Since spring 2010, District 8 has served as the on-scene coordinator for a host of federal, state, and local agencies still working to clean up and repair damages caused by the Deepwater Horizon oil spill in the Gulf of Mexico. District 8 also played a major role in disaster relief efforts after the January 2010 earthquake that devastated Haiti in early 2010.

Lt. j. g. Bradford Clark, assigned to the response division at Coast Guard Sector Ohio Valley, Louisville, Ky., conducts safety checks on the Ohio River as part of Operation Dry Water, June 25, 2011. The Coast Guard worked alongside local, state, and federal agencies in efforts to stop drinking while boating and to help educate boaters about safe boating. U.S. Coast Guard photo by Petty Officer 2nd Class Kelly Turner.

In 2011, while efforts related to those major disasters continued, District 8 found itself, once again, at the heart of some of the worst that nature could produce, from a 5.8-magnitude earthquake that rattled the East Coast along the edge of the district’s area of responsibility, to historic flooding along the Missouri and Mississippi rivers, to evaluation of safety systems of the nation’s largest liquefied natural gas (LNG) facility at Port Arthur, Texas.

All that in addition to a major multiagency exercise dealing with a possible recurrence of the New Madrid earthquake of 1812-1813, the largest in the recorded history of North America and centered around the Bootheel area of Missouri. District 8 deals with the day-to-day efforts involving nearly all of the Coast Guard’s 11 major missions.

Rear Adm. Roy A. Nash, who spent much of 2010 as the deputy Federal On-scene Coordinator (FOSC) in the continuing Deepwater Horizon clean-up in the Gulf, relieved retiring Rear Adm. Mary E. Landry as the 8th District commander on June 1, 2011 – the first day of hurricane season and the day after the Mississippi River spring floods crested in New Orleans.

“Those floods were historic compared to the flooding we experienced in 1927. It was a combination of heavy rains and record snow levels upstream, resulting in unprecedented water levels that were off the chart,” Nash said. “I’d also have to say Deepwater Horizon continued to be a major effort by all levels of government, with the Coast Guard as the lead on-scene coordinator, especially in Louisiana, Mississippi, Alabama, and the Florida Panhandle. Even now [late August 2011], we’re still doing some beach cleaning.”

Geographically, District 8 is the largest of the Coast Guard’s nine districts, covering all or part of 26 states, more than 1,200 miles of Gulf coastline from Florida to Texas, and 10,300 miles of inland waterways, including the entire navigable lengths of the Mississippi, Ohio, Missouri, Illinois, and Tennessee river systems. It also is home to two of the nation’s busiest ports – New Orleans and Houston – and, by tonnage of cargo moving through them each day, 15 of the 40 busiest ports.

Stretching from the Appalachian Mountains and Chattahoochee River in the east, to the Rocky Mountains in the west and from the Mexican border and Gulf of Mexico in the south to the Canadian border in North Dakota, the district’s 4,400-plus active-duty and Reserve members, assisted by some 1,800 auxiliarists and more than 300 civilians, are responsible for marine safety protocols at more than 6,500 oil- and gas-producing wells – and another 130 offshore in the Gulf – and five of the nation’s top seven fishing ports, which account for about 40 percent of the nation’s annual commercial catch.

Preventative safety missions include thousands of ship and barge maintenance inspections, the aids to navigation (ATON) system, passenger vessel inspections, and recreational and small craft examinations. Response activities include more than 6,300 search and rescue (SAR) cases annually involving recreational vessels, fishing vessels, and many other waterborne activities. Accomplishing that requires the assets of four air stations, 15 SAR stations, 14 ATON teams, 19 river tenders, one 225-foot buoy tender, two 175-foot coastal buoy tenders, and three 64-foot self-propelled barges – plus ongoing Coast Guard investments in new patrol boats, the Rescue 21 National Distress Radio System and GPS, and an assortment of other technologies.

Lt. Cmdr. Carolyn Beatty of the Gulf Coast Incident Management Team uncovers oil underneath sand near Venice, La., Jan. 7, 2011. Beatty serves as the Plaquemines Parish operations branch director for the federal government's Deepwater Horizon cleanup response. U.S. Coast Guard photo by Seaman William Benson.

For Nash, the major lessons learned from response operations in recent years boils down to a few key components: understanding the situation, communicating, and effective command and control, including widespread use of the Incident Command System.

“Everyone has their own expertise, and if you can bring all that together through an organizational structure that participants understand such as the Incident Command System, you can have a far better outcome,” Nash noted. “By communicating, often and early, everyone better understood the hard decisions that had to be made. With the river flooding, we worked with the River Industry Executive Task Force, which is made up of leaders from the towing industry, Coast Guard, and Army Corps [of Engineers], along with levee boards along the waterways, to communicate steps being taken to control the waters and traffic along the rivers.”

Even as the water levels increased, marine traffic still moved. But as the risk to the levees increased, communications among stakeholders was increasingly important to implementing safety zones around the affected waterways. When the Corps had to open spillways that put homes and residences at risk, the Coast Guard worked maritime traffic management as well as search and rescue, and helped keep citizens away from spillways when they were opened.

The long-scheduled New Madrid earthquake exercise proved serendipitous to the Coast Guard and every other agency involved.

“We use these exercises to determine how best to organize ourselves as a unified command and help return the population to normalcy. The New Madrid fault exercise in the spring coincided with the record high flooding in that same area. So we were working with almost identical partners on a real situation even as the district supported FEMA [Federal Emergency Management Agency] on that earthquake exercise,” Nash said.

The ability to bring a disparate group of agencies and leaders together under the National Incident Command System, having operations, planning, logistics, and finance sections, is critical, whether it is an oil spill or a natural disaster. The focus for 8th District personnel is on professionalism and teamwork.

“I think the response to the Deepwater Horizon oil spill demonstrated our ability to come together in a unified multi-agency effort and integrate the tools and personnel we have,” commented Nash.

With more natural – and man-made – disasters in the Coast Guard’s future, another major challenge for the district will be maintaining an interagency response capability in the face of future disaster situations.

“One thing we have to do strategically is always be mindful of changes happening around us and how we address the challenges of today to make us more ready for what happens tomorrow. Our new Centers of Expertise [CoEs] are part of that, such as the Towing CoE in Paducah [Ky.], which has brought in some very positive feedback from industry. Another center, for mobile offshore drilling unit examinations in Morgan City, La., participated in the Deepwater Horizon spill,” Nash concluded. “And, of course, the LNG CoE at Port Arthur, Texas, has been very helpful in training our Coast Guard officers on inspecting vessels and evaluating safety.

“We take good care of the Coast Guard assets and equipment we have, but we also have new national security cutters being built, with the third recently delivered, and our new fast-response cutters are beginning to come online. In addition, Rescue 21 is helping us find people in trouble much more quickly. I think we’re doing OK, working hard to effectively and proficiently use every resource we have been given.”

This article was first published in Coast Guard Outlook: 2012 Edition.

War also leads to new medical technologies and techniques, such as vastly improved prosthetics and a greater attention to and understanding of concussive force injuries. Noting that as he transitioned from the Bush to Obama administrations, then-Secretary of Defense Robert M. Gates issued a memo stating an even greater emphasis was required to ensure the military was doing the research needed to restore severely wounded warfighters to full function.

“We did not have a core program in this area until just a few years ago, so without the current conflict, there would not be a CRMRP [Clinical and Rehabilitative Medicine Research Program], for example,” according to the program director, Army Lt. Col. John M. Scherer. “That doesn’t mean certain aspects would not still be under investigation – burn treatment and rehabilitation, for example. We coordinate closely with our Combat Casualty Care office to look at the continuum of burn injuries – where … the injury stops and rehab begins.

“The previous focus of the U.S. Army Medical Research and Materiel Command [USAMRMC] was on care up to a fixed facility, then the VA [the Department of Veterans Affairs], civilian medical community, NIH [National Institutes of Health], and others would conduct research and find solutions to repairing those traumatic injuries because those people would have been discharged from the military. But it was determined DoD [the Department of Defense] also has a responsibility and we needed a coherent program to research traumatic injuries and restore [wounded warfighters] to full function. But much of that would not have happened within DoD without the current conflict.”

