat forces of the U.S. Army and 
Marines in Iraq, 45 he does address the daily operations of the Brigade Support Battalion 
(BSB) and efforts to support the brigade during operations in Mosul. 46 In his analysis, he 
provides a detailed description of the BSB’s ability to adapt by reconfiguring the brigade 
for combat, and the myriad of challenges the unit faced in providing support to a larger 
number of units over greater distances than doctrinally required. 

Russell painstakingly explains the learning process through the synthesis of 
bottom-up innovations, capable leaders, and new adaptation of technology, and stresses 
how the unit examined decades-old logistics doctrine from the 1980s, to find optimal 
solutions to problems, and that lack of logistics doctrine specific to COIN did not prevent 
the unit from undergoing an evolutionary process to adapt to their complex environment 
and expanded mission parameters. Russell also provides insight on how such lessons 
learned may find their way into evolution of future doctrine: innovation is in part driven 
by an organization’s ability to be introspective and judge as to what extent it is 
effective. 47 

Russell also argues that logistics personnel learn their craft primarily during 
wartime rather than during training events. As during wartime, much of what the unit as 

42 Russell, Innovation, Transformation, and War, 11. 

43 The author can authoritatively attest to Russell’s claim, having relieved 172d SBCT at the end of 
2006. Prior to their relief, weekly contacts were conducted over secure Internet protocol (SIPR) video 
teleconferencing prior to deployment. Exchange of information took place once in Iraq through information 
briefings, and exchange via removable hard drives. Additionally, following return to the United States, 
many of the leaders participated in videotaped interviews to document their combat experiences. 

44 Russell, Innovation, Transformation, and War, 52. 

45 Ibid., 159-164. 

46 Ibid. 

47 Ibid., 191. 


23 



collective team leams is non-doctrinal, thus requiring innovation. 48 While Russell does 
not address the topic of medical innovation, it could be implied that similar to logistics 
counterparts, such new nondoctrinal tenets of medical support are learned during combat 
and must adequately be captured into formal doctrine. 

Consistent with Russell’s analysis, this thesis finds that within combat brigades, 
medical companies have attempted to overcome shortcomings at the institutional levels 
of AMEDD found in doctrine and equipment shortfalls. Nonetheless, in spite of 
introspection within medical units at the combat brigade level—and even more recently 
by the new Surgeon General, very few lessons learned at the battalion or brigade levels 
have been channeled up in the chain of command to be implemented into doctrine. 49 In 
contrast, the logistics community has undergone considerable bottom-up learning to 
include both doctrinal and technical innovation. This research thus seeks to build on 
Russell’s work by seeking to explain not only learning on the ground but how such 
learning results in doctrinal shifts. 

Ultimately, this thesis finds that bottom-up learning has been crucial for Logistics 
and notably lacking for AMEDD. In order to understand AMEDD’s failure to innovate 
from the bottom up, it is crucial to take into consideration the question of organizational 
complexity. 

D. ORGANIZATIONAL COMPLEXITY 

This thesis focuses centrally on the highly complex nature of AMEDD relative to 
the Logistics branch. The organizational complexity of AMEDD has implications for 

(1) how lessons are learned—or not learned—and lost within AMEDD and 

(2) communication between AMEDD and the larger army. Chris Demchak’s Military 
Organizations, Complex Machines demonstrates that a complex and technically oriented 
organization will have significant challenges in its ability to adapt either rapidly or 


48 Ibid., 159-161. 

49 Even after nearly a decade of conflict, Stryker ambulances (MEVs) have yet to be placed in the 
medical company and many of the pervasive issues in manpower, structure and operational concepts 
identified by Gary Cecchine in Army Medical Strategy’: Issues for the Future (Santa Monica, CA: RAND 
2000), have yet to come to fruition. 


24 



effectively to new technologies adopted. 50 Additionally they may incur higher costs in 
their ability to effectively innovate both technologically and doctrinally. 


50 Chris C. Demchak, Military’ Organizations, Complex Machines: Modernization in the U.S. Armed 
Services, eds. Robert J. Art and Robert Jervis (NY: Cornell University Press), 40. 


25 



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26 



III. AMEDD AND LOGISTICS BRANCH: DETAILED 
DESCRIPTION OF OUTCOMES 

A. INTRODUCTION 

This chapter describes in detail the substantial degree to which the AMEDD has 
failed to innovate for irregular warfare, both in terms of technology and doctrine, relative 
to the logistics branch and the U.S. Army’s larger combat forces. The chapter provides 
a foundation for the analysis in Chapter IV, which will explain the causal nature of 
AMEDD’s failures to innovate. 

The first facet of innovation pertains to technology, and in particular this thesis 
will examine how such new vehicles are introduced within the medical and logistics 
communities. The second facet is innovation in formal doctrine, which, as the chapter 
will show, may come about both through both bottom-up and top-down processes. This 
analysis draws upon scholarly articles, in addition to writings in periodicals from 
AMEDD leadership found within combat brigades. In this portion of the analysis, a 
sampling of the amounts and type of articles published in both AMEDD and logistics 
periodicals, will then be compared to a review of respective formal publications in order 
to detennine amounts of new doctrine being introduced into such respective fonnal 
doctrinal publications. I am focused wholly on the characteristics, practices, and doctrine 
of army organizations. 

The following vignette facilitates the analysis to come: 

We didn’t have any annored ambulances in our medical company, so we 
carried him by his left leg, his only remaining leg, and wedged him on the 
air conditioner in the center of the guntruck. 

—Major Doug Wekell, Brigade Support Medical Company 
(Charlie Company) Commander, Baghdad, August 2007. 51 


^ 1 From author, relating ambush incident in which the 296 Brigade Support Battalion (BSB) 
headquarters company commander’s (HHC) vehicle was penetrated by a dual-array explosively forced 
penetrator (EFP) improvised explosive device (IED), resulting in instantaneous traumatic right leg below- 
the-knee amputation. 


27 



Similar vignettes have transpired on numerous occasions throughout the last decade of 
asymmetric conflicts in both Iraq and Afghanistan in which there is no differentiation 
between a “front line” and the more secure areas to the rear of conflict. This particular 
experience illustrates the failure of the anny medical community to adapt to irregular 
warfare, both doctrinally and technologically. 

B. TECHNOLOGY 

The aforementioned vignette illustrates the lack of innovation in BSMCs in terms 
of technology. For asymmetric warfare, the most effective evacuation vehicle for 
wounded people is an armored ambulance. The use of such armor is necessitated for two 
reasons. First, in this type of warfare insurgents use unconventional tactics to offset their 
own weakness in firepower. Such tactics may include the targeting of ambulances which 
are seen by the enemy as less risky than attacking a tank or similar vehicle. However, for 
much of the past 20 years the medical community mainly has primarily relied on 
unarmored ambulances, which cannot be safely used in the unpredictably violent context 
of asymmetric warfare. Instead, medical personnel frequently have relied on improvised 
solutions, such as the use of the HMMWV guntruck. 

In addition to such on-the-ground improvisation, the Anny has relied upon 
interim or rapid “fielding” solutions (RFI), which issues equipment to units in a much 
shorter timeframe than the slower conventional equipment development and 
implementation (or fielding) cycle which is based on rigid timelines and more applicable 
to peacetime. These wartime solutions do not represent true innovation for AMEDD, but 
rather the larger Anny who requested such vehicles, outside the traditional methods, to be 
used as a multipurpose vehicle rather than explicitly as an ambulance. 

One such success in short-tenn interim methods has been that the Army began 
issuing the majority of ground forces MRAP ambulances which due to their “V-shaped” 
floor are more resilient to improvised explosives (IED) attacks than flat-bottomed 
vehicles. However, even within this success there have been shortcomings. Such vehicles 
were issued nearly five years after the September 11, 2001 attacks. In addition, MRAPs 
are only issued to units once they arrive in the area of combat operations. Prior to 


28 



deployment, they generally receive training on the limited numbers of MRAP vehicles 
allocated for training purposes at their home stations. 

A second interim vehicle production method has been demonstrated within the 
interim Stryker brigade combat teams (SBCT). These units developed by General Eric 
Shinseki in 2000 were designed to fill a critical gap between lighter infantry forces which 
were rapidly deployable, and heavily armored brigades with more firepower. This 
concept which utilized a combination of lighter armor and allowed for more rapid 
deployment filled the gap in modern counterinsurgency warfare. The first such brigade 
deployed to Iraq in 2003, and utilized an ambulance variant of the Stryker vehicle 
(medical evacuation variants of the Stryker, or MEVs). These ambulances exist only 
within those nine specialized brigades found within the Army. Furthermore, though 
MEVs are used by medics within each maneuver (or combat unit) at lower levels, the 
next level of medical care, the medical company found within the Stryker combat brigade 
still has access only to “soft skinned” (i.e., non-armored) M997 ambulances. Such 
vehicles have limited use in current conflicts due to the vulnerability of the ambulance 
crew in addition to any patients which precludes their use off the confines of the forward 
operating bases where units in Iraq and Afghanistan stage operations from. The lack of 
medical companies’ access to MEVs has continued despite efforts by both medical and 
infantry leadership to grant them such vehicles at this level. Both medical leadership at 
the medical company and leadership within the combat brigade have made written 
requests to agencies such as the Director of Force Design at Fort Leavenworth Kansas, in 
order to attempt to change allocations of MEVs over the last six years. 52 

C. DOCTRINE 

The mission of the brigade support medical company (BSMC) is to orchestrate 
battlefield medical stabilization care and evacuation to larger fixed facilities, if necessary. 
At the lowest levels, we find medics assigned directly to combat (maneuver) units of 

52 The latest such concern was voiced by Command Sergeant Major Bjerke during “2010 Arrowhead 
Operations Warfighter Summary,” forum, 

http://www.dtic.miFndia/2010combatvehicle/8 WarFighterPanelCSMAlanBjerkeUSA.pdf (accessed 
February 12, 2012). 


29 




battalion size which provide initial lifesaving measures and stabilization. This level of 
care is referred to as Role I care. At the next level, or Role II, we find the first company¬ 
sized, or self-contained functional medical unit, the BSMC. This battlefield medical unit 
is located within the support battalion, and manned by approximately 70 soldiers. These 
personnel provide more definitive medical provide care to the approximately 4,500 
soldiers within their assigned combat brigade, and also doctrinally provide 
reinforcements as needed to the Role I levels found within the maneuver units. 

Even in cases in which the larger Anny has provided interim solutions such as 
MRAP ambulances to compensate for AMEDD’s stalled efforts to facilitate armored 
ambulance production, doctrine to support such technology remains incomplete. In the 
case of the Stryker brigade, in 2007, while the newer MRAP ambulances were being 
distributed to medical units in theater, Stryker brigades were omitted as they already 
possessed the Ml 133 MEV. The rationale for such an omission was that, in the 
aggregate, such Stryker brigades already possessed sixteen total armored MEV 
ambulances, all of which are assigned to medics within the maneuver, or combat 
battalions. However, the BSMC within the support battalion was not authorized these 
annored ambulances. Instead the BSMC was still allocated the older thin-skinned 
ambulances as part of its official Modified Table of Organization and Equipment 
(MTOE). This document is generated by the Anny in conjunction with the AMEDD, and 
which officially allocates respective amounts of equipment and numbers of personnel to 
each Army organization. 

The flaw in doctrinal innovation is illustrated by the fact that after a decade of 
conflict and multiple deployments by Stryker brigades, every BSMC with no exception 
upon deployment, has formally identified the lack of armored ambulances, through 
multiple venues to include what is known as an Operational Needs Statement (ONS) 
through documentation assistance review team (DART) beginning in fiscal year 2004. 
However, in spite of such repeated requests, such a shortfall has yet to be filled other than 


30 



in an interim and inconsistent fashion through MRAP ambulance production . 53 Hence, in 
the instance, the combat brigade in the aggregate possessed armored ambulances, as well 
as Stryker MEVs, thereby being technologically sound, but doctrinally flawed in that its 
next level of medical care, the BSMC did not. 

D. TECHNOLOGICAL INNOVATION AND DOCTRINE 

This analysis will now begin by examining the simplest and most tangible form of 
innovation, that of technological adaptation. In doing so, it will first propose that such 
innovation is inextricably connected to the other form of innovation, doctrinal innovation, 
which serves as the focus of the final section of the chapter. 

The modern U.S. Army must be able to mitigate risk and anticipate the requirements of 
the future battlefield, and then detennine how it will best provide medical and logistical 
support to combat forces within such parameters, performing under a spectrum of 
battlefield conditions both in linear and in the complex asymmetric battlefield of 
counterinsurgency operations. In order to facilitate such efforts, U.S. Army combat 
forces must possess a combination of both heavy tracked and wheeled ambulances for 
use within Heavy Brigades, which consist of tanks and other heavily armored weapons, 
and similarly robust firepower. In addition, ground forces must possess a compliment of 
more rapid, lighter wheeled vehicles to operate within its light and interim (Stryker) 
combat forces, or to operate in rear areas of the conventional battlefield where there is 
less likelihood of being fired upon by the enemy. 

Such dual capabilities requirements must then drive the development of new 
vehicles to parallel the pace of combat vehicle development in terms of speed, agility, 
and survivability. Currently, the Anny has relied primarily on incrementally upgraded 
Desert Storm-era ambulances which compose the bulk of wartime medical support. In 

53 MEVs were requested by 172d, 3-2, and 1/25 Stryker Brigade Combat Teams based on 
requirements in Army doctrine found in Field Manual 4-02.6 The Medical Company, which requires the 
BSMC to provide reconstitution and reinforcement for medical assets organic to the maneuver battalions 
and to provide evacuation from Echelon I to Echelon II medical units (medical company in a support 
battalion). Without armored assets, the BSMC is not able to accomplish its mission. Such lessons have 
been informally transferred from each brigade’s previous Operation Iraqi Freedom rotation. Currently, 
Stryker MEVs are the only ground MEDEVAC vehicle used for patient evacuation outside of FOBs 
besides MRAP ambulances. 


31 



the last few decades the U.S. Army and the civilian defense industry, in conjunction with 
input from pertinent internal agencies of the Army Medical Department (AMEDD), have 
attempted several very costly aborted efforts to create modern armored medical vehicles 
for the last two decades. Yet, none of these attempts have been successful in replacing its 
Vietnam-era fleet of tracked Ml 13 and M577 annored personnel carriers retrofitted to be 
utilized as medical evacuation and treatment platforms on the forward areas of the linear 
battlefield. 

Additional attempts at replacements for the fleet of M996 and M997 wheeled 
ambulances have also been met with mixed success. While there have been several false 
starts, and there have also been some successes. Most notably within the last decade we 
are seeing more innovative, yet still interim designs to support the current asymmetric 
fight in the form of the Stryker and MRAP ambulances. However, such innovation has 
been both inconsistent and problematic, hampered by a series of cost overruns and 
cancellations. Efforts to find an adequate solution to address such capabilities gaps in 
medical support of ground forces have resulted in technological success stories such as 
the MRAP ambulance and Stryker MEV development programs, but even though such 
technology exists and there is still a shortage of such vehicles. 

We find multiple approaches in efforts to innovate with regard to battlefield 
capabilities of medical evacuation vehicles within the Army. First, we find legacy or 
heavy brigades which use vehicles such as tanks and which are optimally designed for 
large-scale interstate conflicts undergoing incremental, rather than revolutionary changes 
in vehicle design to address issues of command and control (C2), survivability, and 
maneuverability. These incremental may consist of minor adaptations retrofitted to 
existing ambulances, rather than entirely new vehicle designs. Examples of such 
incremental changes have included upgraded communications or “C4ISR” systems, such 
as Force XXI Battle Command Brigade and Below (FBCB2), bolt on “up-armor” kits for 
vehicles with design specifications which did account for such added weight 
requirements, and which also require larger engines to compensate for the added annor. 


