During its recent engagements—like its long and ongoing mission in Afghanistan—NATO forces have enjoyed a near-complete control of the air and the ability to ensure rapid medical evacuation and access to medical support. However, the changes in the global security environment indicate that NATO countries may need to be ready to deter or defend against a potentially entrenched peer or near-peer adversary with the necessary military capabilities to deny the Alliance the air and sea superiority it has grown accustomed to. These capabilities can threaten rapid access to higher-echelon medical support within and beyond the theatre of operations. The step change in combat with potential adversaries requires a change of mindset, as well as financial and personnel investment in developing solutions for medical support provision in an A2AD environment.

Providing medical support in an A2AD (anti-access/area denial) environment will require changes to NATO’s current approach. This development is due to the implications that deploying to such a complex operating environment may have on such areas as the use of fixed medical facilities for higher echelon and surgical medical care, the need for special equipment to ensure an adequate environment (such as refrigeration) of medical materiel and access to perishable supplies from beyond the theatre of operations, potential disruption of reliable communications, and the ability to quickly transport the wounded by air.

Today, the composition of A2AD measures and countermeasures would vary depending on the theatre and the adversary, and may include missile systems (such as surface-to-air missiles, anti-ship missiles, and land-attack cruise and ballistic missiles), manned and unmanned aircraft, mines, electronic warfare, and cyber capabilities—all enabled by a network of intelligence, surveillance, target acquisition, and reconnaissance assets. In particular, Russia’s air defence systems and aircraft are capable of threatening large swathes of the airspace over NATO territory, complicating not only ground operations but also air-to-air and air-to-ground missions. NATO members may also encounter A2AD environments during out-of-area operations in Asia and the Middle East, facing China’s increased missile, aircraft, and maritime capabilities, and Iran’s Sejil 2 ballistic missiles, which have sufficient range to threaten targets in Europe.

Such capabilities will most likely impact the provision of medical support to NATO troops and those of partner nations, and erode the ability to minimize the rate of battlefield injuries and deaths from wounds. This is due to a number of factors, including the virtually non-existent serious long-range anti-aircraft threats NATO has encountered during casualty evacuation recently and the proximity and availability of medical surgical support (such as forward deployment of medical facilities), that have consequently heightened the expectations for the availability and quality of medical care.

Many challenges may be expected when working in A2AD conditions. They include ensuring rapid access to surgical care, and making certain that the units and medical personnel in theatre have a reliable resupply of medical materiel and access to additional medical personnel located outside of the operational theatre. Yet another challenge is changing the location of the medical support units and facilities within the theatre itself to protect them from assault, while keeping up with the pace of operations.

Forces may need to operate far from secondary and definitive (NATO Role 3 and Role 4 level care) military healthcare hospitals. They may need to develop new tactics, techniques, and procedures for ground evacuation from the point of injury to a safe point of extraction. Consequently, not only would the medical support options for the forces in theatre be limited because they would be cut off from out-of-theatre support, but the overall force readiness and availability could be compromised due to decreased ability to provide the care necessary for soldiers to be able to return to duty.

Addressing the A2AD challenge to medical support to deployed troops will be complicated, but it will depend on the ability of decision-makers to invest in the issue. On a political and strategic level, it may require political and military leaders, as well as the populations of troop-sending nations, to increase their tolerance of risk in deploying forces, implying acceptance on the need for the operation in the first place. It will also require a solid understanding by military decision-makers and planners about the impact of the availability of medical support on operational plans.

However, on a more practical level, some measures may help the preparation and training for the eventuality of a mission in an A2AD environment, such as information sharing, exercises and training, pre-positioning of medical supplies and equipment, development and training of mobile and dispersed medical facilities with low-signature footprint, and use of new techniques and technologies. Ensuring effective multinational medical coordination and understanding the differences in the medical protocols, procedures and practices used by other NATO members and the host-nation civilian medical systems would also help medical planning.

Exercises that have integrated logistics and medical support components can help train the coordination and communication between the fighting force and medical support. Saber Strike 2017, a US Army–led cooperative training exercise in the Baltic states and Poland, included a multinational simulated and real-life medical support element. Another event, Vigorous Warrior, is NATO’s only multinational medical exercise and takes place biennially, each time in a different member state. Pre-positioning medical materiel and equipment as close as possible to the point of use could add to the resilience and robustness of medical support in denied environments.

Novel approaches to the deployment of small medical teams and up-skilling soldiers (such as NATO’s First Responder Trainer Training course available for medical professionals and soldiers) could provide them with a wider range of first care skills. The forward deployment of damage control surgery elements could also at least partially mitigate the challenges posed by A2AD. Mobile, modular, and dispersed medical facilities with low-signature footprint may be used to avoid detection and increase mobility. Lastly, technology innovation may provide some relief, for example, by using rapidly deployable infrastructure and ruggedized medical devices to provide more in-depth medical support in the field.

Provision of medical support could be a worthy priority for NATO planners when considering deterrence of and defense against near-peer or peer adversaries. Countries such as Russia and China, and to a lesser extent North Korea and Iran, continue to develop and expand the ability to integrate long-range strike, anti-ship, anti-air, space and cyber abilities. These capabilities could be used to disrupt movement, threaten bases and destroy fielded forces of their adversaries. Dealing with advanced A2AD threats and ensuring NATO’s ability to deter, defend, and conduct operations will therefore require both political and military leaders to invest in medical support.


Marta Kepe is a defence analyst at RAND Europe and a senior non-resident fellow with the Atlantic Council Brent Scowcroft Center on International Security.

The views expressed are those of the author(s) and do not reflect the official position of the United States Military Academy, Department of the Army, or Department of Defense.


Image credit: Cpl. Mark Doran, Australian Defence Force