In response to the Gates memo and the requirements of the ongoing war in Southwest Asia, both DoD and the individual services ramped up already existing efforts to improve care by creating additional new programs and agencies focused on those requirements. CRMRP was one such example, created by USAMRMC in 2008 to focus on expanding traditional research to include even more innovative means of rehabilitative care required to “reset” wounded warriors, both in terms of duty performance and quality of life.

Doctor Richard Erff, chief of the Carl R. Darnall Army Medical Center Pain Clinic, administers cervical epidural steroid injections to Spc. Michael Ryan, who suffers from chronic neck and back injuries. Ryan's pain stems from a traumatic brain injury he received while deployed to Iraq. Pain management is another CRMRP focus area. U.S. Army photo by Patricia Deal, CRDAMC Public Affairs

According to its mission statement, CRMRP “provides policy and process oversight for all clinical and rehabilitative medicine congressional programs managed by the USAMRMC’s Telemedicine and Advanced Technology Research Center (TATRC) and Congressionally Directed Medical Research Programs (CDMRP). It is the lead for program development and oversight of the Armed Forces Institute of Regenerative Medicine (AFIRM), which is a multi-institutional, interdisciplinary network working to develop advanced treatment options for severely wounded service members. The CRMRP also more tightly links the USAMRMC research and development community with the clinical investigations community of the U.S. Army Medical Command and the Military Health System.”

Although part of the Army’s medical care structure, Scherer emphasizes the program’s comprehensive approach to multiservice needs, especially at the individual warfighter level.

“We’re trying to take basic research that has been done and translate it into clinical practice so we can return function to the most traumatically injured soldiers, sailors, airmen, and Marines from the current conflict. So that is focused on the most severely injured warfighters, returning them to duty or getting them back to function,” he explained. “Our goal is always to restore them back to the function they had previous to the injury – not to get to the ‘good enough’ answer, but the best answer for that person.

“In addition, the medical community at large was expressing a level of interest in progressing into this area because we had been working these traumatic injuries without the ability to treat effectively. Injuries to the head and neck, for example, have gone up substantially in this conflict and we need programs to address those.”

CRMRP came out of the Army’s Combat Casualty Care Program, which already was leaning toward developing and implementing new ways to restore the function of severely damaged tissue. At the same time, Congress increased funding for new efforts in prosthetics, regenerative medicine, and other cutting-edge technologies to address the growing number of service members surviving despite extreme trauma to arms, legs, and head. That also involves advancements in repairing damaged hearing and overall enhancements in rehabilitative care.

CRMRP-sponsored research currently is focused on four key areas:

1. Rehabilitation and Prosthetics: This includes not only advances in returning damaged limbs to full functionality – or replacing them, if necessary, to achieve the same goal – but also dealing with associated problems, from psychosocial recovery and substance abuse to other injuries that may restrict rehabilitation.

2. Pain Management: Improving ways to reduce chronic and acute pain while also establishing safe levels of medication for each individual, identifying and treating pain generators, and developing new ways to empower patients in the management of their own pain.

3. Vision: Advancing procedures to repair retinal/corneal or optic nerve damage, create artificial eyes that are functional rather than merely cosmetic, improve ocular diagnostics, and treat vision problems associated with TBI.

Induced stem cells, adult skin cells that have been genetically reprogrammed to mimic embryonic stem cells, have been made potentially safer by removing the introduced genes and viral vector used to ferry the genes into the cells. These cells were reprogrammed to an embryonic-like state with the aid of a plasmid, a loop of DNA, which prompts the reprogramming but is not integrated into the genome of the cells. The work was accomplished by geneticist Junying Yu in the laboratory of James Thomson, a UW-Madison School of Medicine and Public Health professor and the director if regenerative biology for the Morgridge Institute for Research. Adult stems cells are being investigated today to aid military regenerative medicine initiatives. University of Wisconsin-Madison University Communications

4. Regenerative Medicine and Transplants: Improving wound healing, reducing scarring, improving function and appearance following craniofacial injuries, eliminating the need for tissue rejection therapy, improving surgical techniques, regenerating missing tissue (muscle, bone, skin), repairing nerve gaps, and developing the architecture to integrate “created” tissue.

While DoD, the individual services, the VA, National Institutes of Health, academia, and industry had been pursuing research and implementing advanced care capabilities in many of those areas, CRMRP was deemed necessary to create a “critical mass” of coordinated research expertise on definitive and rehabilitative care innovations. Success will be measured by reducing permanent disabilities, enabling a more rapid return to duty, decreasing long-term care needs and costs and, by resetting wounded warriors to their full health and capabilities, increasing warfighter morale.

Each of the four key focus areas is important in itself – and even more so in combination – to achieving that goal. But the level of effort by CRMRP and the programs and institutions with which it works is perhaps most clearly seen in efforts to repair injuries to the head and face, a complex task still in the nascent phase of research, despite recent headlines about face transplants and other components.

“If you look at a fractured leg, you basically have a one-dimensional direction, with the bone going up and down the leg. But on the face, you have multiple contours, which make repairs much more complicated than a simple leg fracture,” Scherer explained. “The bone scaffolds, molding, even tissue types are different.

“If you have a leg burn, you are dealing with one tissue type. But a facial burn has different tissues and unique functions – lips, eyelids, etc. – that cannot be repaired with a simple skin graft. You have to be able to replace an eyelid, for example, to save the patient’s sight. So we’re not only trying to repair major deformities resulting from a blast injury to the face, but also regenerate different tissue types so they can function as normal. And that has been a challenge.”

Unfortunately, just as CRMRP came into being, the global economic downturn began having an impact on budgets. While that is expected to slow some work, at least in the near term, Scherer said efforts are under way to ensure critical programs and treatments continue to advance. Whatever the status of U.S. combat or the federal budget, the intent is to provide the best care available to those wounded in Afghanistan and Iraq – including after they leave the military and the VA takes over, from rest-of-life health care to furthering future advances through the Veterans Health Administration (VHA) Rehabilitation Research & Development Service.

“We have a wide variety of interaction with the VA, from sitting on our programmatic committees to making sure projects of interest to both continue on from the research side. A good example of that is the DARPA-developed prosthetic arm; we are providing funds to get the next generation of the arm into clinical trials by the VA, probably in the spring of 2012,” Scherer said.

Sgt. Marco A. Robledo explains his prosthetic arm and hand to Lt. Cmdr. Benjamin Nguyen at the Al Faw Palace, Camp Victory, Baghdad, June 21, 2011. Robledo, along with five other soldiers, returned to Iraq to visit forward operating bases to witness the changes that have taken place due to their sacrifices. Robledo was injured May 26, 2007, by an IED while in a convoy. CRMRP is seeking to advance the state of the art in prosthetics. U.S. Army photo by Master Sgt. Michael R. Daigle

While major advances in prosthetics, especially for lower limbs, have garnered considerable media and public attention, that is only one part of CRMRP’s portfolio.

“We’re looking across the spectrum of severe combat injuries. The face transplants in the news recently were DoD-funded efforts managed by CRMRP. We also have a program in hand transplants,” he said. “We’re also looking at regenerating lost tissue. In a traumatic injury, can we salvage those parts of the limb that are not removed by basically regrowing the muscle, bone, and nerves that have been lost? The program is relatively new, but a lot of promising clinical trials are under way looking at many of these aspects.

“Some other efforts, including burn products, are in clinical trials now and likely will move into standard clinical use in the U.S. in the next several years. Cloning is a bit further down the road, although some investigators are working on those things – just not necessarily with DoD funds. And a doctor at Wake Forest has developed a tissue 3-D printer to make small [body] parts.”

Military medical R&D also has to follow the mandates of Congress, which typically specifies how funding it provides is to be spent – so many dollars on face or hand transplants, another specific amount on cranial injuries, TBI, damage to sight or hearing, etc.

“We prioritize what we do based on the types of injuries and degree of trauma from the current conflict, but also the current state of the art. Are industry, DARPA, the VA already working on this problem? We base our effort not only on the type, number, and severity of injuries, but how our funds fit into existing efforts so we don’t over-fund one area and under-fund another,” he explained.

“So the priorities we set, to get the most benefit from the resources we have to apply, are not easy to articulate. We may bump something up to the top just because it is close to going into clinical trial, for example, even though other efforts may be considered more urgent – but that one can get the most immediate impact from available funding.”