32 



A second form of innovation has the more revolutionary designs manifested in the 
aforementioned creation of MRAP ambulance variants to be used as medical evacuation 
vehicles. These vehicles are then distributed or “fielded” to a wide variety of units within 
the Army and Marines, to then be used in interim efforts to bridge capabilities gaps on 
the battlefield. Finally, we see revolutionary, albeit interim changes in the medical 
system brought on by changes within the larger Army organization itself. We see Stryker 
ambulances solely internal to specialized Stryker Brigades, with digital net-centric 
warfare. Ultimately however, in each of these cases we find partial solutions in which 
technology is implemented without proper analysis of doctrine, or in which the right 
numbers of such vehicles are not distributed to the respective units. 

This section will examine ambulance development efforts over the last two 
decades to support conflict across the spectrum of modern warfare. It will demonstrate 
that attempts at innovation have taken place during both peacetime and wartime. 
However, when such technological innovation does take place, two outcomes are 
demonstrated. First, this analysis suggests that such efforts are the result of 
unconventional innovation processes, rather than traditional institutional methods of 
development and implementation. Second, it suggests that when ambulances are 
successfully produced, they are a byproduct of a larger innovation process to develop 
new combat vehicles to support doctrine, rather than a directed effort to specifically 
produce new ambulances. 

Such observations will demonstrate that in accordance with the James Russell, 
who in Chapter II suggests that for logistics forces innovation happens from the bottom- 
up, during peacetime.” While medical units are not addressed in scholarly texts, such an 
observation is evidenced within periodicals, in which medical personnel provide wartime 
insights from new doctrine learned on the battlefield. Yet as evidenced here, in the case 
of the AMEDD, new ambulances only came to fruition as an afterthought when new 
multipurpose vehicles were introduced. Conversely, when peacetime programs were 


33 



implemented to specifically design ambulances, such efforts resulted in cancellation due 
to lack of funding and emphasis by the DoD. 

1. Pre-Global War on Terrorism (GWOT) Tracked Ambulances (Top- 
Down/Peacetime) 

This time period examines efforts at ambulance production during the time period 
prior to the “global war on terror,” or the period following Desert Stonn until the 2003 
invasion of Iraq in which medical personnel did not necessarily require the same levels of 
survivability as in currently produced ambulances, and in which combat operations were 
still defined as primarily linear in nature. This effort to design new ambulances was not a 
new issue and not isolated to later periods of asymmetric warfare. Specific concerns of 
medical evacuation were noted following Desert Storm in a Government Accounting 
Office (GAO) report in 1996, emphasizing that efforts must be addressed at higher levels, 
and not simply within the medical sphere of influence. Additionally, the report noted that 
lack of funding was also seen as hampering modernization efforts, specifically noting the 
lack of funding allocated to the shortcomings. 54 

The challenge of creating wheeled ambulances using a modified HMMWV has 
not been the only attempt at innovation in the medical community. Additionally, the 
creation of a replacement ambulance which could operate on the front lines of the 
battlefield was an ongoing effort beginning shortly after Desert Stonn. Such a vehicle 
design specifications required annor and tank-like tracks to allow its crew to operate in 
parity in terms of mobility and survivability with tanks and other similar combat vehicles 
engaged in armored combat. Such a goal of creating a modem tracked and armored 
ambulance had been initiated well prior to the current focus of contemporary 
counterinsurgency operations. Tracked ambulances, such as the venerable retrofitted 


54 General Accounting Office, Wartime Medical Care DoD is Addressing Shortfalls, but Challenges 
Remain (Washington, DC: U.S. General Accounting Office, September, 1996), 8. 


34 



Ml 13 armored personnel carrier, still currently in use, and first fielded in 1962, were to 
provide evacuation capabilities from forward areas on the battlefield to an ambulance 
exchange point, where casualties could either be loaded into a wheeled M997 ambulance, 
or be transferred to a larger M577 treatment vehicle, which is similar to a 
Ml 13 evacuation vehicle, albeit with a raised rear ceiling, where physicians assistants 
can more easily work to further stabilize patients prior to evacuation further to areas to 
the rear. 

Following Operation Desert Storm, the Army began experimenting with attempts 
to find a replacement specifically for their venerable fleet of Ml 13 tracked ambulances. 
In the decades following there have been several additional attempts to moderni z e 
armored evacuation capabilities on the battlefield using the conventional and perhaps 
outdated spiral design acquisition program. In both cases funding was allocated, and test 
mockups were designed, but neither ever were mass-produced both due to lack of funding 
and emphasis by the DoD. 

a. AMEV (Armored Medical Evacuation Vehicle) 

The AMEV (M113A4) was perhaps the earliest attempt to design a new 
evacuation vehicle using an elongated version of the same Ml 13 ambulance already in 
use. The AMEV mission needs statement was approved by the Army Deputy Chief of 
Staff of Operations in 1995 as well as U.S. Army Training and Doctrine Command 
(TRADOC), the agency responsible for synchronizing equipment, doctrine and training 
throughout the Army. The following year the program was allocated funding. It was 
hoped such a newer design would capitalize on speed, as the Ml 13 was often too slow to 
keep up with supported units. In addition, the newer design used modern 
communications using the Medical Communications for Combat Casualty Care (MC4) 
system. With this system, personnel shared and transmitted patient data to the aid station 


35 



as the patient was being evacuated off the battlefield. 55 The new design was also meant 
to rectify the cramped interior space for patient care en route, and for additional storage 
of medical supplies. In 1997, efforts were made to include a similar test vehicle in the 
Army Warfighting Experiment to further define capabilities requirements. However, the 
program was cancelled and no more funding was allocated, in spite of the fact that the 
rest of the heavy brigade combat vehicles went through a modernization program, with 
newer versions of Abrams tanks and Bradley fighting vehicles (BFV), which further 
exacerbated the already slow Vietnam-era medical assets currently in use. Due to this 
imbalance, the efficacy of medical support being able to maintain momentum in battle 
remains questionable at best as noted even as early as 1995 in the DoD “Medical 
Readiness Strategic Plan 1995-2001 ” in describing deficiencies of evacuation assets 
used during the Desert Storm Campaign, and which are still in use today, albeit with 
incremental modifications. 56 

b. AMTV (Army Medical Treatment Vehicle) 

The AMTV represents yet another failed attempt to create an armored and 
tracked ambulance using conventional Anny procurement methods. Prior to General 
Dynamics being awarded the contract for the Stryker in 2000, the U.S. Anny Medical 
Materiel Activity (USAMMDA) was again working in conjunction with DoD agencies 
on yet another revision of the cancelled AMEV design based on the BFV. The Army 
began investigating the need for a newer ambulance, and began work began on a 
modified multiple launch rocket system (MLRS) M270 tracked vehicle, which was in 
turn a modification of the BFV chassis. The Annored Medical Treatment Vehicle 
(AMTV) was considerably larger than either the Ml 13 or the AMEV, with almost an 
identical silhouette to the MFRS. The design had considerably much more room than 
either of the aforementioned systems allowing much more invasive patient care enroute, 
unlike the M577, of which requires setup of a tent-like structure off the rear section, 

55 Elizabeth T. Beckley, “Cyber Medics: Dependable IT at the point of care proves to be a critical 
component of health service on the battlefield.” FedTech Magazine (May 2009): 1. 

56 Stephen C. Joseph., Assistant Secretary of Defense, Medical Readiness Strategic Plan 
(Washington, D.C: Department of Defense, 1995-2201), iii. 


36 



rendering it capable of true patient care only when stationary. Internally, it also allowed 
for current Command, Control, Communications, Computers, Intelligence, Surveillance 
and Reconnaissance systems (C4ISR) with supported units, and medical specific 
command and control (C2) to include telemedicine interface, such as Medical 
Communications for Combat Casualty Care (MC4). Like both versions of the AMEV, 
the AMTV was also cancelled prior to entering production, as once General Dynamics 
was awarded the contract for the Stryker wheeled vehicle, USAMMDA’s Integrated 
Product Team (IPT) who was in coordinated efforts with Directorate of Combat and 
Doctrine Development (DCDD) was told to cease work on the Bradley chassis based 
ambulance. 57 

2. Pre-GWOT Wheeled Ambulances (Top-Down/Peacetime) 

In the case of finding an adequate solution to the wheeled M977 and M996 
unarmored ambulances, efforts instead focused on retrofit rather than replacement 
programs to address the lack of armor for these ambulances originally designed for rear 
area use on the contemporary linear battlefield where there is less likelihood of being 
engaged by enemy forces. While this limitation was of relatively minor concern to 
medical personnel during the Cold War, in which such ambulances were anticipated to 
operate behind areas of such danger, this capabilities gap has been exacerbated early on 
in both current theaters of conflict in the Middle East. These current conflicts suggest that 
a combination of annor and wheels are optimal for use in counterinsurgency as it allows 
for both speed and protection while evacuating patients. 

There have been limited attempts at retrofitting armor to the older wheeled M997 
ambulances. Such experimental modifications addressed both the crew area and the 
raised compartment in the ambulance for patients. However, these efforts were 
discontinued due to weight and center of gravity issues, and a lesser requirement for 
annored assets in such units, which even on the contemporary asymmetric battlefield, 
traditionally do not leave confines of the forward operating base (FOB) where they 

57 Steve W. Reichard, Project Manager, MEDEVAC MEP, USAMMA, telephone interview, February 

11,2011. 


37 



routinely operate aid stations. Understandably, since 2003, the entire M997 fleet which 
makes up the majority of evacuation assets in the Anny, has been strictly regulated to 
patient transport duties inside such FOBs. Even so, we still find ongoing efforts to 
modify such a limited use vehicle specifically for Stability and Support Operations 
(SASO) missions, such as the M997A3, with modifications to its frame which allow for 
added weight from added annor. However, such ambulances are still unable to be 
retrofitted with critical patient compartment annor. 58 

3. Post-GWOT Attempts at Innovation 

In order to conduct an analysis of more modern design programs we will use the 
comparative method to examine three methods of acquisition and their outcomes 
throughout the last decade since the Bush Administration’s initiating the Global War on 
Terror. The definition of the term Global War on Tenor can be somewhat vague and 
problematic. However, in the larger context it refers to the more nanow definition of a 
period in which the Army addressed the threat of global tenorism through armed conflict. 
In addition, it specifically refers to the expectation of the Army to be able to medically 
and logistically support such conflict on a non-linear battlefield. 

First, we will examine “top-down” Stryker innovation, and the implementation of 
its medical evacuation variant. Second, we will examine “bottom-up” MRAP 
development and development programs. Finally, we will examine programs within the 
conventional acquisition program, as typified by ongoing tracked ambulance 
development. If evidence suggests the need for more intensive examination, perhaps 
more detailed statistical analysis would be the next logical step to validate concerns with 
regard to current acquisitions programs, and the external variables which potentially 
affect medical transformation efforts. 

a. Stryker MEV (Top-Down/ Peacetime) 

The Stryker was the Army’s first new vehicle since the implementation of 
the Bradley Fighting Vehicle 15 years earlier. The Stryker itself was not a new type of 

58 Scott R. Gourley, “Soldier Armed Tactical Medevac Ambulances: New Capabilities for New 
Battlefields.” Army Magazine (May 2010): 70. 


38 



vehicle altogether, as it was a variation of the Canadian Light Armored Vehicle (LAV) 
which had been in use for a few years already. It also resembled the numbered series of 
similarly designed Soviet vehicles had been in use in decades prior to the modernized 
Canadian LAV. However, the new vehicle, combined with its enhanced digital capability 
made it somewhat revolutionary, allowing it to get inside the enemy planning cycle. 59 
Such thinking parallels to German use of the tank following World War I, as the tank 
itself was neither developed by the Germans, nor was the initial doctrine to employ such 
a platform credited to Gennany. Doctrinal development took advantage of a series of 
Stryker forums, to share infonnation, and such additional forums were continued during 
deployments to share innovations which developed out of combat. Part of this ongoing 
synergy to develop doctrine on the fly actively included members of the medical 
community at the brigade combat team level both prior to, and during deployments. 

The Program Executive Office (PEO) Stryker program has demonstrated 
one of the most critical tenets of transformation, that as an ongoing evaluation process. 
Since its implementation the program has conducted multiple refit and add-on programs, 
with the most recent being the development of the Stryker double-V Hull or DVH Stryker 
in an effort to provide more comprehensive underbelly protection from increasingly 
sophisticated improvised explosive devices (IED)s used in Afghanistan. 60 Yet another 
modification includes the addition of side skirts made of ballistic paneling, a response to 
the field-expedient HESCO barrier wire and Kevlar side skirts soldiers fashioned in Iraq. 

The success of the Stryker is counterbalanced by two unresolved issues: 
First, there are currently a total of 73 (45 active and 28 reserve) combat brigades within 
the U.S. Army inventory, and only a total of seven Stryker Brigade Combat Teams, of 
which six are active and one Reserve Component. However, the current Quadrennial 


59 Daniel Gonzales et al., Network-Centric Operations Case Study: The Stryker Brigade Combat Team 
(Santa Monica, CA: RAND corporation) 2005, xxii. 

60 “peo Ground Combat Systems,” Soldiers Magazine, January 1, 2011, 13. 


39 



Defense Review proposes nearly doubling that number to a total of 13. 61 Accordingly, 
the majority of Army forces rely on either the older ambulances or interim solutions such 
as MRAPs. 

Implementation of this new interim brigade built around the Stryker 
vehicle featured an ambulance version, the Ml 133 MEV. Both the Stryker program and 
the ambulance variant were successful in tenns of technological innovation. However, in 
the case of the MEV the doctrinal limitations to the program include two fundamental 
and as yet unresolved issues. The MEV variant is currently only distributed by the Army 
to Role I care within the combat units of the brigade, Role I care consists of first aid and 
immediate lifesaving measures. The BSMC level (Role II) care at still possesses the soft 
skinned M997s as the only means of evacuation., and retrofitted Ml 13 tracked 
ambulances for medical companies in heavy brigade combat teams. 62 Neither type of 
vehicle allows for rapid doctrinal reinforcement of evacuation assets from the medical 
company in modern urban combat. While only recently the Anny has authorizations to 
provide MEVs to Role II care at the BSMC, were approved, currently constrained 
funding prohibits such efforts from coming to fruition any time in the near future. 

b. MRAP Ambulances (Bottom-Up/Wartime) 

Additionally, we have seen recent advances in MRAP vehicles designed 
for medical evacuation and in support of asymmetric warfare resulting from spin-out 
technology from the defunct FCS Program. In 2004, due to an increase in incidences of 
IED attacks, the United States Marine Corps Systems Command (MCSC) submitted a 
critical needs request, which resulted in a series rapidly manufactured vehicles resistant 
to such attacks. Unlike the cancelled tracked ambulance prototypes, the MRAP program 
in general has been more successful in providing an interim capability ambulance based 
on current needs, due to two outstanding factors. First, and perhaps the most obvious 
factor, there is a current capabilities requirement for a future annored wheeled vehicle 

Department of Defense, Quadrennial Defense Review Report (Department of Defense, 2010), xvi. 

62 The current terminology for levels of medical care is found within the NATO Logistics Handbook, 
October 1997, Found online at http://www. nato. int/do cu/lo gi - en/1997/lo -1610. htm (accessed March 4, 
2012 ). .. 


