Medical Support to Irregular Warfare: A Systematic Literature Review, 2000-2024

Abstract Introduction Irregular Warfare (IW) is used by the United States and other nations to shape the environment, deter, or prevent conflict, and prevail in war through asymmetric activities. Irregular Warfare occurs in resource-constrained environments with inadequate medical infrastructure or in those that are contested, denied, or sensitive. These environments pose challenges to providing medical care to U.S., ally, and partner nation forces and civilians. The purpose of this research was to identify what global lessons learned since 9/11 can be applied to current challenges and future direction that enhance medical support to IW. Materials and Methods A systematic literature review of peer-reviewed and grey literature using 88 databases within PubMed, Scopus, EBSCOhost, and ProQuest was conducted. Data on the characteristics of irregular warfare medicine from 2000 to the present were extracted and documented. This included the US Department of Defense (DoD) doctrine, organization, training, materiel, leadership and education, personnel, facilities, and policy (DOTMLPF-P) framework and DoD medical functional areas. Results Of the 12,656 sources identified, 7,988 remained after excluding duplicate matches. A total of 1,063 met the inclusion criteria and were primarily written by civilians (51.7%), covering 81 different countries, representing all Geographical Combatant Commands. US Central Command featured most prominently (61.9%) and was therefore heavily biased toward counterinsurgency (30.3%) as a form of IW. Most publications focused on hemorrhage (14.5%), with disease non-battle injury closely behind (14.2%). Noncombatants were the focus of a majority of the articles (29.6%) while service members were most cited as the recipients of care (41.6%). From a DOTMLPF-P perspective, organization was discussed the most (17.2%) followed by personnel (15.2%). When considering medical functional areas, medical treatment featured prominently (28.9%) trailed by medical logistics (17.6%). The key findings were categorized into 10 themes: (1) interagency and multinational synchronization are essential, (2) medical resiliency requires strategic planning, (3) Global Health Engagement is an important enabler, (4) gaps remain in medical doctrine, (5) low-signature operations drive new needs, (6) host nation capabilities are vital, (7) extended care drives new training requirements, (8) ethics and human rights remain a concern, (9) mental health remains a priority, (10) and technological innovations are required. Conclusions The advancement in medical care during the past 24 years of IW have enhanced survivability of combatants and noncombatants alike. Unfortunately, challenges remain. The lack of clear IW medicine policy and doctrine has obscured roles, responsibilities, requirements, and capabilities among the various stakeholders within the DoD and beyond. Efforts to advance the provision of medical support in IW have progressed without a cardinal direction or universally shared foundation of knowledge. This research provides a DOTMLPF-P framework to support closing existing gaps and moving forward recommended solutions in the near and long term. Now is the time in this era of potential Large Scale Combat Operations to leverage IW medicine as part of integrated deterrence to mitigate the risk to force and mission while preparing for future conflicts across continents, climates, and geopolitical circumstances.