This generation of warfighters also has shown a determination to use advances in military medicine, especially prosthetics, to either remain in uniform – including returning to war – or re-enter civilian life with at least the same capabilities as before they were injured. An unexpected development, however, has been an increase in the number of “elective” amputations – patients whose limbs were saved by surgery, but with some loss of function, believing they would have a better life with a prosthetic.

As a result, military researchers now are looking not only at how to improve prosthetics, but how to achieve full recovery without prosthetics.

“I don’t have the statistics, but we have had a lot of elective amputations, where the surgeon saved the limb but it did not function to the patient’s satisfaction. Looking around at others who are functioning better with prosthetics, they elect to do the same,” Scherer said. “And I find that a tragedy – that a limb the surgeon was able to save is still amputated because the individual believes a prosthetic will be better than keeping an injured real limb.

“Basically, the loss of a limb or multiple limbs is an area in which we are very, very focused. There are lots of approaches to restoring some level of function. If you lose a lower limb, obviously you could do a prosthetic replacement. But is there something else we can do? Did that individual even have to lose that limb? Is it an issue of muscle loss, bone loss, nerves? How can we take what we know and apply new techniques coming into clinical trial so individuals do not elect amputation when the limb can be saved?

U.S. Army Spc. Saul Martinez trains with a medicine ball while standing on a balancing tool and using the hands-free harness walking gait-training device during a therapy session in the new Comprehensive Combat and Complex Casualty Care (C5) facility. C5 is a program of care that manages severely injured or ill patients from medical evacuation through inpatient care, outpatient rehabilitation, and their return to active duty or transition from the military. The new 30,000 square-foot facility incorporates new, state-of-the-art technologies that improve prosthetic and rehabilitation services including a 3,500-square-foot multi-terrain obstacle course, a 30-foot climbing wall, and a technologically advanced training apartment. U.S. Navy photo by MC2 Greg Mitchell

For military personnel, both while still in uniform and in later life as veterans under VA medical care, any advancements in artificial limbs, new ways to restore or improve hearing or vision, reconstructive surgery or other techniques for skull, dental, facial, or other severe injuries are covered by the nation’s contract with those who fight its wars. While those same advances also become available to the civilian population at large, ease of access does not.

“Medicare is looking closely at what should be paid for for civilians, especially prosthetics,” Scherer said, “but we are here to look at what can be developed and made available.”

After only three years of bringing a new level of coordination and focus to some of the most difficult and cutting-edge technologies and procedures in combat medical care, CRMRP is anticipating the development and eventual clinical use of a number of products. Those include:

• engineering skin products, bio-printing artificial skin in the field, and using stem cells to effect repairs to burned skin;
• Compartment syndrome treatments to reduce post-surgical inflammation, a potential cause of impaired blood flow, nerve damage, and muscle death.
• products to heal severe wounds without scarring, leading to both increased function and improved cosmetic appearance;
• improved and more “natural” foot and knee prosthetics and the capability to rebuild lost bone and tissue by capitalizing on advances in neural interfaces, nanotechnology, and prosthetic design; and
• improved eye injury diagnostics, treatments, and technologies to rehabilitate and restore vision.

Even with U.S. forces withdrawing from Iraq and Afghanistan and ever-tighter budgets anticipated through the next few years, Scherer believes the military will continue to push forward in developing new medical technologies and techniques. It is a requirement not only to meet the lifelong needs of those injured during Operation Enduring Freedom-Afghanistan and Operation Iraqi Freedom, but also wounded warriors from previous and future conflicts.

“Combat casualty care, infectious research, and so on were in existence prior to 9/11, so I would say we will continue on in this office because the injuries already sustained will still be there,” he concluded. “Just because the conflict is over, those injuries already have been sustained and our job is to return their function. The future is uncertain with budget cuts, but I have heard no talk of what we are doing here being disbanded.”

This article first appeared in The Year in Veterans Affairs & Military Medicine: 2011-2012 Edition.

The Marine Corps Forces Cyberspace Command (MARFORCYBER) is one of four service components of the equally new joint U.S. Cyber Command (USCYBERCOM), along with the Navy Fleet Cyber Command/10th Fleet, the Army Cyber Command (ARCYBER)/2nd Army, and the Air Forces Cyber Command (AFCYBER)/24th  Air Force.

According to its mission statement, USCYBERCOM was established in May 2010 to “plan, coordinate, integrate, synchronize and conduct activities to direct the operations and defense of specified Department of Defense [DoD]  information networks and prepare to – and when directed – conduct full spectrum military cyberspace operations in order to enable actions in all domains, ensure U.S./Allied freedom of action in cyberspace and deny the same to our adversaries.”

Lt. Gen. George Flynn, then-deputy commandant commanding the Marine Corps Combat Development Command, was dual-hatted as the first head of MARFORCYBER. He summed up the Marine role as ensuring defense of the Corps and DoD “cyber turf.” “The cyberspace domain is the newest and possibly the most complicated we must now dominate. If we are to be dominant on land, at sea, and in the air, we must be dominant in cyber,” he said.

Col. Steve Zotti, chief of staff for the new Marine command, said every aspect of military, government, industry, academia, and personal life worldwide has become so dependent on the Internet and other computer networks that they have become a major strategic target for terrorists and potential nation-state adversaries.

“In 2008-09, it became apparent cyber had become an operational domain requiring specialized focus, but there was not a command doing that,” he explained. “There were organizations and people throughout the services focusing on aspects of it, but no one command focusing specifically on cyber as a new operational or warfighting command. In addition, a number of state and non-state actors were developing weapons and tools – we were very vulnerable to and needed both a defensive and offensive capability beyond what we had.

“Each service component will have similar responsibilities, not tethered to any one mission set or area. USCYBERCOM will provide support to various COCOMs [combatant commanders] to coordinate, deconflict, and organize cyber ops; how that will be done is yet to be determined. One of the challenges is that cyber, by its very nature, is a global domain, so you need some level of standardization, but also the ability to tailor TTPs [tactics, techniques, and procedures] to specific regions and threats, although traditional boundaries do not necessarily apply.”

The Marine command will be the smallest of the service components, with fewer than 300 uniformed and civilian personnel at full operational capability, compared to 1,000 for the Army, for example, and 600 for the Navy. But Marines assigned to MARFORCYBER will still be riflemen first and not Hollywood-style “geeks” with only computer skills.

Gen. James Amos addresses members of the media at the 39th IFPA-Fletcher Conference on National Security Strategy and Policy April 15, 2011. The commandant and about 250 attendees discussed topics that ranged from warfighting concepts to cyber warfare, and devising an affordable, agile, and responsive Marine Corps force structure. U.S. Marine Corps photo by Sgt. Ben J. Flores

“A Marine is a Marine – and the value of a Marine is his discipline, work ethic, and culture. While there will be some associated skills for cyber, they will remain Marines first, cyber warriors second,” Zotti said. “But there also are career tracks that keep you progressing along specific areas and we will manage cyber the same way. The value of cyber ops to the Corps is how well it is integrated at the lowest tactical level.

“Cyber has to be heavily integrated with all warfighting functions because all are critically dependent on cyber for speed, precision, and lethality. So our success in the future is based on how well we can integrate it, not on creating a stand-alone capacity. It’s no different than any other aspect of warfare. In any staff, you will have different people with different levels of knowledge and skill; the important part is how you put together not just the IT-specific skill sets, but command skills as well.”

Protecting computer networks that have become intrinsically integrated into both garrison and critical warfighting tasks has become as important to the ability of Marines and other warfighters to survive and win on the battlefield as armor, tanks, aircraft, and reliable communications. Flynn, who left his Marine commands in July to become director, J-7 (Operational Plans and Joint Force Development) for the Joint Chiefs of Staff, saw the creation of both MARFORCYBER and USCYBERCOM as natural evolutions in 21st century military operations.

“Cyber is an emerging, man-made environment that we learn more about every day, so yesterday’s cyber domain is different from today’s,” he said. “It is something that is evolving over time and we will have to learn within the cyber world, in both our personal and professional lives. Keeping the networks operating safely and securely will be a key task in the future, which is why you are seeing this evolution in both the civilian and military establishments.

“We are trying to understand this new environment that came up with the Age of Computers and all we now do in that domain, how much of our daily lives depends on it and how much of that has been carried over to the military, where many of our current capabilities are due to our ability to network so effectively. One of the reasons the Marine Corps felt we needed to be part of Cyber Command was we saw this as something that was occurring now that would continue to evolve in the future and an area where we need to have expertise in order to operate effectively.”