40 



which takes precedence over the future need for a much heavier (and much slower) 
tracked vehicle for high-intensity conflict of the future. Second, the implementation did 
not take the same path as the failed tracked ambulance prototypes, using an 
unconventional and accelerated development program. Accordingly, there has been a 
rapid emphasis and evolution of wheeled vehicles beginning with the Ml 114 Up- 
Armored HMMWV and the Cougar ambulance. Both of these vehicles were early 
attempts specifically designed to fill gaps in capabilities with later improvements in 
design, to include the current Oshkosh M-ATV Ambulance and BAE Caiman 
Ambulances. 63 Both of these vehicles provide rapid power evacuation capability from 
point of injury, especially when the risk is too high or weather does not permit use of air 
MEDEVAC assets. The further evolution of the now-familiar V-shaped hull continues to 
provide superior blast deflection to occupants of such vehicles as do evolutions in 
ballistic glass and electronic warfare countermeasures. 

MRAP vehicle implementation represents a similar success outside the 
traditional acquisitions timelines of DoD programs in which the “bottom-up” method of 
innovation was used by both the United States Army and Marines in their successful 
requests for interim solutions. Requests for the MRAP were initiated by officers at lower 
levels through reports which suggested a critical need for a vehicle capable of resisting 
mines and IED threats. The MRAP was then developed, tested and issued to units on a 
much shorter timeline than if it were developed from the top-down through conventional 
methods. Shortly thereafter the vehicle was then further modified for other specialized 
functions, of which have included several variants were specifically designed to be used 
as medical treatment and evacuation vehicles to address the current critical needs of 
asymmetric warfare. Unlike the Stryker MEV which is unit-specific, these vehicles were 
designed to fill the role of evacuation throughout multiple types of units, from Special 
Operations Forces (SOF), to conventional brigade combat teams. 


63 Kris Osborn, “New MRAP Ambulance Prototypes: Many Improvements,” Army News Service, 
November 18, 2010. 


41 



c. Post-GWOT Conventional Methods (Top-Down/Wartime) 

This section will demonstrate that in parallel to bottom-up efforts to 
develop wheeled annored ambulances, the Army as part of a joint effort across the 
services, intends to redesign its larger fleet of multipurpose HMMWV and transition to a 
vehicle which has broader applications in both armored and unarmored versions. As this 
next section will again demonstrate, ongoing issues persist with regard to innovation for 
asymmetric warfare. Not only has innovation of these ambulances been slow, but the 
JLTV project itself has been backward with regard to medical innovation. Specifically its 
focus on any kind of unarmored ambulance in the current battlefield environment 
represents a failure to adapt. 

Wheeled ambulance evolution using conventional methods continues to 
repeat similar design shortfalls regardless of a decade long conflict of lessons in non¬ 
linear combat. The current Joint Light Tactical Vehicle (JLTV) program is an effort to 
replace the ubiquitous High Mobility, Multi-Wheeled Vehicle (HMMWV) across the 
military services. However, the program repeats such capabilities shortfalls found in the 
current M997 ambulance in that the new ambulance variant of the vehicle is once again 
unarmored. In addition, in an all-too familiar turn of events, the entire JLTV program is 
now threatened by cancellation due to cost overruns in addition to weight concerns. 64 

Over the last few decades, the use of the tracked BFV chassis as an 
potential candidate for a future ambulance has been the focus of subsequent attempts to 
re-initiate production efforts, as a functional variant within the now defunct Future 
Combat Systems, and finally the latest attempt being the BAE Medical Variant of the 
Ground Combat Vehicle program, both of which have yet to produce an armored tracked 
ambulance capable of survivability in countering potential future threats on the high- 
intensity conflict battlefield. The GCV is at risk of yet another cancellation due to budget 
limitations. 65 


64 Andrew Feickert, Joint Light Tactical Vehicle (JLTV): Background and Issues for Congress 
(Washington, DC: Congressional Research Service, January 3, 2012). 

65 Kate Brannen, “Budget Limits Efforts to Add, Upgrade Vehicles,” Army Times (January 2011): 2. 

42 



The Ground Combat Vehicle (GCV) Program once again revived the 
cancelled Future Combat Systems (FCS) Program as a nearly identical program, using 
nearly the same government defense contractors, under a different acronym, in the 
attempt to provide a modernized tracked medical variant for heavy brigade use in high 
intensity conflict. 

However, an examination of the current prototype reveals some repetition 
of mistakes of previous modernization efforts as illustrated by Chris Demchak in an 
allegory using the new Ml Abrams ta nk program in the early 1980s. When compared to 
its less complicated predecessors, the design, initial testing and issuing process was 
accomplished by civilians, and Anny was not nearly as involved with the intricacies of 
the design of the tank itself, but rather the monitoring of the program and final testing. 66 
Such an allegory can be made with modem attempts in developing a new tracked 
ambulance through recent defense contracts. According to BAE’s publicly released 
specifications, the top speed of the tenuous future evacuation vehicle is still only 40 miles 
per hour; 67 such a capability of a cutting edge ambulance is actually slower than the 
current maximum speed of the M113A3, an incrementally upgraded vehicle designed 
prior to the Vietnam War. Additionally, modification requests by medical personnel 
with combat experience have not been met. Such additions have included mounts for 
defensive small arms and air guard hatches for security. In particular, the latter two 
programs were an effort to address known threats and limitations and were requested by 
brigade level medical personnel. 

4. Technological Intersection and Disparity (Medical and Logistics 
Companies) 

The majority of analysis thus far has been focused on medical vehicles. However, 
both the medical community and the logistics communities at the brigade combat team 
share similar missions in that they are both required to operate and survive under a 
variety of conditions like their combat arms counterparts, whether it be an asymmetric 

66 Demchak, Military’ Organizations, Complex Machines, 48^9. 

67 BAE Systems, Ground Combat Vehicle Medical Variant Technical sheet , BAE Systems, 2009. 

43 



battlefield, a more linear high intensity conflict, or stability operations during a low 
intensity conflict. In doing so, both units have the challenge of conducting either 
logistics missions or medical support with limited firepower and in which they must 
perform skilled tasks such as repairing or recovering damaged vehicles, or stabilizing an 
injured patient for transport to definitive medical care. In order to be able to accomplish 
this mission they must first survive uncertainties on the battlefield itself. 

However, there is a telling disparity with regard to the nature of survivability 
requirements in the comparison between the medical company and the other two 
respective logistics companies in the support battalion. Unlike the medical community, 
logistics companies within the support battalion man a wider variety of vehicles and such 
tasks, while demanding, have much different requirements than the transport of wounded 
human beings. 

For the purposes of simplification, logistics units provide sustainment, or critical 
life support needs on the modem battlefield using two methods. They distribute various 
classes of supplies to include fuel, water, and repair parts, and other consumable goods in 
order to sustain troops, their equipment and the vehicles they use in combat. In addition, 
logistics units organize routine convoys which provide maintenance and vehicle recovery 
teams both on major forward operating bases, in order to repair and maintain vehicles. 

This analysis will examine two logistics vehicles used by the support battalion, 
the Heavy Expanded Mobility Tactical Truck (HEMTT) series issued to Army units in 
1982, and the Family of Medium Tactical Vehicles (FMTV) similarly distributed to 
Army units in the mid-1990s. Similar to the outdated M997 wheeled ambulance, both 
vehicles were designed and distributed to units prior to the Global War on Terror 
(GWOT). However, both the HEMTT and the smaller FMTV were designed prior to the 
GWOT, they still possesses the required capabilities in their logistical support roles, to 
include the HEMTT’s use as a Palletized Loading System (PLS) which delivers bulk 
supplies, a heavy wrecker, as well as a transporter of bulk fuel. The FMTV, also 
provides transport of supplies and can be armored for use in Iraq and Afghanistan. , its 
vehicles designed in the 1980s-90s were already largely sufficient for the asymmetric 


44 



context. However, this LSAC innovation was critical for the new context, and Logistics 
was able to innovate by doing the LSAC change. 

Both medical and logistics vehicles share the need for armored crew areas, such 
as in the case of the modern FMTV which has recently seen modifications such as the 
Low Signature Armored Cab (LSAC) armor for its occupants beginning in 2004. How 
can such disparity exist between such logistics and medical evacuation vehicles exist, 
when given similar timelines and operating environments? 

Key to such analysis are the additional requirements for Army ambulances when 
compared to vehicles used by logistics counterparts. Conversely, in the case of the 
ambulance there has been a less concentrated effort to produce similar retrofitted and 
modem armor. This is primarily due to the more difficult problem of regardless of 
whether the cab is upgraded with armor, the fact remains that the vehicle still cannot 
leave the confines of a FOB. Such a stipulation exists for one overarching reason, 
specifically, the requirement of armor for protection of the “cargo” or, in this case, the 
injured personnel who must be transported in the thin aluminum rear of the vehicle. 
However, such protection is not required for simply transporting logistics cargo, which 
has made the ability to retrofit such vehicles much easier. Consequently, due to such a 
lesser requirement in terms of technological complexity, the logistics community has 
done a better job of adapting to the new threat environment. In conclusion, it is apparent 
that the requirements for logistics contrast with the AMEDD in terms of technological 
innovation requirements. 

E. OPERATIONAL INNOVATION AND DOCTRINE 

1. Formal Doctrine 

Once of the primary measures of adaptation that will be used in this research 
study is operational innovation consisting of formal doctrine. Within the AMEDD, 
doctrine should ultimately impact the execution of training of its medical personnel, how 
its subordinate organizations are manned and organized, and how it equips the 
organization, both in terms of equipment capabilities and in its numbers. As AMEDD is 
a support organization, it must be aware of how combat forces doctrine is continuously 

45 



evolving, and mirror its capabilities accordingly in order to properly support its combat 
forces counterparts. Such innovation may be measured in the development of the 
interrelated concepts of both training and doctrine of which exist as the formal written 
version. Formal doctrine can be conceptualized as both the culmination and continuation 
of the AMEDD’s body of knowledge and from which leaders draw their knowledge base 
in the execution of their duties. 

To facilitate such efforts throughout the organization there three layers of doctrine 
which are then used to synchronize the three layers of war, that of the tactical, 
operational, and strategic levels. Even with regard to the AMEDD as a support 
organization, such differentiation in levels of doctrine is critical, as the AMEDD must 
support such operations at each level. While this study suggests gaps in execution of 
doctrine at the tactical and operational levels, it also suggests a portion of the issues stem 
from failings at the strategic level. However, many of these concerns are outside the 
scope of even the AMEDD itself. 

There are some external constraints both with regard to doctrine production 
within the AMEDD and its contribution to higher levels of doctrine outside the 
organization. Such comparison requires examination against two interrelated 
comparisons. First, when comparing the timeliness of AMEDD formal doctrine when 
compared to the larger Army organization, there is an inherent delay in AMEDD doctrine 
production, as it which must wait for the Army to create its own revised formal doctrine 
and then parallel such tenets. However, such delay still does not adequately explain the 
inherent disparities between the AMEDD its logistics counterparts. 

Since military operations commenced in Afghanistan and Iraq, there have been 
internal and external expectations for a paradigm shift within the military as a whole, as 
echoed in the previous administration’s issuing Department of Defense Directive 3000.05 
in November of 2005, which placed nation-building on the same priority as combat 
operations. 68 Implementation throughout a large bureaucracy takes considerable time 

68 Center for Strategic and International Studies, “DoD Directive 3000.05, One Year Later,” 

December 11, 2006, http://csis.org/event/dod-directive-300005-mdash-one-year-later (accessed June 7, 
2011 ). .. 


46 



within the context of the larger Army organization. This further complexity of 
requirements has increased the tasks all Army forces must be adept at, thus requiring 
combat forces to innovate and change their fonnal doctrine. This creates an additional 
lag, as once combat forces have codified their own doctrine, both medical and logistics 
organizations in supporting roles must now mirror how they will best support such newly 
codified efforts. 

In previous chapters proponents of top-down doctrinal development have 
suggested that large changes to doctrine are primarily successful when implemented from 
senior leadership at institutional levels. An oft used example has been that of General De 
Puy who wrote the new Army Operations Manual after assuming command of TRADOC 
in 1976, yet such an example when given a second glance illustrates shortcomings in that 
the new doctrine when introduced addressed only one enemy, in one locale, Specifically 
that of the Soviets, during the Cold War. 69 

a. AMEDD and Sustainment Doctrine (Top-Down Efforts) 

The most current definition of Army health service support (AHS) in 
formal AMEDD doctrine, from Field Manual 4.0 Sustainment, is “all support and 
services performed, provided, and arranged by the AMEDD to promote, improve, 
conserve, or restore the mental and physical well being of personnel in the Army.” 70 Of 
critical importance in the most current version of the aforementioned text, is the 
relinquishment of the entire doctrinal development function to the separately managed 
organization. Sustainment as a military concept may be seen as the bridge between the 
larger joint or cross-services support of combat and Anny logistics. 

While both the logistics community and the AMEDD organizations may 
share infonnation to a certain extent, the task of synchronizing healthcare under 
Sustainment can be problematic if the AMEDD is one the only function found under 
Sustainment which as organization is completely separate, not only in terms of doctrine 
production but the only Army agency geographically separated at Joint Base Sam 

69 Adams, The Army After Next, 16-18. 

70 Department of Defense, Field Manual FM 4-0, Sustainment (Washington, DC: Department of 
Defense, April 2009), 1-4. 


47 



Houston in San Antonio Texas. Published doctrine demonstrates such shortcomings in 
that if one examines publications from within Sustainment and the AMEDD, it is the 
latter which is lagging behind in medical doctrinal terms. 71 When compared to the 
logistics community at these lower levels, one finds lessons learned in combat by the 
logistics community are being transferred into higher Anny-wide institutional levels into 
formal doctrine. Modern logistics doctrine is even found in larger Anny publications 
such as FM 3-24, Counterinsurgency Operations, and within documents which address 
Army-wide technological transformation efforts. 72 Conversely, medical content within 
the manual is limited to its mention only, rather than the entire chapter dedicated to 
logistics. Stryker doctrine is now being transferred into formal doctrine, yet the latest 
version of the medical company field manual, Field Manual 4-02.6, 2002, reflects the 
outdated 1997 version with minor changes, such as the mention of employment within 
the Stryker brigades. In addition the BSB manual appears to be updated. 

b. Medical and Logistics Formal Training as Doctrine Rehearsal 
(Top-Down) 

There is evidence to suggest the way in which the Army trains for war or 
rehearses its own doctrine is perhaps even more important than its formal written 
doctrine. In the case of the AMEDD, its inherently complex nature as an organization 
may be inhibiting its personnel from being adequately incorporated into realistic large- 
scale training, and it may be challenged to adequately articulate such a shortfall. This 
may be problematic as such realistic training may in many cases be the decisive factor or 
tipping point between training and technology. Such a claim has been voiced by Thomas 
K. Adams that the United States only recently developed the capacity for large-scale 
realistic training and in many cases training, not technology has been the deciding factor 

71 Field Manual (FM) 4-02.6, The Medical Company, published by the AMEDD refers to levels of 
medical care as the older Echelons I and II Combat Health Support (CHS), while FM 4-90, Brigade 
Support Battalion, August 2010 which is instead published by the logistics proponent at Fort Lee refers to 
the same levels of care by their more current joint or NATO terminology, as Role 1 and 2 Army Health 
System (AHS) support. 