Pentagon officials have told Congress the .mil network is probed as often as 250,000 times an hour by both amateur and professional hackers around the globe, looking for weaknesses, ways to gain entry, or even take control of military websites and Internet-connected databases and systems. Of even greater concern is the possible exposure of military networks, especially in battle theaters, to expertly designed viruses capable of shutting down or redirecting combat computers and systems.

The world witnessed the most sophisticated such attack yet in 2010 when a virus called Stuxnet – origin still unknown – attacked and destroyed specific computers at specific nuclear development sites in Iran. Referred to as the world’s first precision-guided digital munition, Stuxnet also is seen as the opening shot in a new kind of warfare, a new kind of WMD – a “weapon of mass disruption.” Flynn said it is difficult to talk too specifically about such threats for security reasons.

“But the threat is real and comes in many different facets,” he continued. “And we have to defend the network against those probes to keep it operating effectively. To speculate on how large that might be, however, really would not be responsible for me to do right now.

“I’m not sure I would characterize it as cyber warfare, only that this is an environment we have to operate in and protect. We have to maintain our ability to use computer networks and the cyber environment to enable all the things we do in the future.”

Others, however, have no problem with calling it cyber warfare, especially China, which has made becoming the world’s dominant cyber warfare power in the next two decades public policy for its military. Indeed, as other nations find it increasingly difficult to keep up with U.S. technological advances in fifth-generation fighters, stealth, globally commanded precision-guided weapons, etc., they are putting more money and effort into cyber weapons that could negate those advantages before they can even be employed.

As a result, USCYBERCOM and its service components are committed to defending both the national and military computer network architecture, providing information assurance to COCOMs and moving toward what Zotti calls “active defense – proactive hunting in and outside those networks.” That means being able “to provide, operate, and defend [U.S.] networks through offensive operations” when and where necessary.

“Cyber planners will be fused into cyber cells to provide expertise and the ability to advise on and conduct cyber ops as the MAGTF [Marine Air-Ground Task Force] requires,” he said. “Internet security is just one aspect of the domain; defensive operations are only one part of what we will be doing. We are not limited to cybersecurity, but will provide a full spectrum of network defense, offense, and so on to meet the COCOMs’ requirements.

“Broadly, the cyber domain is very competitive and with the proliferation and democratization of technology, you have a wide spectrum – from individual activists with high skill sets and tools to ideological motivations to nation-states. So there is a broad spectrum of threats the nation and military services must be concerned about and have the ability to defend our networks and conduct offensive and exploitation operations as required.”

There are a number of difficulties unique to doing battle in cyberspace, from quickly responding to new, never-before-seen methods of attack to identifying the capabilities of potential cyber adversaries and even the identities of real attackers. At the same time, overreacting before anything happens can do as much harm as failing to prepare.

“We have critical vulnerabilities, but there remain many ways and systems to communicate. So we don’t want to give the enemy incredible plus-ups; everything has a limit on its ability to inflict harm,” Zotti warned. “One of the active defense pieces is how to conduct counter-cyber ops to determine who is attacking and from where. That’s a critical piece, but attribution is very difficult, which gives the enemy – whatever type of enemy – freedom of maneuver.

Marines first, cyber warriors second. Clockwise from bottom left: Sgt. Jeremy D. Sadler, Sgt. Alexander Papiernik, Cpl. Andrew P. Parsons, and Lance Cpl. Michael D. Hargis are tactical data network specialists with 2nd Battalion, 3rd Marine Regiment. The self-proclaimed cyber warriors demonstrate the growing trend in the Marine Corps evolution to a modern battlefield. U.S. Marine Corps photo by Sgt. Robert M. Storm

“MARFORCYBER is the physical manifestation of the Corps’ commitment to providing skills and capabilities to the MAGTF, the joint force, and our allies. It’s a growth industry and a very competitive environment. Marines throughout the Corps have a lot of work to do because, just as with any other type of warfare, the end state is yet to be determined.”

In these early days, little more than a year after both USCYBERCOM and MARFORCYBER stood up, part of that effort is identifying future cyber warriors and ensuring they receive the proper training and equipment – both of which are likely to change far more quickly and radically than any other combat domain. Even so, both Flynn and Zotti believe the standard approach to recruiting, military occupational specialty (MOS) designations, and career progression will remain relatively unchanged.

“Luckily for us, the same attributes apply to everyone seeking to join the Corps. They need to be technologically savvy, which is required to survive, but today’s young people are, by and large, cyber natives – they’ve grown up with this technology,” Zotti noted. “For special skills, like hacking, you must be very adaptive. But in terms of the full spectrum of cyber, that is something the current generation has grown up with in terms of the interface of technology to systems to people.

“Coming into the Corps, officer or enlisted, they go to Marine schools and get different levels of training as they progress. We are currently working very hard with C4 [Command, Control, Communications and Computers], which is responsible for the O6 [communication], to give people training and operational experience as we work toward integrating them into the MEUs [Marine Expeditionary Units], MEF [Marine Expeditionary Force], MAGTF, etc.”

A number of existing MOSs primarily associated with cyberspace and computer operations will be consolidated within MARFORCYBER, although some will be redesignated, such as MOS 0650 (network operations and systems) limited duty officers (LDOs), who will become 0605 (cyber network operations) LDOs. Such changes are more than bureaucratic designations ; the new 0605s will bring in critical experience in cyberspace information technology (IT), doctrine, TTPs, and other skills needed to support the nation’s cyber warfare capabilities in a permanent, integrated domain.

“Going to MARFORCYBER is one command element level for those people who could conduct cyber ops, so cyber planning is a key component. If they are going into defensive ops, there are O6-related skills,” Zotti said. “Prior to the new command, MCNOSC [Marine Corps Network Operations and Security Center] existed to provide and operate networks for the Marine Corps – SPR, NPR [secure and non-secure packet radio], and associated top secret networks. That is now OPCOM [Operational Command] to MARFORCYBER.

“There were other units associated with the Marine Cryptologic Support Battalion [MCSB], which worked with the net warfare entity associated with NSA [National Security Agency] and DSA [Defense Security Agency]. The MCSB Marines were aligned with those organizations, conducting active defense and some kinds of offensive operations.”

Others brought into the new command were more general experts in planning, communications, and intelligence, along with specialists from the Marine Corps Network Operations Center and Marine support and radio battalions. As with the now 5-year-old Marine Forces Special Operations Command (MARSOC), decisions are still being made on whether and how to create a specific career track for cyber warriors, even as existing MOSs are expanded and new ones created.

“We may look at some MOS designations, at what the structure should look like, but there’s really no new skill sets we weren’t already doing. We haven’t created any new specialties, just increased the capacity of those that exist and where they should be put in both the operational forces and support commands to work in this new environment,” Flynn said. “You will find cyber Marines on the staffs of the MAGTF to facilitate traditional military operations enabled by the use of networks and also on joint and service staffs, providing expertise consistent with their MOS.

“In the Force Structure Review [see Flynn Q&A elsewhere in this issue], we identified an increase for the skill sets that will be needed in cyber ops – about 260 or so additional Marines to support our service network, man the component staff, and provide the appropriate amount of manpower to meet joint requirements. All the service components are coming into this on an equal status in terms of what they have to do to operate and secure their future networks. The major difference is the size of the force each service brings to USCYBERCOM.”

MARFORCYBER is expected to provide about 10 percent of that requirement, in line with Marine Corps contributions to other joint force commands.

Because a cyber attack can occur anywhere, any time, literally at the speed of light, cyber warriors must maintain a constant, yet adaptable, level of cyber situational awareness. As a result, evolving doctrine requires these Marines not only collect and analyze network data – Marine Corps, joint force, allied, and potential adversary – but also develop the TTPs required to determine the source of an attack, conduct dynamic cyber defense, assess network vulnerabilities, help develop and evaluate threat-based security systems, take offensive as well as defensive action, as needed – and ensure the U.S. military can continue to fight and win even if a cyber attack takes down its technological advantages.

“[Deputy Secretary of Defense William] Lynn and [Vice Chairman of the Joint Chiefs of Staff Gen. James] Cartwright have said cyberwar will be more characteristic of future war than not. Even as we bring MARFORCYBER and USCYBERCOM online, others, from China to Brazil – and especially in Europe – are creating organizations similar to our command organization,” Zotti concluded. “But the extent to which cyber may replace other forms of warfare is yet to be determined.