72 U.S. Department of the Army, Counterinsurgency Operations. Field Manual (FM) 3-24 
(Washington, D.C: U.S. Department of the Army, December 2006); Examples of Army transformation 
efforts found in: U.S. Department of the Army. The Army 2010 Tactical Wheeled Vehicle (TWV) Strategy> 
(Washington, DC: Department of the Army, 2011). 


48 



in winning on the modern battlefield. 73 In his latest work, he provides a poignant 
example of how Marines using obsolete M60 Vietnam-era tanks achieved the same kill 
ratio as American Anny soldiers using Ml Abrams tanks during Operation Desert Storm 
to illustrate such a point. 74 Such a claim when combined with the inherent organizational 
separateness of the AMEDD, both with regard to doctrine production, and as this text will 
demonstrate its organizational dissimilarity makes synchronization of such medical units 
into larger training events extremely difficult. It is Adams claim that is at the core of the 
matter on the importance of training and lack of innovation. 

While the AMEDD has developed elaborate simulations internal to its 
own organization, it remains challenged to incorporate such simulations into larger 
combat scenarios involving non-medical personnel and which avoid the reliance on 
outdated linear doctrine. Even as late as 2006, one finds such linear battlefield rules 
incorporated into the National Training Center at Fort Irwin, CA, in which “wounded” 
personnel had to travel to each echelon of care in sequence as though the organization 
were fighting on a linear battlefield. 75 It is acknowledged that it is no simple task to 
simulate such realistic training on a grand scale, and it is much more difficult to 
realistically combine such training into simulated asymmetric warfare. By inference 
then it is perhaps even more challenging then is to simulate medical training using 
obsolete vehicles in such a non-permissive environment. 

The AMEDD is extremely adept at conducting training within a lab, or 
conducting a portion of a medical scenario within a larger event, but rarely do such 
exercises work well. With regard to the former, the RAND Corporation notes that when 
such event took place the medical unit did not participate in the simulation in the same 
capacity as the other forces. Instead the medical unit took part in a “tabletop” exercise 
and incorporated technologies of which had not been fielded yet, such as “bio-stasis 


73 Thomas K. Adams, The Army After Next: The First Postindustrial Army (CT: Praeger, 2006), 27- 

28. 

74 Ibid., 28. 

75 Authors observations in which the 3-2 SBCT was assessed at the National Training Center prior to 
deploying to Iraq in 2006. National Training Center Fort Irwin, CA. 


49 



pods” but were assumed to be available on the battlefield of the near future. 76 While 
such forward thinking is clearly admirable, it is apparent that the AMEDD in conjunction 
with personnel at RAND have focused efforts inordinately on the battlefield of the far, 
rather than the immediate future. 

c. Logistics 

In contrast to the medical community, as a branch Logistics has 
demonstrated an impressive capacity to adapt doctrinally to prepare for asymmetric 
warfare. In particular, we find evidence of such learning found within current doctrinal 
publications, in the use of armored logistical support vehicles, and in the techniques 
practiced during training exercises. 

The tenets of logistics are more readily simulated into training events at 
the brigade combat team (BCT) level due to a variety of factors including the reality that 
logistical support based predominantly on forecasting rather than managing crisis. 
During routine training exercises tanks will continue to consume fuel, troops will need to 
be provided food and water, and vehicles will break. Such tasks will require that logistics 
units forecast and distribute such supplies within the combat brigade it supports. While 
such evidence clearly supports that the logistics community has succeeded in innovating 
doctrinally for asymmetric warfare much more than its medical counterpart AMEDD, 
there is an important caveat to be made. Replicating wartime scenarios for the medical 
units is much more challenging task. Innovation within AMEDD in terms of training, for 
the asymmetric reality, demands obvious, major challenges that logistics does not face. 
Due to the emergency nature of much of the work of medical units, it is also much more 
difficult to simulate medical support training than training for logistical support. Medical 
assets such as MEDEVAC helicopters at large training sites such as the National Training 
Center at Fort Irwin California are understandably hesitant to utilize MEDEVAC 
helicopters for training rather than maintain such aircraft on standby in the event they are 
required for transport of real rather than simulated patients. When such aircraft are used 

76 Gary Cecchine, David E. Johnson. Conserving the Future Force Fighting Strength: Findings from 
the Army Medical Department Transformation Workshop 2002 (Santa Monica, CA: RAND Corporation, 
2004), 34. 


50 



during such training it is on a limited basis for a number of reasons in addition to the 
limited flying hours. Evidence supports more instances of logistics personnel being fully 
incorporated into large training exercises. It is acknowledged that some of this is due to 
lesser degree of complexity in that such materials are generally less perishable in nature. 
For example, while transport of ammunition and foodstuffs must be accomplished under 
certain conditions, such supplies do not require the controlled conditions of medicines, 
whole blood, or live patients requiring care enroute. 

F. CONCLUSION 

This section has provided a number of negative outcomes which demonstrate the 
disparity in levels of adaptation between logistics and medical counterparts which 
support combat brigades. While this disparity remains evident in linear combat, 
conditions are exacerbated when laid against the broader range of requirements for 
asymmetric combat. Such disparity is evident in terms of its formal doctrine in which 
lessons learned by logistics leaders seem to be captured and incorporated within not only 
publication dedicated to such tenets, but also within larger Army publications. 

In addition, we find while there are some notable exceptions within Stryker 
brigades and in use of MRAPs, that ambulances used by AMEDD personnel are decades 
behind in terms of battlefield capabilities when compared to logistics vehicles. In 
addition, it is ascertained that while both medical and logistics personnel leam new 
doctrine during wartime and that such learning occurs primarily from the bottom up and 
within combat brigades. While there is almost no academic literature on the subject of 
support forces at this level, the tenets used in the larger study of military innovation 
provide a rich source of theory to apply to this study. Accordingly, the subsequent 
chapter will conduct an analysis of learning as either taking place during wartime or 
peacetime and from either a top-down or bottom-up perspective. This study will also 
advocate that organizational complexity also plays a pivotal role in explaining such 
disparity, between the medical and logistics communities. 


51 



THIS PAGE INTENTIONALLY LEFT BLANK 


52 



IV. AMEDD AND LOGISTICS BRANCH: A THREE-PRONGED 

COMPARATIVE ANALYSIS 


A. INTRODUCTION 

This chapter shifts from describing the disparity between logistics and medical 
units within the support battalion in tenns of adaptation to explaining that disparity. 


"Top-Down" 

Doctrinal Development 

S 

"AMEDD: (isolated from Army) 
Logistics: (integrated with Army) 


Organizational 

Complexity 

AMEDD:(High) 
Logistics: (Low) 



Logistics: Singular 
"Com bat-Focused" 
Career 

AMEDD: Dual Missions 


*■ 


Combat Focused Career 
AMEDD: (Truncated Lifespan) 
Logistics: (Vertically Integrated) 


Doctrinal /Technical 
Innovation 
AMEDD: (Slow) 
Logistics: (Rapid) 



Figure 2. Theoretical Framing and Argument 


The causal argument, summarized in Figure 1, draws on literature reviewed in 
Chapter II. In particular, the analysis applies general theories about military innovation 
and military organizational dynamics to medical and logistics units within combat 
brigades. The analysis rests on Chris Demchak’s insight that, while complexity itself 
creates an inherent learning burden upon an organization, such a phenomenon is seldom 
studied as an independent variable. 77 

A first step in the causal story for why AMEDD has largely failed to innovate is 
to investigate AMEDD’s high level of internal complexity when compared to its logistics 


77 Chris Demchak, Military Organizations, 15-16. 

53 



counterpart. AMEDD’s multi-function character has made innovation difficult both from 
the bottom up and from the top down. AMEDD’s organizational complexity has 
substantially weakened its capacity to learn and adapt. AMEDD is responsible not only 
for moving people and medical equipment during wartime but also for treating those 
people and treating military personnel from all services, their families, and retired 
military personnel in large hospitals in the United States and abroad. 

The complex nature of AMEDD has in part contributed to the isolated way in 
which AMEDD has examined its own doctrine, thereby slowing the top-down learning 
process. On the other hand, the fact that AMEDD is a complex organization has also 
prevented bottom-up capturing of lessons learned at the brigade level. Because AMEDD 
is responsible for many tasks other than staffing low level units during wartime, medical 
officers who gain field experience do so for only a short period of their career, as low- 
ranking officers who to a certain extent, have both little time and little sway in 
influencing doctrine or AMEDD practices. Furthermore, those junior level officers serve 
under a logistics commander, who diverts the lessons learned within the medical 
company into logistics publications, further stifling bottom-up learning. Though the focus 
of this analysis, and the broader thesis, is on AMEDD’s failure to innovate, a final part of 
this analysis will highlight how the complexity of the AMEDD organization has not only 
interfered with AMEDD’s innovation but that it has also impeded the training and 
performance in the field of BSMCs. 

B. KEY INDEPENDENT VARIABLE: ORGANIZATIONAL COMPLEXITY 

The fragmented mission of the AMEDD when compared to the logistics 
community is exemplified by in its two dissimilar medical support missions. One of the 
primary missions of the AMEDD is its mission to provide medical care to the entire 
Anny in addition to family members and retirees, a total of over three million 
beneficiaries both within the United States and abroad. In providing care it must adhere 
to the identical requirements of its civilian healthcare counterparts within the fixed 
medical treatment facilities it maintains both within the United States and abroad. It is 
this role which is the most complex and resource-intensive portion of its support role. In 


54 



order to execute such a support mission it manages and provides oversight to eight major 
hospitals and many smaller medical facilities within the United States. Comparably large 
medical facilities may also be found globally, wherever there are concentrations of 
military personnel and their families. When compared to its respective civilian 
counterparts, the AMEDD, is ranked as the fifth-largest healthcare system globally. 78 
Yet its composition is such that 65% of its manpower is found in the Reserve Component 
of the Army, a fact which adds further complexity to the organization. 79 

A disproportionate emphasis is not surprising these two nearly separate missions, 
and given the fact that its wartime mission of providing care to soldiers in combat, while 
also of importance, is comparatively less complex in terms of resources, people, and 
oversight than the operation of fixed facility hospitals. Consequently, such dual roles 
ultimately divide its manning, focus, and training in a variety of ways which are not 
applicable when compared to its logistics counterparts. 80 In addition to fixed medical 
facilities, it also provides medical care for deployed forces worldwide, both during 
peacetime and wartime. With regard to the latter, the AMEDD is specifically prohibited 
from degrading its fixed facility mission to support its wartime role. 81 

The AMEDD as an institution is one of the most complex organizations within all 
branches of the military, as exemplified by the fact that 31 out of 99 executive agencies 
found within the Army fall specifically under the purview of the AMEDD. 82 Even its 
leadership is “dual-hatted,” with the Surgeon General of the Army responsible for two 
critical leadership roles, as the head of both the AMEDD and the MEDCOM. The 

78 U.S. Medicine: The Voice of Federal Medicine, February 28, 2012. 
http://usmedicine.com/outlook/maintaining-troop-readiness-after-more-than-a-decade-of-war.html 
(accessed February 29, 2012). 

79 Gary Cecchine Cecchine et ah, Army Medical Strategy’, Issues For The Future (Santa Monica, CA: 
RAND Corporation, 2001), 21. 

80 The Military Flealth System Strategic Plan: A Roadmap for Medical Transformation 
http://fhp.osd.mil/pdfs/MFlS%20QDR%20Medical%20Transformation%20Roadmap.pdf (accessed 
February 22, 2012). 

81 Lois M. Davis et ah. Army Medical Support for Peace Operations and Humanitarian Assistance, 
(Santa Monica, CA: RAND Corporation), MR-773-A, 1996. Online at 
http://www.rand.org/pubs/monograph_reports/MR773/index.html (as of July 2006). 

82 Army Resources and Programs Agency, Office of the Administrative Assistant to the Secretary. 
2004. 


55 



AMEDD has been given a wide scope of responsibilities given its size, and each mission 
is manpower intensive, broad in scope, and inherently technical in nature. The only other 
Army organization which provides such a large mission outside the confines of the 
military is the Army Corps of Engineers. 83 

Exacerbating such broad mission scope is the somewhat small size of the 
AMEDD disproportionate to its counterparts. Given its the AMEDD, or those affiliated 
with the Army Medical Regiment is one of the smallest branches, when compared to the 
Logistics Branch as well as other branches of the Army. If reduces numbers to active 
duty personnel and examines aggregate numbers of personnel, the logistics branch 
contains over 149,188 total personnel compared to only 15, 315 within the active duty 
AMEDD. 84 This is due to its specialized nature, that of providing healthcare to military 
personnel, retirees, and family members of military personnel, which are kn own as 
dependents. Similarly, a 2011 demographic study provided by the Office of the 
Surgeon General (OTSG) compares the AMEDD division of labor and the results show 
that over 72% of its officers are found within the MEDCOM, and away from the 
battlefield level of focus, (see Figure 2). Such a figure is exacerbated considering that the 
majority of these officers are assigned in functional medical brigades rather than the 
current 45 active-duty combat brigades within the Army. In the case of the latter we find 
between 10-12 Medical Service Corps Officers per brigade ultimately responsible non- 
clinical medical functions such as medical planning and operations. This number would 
allow for between 320-450 Medical Service Corps officers conducting this function 
throughout the Army at a given time. 


83 Frank Camm, Cynthia R. Cook et at. What the Army Needs to Know to Align Its Operational and 
Institutional Activities (Santa Monica, CA: RAND Corporation, 2007), 248. 

84 Defense Manpower Data Center, Active Personnel Master Files, as of September 30, 2011 
(provided October 31,2011). 


56 




MEDCOM 

NON-MEDCOM 

AMEDD (TOTAL) 

MEDCOM % 

OFFICERS 

11,948 

4,585 

16,533 

72.27% 

ENLISTED 

14,447 

21,967 

36,414 

39.67% 

CIVILIAN 

41,790 

1,223 

43,013 

97.16% 

TOTALS 

68,185 

27,775 

95,960 



Table 1. Division of Labor within AMEDD 55 


C. SEPARATENESS AND TOP-DOWN DOCTRINAL DEVELOPMENT 

The complex nature of AMEDD seems to have facilitated AMEDD’s 
marginalization in relation to the larger Army, which perceives many issues central to the 
AMEDD as simply “medical issues.” This perception of the AMEDD as somewhat 
extraneous is typified by the lack of effort by the DoD to facilitate new ambulance 
production, resulting in a half-dozen costly aborted attempts, spanning a 15-year period. 
Furthermore, and critically, AMEDD’s complexity seems to have been a barrier to 
integrating AMEDD’s top-down doctrinal development with the larger army, thereby 
contributing to AMEDD’s falling behind in doctrinal innovation in relation to the Army. 

As evidence of the AMEDD’s separateness, the AMEDD is part of what consists 
of the three Professional Branches of the U.S. Army, the Judge Advocate General (JAG), 
which also consists of military legal professionals; and the Chaplain Corps. As part of the 
professional branches many AMEDD officers may receive what is known as a direct 
commission to become an officer, and additionally, they are promoted entirely within a 
parallel yet separate, Army non-competitive promotion structure. Such separateness is 
also noted in that the AMEDD is predominantly made up by MEDCOM units which 
manage all medical treatment facilities and, with the majority of the remaining smaller 
portion under field units under FORCES Command (FORSCOM). 86 


85 Data provided by Office of the Surgeon General, as of February 2, 2012. 

MEDCOM includes the vast majority of AMEDD units with the exception of field medical units, 
which includes the portions of medical personnel in brigade combat teams, which fall under U.S. Army 
Forces Command (FORSCOM). 


57 




In order to accomplish such a diverse mission, the AMEDD consists of six 
different corps to include the Medical Corps, Dental, Army Medical Specialist, Nurse, 
Medical Service, and Veterinary Corps, (compared to the three corps which in 2008 
combined under the Logistics Branch) Additionally, within each of these Corps there are 
over 80 different subspecialties when only considering the officer corps. To further add 
to such complexity, we find the challenge of a non-linear rank structure when applied to 
the medical company. The Army, like its sister services is organized in a linear fashion, 
in which lower ranking units are commanded and consist of lower-ranking personnel. 
The brigade commander, or the pinnacle of leadership within the area of study, that of a 
brigade combat team has normally attained the rank of Colonel, and is in charge of the 
4,500 soldiers under his command. His subordinates are of generally lesser ranks, with 
the exception of one company. 

The medical company found within the brigade support battalion may have 
officers which are of equal rank to the brigade commander. In preparation for combat, 
one may find senior medical officers temporarily assigned to the medical company 
through the Professional Filler System (PROFIS) who have also attained the same rank as 
the commander of the brigade itself. 87 This system is used by the Army in order to cost 
manning costs, in addition to allowing medical personnel to maintain their skills by being 
assigned to a hospital until they are needed. This method of manning can be problematic 
if as Demchak suggests, a relationship between learning requirements, doctrinal 
development, and complexity within the current context of combat operations. 88 
Demchak further posits, complexity imposes costs upon complex organizations, and such 
costs can be exacerbated when an organization is constrained. 89 This point is particularly 
poignant when examining the current status of the AMEDD in terms of manning, mission 
scope and complexity. 


87 U.S. Department of the Army. Army Regulation 601-142 Personnel Procurement, Army Medical 
Department Professional Filler System (PROFIS) (Washington, DC: Headquarters Department of the 
Army) April 9, 2007. 

88 Demchak. Military Organizations, 1991. 154. 

89 Demchak, Military’ Organizations, 1991. 163. 

58 



DCDD LIAISON 


COMBINED 
ARMS CENTER 

(CZ) 


i 


COMBAT BRIGADE 


• BRIGADE HEADQUARTERS 
■INFANTRY BATTALIONS 

• CAVALRY REGIMENT 

• FIELD ARTILLERY 


ARMY 
DOCTRINE 

fTRADOC) 

I ^ CASCOM 
OTHER CENTERS LOGISTICS 

DOCTRINE 

(SUSTAINMENT CENTER 
OF EXCELLENCE) 

i 

BRIGADE SUPPORT 
BATTALION 

(SUPPORTSCOMBAT BRIGADE) 


of EXCELLENCE 
(CoEs) 

(EG. INFANTRY, ARMOR, 
ENGINEERS) 


▼ 

MEDICAL 

DOCTRINE 

(AMEDD) 


i 


•H EADQUARTERS COMPANY 
•SUPPLY DISTRIBUTION COMPANY 
•MAINTENANCE COMPANY 

•MEDICAL COMPANY < - 


Figure 3. Top-Down Army Doctrinal Information Flow 


This section analyzes top-down doctrinal development within the Army at large, 
AMEDD, and Logistics and shows how in the case of AMEDD doctrinal development 
takes place relatively autonomously. Figure 2 summarizes the organizational structure of 
top-down doctrinal development in the Army. 

In doing so, it specifically addresses each respective agency responsible for 
producing doctrine, beginning with Training and Doctrine Command (TRADOC), the 
institution tasked with integrating doctrine throughout the Army (refer to Figure 3). Such 
analysis will continue in examining the respective doctrine producing agencies within the 
respective medical and the logistics communities, beginning with CASCOM, the 
respective doctrinal agency within logistics community. This portion will conclude by 
conducting an examination of DCDD and its subordinate organizations, which produce 
doctrine specifically for the AMEDD. 

1. Army Doctrine 

In the case of the Army, Training and Doctrine Command (TRADOC) is Army’s 
lead agency responsible for the ensuring that soldiers, equipment and doctrine are 
synchronized in combat. 90 Its function was to standardize and synchronize training and 


90 Demchak, Military Organizations, 64. 


59 



doctrine throughout the Army. Accordingly TRADOC’s mission is as follows: Training 
and Doctrine Command develops, educates and trains Soldiers, civilians, and leaders; 
supports unit training; and designs, builds and integrates a versatile mix of capabilities, 
formations, and equipment to strengthen the U.S. Army as America’s Force of Decisive 
Action. 91 

Throughout the last few decades TRADOC has continued to streamline and 
integrate its efforts in order to better synchronize doctrine. In 1990 it created two 
subordinate organizations, the CAC (Combined Arms Center), which provides doctrine 
for command and control (C2), and the CASCOM (Combined Arms Support Command), 
which develops multifunctional logistics doctrine at its Sustainment Center of Excellence 
(CoE), to compliment the other CoEs under TRADOC which develop doctrine for each 
combat function. 

However, there exist structural deficiencies manifested as bottlenecks in such 
complex processes. TRADOC has no similarly subordinate organization dedicated to 
medical standardization with the exception of a single individual liaison to integrate all of 
its medical doctrine. 92 Similarly, a CASCOM information briefing denotes its integration 
responsibility to the AMEDD as a simple dotted line on an organizational chart. 93 The 
only other medical staff consists of a small surgeon’s section whose role is as a medical 
advisory staff rather than a publisher of Army-wide medical doctrine. 94 

2. Logistics Doctrine 

Doctrine for the Logistics Branch is produced by Training and Doctrine 
Development Directorate (TDDD) which is a subordinate agency within CASCOM. 
TDDD is similar to its DCDD counterpart within the AMEDD, however it has combined 

TRADOC Homepage, http://www.tradoc.army.mi1/Aboiit.asp#CommandMission (accessed 
January 13, 2012). TRADOC was created in 1973, at Fort Monroe, Virginia, to address the poor 
performance associated with the Vietnam War. 

92 AMEDD Combat Developer Staff Officer Duties and Responsibilities Briefing, Slide 12 (Medical 
Capabilities Integration Center) Joint Base Sam Houston. No date. 

9 3 CASCOM Command Overview Brief, dated 31 August 2011. 
http://www.cascom.armv.mil/documents/CurrentCommandOverview.pdf (accessed March 11, 2012). 

9 4 TRADOC Organization, http://www.tradoc.army.mil/images/pao/TRADOC%20organization.ipg 
(accessed January 11, 2012). 


60 



its three functional areas (transportation, ordnance, and quartermaster) into a single 
multifunctional Logistics Branch since January 2008. It also maintains internal 
organizations with the responsibility of synchronizing the prurient interests of the 
respective subcategories of logistics doctrine such as supply distribution, and vehicle 
repair. 

TDDD contributes both to the Army as well as to higher cross-service, or “joint” 
doctrinal publications. 95 However, there is no respective medical doctrine section. While 
such an omission is less troubling at levels where “pure” medical brigades exist, such 
disjointedness can be telling within a BSB where both medical and logistics units exist 
and for which multiple publications are pertinent. If one compares FM 4-90, Brigade 
Support Battalion, for which the proponent is CASCOM, the tenets of medical doctrine 
are more current both in terminology and content than respective AMEDD manuals 
which provide BSMC doctrine. 96 

3. AMEDD Doctrine 

Army medical doctrine is produced almost exclusively through the Directorate of 
Doctrine and Combat Development (DCDD) at Fort Sam Houston Texas, the location of 
the Headquarters of the AMEDD. It is where the vast majority of training takes place all 
officers and enlisted soldiers who are affiliated with the Army Medical Department as 
part of their functional area. The task of this organization is challenging given its 
separateness from the rest of the Army, and its current levels of manning. DCDD is 
directed by Army regulation to collect observations, insights, and lessons in addition to 
tactics, techniques and procedures (TTPs). It is also responsible for gathering After 


95 U.S. Department of the Army. TRADOC Regulation 71-4. Force Development: Standard Scenarios 
for Capability’ Developments. Headquarters, Fort Monroe, VA United States Army Training and Doctrine 
Command; CASCOM also incorporates input from the Army Medical Department Center and School 
(AMEDDC&S), The Judge Advocate General’s Legal Center and School, Soldier Support Institute, and 
their proponent schools. CASCOM, Planning Data Branch provides logistics planning data (classes of 
supply), per Army Regulation (AR) 700-8. 

96 Headquarters, Department of the Army, FM 4-90, The Brigade Support Battalion, August 2010. 
Conversely the most current (aside from a Draft 11 August 2008) FM 4-02.21, Division and Brigade 
Medical Operations is 15 November 2000. The most current version of FM 4-02.6, The Medical Company 
is August 2002. 


61 



Action Reviews (AARs), in order to effect change to manpower and equipment levels. 97 
Problematic is the fact that while a nearly every civilian within DCDD has military 
experience, none of its veterans within the Doctrine Literature Division of the 
organization have ever served at the brigade combat brigade team level. 98 Such a factor 
is problematic when laid against Dr. Russell’s previous claim that military units draw on 
a synergy of both formal and informal doctrine in wartime. 

There are a number of AMEDD agencies which must coordinate with external 
agencies to facilitate new technologies in support of such new doctrine. In the case of 
ambulance development, TRADOC indirectly synchronizes efforts for the vehicle 
through DoD level programs such as the Ground Combat Vehicle (GCV) or Program 
Executive Office (PEO) Stryker develop the vehicle itself. The ambulance interior 
components are then synchronized through a number of DCDD agencies. The Medical 
Materiel Systems Division (MMSD) is responsible for the assisting in the development of 
a number of military ambulances such as the Stryker MEV, various MRAP ambulances, 
and the Ml 13 tracked ambulance replacement, the Bradley Fighting Vehicle AMEV. It 
accomplishes such tasks in conjunction with other internal organizations such as the 
Medical Capabilities Integration Center (MCIC) whose function is to develop, coordinate 
and integrate force modernization processes within the AMEDD. In addition, it 
coordinates with TRADOC, the Headquarters, Department of the Army (HQDA), as well 
as its sister services. The Medical Materiel portion of DCDD and designs and test the 
interior medical portions of the vehicle. 

Additional deficiencies are noted, as noted in Field Manual 4-0, Sustainment, 
which attempts to bridge Army logistics with joint Sustainment functions. Within the 
publication there are key discrepancies when compared to the narrower tenets of Army 
logistics. Army Health Support (AHS) is not considered a logistics function, yet at the 
higher level it becomes incorporated into the functional area of Sustainment. 
Compounding this is while AMEDD units actually execute medical support at both 

97 Headquarters, Department of the Army, Army Regulation 11-33, paragraph 3-la. 

98 Cecily Price, Action Officer Slide Presentation, DCDD, Slide #6, Joint Base Sam Houston, San 
Antonio, Texas. 


62 



levels, such efforts at the brigade combat team are primarily orchestrated by leadership 
affiliated with the logistics branch with input by clinical medical leadership. The 
implication of these divided responsibilities and leadership affiliation is the potential for 
disjointed efforts, inherent tensions due to misunderstanding of medical operations, and 
possible medical support degradation." 

An examination of AHS principles within doctrine reveals notable differences in 
tenets if compared with the previous logistics function. Specifically, if one examines the 
tenet of mobility as defined by the AMEDD within Table 2: 


Tenet 

Definition 

Source 

Mobility: 

The mobility and survivability of medical units 

FM 4-0 

(Sustainment 

and medical platforms must be equal to the 

(April 2009) 

Propenency) 

forces supported. 


Mobility: (AMEDD 

CHS units must have mobility comparable to 

FM 4-02.6 

Proponency) 

that of the units they support. Mobility is 

measured by the extent to which a unit can 

move its personnel and equipment with organic 

transportation 

(August 2002) 


Table 2. Comparison of Survivability and Mobility Definitions 


Of critical importance, survivability is not even mentioned as fundamental in 
which the AMEDD is the proponent for specified manuals. This omission is particularly 
telling as we have previously noted in the analysis of the unarmored, unarmed, and slow 
ambulances currently found in current conventional Army inventories through 
conventional implementation methods, and compare them to their armored logical 
support counterparts. This issue is even more revealing when one examines potential 
ambulance prototypes currently in development to replace interim MRAP efforts. These 


" U.S. Department of the Army, Change 1 (Feb 2011) to Field Manual FM 3-0 Operations , 1-1. 

63 








new vehicle designs repeat the mistakes of the past being either described as unarmored 
(JLTV ambulance) or just as slow as their Vietnam-era predecessors (BAE systems 
AMEV) as discussed in Chapter III. 100 

As demonstrated, a potential reason for why medical doctrine (technological 
advancement in particular) has seemingly only progressed through outside agencies is 
that unlike logistics and other battlefield functions, the medical community’s doctrine is 
developed in somewhat isolation from the larger army, as well as from its logistics 
counterparts. It is evident both of the latter organizations have taken major steps toward 
innovation for counterinsurgency in terms of doctrine as well as new technology to 
support such new doctrine. Demchak states a likely rationale for such sluggish 
adaptation: “For complex systems it takes more time to move significantly upward on the 
learning curve.” 101 While this separateness in doctrinal development explains a portion of 
sluggish adaptation, it does not fully account for deficiency as posited by Dr.Russell, who 
suggests that such top-down efforts are only a portion of the innovation process, and that 
leadership at the combat brigade level used an amalgam of formal doctrine, informal 
battlefield learning, and new mission requirements to create an appropriate set of 
procedures for combat conditions. 102 Accordingly this study must delve further to find 
additional reasons for the causal nature of such a gap. 

4. AMEDD: Lessons Learned, Lessons Lost (Bottom-Up) 

In addition to the isolated way in which formal AMEDD doctrine from the top- 
down is hindered, a second factor explaining AMEDD’s failure to innovate is found at 
the lower levels in Anny hierarchy which affect whether or not bottom-up learning is 
captured in formal doctrine. As a foundation for this discussion, it is critical to establish 
how, due to AMEDD’s complexity, few AMEDD personnel gain experience in combat 
settings, and those who do are not there for very long. 


100 Army-technology.com, Projects: JLTV, www.Army-technology.com/projects/jltv (accessed 
February 12, 2012). 

101 Demchak, Military Organizations, 18. 

102 Russell, Innovation, Transformation, and War, 53. 


64 



Career paths of AMEDD officers are truncated when compared to their logistics 
counterparts. This is due to the specialized nature of medical care in which there are very 
few assignments for AMEDD officers within combat brigades when compared to the 
aggregate number of positions found throughout the larger AMEDD institution. Such 
areas include positions within functional medical brigades, manning of hospitals and 
medical clinics, and in the large staffs assigned to Medical Commands or teaching 
centers. While there notable exceptions in which medical operations officers may be 
assigned to higher levels within the support battalion itself, to include commanding the 
BSB itself, the instances of AMEDD officers filling such positions is not the norm. 103 

In isolating the BSMC, we find it is by far the smallest of the sub-organizations 
within the BSB, consisting of approximately 67 soldiers and being roughly a third of the 
size of its respective supply distribution and maintenance companies. BSMCs are 
organized to support their combat brigade consisting of approximately 4,500 soldiers, 
which are the modern building blocks of the U.S. Army’s conventional force structure. In 
current conflicts, such as those in Iraq and Afghanistan, where support personnel and 
infantry units are closely intenningled within the areas of conflict, we find the medical 
company simultaneously operating in multiple capacities: providing medical support to 
their brigade, as their mission dictates, providing support to large numbers of other teams 
without their own medical units, treating military personnel and civilians from other 
nations, and treating U.S. civilian contractors. In addition, BSMCs are routinely called 
upon to conduct operations in multiple locations simultaneously (“split-based 
operations”). This task of dividing the company into two or more geographic locations is 
a significant challenge for such medical companies, as they do not have adequate 
manpower or equipment levels (such as duplicate pieces of specialized medical 
equipment) to enable such efforts. More generally, BSMCs continue to be manned, 
equipped, and trained as though they were to provide support from generally secure areas 

103 Comparatively few allocations exist for junior AMEDD officers to attend the 20 week Combined 
Logistics Captains Career Course (CLC3) at Fort Lee, VA. Respectively, few AMEDD officers may 
prolong their career path within combat brigades by filling logistics officer positions by virtue of a “hybrid” 
multifunctional logistician career path. There are mixed opinions within AMEDD senior leadership, some 
of which discourage officers from attending the course in lieu of the AMEDD Officers Advanced Course. 