“I think, in the 21st century, there will be no one superpower with the means to dominate any battlefield – it will always be a combination of weapons you can bring to bear. There will still be human factors, aviation, long-distance strike – even hand-to-hand combat – every time we think we’ll be dealing with high-tech warfare. We may have to operate in a degraded status, which we will have to prepare for, but we are critically dependent on cyber technology and so must protect those even as we find ways to operate them in a degraded state.”

This article first appeared in Marine Corps Outlook: 2011-2012 Edition.

While commonly used throughout Asia for thousands of years, fingerprints were “rediscovered” by Western law enforcement less than 200 years ago. Even that came after numerous papers and books were written on the subject by European physicians and scientists as far back as the 1600s.

In 1892, Argentine police chief Juan Vucetich set up the first fingerprint bureau, where both criminal fingerprints and latent prints taken from crime scenes were recorded and used for later comparisons. It was another 14 years before this early biometric was recognized in the United States, beginning with the New York City Police Department.

Two crewmembers from a U.S. Coast Guard cutter capture a fingerprint biometric from an interdicted vessel. The Coast Guard furthers its missions of law enforcement and homeland security through the collection of biometric data. U.S. Coast Guard photo by Lt. Josh Brandt

Faster – and commonplace – computers spurred the development of new biometrics, including retinal or iris scanning, facial recognition software, voice “prints,” DNA – even the unique shape of individual human earlobes. Fingerprinting also has benefitted from new technology – not only in the speed and accuracy of shared records, but replacing ink on paper with digital scans and recording all 10 fingers rather than just two.

In its law enforcement mission, the U.S. Coast Guard is a relative newcomer to biometrics, primarily using two-digit fingerprinting to identify suspected alien smugglers, most recently taking that biometric to sea. Testing currently is under way on a 10-print system, which is fast becoming the international standard for law enforcement. In addition, the Biometric Integrated Product Team (IPT), led by the service’s Capability Directorate, is following the development of other biometrics in law enforcement and how they might speed the identification of suspects.

That is especially important for those being held aboard a Coast Guard cutter following an interdiction and boarding at sea. Verifying the identity of those interdicted is a major issue for Coast Guard personnel involved, as well as others taken from the seized vessel. But the often-harsh environment at sea complicates the use of any biometric system.

“There are a number of challenges. The current two-print system is a proof-of-concept that has been operationalized into a system of record to help develop requirements for future development and expansion,” noted Cmdr. Pat DiBari, deputy chief of the Office of C4 and Sensors Capability and Biometrics program manager.

The Coast Guard’s current hardware, software, and modalities being used are effective, DiBari said, but they could be improved. For example, expanding from two fingers per encounter to 10 would capture quite a bit more data requiring more communications bandwidth and autonomous information flow – all of which would have to be incorporated into the capability at sea – but that also would allow the service to access other databases within the law enforcement and defense community.

In November 2010, the Coast Guard held a biometrics exercise, bringing in operators from District 7 in Miami, Fla., and the departments of Defense, Justice, and Homeland Security (DHS), among others. The goal, involving a number of operational scenarios, was to evaluate capability gaps. The biggest gap is how information currently is transferred – by email, one encounter at a time.  “Having more autonomous data exchanges, integrated with our existing systems of record, would be ideal,” he said.

The service has started with upgrades to its cutters’ bandwidth to achieve the goal to transmit data and get a response in a more reasonable amount of time.

If the Coast Guard cutter has the bandwidth to send and receive biometric data directly to shore, the entire process can take less than 10 minutes. The goal is to eventually upgrade from the existing two-print technology to a 10-print, multimodal capability. The service also is working to install that capability on cutters serving with the Department of Defense (DoD) in Southwest Asia.

MST1 Ashley Kelley captures a fingerprint of a crewmember on a SEEK device during an LNG vessel boarding. This biometric data is used to verify the identity of crewmembers. U.S. Coast Guard photo by Lt. Josh Brandt

Increasing demands on Coast Guard law enforcement, homeland security, and defense missions highlight the need for new and more advanced technologies. But the Capability Directorate has identified a far more widespread requirement.

“What we’ve learned through our analysis is the need for identity certitude – using the best data available, based on a biometric characteristic and related intelligence, to identify an individual – is needed for nine out of the 11 Coast Guard missions. Today, less than 10 percent of Coast Guard forces, charged with protecting 95,000 miles of the maritime border, have this capability,” DiBari said.

The cutters on which a two-print system is being evaluated all operate in the waters off South Florida and in an area between Puerto Rico and the Dominican Republic known as the Mona Pass – one of the most heavily used sea lanes for smuggling narcotics and illegal immigrants.

However, according to Lt. Josh Brandt, the Coast Guard Biometrics Mission manager, the service also is conducting a 10-print pilot project for crew verification on liquefied natural gas (LNG) tankers arriving from Yemen at the two primary LNG ports in the United States – Boston and Port Arthur, Texas. Eventually, other data already being collected, but not used, will also be incorporated.

“We don’t use facial imaging for crew identity verification, but it is stored when we take fingerprints from someone who is interdicted, along with biographic information. This data is combined into a digital file that is emailed to the DHS central database – Automated Biometric Identification System [IDENT] – the largest biometric database in the country,” Brandt said. “It also includes visa applicants, border crossings – basically anything any DHS component collects.”

While the DHS central database contains INTERPOL and DoD database records, there is currently no linkage that would enable the Coast Guard to search all available DHS, DoD, and DoJ databases at one time. However, Brandt said, all agencies collecting biometric data are working closely to establish a good path for data-sharing at the federal level.

The Coast Guard is using asset forfeiture funds received from the Treasury Department for the upgrade to 10-fingerprint technology. Once that is completed, the service’s deployment plan calls for potentially expanding biometrics into the Gulf of Mexico and Southern California – the top priorities – and into some port security mission areas.

Homeland Security Presidential Directive 24, “Biometrics for Identification and Screening to Enhance National Security,” requires federal agencies to “use mutually compatible methods and procedures in the collection, storage, use, analysis, and sharing of biometric and associated biographic and contextual information of individuals in a lawful and appropriate manner, while respecting their information privacy and other legal rights under United States law.”

Collection of biometrics is dealt with on a case-by-case basis and in strict accordance with applicable laws. According to DiBari, if there is reasonable suspicion of criminal conduct, there could be justification to collect biometrics. Making such decisions emphasizes the other major components of using biometrics – training and an understanding of the context of other agencies’ databases.

This depiction provides the future operational view of how the Coast Guard, through interagency collaboration, will collect and verify identities while employing policy, protecting privacy, and leveraging national databases. U.S. Coast Guard diagram courtesy of Lt. j.g. Al Sowers

“A lot of people focus on the technology, but part of implementing a capability includes eventually embedding it in your regular training program. Those using it need to not only understand the technology, but also the policies involved, the legal requirements, the databases being searched, the context behind that data, etc., so they can put a picture together and ‘connect the dots’ on scene,” DiBari said. “And that requires comprehensive training, which is clearly a major part of making a system effective.”

Brandt is confident the Coast Guard will stay on top of new biometric technologies, especially how they are used by other government agencies, as well as knowing some will not be appropriate for use on ships at sea. Current facial recognition technology, for example, may not handle the rough environment of moving platforms at sea. Nor is it yet possible to use facial recognition at a distance, such as from a cutter to another boat.

For now, the Coast Guard sees its biometric needs as being very fundamental – but growing.

It’s hard to predict what’s next for the service. According to the Coast Guard Authorization Act of 2010, it requires DHS to evaluate emerging technologies for biometrics and evaluate more non-intrusive collection technology. In the maritime environment, DiBari concluded, that is particularly challenging, where there are environmental factors, such as sea spray and direct sunlight, that impact the quality of this technology.

“It also requires the department to stand up a maritime biometrics program of record. We’re looking at different options on how to do that; clearly, with our current budget environment, we need to look at implementing joint programs and shared standards and architectures with our partners – DHS, DoD, and Justice. We believe continued research will yield less intrusive and more efficient methods, which in turn will drive which modes we adopt.”

More than 900 prosecutions have been conducted using fingerprints collected by the Coast Guard since the biometric proof-of-concept system was implemented in 2006. In fiscal year 2011 alone, the system helped facilitate the prosecution of 85 individuals for human smuggling or illegal entry/re-entry into the U.S., and on six occasions helped verify citizenship of migrants interdicted at sea.  When a 10-print system is implemented more interdictions could be considered for prosecution, especially when combined with other emerging biometrics. The success of this proof of concept presents a compelling justification to expand use in other sections of the maritime border and will help the service take another step in DHS’ comprehensive strategy to secure the nation’s borders.

This article was first published in Coast Guard Outlook: 2012 Edition.

The oldest confirmed human – a French woman named Jeanne Louise Calment who died in 1997 at the age of 122 – marked what generally is thought to be the maximum human lifespan. However, recent research indicates there may be no absolute maximum lifespan, only a life expectancy limited by infant mortality, childhood deaths, disease, accidents, and war.

When Social Security was enacted in the United States in 1935, it set a benefits-eligible retirement age of 62, which was beyond the actuarial tables’ American life expectancy at the time. That has increased, for full benefits, to about 67 today, but U.S. life expectancy for those reaching retirement is more than 10 years beyond that age and the number of Americans living into their 80s, 90s, or even past 100 has increased dramatically.

While that – and especially the beginning retirement of the Baby Boom generation (born 1945-65) – is putting Social Security under extreme pressure, an aging population of military veterans – significantly expanded by a decade of war in Southwest Asia – will do the same for the Department of Veterans Affairs (VA). Even the Department of Defense (DoD) is being affected, with service members living longer, healthier lives not as eager to leave the military and the new TRICARE for Life program acting as a Medicare supplement for veterans 65 and older.

The current veteran population dates back to those born as early as the 1920s and grows larger with each succeeding generation. Even with better overall health, those numbers mean the VA will face a constantly increasing demand for health care, at least through most of this century. And in addition to the possibility of an older active duty, Reserve, and Guard population, more veterans also will mean increased TRICARE for Life expenditures for DoD.

War and military medicine – especially in the past decade – have played a significant role in increasing American life expectancy. Treatments for what in the past would have been fatal wounds, improved long-term care and rehabilitation, and advances in bio-technology, regenerative medicine, transplants, etc., for the military have provided equivalent life-saving care to the civilian population. And military medical research, which has become far more expansive and intensive in recent years, also has opened new doors and possibilities for non-military-specific research that could dramatically increase human health and life expectancy even more.

World War II veterans sign autographs after a commemoration ceremony at Angoville au Plain, France, June 4, 2011. The ceremony honored two medics from the 101st Airborne Division who rendered aid to 80 combatants and a local child in 1944 during the war. The U.S. military and government have pledged to provide health care for all veterans, a challenge given increased life expectancy and current economic conditions. U.S. Army photo by Staff Sgt. Tramel S. Garrett

“That’s a good news story – there’s no question people are living longer and we hope both the DoD and VA health care systems will add to that,” said Dr. Jonathan Woodson, assistant secretary of Defense for Health Affairs and director of the TRICARE Management Activity. “And if we build healthier populations, we can care for these individuals longer and at lower cost.

“But for those wounded in war who are likely to survive longer and require services, I would like to state unequivocally we have a commitment and understanding to provide services for as long as they need them. That includes prosthetics, mental health care, etc. One of our strategies is to improve overall population health, making sure we bring the important focus to prevention measures to keep our people healthy as long as possible.”

Not everyone is as sanguine about the prospects of a population of centenarian – much less super-centenarian – veterans later in this century and beyond, as there is general agreement many young warfighters now in combat in Afghanistan almost certainly will still be on the VA health care rolls at and after the turn of the 22nd century.

The Census Bureau reported the number of centenarians in the United States more than tripled from 1980 to 2010. And according to the Department of Health & Human Services (HHS) report, “A Profile of Older Americans: 2010,” the United States will see a 36 percent increase in the over-65 population during this decade alone.

“By 2030, there will be about 72.1 million older persons, almost twice their number in 2008 [and more than 23 times as many as in 1900]. People 65-plus represented 12.9 percent of the population in the year 2009, but are expected to grow to be 19.3 percent of the population by 2030. The 85-plus population is projected to increase from 5.6 million in 2009 to … 6.6 million in 2020,” the report predicted. “In 2009, 41.6 percent of noninstitutionalized older persons assessed their heath as excellent or very good, compared to 64.5 percent for all persons aged 18 to 64 years.

“During the next three to four decades, we can expect a very dramatic increase both in the number of elderly persons and in the proportion of elderly persons in the population. The arrival of the large Baby Boom cohorts at age 65 will trigger the large increases in the number and percentage of elderly in the next half century. These prospective demographic changes have given rise to a general concern about the social, economic and physical ‘health’ of our nation’s population,” according to the report.

As the Baby Boom generation continues to age, it will push each succeeding age category to record highs – such as an estimated 88.5 million people age 65 and older by 2050. That includes a 400 percent increase in the over-85 population, boosting their part of the total population from about 1.4 percent today to 5 percent by midcentury. Aside from the sheer number of Baby Boomers, those changes will be heightened by shifts in birth rates, the volume and age pattern of future immigration, improved medical care – and lower birth rates in the generational groups born after 1965.

“The rapid growth of the elderly, particularly the oldest old, represents in part a triumph of the efforts to extend human life, but these age groups also require a disproportionately large share of special services and public support. There will be large increases by 2030 in the numbers requiring special services in housing, transportation, recreation, and education, as well as in health and nutrition,” the aging report continued.

“There will also be large increases in some very vulnerable groups, such as the oldest old living alone, older women, elderly racial minorities living alone and with no living children, and elderly unmarried persons with no living children and no siblings. These are also groups with high percentages living in poverty or with low incomes. The number of persons requiring formal care (mainly nursing home care) and informal care (mainly care at home) will rise sharply even if the share of persons at each age remains unchanged. Accordingly, there will be a large increase in the numbers participating in various entitlement programs, such as Social Security and Medicare.

Retired U.S. Air Force Master Sgt. Alfredo Alferez, left, undergoes a screening for diabetes, provided by the 61st Medical Group, at the annual Retiree Expo in the Gordon Conference Center, Los Angeles Air Force Base, Calif., June 26, 2010. U.S. Air Force photo by Joe Juarez

And the VA.

Committees in both houses of Congress, as well as independent studies by DoD, VA, HHS, academia, and others, are trying to determine the best projections, not only for the number of increasingly older veterans, but also what it will cost to continue benefits. Those numbers also tend to change rapidly, as with the VA’s August 2010 extension of grant payments to Vietnam veterans for Parkinson’s Disease, certain types of leukemia, and heart disease – the nation’s leading cause of death – in addition to lung cancer, prostate cancer, and other major ailments. The initial cost projection for that change, based on disease rates in the general population, was $42.2 billion across 10 years, but a later recalculation, looking only at Vietnam veterans, raised that projection by 60 percent, to $67 billion.

“The irony [is] that the veterans who saved this country are now, in a way, not helping us to save the country in this fiscal mess,” Sen. Alan Simpson, R-Wyo., an Army veteran, former chairman of the Senate Veterans’ Affairs Committee and co-chair of the president’s deficit commission, said at the time. “It’s not that I’m an uncaring person, but common sense is the most uncommon thing in Washington.”

However, there are those who believe an aging population will cost the government less. In order to reach those high ages, they first must survive the most costly and health-destructive period in American life – the 50s, where obesity, lack of exercise, poor diet, etc., are the leading causes of poor health and death. Those who live beyond 70, especially with the ongoing and increasingly rapid evolution in medicine, thus are likely to be healthier, overall, than those in middle age.

A National Research Council study released in January 2011 confirmed better health care for middle-aged Americans will lead to longer lives. While that also would mean more funds to cover later-life pension and Social Security benefits, the study estimated it also would result in a major decrease in health care costs – nearly $18,000 per person. That converts to a health care savings of more than $1.1 trillion by 2050, more than half in government payments.

The nation’s oldest veteran and last surviving combatant from World War I – having lied about his age (16) to join the Army in 1917 – died in February 2011 at the age of 110. While there are few veterans even close to Frank Buckles in longevity, more and more are moving in that direction. An 18-year-old who went to war in 1942, for example, would now be almost 90, which is no longer a major anomaly.