65 



rather than many some instances when they even operated from Iraqi FOBs, providing 
their own security and far from U.S. forces. 104 

Using currently available forecasts and publications to include the Quadrennial 
Review for 2010 and the 2011 Army Posture Statement establishes a baseline of the 
requirements of medical and logistics units at lower levels. 105 The current status of the 
AMEDD within the BSB can be evaluated using those guidelines. Once the degree of 
adaptation has been detennined it will be possible to better quantify and articulate current 
shortfalls and project the future capabilities requirements to adapt to a broader range of 
battlefield conditions. 

In some cases, such separateness not found in the Logistics Branch is due to 
external constraints of which the AMEDD has little control. A portion has its origins in 
centuries-old restrictions by medical personnel engaging in combat other than to defend 
patients. Such requirements have been codified under international humanitarian law 
(IHL) and the by the Geneva Convention, which identifies medical personnel, equipment 
and facilities as noncombatants and hors de combat or “outside the fight.” 106 
Traditionally such differentiation was honored by Western armies during both World 
Wars. However, such a longstanding distinction has become somewhat irrelevant within 
current combat operations in which the enemy deliberately attacks medical personnel and 
their vehicles, even using the red crosses on ambulances as references for aiming points. 
Such violations create tension between medical personnel assigned to combat brigades 
who disproportionately become targets of insurgents, and the AMEDD which provides 
formal oversight of IHL and the Geneva Convention. Specifically, medical personnel are 

104 The author, in which his medical company split during combat operations in Baghdad in 2003 and 
Baqubah in July 2007, where a portion of the company provided medical support from an Iraqi FOB (FOB 
Gabe) in Diyalah Province, utilizing self-securing escort with Mil 14 guntmcks, .50 caliber M2 
machineguns, AT4 antitank weapons, and other weapons which are not doctrinally used by medical 
personnel. 

105 Both nonacademic directives such as the current Quadrennial Defense Review’ February 2010, in 
addition to sources from the realm of the practitioner, such as General Eric Shinseki, suggest the need to 
operate under “full-spectrum” battlefield conditions. This broad range of capabilities includes both non¬ 
linear and linear combat operations, asymmetric warfare, and humanitarian relief operations that may be 
performed concurrent or consecutively. 

106 Convention (I) for the Amelioration of the Condition of the Wounded and Sick in Armed Forces in 
the Field. Geneva, Article 6 (August 22, 1864), 134. 


66 



still required to act according in adherence to international law, and may not use heavy or 
“crew-served” weapons, nor may they fire at the enemy except in self-defense. In 
practice, however, we find legal attempts to bypass such constraints, and in which 
medical personnel have successfully petitioned to mount small weapons to their 
ambulances for the purposes of simply providing for their own self-defense and that of 
their patients. 107 

5. Logistics 

Aside from the headquarters element, there are two other commensurate 
functional organizations which exist at the same level as the medical company within the 
support battalion. In contrast to the BSMC case, we find the U.S. Army logistics 
community better suited to its combat mission based on current manpower allocations, 
and more suitable types and amounts of equipment, both possible due to the central 
orientation of Logistics toward a single function: to provide supplies and maintenance to 
troops, mainly in training and combat situations. Such adaptation has allowed such units 
to more effectively provide split-based operations in support of combat operations, a task 
also routinely required of this type of unit during deployments. Comparably sized 
logistics units have seen advances in manning, modular organizational structure, and 
equipment, thus allowing such units to support combat forces more effectively in 
multiple locations. Russell provides a unique insight which sheds light on innovation 
within the BSB and de facto to the medical company. He suggests part of innovation is 
found in the combat brigade creating new missions and by the fusion of combat and 
support units into new missions not found during peacetime. 108 Such new missions were 
routinely the case in which the medical company, driven by its logistics leadership and 


107 Kevin C. Kiley, Lieutenant General, Surgeon General of the Army Memo for Defense of Medical 
Units, Personnel and Patients Under Their Care Under the Provisions of the Geneva Convention, 
Memorandum For U.S. Army Medical Center and School (Washington, D.C: Falls Church, VA, January 
21,2007). 

108 Russell, Innovation, Transformation, and War, 53. 


67 



participating in missions not routinely practiced prior to deployment such as the convoy 
security missions, detainee medical coverage, and attachment of female medics to 
infantry units for extended periods. 109 

At the lowest level, an AMEDD affiliated officer commands the BSMC. In turn, 
the BSMC is nested within its higher BSB. Because of this command structure, we find 
that a large portion of lessons learned are published within journals regularly known to 
the logistics community. The vast majority of support battalions are commanded by 
officers trained as multifunctional logisticians who encourage their subordinate 
commanders to publish solely within logistics publications—such as Army Sustainment 
Magazine 110 —rather than journals regularly accessed by the AMEDD such as the 
AMEDD Journal. This in combination with the infonnal wartime transfer of non- 
doctrinal knowledge between BSMC leadership as they assume the wartime mission 
suggests lessons learned by BSMCs in the field do not trickle up to AMEDD institutions. 

Evidence supports this inverse correlation between such topics being found in the 
non-medically oriented publication. A search of Army Sustainment magazine back issues 
dating to November-December 1996 (96 issues) reveals a total of 41 articles related to 
medical topics, particularly on medical logistics, with a secondary emphasis on medical 
operations within medical units, to include support battalions. Consequently, these 
lessons are unlikely to lead to high-level changes within the medical community, either 
doctrinally or in tenns of technological innovation. 

Similar to the logistics community, there exist magazines outside the sphere of 
control of either the AMEDD or logistics communities which publish medical articles 
and address concerns of a broader non-medical audience. An example includes the 
periodical Joint Forces Quarterly which published an article on the Golden Hour 


109 Authors experiences, while assigned as medical company commander in Baghdad and Baqubah, 
Iraq, 2006-2007. 

110 A rm y Sustainment Magazine, is published bi-monthly at Army Combined Arms Support 
Command which is located at Fort Lee, Virginia, the home of the Logistics Corps. It was created in 1969 as 
the official magazine of Army Logistics. The magazine was formerly published under the name Army 
Logistician until 2009. 


68 



Standard of medical care in 2006. 111 Military Review also recently published an article 
applicable to practitioners of battlefield medical care, “Medical Operations in 
Counterinsurgency.” 112 

The AMEDD maintains its own periodicals that publish on a broad range of 
medical topics which reflect its diverse audience. While somewhat subjective in terms of 
analysis, these periodicals understandably possess a lesser degree of usefulness for 
AMEDD personnel assigned within combat brigades when compared to Sustainment 
Magazine. The U.S. Army Medical Department Journal provides a forum for the entire 
AMEDD, and accordingly its content ranges from articles on topics purely clinical in 
nature, to operational and deployment issues. 113 A searchable database with archived 
articles from 1989 to the present date of publication reveals approximately 20 articles that 
deal with either Iraq or Afghanistan from the standpoint of information applicable to 
concrete planning and operations rather than from a clinician’s perspective. In addition, 
The Mercury provides similar information albeit from primarily clinical or historical 
perspectives. The content of articles found within both AMEDD periodicals are 
understandably both diluted in terms of content when compared to medical topics 
addressed within logistics publications as the articles within the AMEDD journal and the 
Mercury cover a much broader range of medically-oriented topics given the diversity of 
highly technically-oriented career fields within its ranks. 

While the logistics community has also been challenged, it has managed to 
overcome such obstacles over the last decade. Conducting logistics operations on an 
asymmetric battlefield and ad-hoc procedures for mitigation of shortfalls in terms of 
manpower are routinely found in periodicals and occasionally within academic works. 
Dr. Russell notes in his case study of the 172d Stryker Brigade in Mosul, that such 
change can be a challenge for an institution when lessons learned are a departure from 

111 Guy S. Strauder, “The Golden Hour Standard,” Joint Forces Quarterly, 41, 2 nd Quarter (2006): 
60-67. 

112 Rice, Matthew S. Jones, Omar J. Jones. “Medical Operations In Counterinsurgency Warfare: 
Desired Effects and Unintended Consequences," Military’ Review (June 2010): 47-57. 

113 The Army Medical Department Journal is a quarterly publication and has been published since 
1922 as the Bulletin of the U.S. Army Medical Department. 


69 



formal doctrine. However, in the limited portion of his study devoted to battlefield 
logistics, he notes that logistics personnel were able to react in combat by realigning its 
personnel and practices to complexities of the environment. 114 This author agrees having 
replaced that same unit in the same location. 

However, with logistics we find these adaptations previously found within 
periodicals are now codified within formal doctrine and outside the purview of the 
logistics community to address the complexities of providing logistical support within the 
context of current conflicts. 115 However, such alignment of doctrine has been a 
challenge for the AMEDD in that much of its doctrinal focus is understandably oriented 
at echelons above the brigade combat team in their addressing adaptation. 116 

Such limited focus and expertise within higher levels of the AMEDD is 
exacerbated when medical leadership have a limited portion of their career within a 
combat brigade, leaving little time for such bottom-up lessons learned being captured. 
Demchak presents a similar allegory in her discussion of frequent enlisted personnel 
turnover enlisted and the issues in maintaining the M1A1 main battle tank. 117 In the case 
of the AMEDD, the complexity of the new tank can be substituted by the complexities of 
associated with medical care, which are more complex than logistics. In addition, 
battlefield medical care must be provided within the same stringent parameters as within 
a fixed medical treatment facility regardless of conditions. This disparity in terms of 
complexity and acceptable parameters for accuracy in tasks once again suggests a larger 
knowledge burden on the part of the AMEDD. A variety of academics ultimately suggest 
that such complexity may have unintended results which manifest themselves in a variety 
of ways. This is particularly true in highly technically-oriented organizations, such as the 
AMEDD. 118 This work demonstrates from the lens of theory in addition to its 

114 James Russell, Innovation, Transformation, and War, 162. 

115 Headquarters, Department of the Army, Counterinsurgency, Field Manual 3-24 (Washington, 

DC: Department of the Army, December 2006), 8-1. 

116 Academy of Health Sciences. U.S. Army. Health Service Support Futures Medical Force 2000, 
White Paper. Final Draft. (Fort Sam Houston, Texas: Academy of Health Sciences, March 1989). 

117 Demchak, Military Organizations, 169. 

118 Ibid., 171. 


70 



reinforcement by practical anecdotal evidence there exists impediments associated with 
capturing bottom-up efforts in addition to already noted top-down issues. 

D. CONCLUSION 


This chapter has demonstrated both the inherent complexity of the AMEDD and 
how that complexity has affected its ability to innovate; both from the top down and from 
the bottom up. Several authors, including Chris Demchak and James Russell, provide 
insight into such phenomenon. Demchak hypothesizes that a complex organization must 
be able to both accurately identify a problem and provide a rapid response. However, she 
ultimately suggests that as the complexity of an organization increases the less likely it is 
to be able to provide either an accurate or timely solution. 119 When such analysis is 
applied to the AMEDD many authors, including Demchak, suggest the organization will 
remain challenged at controlling its own innovation, suggesting instead it may better 
suited to simply manage itself. 120 


119 Demchak, Military Organizations, 134. 

120 M ar tin Landau and Russell Stout Jr., “To Manage is Not to Control: The Folly of Type II Errors,” 
Public Administration Review 39 (March-April, 1979): 148. 


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72 



V. CONCLUSION 


A. SUMMARY 

The last two decades of non-linear warfare have necessitated widespread demands 
for doctrinal innovation throughout the United States Army, to include medical and 
logistics units that support combat operations. Since Operation Desert Storm there have 
been several reports clearly identifying shortfalls within the AMEDD regarding its ability 
to support combat forces during combat operations. Such documents specifically 
addressed the need for the AMEDD to adapt technologically, both in tenns of its 
survivability and agility in order to better support combat operations. 121 

At the practitioner level, the BSMC leadership within the support battalion has 
innovated to address shortfalls and such critical infonnation is being routinely passed 
between the leadership of these units during wartime. Yet, such lessons are not being 
fully captured at the fonnal institutional levels within doctrine, to include technological 
adaptation. Stephen Rosen provides insight into this phenomenon in his differentiation 
between organizational innovation and organizational learning. In doing so, he suggests 
that while units may innovate during wartime to accomplish their missions, organizations 
must then internalize such changes and transfer these lessons into institutional 
knowledge. In order to accomplish this task, organizations must possess self-awareness 
and be introspection in determining if in fact they are accomplishing their mission. 122 

The Army has been able to mitigate such ongoing capabilities shortfalls within the 
AMEDD through nontraditional procurement methods, with bottom-up efforts facilitating 
vehicles such as the newer MRAP vehicles and their ambulance variants. Top-down 
efforts have produced the Stryker MEV, which fills such capabilities gaps solely within 


121 Studies by the RAND Corporation have included: Perry, Walter , Bruce Pirnie, and John Gordon 
IV. The Future of Warfare Issues From The 1999 Army After Study Cycle. Santa Monica CA: RAND 
Corporation, 2001; In addition, a Government Accounting Office report also provided detailed insight in 
which the AMEDD must adapt: General Accounting Office, Wartime Medical Care DoD is Addressing 
Shortfalls, but Challenges Remain (Washington, DC: U.S. General Accounting Office, September, 1996). 

122 Rosen, Winning the Next War, 35. 


73 



Stryker brigades. In spite of these interim solutions, U.S. Army forces continue to 
maintain an unarmored wheeled ambulance (M997) and a lightly armored, yet slow 
Vietnam-era tracked ambulance both of which make up the bulk of its ambulance fleet. 

This thesis has demonstrated that such technological failings at innovation are 
symptomatic rather than causal. Instead, such issues stem from the organizational 
complexity of AMEDD, part of which is manifested as isolation. Due to such 
disassociation from the larger Anny, its shortfalls are perceived as simply “medical 
issues” while in fact many such issues fall clearly within the purview of the larger Army 
or the DoD who are ultimately responsible for producing new military vehicles using 
input from subject-matter experts within the AMEDD. However, even these vehicles 
which are technologically optimized for capabilities within contemporary conflict have 
not been synchronized with requisite innovation in the form of new medical support 
doctrine. 

Recently, the new the new Surgeon General of the Army, as the head of the 
AMEDD, vocalized such a longstanding concern in her urging of AMEDD leadership to 
become more introspective with regard to innovation. 123 This thesis has echoed such 
concerns which have originate from both internal and external agencies. In doing so, it 
has provided several negative outcomes with regard to both doctrine and technology and 
demonstrated that such unfavorable outcomes with regard to innovation within the 
AMEDD stem from its nature as one of the most complex organizations throughout the 
United States Army. 