VA costs also are likely to begin rising as more and more veterans become Internet literate and learn about programs they may not have known existed. One VA analysis reportedly discovered only 27 percent of veterans and 14 percent of surviving spouses with potential eligibility have applied for the Veterans Non-Service Connected Improved Pension Benefit Program. It is open to any veteran (including Coast Guard) with at least 90 days active duty, at least one of which was served during a U.S.-declared war, even if not as a combatant. The benefits help cover specific financial needs for those demonstrating a physical need for health care not already covered.

States, counties, and cities also are beginning to expand services to veterans, programs that also will be affected by a population increased by post-9/11 military expansion and living decades longer than their predecessors. New York State, for example, estimates at least 78 percent of its 1 million resident veterans are older than 55, with both total numbers and ages rapidly increasing.

Then-Chief of Staff of the Army Gen. George W. Casey, left, and then-Chairman of the Joint Chiefs of Staff Navy Adm. Mike Mullen give interviews at the premiere of the HBO documentary "Wartorn 1861-2010" Oct. 28, 2010, at the Pentagon. The film explores the history of post-traumatic stress disorder and its impact on service members, veterans, and their families. New health concerns may develop in the future for veterans of today's wars related to TBI and PTSD, along with recognized age-related illnesses. DoD photo by Mass Communications Specialist 1st Class Chad J. McNeeley, U.S. Navy

Concerns about the impact of aging veterans on the VA health care system are not new, as evidenced by a 1983 National Institutes of Health (NIH) study entitled, “Aging Veterans: Will They Overwhelm the VA Medical Care System?” But it is more than just raw numbers and percentages or even increasing age.

With each increase in human life expectancy has come the appearance of ailments rarely – if ever – seen before, simply because few people lived long enough for those to appear or become life-threatening. Adult onset (Type II) diabetes and Alzheimer’s are two major examples, but others may develop in the future as the result of recently recognized combat-related problems, such as post-traumatic stress disorder (PTSD) and traumatic brain injury (TBI), along with problems that may develop with increasing age for amputees or those who survived severe burns.

According to the VA National Center for PTSD, “many older veterans find they have PTSD symptoms even 50 or more years after their wartime experience.” As combat-related problems, both TBI and PTSD are as old as war itself, the latter previously having been known as “shell shock,” “battle fatigue,” “combat stress reaction,” etc. But only now, with the accumulation of clinical data leading to its redesignation as PTSD, are those afflicted living past age 75 in large numbers.

“Many older Veterans have functioned well since their military experience. Then later in life, they begin to think more or become more emotional about their wartime experience. As you age, it is normal to look back over your life and try to make sense of your experiences. For Veterans, this process can trigger Late-Onset Stress Symptomatology (LOSS),” according to the VA.

Similar age-related developments already have begun to emerge or are expected for those who survived a range of battlefield wounds that would have meant death – or significantly shorter post-combat lives – in earlier wars.

Another change in the veteran population – and one with significant questions as they grow older – is the number of women who have served in the military, especially in the current conflict. While comprising only about 1.8 million of the nation’s 23 million living veterans, women are one of the fastest growing segments of that population. The VA estimates female veterans will increase from 7.8 percent today to 10.5 percent by 2020. Given women in the United States continue to outlive men by five to 10 years (although that gap has been growing slowly smaller) and more women are joining the military, by 2050 they are expected to be a significant share of the veteran population – especially those 70 and older.

An aging population is more widespread than U.S. military veterans, of course. It extends to the entire U.S. population and globally, with the number of people age 65 and older worldwide expected to double by 2040 to 1.3 billion – 14 percent of the Earth’s forecast population at that time – according to a National Institute on Aging study. Medical advances developed for the U.S. military – and following on to the care of veterans – also will affect global health care, just as developments elsewhere will have application in the United States.

The big question for the VA – and all federal, state, and local governments – as the 21st century progresses will be cost: With a presumably unshakeable pledge to provide health care for all senior citizens – and a particular emphasis on veterans – but a U.S. and global economy currently facing severe problems, how can that rapidly growing population best be served?

As noted by former Census Bureau Director Louis Kincannon: “The social and economic implications of an aging population – and of the baby boom, in particular – are likely to be profound for both individuals and society.”

This article first appeared in The Year in Veterans Affairs & Military Medicine: 2011-2012 Edition.

Overseeing more than 133,000 military and civilian doctors, nurses, medical educators, researchers, health care providers, allied health professionals, and health administration personnel worldwide is Dr. Jonathan Woodson, assistant secretary of defense for health affairs. He also is director of the TRICARE Management Activity and principal medical advisor to the secretary of defense.

A vascular surgeon and brigadier general in the U.S. Army Reserve, Woodson has had combat deployments to Saudi Arabia (Operation Desert Storm), Kosovo, Operation Enduring Freedom-Afghanistan, and Operation Iraqi Freedom. As a senior medical officer with the National Disaster Management System in 2001, he responded to the Sept. 11, 2001, attack in New York City. Woodson has been awarded the Legion of Merit, the Bronze Star, and the Meritorious Service Medal (with oak leaf cluster).

He recently spoke with senior writer J.R. Wilson about how combat health care has evolved since 9/11 and how the Department of Defense (DoD) is working with the VA and civilian medical community to further advance and maintain cutting-edge technologies and procedures.

The Year in Veterans Affairs and Military Medicine: After a decade of war, how has the DoD health care system changed to meet the medical needs of U.S. warfighters?

Dr. Jonathan Woodson: Throughout periods of war there always are advancements in medical care. Ten years ago we had a legacy system of battlefield care that involved larger, more complex combat support hospitals and infrastructure. The nature of this war and advancements in technology allowed us to meet the mission of superb battlefield care even as we maintain a relatively small footprint far forward.

It begins at the point of injury with a system that allows us to get injured service members to care within that first “golden hour” – a time limit defined by civilian trauma systems and refined by our military medical strategy. So the wounded are taken to medical facilities that can perform resuscitative care in minutes. This has led to unrivaled statistics in the history of warfare, including the lowest killed in action numbers ever.

We also bring advanced technology to the battlefield and medics who have been trained to a level unequaled in the past, certified to EMT [emergency medical technician] national standards and able to recognize and resolve life-threatening injuries at the point of injury. Including significant wounding events, such as those resulting from IEDs, we have specifically addressed ways to stop hemorrhaging and treat TBI [traumatic brain injury].

The care continues on through the continuum, with our overall strategies refined by an unparalleled strategic evacuation system in which a wounded service member can be sent to Landstuhl [Germany], a Level 4 facility, within a day. And the care continues on from there, including transport back to CONUS [the continental United States] for Level 4 and 5 care and reconstruction and rehabilitation.

What have been the most demanding requirements to date?

There are several levels to that. The kinetics of these two wars are a little different from prior combat. There are no battle lines, which makes delivering care more difficult because battle and communications and medical logistics are all intermixed.

One of the things I’m proudest of is, in the early days of the war, some forward-thinking leaders established the Joint Theater Trauma System and Registry. That allows us to examine the care of the wounded warrior and make improvements almost as we deal with them.

Each casualty is entered into the database and care delivered is tracked from the point of injury through the combat support health care system to Langstuhl and back to the U.S. We can then analyze how to improve that care, with weekly conference calls looking at the care given every service member and how to improve that.

Another challenge has been recognizing the extent of invisible injuries such as TBI, mental health support, and building resiliency. We have a strategy now to assess mental health needs and have embedded mental health professionals far forward, which not only is helpful to behavioral health issues but also in treating TBI. And now we have better strategies that begin in basic training to build skills to help service members become resilient and resistant to the stresses of war.

What have been the most important developments in medical technology for DoD?

We can look at individual products, such as the combat action tourniquet, hemostatic agents, resuscitation formulas that look at products to be transfused, fielding of blood supplies, the use of technology in the forward area to support diagnosis and treatment. On the other end, our strategy for training folks in these technologies has included extensive use of medical training simulators, which allow us to produce greater degrees of skill in medics as well as advanced practitioners.

Other advances have been in the way we communicate data, including telemedicine and teleconsultation, which has been a great enhancement in our ability to deliver mental health care to the battlefield when there is not a co-located mental health professional.

And in overall medical capability, with respect to the needs of the warfighter?

You can’t do strategic evacuation without a sophisticated group of health care providers using advanced technology to monitor the wounded en route, especially when the altitude of the aircraft carrying them can alter physiology.