The isolated nature of the AMEDD organization is multifaceted, existing 
structurally in its manning, to include the truncated life cycle of medical personnel within 
combat brigades. This inherent separateness is readily apparent in the AMEDD being 
organized under one of the three professional Branches of the Army, in which personnel 
are promoted and managed separately from the rest of the Army. The life cycle of both 
medical providers and medical operations officers is much different than that of their 

123 Patricia D Horoho, Lieutenant General, 43 ld Surgeon General of the Army and the U.S. Army 
Medical Command. Commander’s Thoughts: On Leadership and Strategy ; (Falls Church, VA: Office of the 
Surgeon General, January 30, 2012). 


74 



logistics counterparts. The majority of medical personnel are formally dedicated to 
manning fixed medical facilities rather than being assigned to roles within combat 
brigades where during peacetime or when not deployed there is a much lesser need for 
their skills. It is only when combat brigades are in the final preparation phases of 
deployment that physicians are removed from such fixed facilities to participate in such 
training. This dual mission is unavoidable however in that medical skills are extremely 
perishable and medical providers must operate in such a cycle to maintain medical 
credentials and requisite skill levels. 

A similarly short assignment within combat brigades is also commonplace when 
one examines AMEDD leadership. When compared to their logistics counterparts there 
are only a small number of positions at senior levels for such officers and such positions 
represent a comparatively smaller time period in the officers life cycle. This narrower 
window in their life cycle allows for a lesser degree of input with regard to innovation 
before such officers move to higher levels in functional medical brigades. 

It is perhaps this structure inherent within combat brigades that may hinder 
interactions with both the Logistics Branch and the larger U.S. Army. In contrast to the 
low level of technical innovation in the medical community, one finds that within its 
logistics counterparts there was effective technical innovation, due to its robust 
integration within the larger Army at all levels both internally within CASCOM, as well 
as in its structural integration to TRADOC. It is acknowledged that the AMEDD does 
facilitate integration into these organizations by maintaining a liaison at TRADOC, it is 
the only sustainment function which does not have requisite amounts of formal 
representation at the same levels to within either organization. 

Not surprisingly, one finds that within the logistics community bottom-up efforts 
have been captured and transferred to its institutional levels. However, such disparity in 
tenns of innovation both in terms of technology, and new doctrine stem from the nature 
of the AMEDD as an inherently complex organization and its more complex mission 
which requires the medical treatment and safe evacuation of wounded personnel off the 
battlefield. 


75 



B. IMPLICATIONS 

This thesis provides discourse based on the study of complexity within military 
organizations. Its particular significance is in its bridging a body of literature which 
examines innovation almost exclusively within combat units and successfully applied 
such literature to units which support such operations. In doing so it provides new insight 
into such support organizations while simultaneously reinforcing existing literature on the 
subject in demonstrating its utility in other similar applications. 

In addition to its contribution to complexity within military organizations in a 
theoretical sense, it also has the potential to be of significance in its more pressing, 
practical application given the tenuous situation of a nation decisively engaged with a 
clearly dedicated foe. If indeed the AMEDD has not been able to challenge its own 
doctrine, this raises some troubling issues, as it may jeopardize the lives of injured or sick 
soldiers and civilians. Only by learning how to change the way the Army Medical 
Department is equipped, manned, and trained, is it possible for the AMEDD to better 
support a broader variation of combat operations, and ultimately saving more lives in the 
process. 

The thesis suggests that the organizational structure of the AMEDD in relation to 
its parent organization, the United States Army contrasts sharply when compared with its 
logistics counterpart. It is this organizational complexity which is the causal variable and 
which explains the pervasive issues regarding the AMEDD’s efforts to effectively 
innovate its medical doctrine at the combat brigade level. It follows that in order to 
improve AMEDD’s capacity to innovate it would be desirable to either reduce the 
organization’s complexity or somehow change the working of the AMEDD organization 
in some other way to overcome the barriers posed by organizational complexity. 


76 



However, as a number of authors across a variety of disciplines suggest, organizational 
innovation is perhaps one of the most challenging types of innovation in which to effect 
change. 124 

Organizational theory suggests that the AMEDD will be challenged in its efforts 
to affect change upon itself. In particular, its own complexity creates a large number of 
rogue sets, or unexpected outcomes as it effects change. A potential way to mitigate such 
risk, or to increase accuracy is to reduce complexity. With regard to the AMEDD there 
are a number of areas which are inherent conditions and others in which it can effect 
change. The AMEDD should examine areas in which to exploit control, such as 
integration into other agencies and developing methodologies for capturing lessons 
learned by practitioners. Conversely, it should avoid application of resources where 
structurally it cannot effect change and in which such efforts should be limited. Such an 
example is the numbers of medical leaders within combat brigades. The mission of 
combat brigades is such that the majority of its forces will continue to consist of tasks 
related to destruction of enemy forces. Similarly, the composition of such forces is such 
that medical personnel are highly specialized, thus requiring less medical personnel when 
compared to the number of logistics counterparts. This ratio will preclude long career 
life cycles by medical personnel at the combat brigade level. Consequently, resources 
should be directed to areas in which are not structurally inherent conditions and which are 
most likely to produce results with regard to innovation. 

1. Facilitate Increased Integration with Logistics Counterparts 

Clearly, the AMEDD is challenged with both resources and manpower and must 
prioritize and maximize both in order to facilitate innovation efforts. A methodology for 
achieving such goals could be its emphasis in two related areas. First, the AMEDD must 
facilitate better integration with its logistics counterpart within CASCOM, TDDD, and 

124 Amy Zegart, as one of proponents of New-Institutionalists theory, hypothesizes institutions will 
be difficult to change structurally once implemented, unless precipitated by drastic external events. James 
Russell addresses innovation and adaptation within ground forces, suggesting that while units use formal 
doctrine as a reference point they modify as needed to optimize operations in combat. Douglas MacGregor 
routinely writes on structural change in response to changes in combat conditions, but over the course of a 
decade has noted that such pervasive change is difficult. 


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the Sustainment Center of Excellence at Fort Lee. Second, it must better integrate within 
the larger Anny institution. Such disparity is clearly evident when comparing its own 
published doctrine when compared to more current medical doctrine published by 
logistics counterparts, in addition to higher level sustainment doctrine. By articulating its 
shortfalls with an organization which is better integrated its doctrine into the combat arms 
community it can perhaps facilitate better synchronized efforts and create a louder voice 
with regard to its inability to support combat forces with more than either interim or risky 
solutions. From a practical standpoint the AMEDD must find ways to facilitate its formal 
integration into its logistics counterparts at and TRADOC and at CASCOM both of 
which are in Virginia. By changing organizationally the organization can through fusion 
of its logistics counterparts. 

If one examines recent trends in the logistics community it appears that the 
organization is adopting such techniques to better facilitate use of its own resources and 
coordination efforts. In 2007, the leadership of two U.S. Transportation Command 
(TRANSCOM) and U.S. Joint Forces Command (JFCOM) formally announced the goal 
of combining their efforts in their signing of a joint vision statement to align their efforts. 

In addition, Army-level publications addressing transformation efforts exclude 
any mention of medical transformation. If one examines the Elements of Transformation 
2004, Fire, Maneuver, Protection, C2&C, ISR and Logistics are all separately addressed. 
Yet Medical transfonnation is not even addressed within a sub-category of logistics or 
sustainment within the publication. 125 Such omission occurs frequently with regard to 
medical transformation efforts, as it seemingly “falls between the seams” of logistics and 
larger Anny-wide efforts. There is little to no focus on medical transformation found 
within other transformation documents suggesting that its own isolation has marginalized 
the organization. 126 


125 Director, Office of Force Transformation “Elements of Defense Transformation” (Office of the 
Secretary of Defense, October 2004), 12-13. 

126 office of the Deputy Chief of Staff, 2004 United States Army Transformation Roadmap, July 
2004; and the 2010 Army Tactical Wheeled Vehicle Strategy’, 2010. 


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Perhaps the most difficult of tasks, the AMEDD, must also better differentiate 
between invention and innovation. As Klaus Knorr and Oskar Morgenstem suggest, 
invention can be seen as the creation of new systems and technologies and innovation as 
the decision on which of those inventions to implement. 127 In the case of the AMEDD, 
it must narrow the scope of development efforts if any of them are to come to fruition. 
While the AMEDD has been able to develop numerous concepts such as possible use of 
drone aircraft to evacuate patients, telemedicine or surgery using robotic anns over 
remotely over vast distances, yet it is unable to facilitate the development of a viable 
annored ambulance after a two decade period. 

2. Prioritization of Ambulance Production 

Only after addressing the aforementioned structural changes, in which it better 
integrates and prioritizes its efforts, can it then move forward to facilitate shortfalls in 
other areas. Integration will allow the AMEDD to better articulate its vehicle shortfalls 
which are desperately in need of modernization in order to adequately support operations 
across the full spectrum of conflict. In order to mitigate such risk, the AMEDD must 
develop requisite doctrine and vehicles designed for supporting both linear and non-linear 
combat. Its can then regulate its current unarmored ambulances to use in environments 
where it is less vulnerable, to include rear areas in linear conflict, inside forward 
operating bases in asymmetric warfare, or finally used solely within the confines of the 
United States in support of natural disasters. 

Clearly, such a requirement has proven to be problematic as the AMEDD has 
been unable to facilitate production of such vehicles by the DoD, even after two decades 
of efforts. Such an external constraint was succinct in a 1996 GAO report, emphasizing 
that efforts must be addressed at higher levels, and not simply within the medical sphere 
of influence. Additionally, the report specifically noted funding allocation was also seen 
as hampering efforts to modernize, with none of the shortcomings being allocated extra 


127 Klaus Knorr, and Oskar Morgenstern, Science and Defense: Some Critical Thoughts on Military’ 
Research and Development, Policy Memorandum No. 32, Center of International Studies, Woodrow 
Wilson School of Public and International Affairs, Mimeo (New Jersey: Princeton University, 1965), 3-4. 


79 



funding for corrective action. 128 Ultimately, the AMEDD must better envision and 
articulate to the DoD its anticipated threat environment, and better articulate such 
requirements to the larger U.S. Army. Then, it must secure and allocate resources 
appropriately to correct current deficiencies in survivability and maneuverability in order 
to adequately mirror combat forces, rather than allowing the anticipated production of yet 
another unarmored ambulance in the JLTV program and a future slow tracked ambulance 
which is a modified thirty year old modified Bradley Fighting Vehicle (BFV). 129 Such 
vehicles are expensive and offer little in the way of new capabilities. 

In addition, this study suggests there are externally driven problems within current 
acquisition methods for producing ambulances. These problems originated well prior to 
either the Stryker MEV, or the even MRAP evacuation vehicle. While the Stryker 
program was a top-down effort, it was clearly unconventional, taking place at both an 
accelerated pace at each step, and it also bypassed several roadblocks in efforts to 
produce the vehicle currently used by the Stryker Brigade combat Team, and which 
continues to undergo subsequent transformations to counter the increasingly complex 
IED threat environment. 

3. A Case of Viable Alternatives (Air MEDEVAC) 

Another doctrinal impediment to BSMC adaptation is perhaps the uncontested use 
of rotary-wing medical evacuation over the last two decades. The use of such aircraft is 
clearly advantageous, both in terms of speed and risk when compared to ground 
evacuation, as helicopters may bypass rough terrain features as well as enemy forces on 
the ground. However, it can be argued due to such longstanding reliance on air 
MEDEVAC assets have been at the expense of ground evacuation modernization. It also 
perpetuates the erroneous assumption that in future conflicts the United States will 
always maintain overwhelming air dominance, or at least air superiority, thus allowing 
unconstrained air MEDEVAC use. Rotary wing aircraft are subject to a secure 

128 “Wartime Medical Care DoD is Addressing Shortfalls, But Challenges Remain,” Washington, DC: 
United States General Accounting Office, 1996), 8. 

129 Andrew Feickert, Joint Light Tactical Vehicle (JLTV): Background and Issues for Congress 
Congressional Research Service, January 3, 2012. 


80 



Helicopter Landing Zone (HLZ), which can be problematic in a three-dimensional 
urbanized environ. A case which suggests the nature of this problem is the well- 
publicized case operations in Somalia in which two MH-60 helicopters crashed after 
coming under RPG and small arms fire and in which no annored ambulances were 
readily available to evacuate wounded personnel. 130 In addition, they are subject to 
weather and reduced visibility to include, dust, and darkness which has precluded flights 
and forced the use of antiquated ambulances in medical support planning and caused fatal 
crashes of helicopters in reduced visibility. 131 The AMEDD has placed considerable 
weight upon the ability of air evacuation, and is challenged to facilitate innovation of its 
ground ambulance capabilities. In order to mitigate such risk of a non-permissive 
environment in which the Army may not possess air dominance as it currently does, the 
DoD must develop and field the requisite numbers of armored ground ambulances. 
Contingency planning necessitates that in the event air assets are not available, ground 
assets should be able to perform such tasks, and this is not always the case, especially for 
units which do not possess Stryker MEVs or MRAP ambulances. 

C. RECOMMENDATIONS FOR FUTURE RESEARCH 

While modest in scope in terms of its focus on the lowest levels within the combat 
brigade, this exploration of the challenges in innovation within the AMEDD suggests the 
need for an analysis of a much larger in scope. While this study did elicit key data from a 
number of organizations, such as the AMEDD, the RAND Corporation, and several GAO 
reports, it did not gather the individual opinions of the leadership and practitioners within 
applicable Army organizations. A future study could include the opinions of medical, 
logistics, and combat arms personnel in order to detennine additional shortfalls in support 
as well as perceptions, which could ultimately guide further efforts. 


130 Kenneth Allard, Somalia Operations: Lessons Learned (Washington, D.C: National Defense 
University Press, 1995). 

131 Author, in which one of his medics Army Sergeant Steven P. Mennemeyer of Granite City, Illinois 
was killed when his UH-60 Blackhawk crashed into a lake in the vicinity of Korean Village in Rubtbah, 
Iraq on August 8, 2006, Steve Mennemeyer was assigned to the 82nd Medical Company (Air Ambulance), 
Fort Riley, Kansas. 


81 



It is clear there is still a critical need for modern doctrine and an annored 
ambulance in anticipation of potential future threats. Instead, we continue to see a failure 
for such a modernized vehicle come to fruition over the last two decades of energy and 
funding efforts, of which is in its second large-scale development cycle in the GCV and 
JLTV programs of which are both costly and offer little advantages in speed or armored 
capabilities, and of which are ultimately threatened by cancellation. Such a trend is 
problematic in that if the United States were to become embroiled in a high-intensity 
conflict necessitating use of heavy legacy forces, our medical evacuation support plan 
would be built upon a converted armored personnel carrier designed prior to the Vietnam 
War. 


82 



LIST OF REFERENCES 


Academy of Health Sciences. U.S. Army. Health Service Support Futures Medical 
Force 2000, White Paper. Final Draft. Fort Sam Houston, Texas, March 1989. 

Adams, Thomas K. The Army After Next: The First Postindustrial Army. CT: Praeger, 
2006. 

Allard, Kenneth. Somalia Operations: Lessons Learned. Washington, D.C: National 
Defense University Press, 1995. 

Army Capabilities Integration Center. “The Ground Combat Vehicle Strategy.” 
http;//www. arcic.army.mil (accessed February 11, 2011). 

Army Sustainment Magazine http://www.almc.armv.mil/alog/index.html (accessed 
September 11, 2011). 

Army Technology.com. “Joint Light Tactical Vehicle,” http://www.army- 
technologv.com/proiects/iltv (accessed Feb 12, 2011). 

Brannen, Kate. “Budget Limits Efforts to Add, Upgrade Vehicles.” Army Times Online 
http://www.armytimes.com/news/2011/02/armv-budget-limits-efforts-to-upgrade- 

vehicles-02071 lw/ (accessed May 11, 2011). 

Camm, Frank, Cynthia R. Cook, Ralph Masi, and Anny Wong. What the Army Needs to 
Know to Align Its Operational and Institutional Activities. Santa Monica, CA: 
RAND Corporation, 2007. 

Cecchine, Gary, David Johnson, John R. Bondanella, J. Michael Polich, and Jerry 

Sollinger. Army Medical Strategy, Issues For The Future. Santa Monica, CA: 
RAND Corporation, 2001. 

Cecchine, Gary, and David E. Johnson. Conserving the Future Force Fighting Strength 
Findings from the Army Medical Department Transformation Workshop 2002. 
Santa Monica, CA: RAND Corporation, 2004. 

Committee on Armed Services. House of Representatives. Report to the Chairman, 
Subcommittee on Military Personnel and Compensations, Operation Desert 
Storm: Full Army Medical Capability Not Achieved. Washington, DC: U.S. 
General Accounting Office, August 1992. 

Cooper, Derek. “Technologies for Tracking and Caring for Injured Soldiers.” Army 
Logistician 32, no. 5 (September-October 2005): 13-19. 


83 








Customer Support. “Stryker Interim Armored Vehicle: Heralds New Transformation for 
the Army-and DCMA.” Defense Contract Management Agency (DCMA) 
Magazine, 4, no.l (Spring-Summer 2003): 6-10. 

Czerw, Russell J. Fiscal Year 2010 U.S. Army Medical Department Center and School 
(AMEDDC&S) Commanders Training Guidance. Fort Sam Houston, TX: 
AMEDD Center and School, 2010. 

Davis, Lois M. et al. Army Medical Support For Peace Operations and Humanitarian 

Assistance. Santa Monica, CA: RAND Corporation, 1996. 

Defense Logistics Agency Homepage. “Defense Logistics Information Service History.” 
http://www.dlis.dla.mil/history.asp (accessed October 2, 2011). 

Demchak, Chris C. Military Organizations, Complex Machines: Modernization in the 
U.S. Armed Services. Edited by Robert J. Art and Robert Jervis. NY: Cornell 
University Press, 1991. 

Denning, Peter J., and Robert Dunham. The Innovator’s Way: Essential Practices For 
Successful Innovation. MA: Massachusetts Institute of Technology Press, 2010. 

Dennis, Lisa M. “Female medics in line units” Army Logistician, 40, no. 1. (January- 
February 2008): 18-19. 

Department of Defense. Quadrennial Defense Review. Department of Defense, February 
2010 . 

-. Field Manual 4-0 Sustainment. Department of Defense, April 2009. 

Doboszenski, Scot A. “Combat health support in the Army’s first Stryker Brigade.” Army 
Logistician, 37, no. 1 (January-February 2005): 4-9. 

Echevarria, Antulio II. J. Fourth Generation War and other Myths. Carlisle, PA: 

Strategic Studies Institute, 2005. 

Feickert, Andrew. Joint Light Tactical Vehicle (JLTV): Background and Issues for 
Congress. Congressional Research Service, January 3, 2012 

Fitzsimonds, James R. and Jan M. Van Tol. Revolutions In Military Affairs, Joint Forces 
Quarterly {Spring 1994): 24-31. 

Fleming-Michael, Karen. “Stryker Ambulance First with Most.” Mercury Magazine 
(December 2002). 


84 




Galula, David. Counterinsurgency Warfare; Theory and Practice. New York: Frederick 
A. Praeger, Publishers, 1964. 

General Accounting Office. Wartime Medical Care DoD is Addressing Shortfalls, but 
Challenges Remain. Washington DC: U.S. General Accounting Office, 
September, 1996. 

-. Military Personnel: Perspectives of Surveyed Servicemembers in Retention of 

Critical Specialties, briefing report to congressional requesters, GAO/NSAID-99- 
197BR, Washington D.C: GAO, August 1999. 

Ginn, Richard V.N. The History of the U.S. Army Medical Service Corps. Office of the 
Surgeon General and Center of Military History, United States Army, Dec 1, 
1997. 

Gonzales, Daniel, et al. Network-Centric Operations Case Study: The Stryker Brigade 
Combat Team. Santa Monica, CA: RAND Corporation, 2005. 

Gouge, Terrence J. U.S. Army Mobilization and Logistics During the Korean War; A 
Research Approach. Center of Military History, Washington, DC: United States 
Army: 1987 

Gourley, Scott R. “Soldier Anned: Tactical Medevac Ambulances for New Battlefields.” 
Army Magazine (May 2010): 69-70. 

Gray, Cohn S. War, Peace, and International Relations: An Introduction to Strategic 
History. Routledge, New York, NY, 2007. 

Greenwood, John T., and Clifton Berry. “ Medics at War : Military Medicine From 

Colonial Times to the 21st century. ” Naval Institute Press: Annapolis MD, 2005. 

Herbert, Paul A. “Deciding What Has to be Done: General William E,. DePuy and the 

1976 Edition of FM 100-5.” Leavenworth Papers, no. 16, Library of Congress, 
1988. 

Historical Division, Army Medical Library. “The Army Medical Department During the 
Tenure of Major General Norman T. Kirk as The Surgeon General: 1 June 1943- 
31 May 1947,” appeared in consecutive issues of The Bulletin of the U.S. Army 
Medical Department, 7, no. 6 (June 1947): pp. 520-62, and no. 7 (July 1947), pp. 
594-646, 623-624. 

Horoho, Patricia D. Lieutenant General, 43 ld Surgeon General of the Army and the U.S. 
Army Medical Command. Commander’s Thoughts: On Leadership and Strategy. 
Falls Church, VA: Office of the Surgeon General, January 30, 2012. 


85 



Johnson, David E., and Gary Cecchine. Medical Risk in the Future Force: Unit of Action 
Results of the Army Medical Department Transformation Workshop IV. Santa 
Monica, CA: RAND Corporation, 2005. 

-. Medical Risk in the Future Force: Unit of Action Results of the Army Medical 

Department Transformation Workshop V. Santa Monica, CA: RAND 
Corporation, 2006. 

Kanter, Rosabeth Moss.’’The Middle Manager as Innovator,” Harvard Business Review 
82 (July—August 2004): 153. 

Kilcullen, David. “Understanding Current Operations In Iraq.” Small Wars Journal. June 
26, 2007. http://smallwarsiournal.com/blog/understanding-current-operations-in- 
iraq (accessed June 15, 2011) 

-. Twenty-Eight Articles: Fundamentals of Company-level Coun terinsurgency 

Edition 1 (Washington, D.C., Written from fieldnotes compiled in Baghdad, Taji and 

Kuwait City, March 2006). 

Kiley, Kevin C. Surgeon General of the Army Memo for Defense of Medical Units, 

Personnel and Patients Under Their Care Under the Provisions of the Geneva 
Convention , Memorandum For U.S. Army Medical Center and School. 
Washington, D.C: January 21, 2007. 

Knorr, Klaus, and Oskar Morgenstem. Science and Defense: Some Critical Thoughts on 
Militaiy Research and Development, Policy Memorandum No 32, Center of 
International Studies, Woodrow Wilson School of Public and International 
Affairs. Mimeo, Princeton University: New Jersey, February 18th, 1965. 

Fandau, Martin and Russell Stout Jr. “To Manage is Not to Control: The Folly of Type II 
Errors.” Public Administration Review 39 (March-April 1979): 148-156. 

Fedford, Frank F. Jr, Fieutenant General, and Matthew W. Fewis, et al. “From The 

Surgeon General of the Army: Medical Support for Operation Desert Storm.” The 
Journal of the U.S. Army Medical Department (January-February 1992): 3-6. 

Finn, Brian McAllister. The Echo of Battle: The Army’s Way of War. Cambridge, MA: 
Harvard University Press, 2007. 

Macgregor, Douglas A. Breaking the Phalanx: A New Design for Landpower in the 2T' 
Century. Westport CT: Praeger, January 1997. 

McChrystal, Stanley A. General, U.S. Army. Commanders Initial Assessment. United 
States Forces Afghanistan. 30 August 2009. 


86 



McHugh, The Honorable, John M., and General George Casey, Jr. A Statement on the 
Posture of the United States Army 2011, submitted to the Committees and 
Subcommittees of the United States Senate and the House of Representatives, 1st 
Session, 112th Congress, March 2011. 

McVeigh, Bryan. Combat Vehicles Conference-PMFCS (BCT) Platform Overview. 

Fort Bliss, Texas: Army Brigade Combat Team Modernization Program, 2008. 

Murray, Williamson A. “The West at War,” in The Cambridge History of Warfare, edited 
by Geoffrey Parker. NY: Cambridge University Press, 2005. 

Medical Warfighter Forum, United States Army, (MedWfF) 

https://www.us.armv.mil/suite/page/131414. accessed October 18 , 2011. 

Michaud, Ed, et al. “Medical Operations in the Stryker Brigade Combat Team.” U.S. 
Army Medical Department Journal (July-September 2006): 3-9. 

NATO Logistics Handbook. October 1997. found online at 

http://www.nato.int/docu/logi-en/1997/lo-1610.htm (accessed March 4, 2012). 

Nazzaro, Ralph W. “Redefining the role of the BSMC in Operation Iraqi Freedom: 
brigade support Medical Companies Find Themselves Sidelined From Their 
Doctrinal Roles. What New Roles Can They Adopt To Better Support Their 
BCTs T' Army Logistician , 38, no. 2 (April 2006): 19-23. 

Neal, Derrick, Henrick Friman, Ralph Doughty, and Linton Wells. “Crosscutting Issues 
in International Transformation: Interactions and Innovations among People, 
Organizations, Processes and Technology ” edited by Derrick Neal, Henrik 
Friman, Ralph Doughty, and Linton Wells II. National Defense University 
Washington, D.C., 2009. 

Neel, Spurgeon, Major General. Vietnam Studies: Medical Support of the U.S. Army in 
Vietnam, 1965-1970. Washington, DC: Department of the Army, 1991. 

Neilsen, Suzanne. “An Army Transformed: The U.S. Army’s Post-Vietnam Recovery 
and the Dynamics of Change In Military Organizations.” In The Letort Papers, 
U.S. Army War College, PA: Strategic Studies Institute (Sept 2010). 

Office of the Deputy Chief of Staff, U.S. 2004 Army Transformation Roadmap. July 
2004. Washington, DC: Army Operations, Army Transformation Office, 2004. 

Office of the Secretary of Defense. Elements of Defense Transformation. Director, Office 
of Force Transformation, Office of the Secretary of Defense. October 2004. 


87 




Office of the Surgeon General, U.S. Army, Briefing Slides, “Medical Reengineering 
Initiative: Combat Health Support of Force XXI,” April 14, 1999. 

Onibene, Andre J., Brigadier General, and O’Neill Barrett, Jr., Colonel, USA (Ret.) eds. 
Internal Medicine in Vietnam, Army Medical Department, Volume II: General 
Medicine and Infectious Diseases (Office of the Surgeon General and the Center 
of Military History: Washington D.C, 1982). Available at 
http://historv.amedd.armv.mil/booksdocs/vietnam/GenMedVN/default.html . 
(accessed March 12, 2011). 

Osborn, Kris. “New MRAP Ambulance Prototypes Many Improvements.” Washington, 
Army News Service. November 18, 2010. 

Pandolfi, Philip J. “Desert Stonn: The Dentist in the Forward Support Battalion.” 

The Journal of the Army Medical Department (January-February 1992): 49-53. 

Perry, Walter , Bruce Pirnie, and John Gordon IV. The Future of Warfare Issues From 
The 1999 Army After Study Cycle. Santa Monica CA: RAND Corporation, 2001. 

Petraeus, David. “Counterinsurgency Concepts: What We Learned In Iraq” Global 
Policy, l,no. 1 (January 2010): 116-117. 

Pierce, James G. “Is the Culture of the U.S. Army Congruent with the Professional 

Development of its Senior Level Officer Corps?” The Letort Papers, U.S. Army 
War College, PA: Strategic Studies Institute (Sept 2010). 

Posen, Barry. The Sources of Military Doctrine: France, Britain, and Germany Between 
the World Wars. Ithaca, NY: Cornell University Press, 1984. 

RAND Corporation. New Equipping Strategies for Combat Support Hospitals. Santa 
Monica, CA: RAND Corporation, 2010. 

Rice, Matthew S. Jones, and Omar J. Jones. “Medical Operations In Counterinsurgency 
Warfare: Desired Effects and Unintended Consequences.” Military Review (June 
2010): 47-57. 

Rosen, Stephen P. Winning the Next War: Innovation and the Modern Military. New 
York: Cornell University Press, 1991. 

-. “New Ways of War: Understanding Military Innovation,” International 

Security, 13,no.l (Summer, 1988): 167. 

Russell, James A. “Innovation In War: Counterinsurgency Operations In Anbar and 
Ninewah Provinces, Iraq, 2005-2007,” Journal of Strategic Studies 33, no. 4 
(August 2010): 595-624. 


88 



-. Innovation, Transformation, and War: Counterinsurgency Operations In Anbar 

and Ninewah Provinces, Iraq, 2005-2007. Stanford, CA: Stanford University 
Press, 2011. 

Sosa, Ingeborg. “The Journal Interviews MG Michael J. Scotti, Jr., Commanding 
General, 7th Medical Command, Europe.” The Army Medical Department 
Journal (January-February): 1992. 

Strauder, Guy S. “The Golden Hour Standard.” Joint Forces Quarterly, 41, 2nd Quarter 
(2006): 60-67. 

Thorpe, George C. Lt. Col: Pure Logistics: The Science of War Preparation (WA DC: 
U.S. Government Printing Office, 1917), 4. 

TRADOC Organization website. http://www.tradoc.army.mil/images/pao/TRADOC%20 
organization.jpg (accessed January 11, 2012). 

U.S. Department of the Army. Change 1 to Field Manual (FM) 3-0 Operations. FM 3-0. 
Washington, D.C: U.S. Department of the Army, Feb 2011. 

-. Counterinsurgency Operations. Field Manual (FM) 3-24. Washington, D.C: 

U.S. Department of the Army, December 2006. 

-. The Army 2010 Tactical Wheeled Vehicle (TWV) Strategy. Washington, DC: 

Department of the Army, 2011. 

-. TRADOC Regulation 71-4. Force Development: Standard Scenarios for 

Capability Developments. Headquarters, Fort Monroe, VA United 
States Army Training and Doctrine Command, September 23, 2008. 

U.S. Air Force Air University, Air War College Naval Supply Systems Command, 
Logistics Quotations. 

http://www.au.af.mil/au/awc/awcgate/navy/log quotes navsup.pdf (accessed 
October 12, 2012). 

U.S. Joint Forces Command. Irregular Adversaries and Hybrid Threats: An Assessment- 
2011. Joint Irregular Warfare Center. 2011. 

United States Congress. A CBO Study: Army’s Transformation Programs and Possible 
Alternatives, June 2009 (Congressional Budget Office, Publication 3193. 2009). 

Wolfe, Edwin P. Colonel, Medical Department of the United States Army in the World 
War Volume III, Finance and Supply, (U.S. Government Printing Office 
Washington, DC, 1928), 265. 


89 









Zegart, Amy A. Flawed By Design: The Evolution of the CIA, JCS, and NSC. Stanford: 
Stanford University, 2009. 


90 



INITIAL DISTRIBUTION LIST 


1. Defense Technical Infonnation Center 
Ft. Belvoir, Virginia 

2. Dudley Knox Library 
Naval Postgraduate School 
Monterey, California 


91