That rapid movement of wounded not only meets their medical needs but also their social and psychological needs, getting them back to their families, who deeply care for them and can contribute to the healing process.

The American public will not accept care [for wounded warriors] that is not at least to the standard of the civilian population – and now, I believe, superior to it. For any injury severity score, which is the metric we use to gauge how sick or injured an individual is, survival rates for the military now surpass those of the civilian sector.

There also has been a growth in health care needs for service families – how is DoD addressing the needs of military spouses and children?

That involves a whole strategy for maintaining care for active-duty family members, who often receive care at military treatment facilities. TRICARE has worked hard, as military members have been deployed, to not interrupt care for dependents left behind. So we have provided more providers and contractors to help support delivery of care.

One specific health care issue I think is important to dependents is the psychological stress on the family, both children and spouses, left behind, as these disruptive and sometimes multiple deployments have become necessary. We have enhanced access to mental health specialists, both face-to-face and via teleconsult, and added a significant number of mental health care providers to our network.

What are the most important medical lessons learned from the war in Southwest Asia?

There are a number of different levels to that. One lesson clearly learned early is if you are going to save lives you must have medics with advanced skills. When injuries happen, our frontline medics, men and women who walk shoulder to shoulder with units going into harm’s way, are well-trained to recognize and address life-threatening wounds by applying these advanced technologies and procedures.

We’ve learned a lot about blood products, especially component blood products in the right proportion – red cells plus platelets – instead of water, which can lead to secondary problems that compromise respiration and cardiovascular function.

We’ve learned a lot about rapid assessment and not trying at the earliest moment to definitively repair all injuries, but instead perform damage control surgery. That means we stop the bleeding and prevent further damage without spending excessive time trying to fix all injuries when the wounded need to be cleared off the battlefield to an area more able to do definitive care.

Dr. Jonathan Woodson, assistant secretary of defense for health affairs and TRICARE Management Activity director, asks Lt. Gen. Eric Schoomaker a question during a briefing at the Fort Belvoir Community Hospital project office, Jan. 14, 2010. Schoomaker is the U.S. Army surgeon general and U.S. Army Medical Command commander. Construction of the $1 billion hospital began in January 2008, and is scheduled for completion this year. When complete, the hospital will be a joint-service facility serving all branches of the U.S. military. U.S. Army photo by Marc Barnes

How does military medicine work with the designers and builders of modern combat equipment – from helmets and vests to vehicles – to help increase and improve protection against injury?

In times past, things were looked at in isolation. Contractors produced trucks and vehicles and helmets in isolation, the safety people looked at safety often based on civilian standards that did not consider the combat environment or preventing [changing types of] battlefield injury. Today that is radically different, so much so we are producing metrics and models to produce equipment to prevent specific medical injuries we have recognized occur.

Unfortunately, there are individuals who do not survive their wounds and armed forces medical examiners use rigorous means to see if their equipment failed to protect those individuals from injury, then feed that to the safety people. So patterns of injury are recognized, as are equipment improvements, to prevent future injury and focus on where to produce improvements.

What role does the DoD play in providing medical assistance to host nation civilians?

If war is viewed as the dark side of humanity, I like to say military health care is what introduces renewed humanity into inhumane situations. We ethically and by mission are responsible for saving lives; once someone is ill or injured, we don’t really distinguish who they are. Obviously that includes host nation civilians caught in the crossfire or injured on the battlefield, and we put as much into saving them as we do our own service members.

That not only is the right thing to do, from an ethical and moral point of view, but I think it has a major role in creating goodwill. I’ve had direct experience in my own deployments, where when host nation civilians see us deliver the same care to them that we do to our own service members, they have a new view of us, no matter what they may think of our politics.

In what ways do you provide field care for and work with host nation and allied medical care, with respect to both military and civilian needs?

Quite extensively, looking at what happened in Iraq and is happening in Afghanistan, where we have multi-national medical facilities.

If you look at what is happening around the world, the United States has the most robust ability to project a military medical system into austere environments, whether for kinetic warfare operations or military operations other than war, such as a humanitarian crisis or natural disaster. But a number of other nations are willing to be partners in delivering care.

After 10 years of war, we have become more skilled at working with international partners and NGOs [non-governmental organizations] and understanding where the military effort starts and stops and should transition to the State Department or USAID or NGO missions or the host nation, which ultimately will have the long-term responsibility for caring for its citizens.

What are the most important ways DoD and VA cooperate on health care?

In the years since 9/11, we clearly understand we need to take a whole-of-government approach to the long-term care and rehabilitation of wounded warriors. One of our most significant partners in that is the VA and the beneficiaries they do or will serve are those we have or are serving. So we have created a number of collaborative programs to allow smooth transition from DoD to the VA care system.

If you take a larger than one partner agency approach to care, you can produce a lot of efficiencies. So we have programs looking at the appropriate use of VA hospitals – the five polytrauma centers – to provide care to active-duty members, especially for TBI. These programs care not only for the physical needs, but the psychological and rehab needs, not only making sure they can walk again, for example, but long-term planning to build new skills and find lifelong jobs.

The VA is helping us a lot in terms of mental health and telemed support, especially for the Guard and Reserve, both service members and their families, along with sharing agreements on training, especially for mental health providers. We have a health executive committee – co-chaired by myself and the deputy under secretary at the VA – to actively look for new projects on which we can coordinate.

How does DoD work with the civilian health care community in developing medical advances, from R&D to testing to training?

We work very closely with our civilian partners. Historically, this is not new, but we have taken it to a new height.

We have a robust ability to do medical research within DoD, but research and innovation have always been a collaboration between the military services, civilian partners, academia, and industry. Academic medical centers, because of their fundamental approach, produce those individuals involved in investment and innovation in the development of new techniques and technologies.

Warfighters and combat support personnel have been called on for repeat tours of duty in Southwest Asia, but what about military medical personnel?

Military medical personnel are tremendous individuals who have committed to this kind of service to troops going into harm’s way. And it is some of the most professionally rewarding work a medical care professional can do.

But there are only a finite number of high-end specialists – surgeons, critical care nurses, etc. – so when you have a war that lasts a decade, clearly some are going to be called upon more than once – and, if asked, they would do it again.

There is an interesting dynamic occurring in the U.S. at this time – the proportion of individuals who have served in combat, in relation to the total population, is the smallest in the nation’s history. So those medical professionals who have served need to tell their stories so others will do the same.

Before 9/11, military doctors and nurses received trauma care experience in urban hospitals; is that still necessary – or are those hospitals now benefitting more from the experiences of returning military doctors and nurses?

That’s an interesting dynamic. In peacetime, the urban centers provide a platform for maintaining skills in trauma management, but in wartime, military health providers have a greater experience and depth in managing complicated injuries.

I do think we need to maintain our connections with civilian trauma centers. The advances we learn about in war eventually should be transmitted to those civilian centers for the benefit of the public at large. And when the kinetic war is over, then it is about maintaining skills and continuing to improve even as we look at non-combat related wounds. Then, if another kinetic war comes along, we have a basis to provide skilled health care providers to care for our warfighters.

Overall, how does current military health care compare to what was in place just before 9/11?

Our effort has always been to stay ahead of the curve and constantly improve what we do. We now have put into place some systems to monitor that.

For families, we do not think access to or quality of care is a problem any more. We continue to have challenges with Guard and Reserve families in remote locations, but we have made great strides, especially in partnership with the VA.

What other changes do you expect in the next 5, 10, 15 years?

Can we do better? Absolutely.

Military health is a complex system that really provides, first of all, a strategy for keeping people healthy, with robust public health and force protection programs on the battlefield. We’re also a learning organization and 10 years of war has resulted in advances in saving lives that would not have been saved in prior conflicts.

This is an area without a lot of existing investigation and science, but we are forging ahead in building and understanding the science, not only for our service members, but also their families.

This article first appeared in The Year in Veterans Affairs & Military Medicine: 2011-2012 Edition.

But a decade of constant combat in Southwest Asia has led to a heavy new emphasis on critical predeployment training that all Marines, regardless of rank, receive to ensure they benefit from the most recent lessons learned. It also seeks to make them fully proficient not only in the equipment, tactics, techniques, and procedures (TTPs) they will use in theater, but in the local culture, language, and political structure, as well.

Two organizations with major responsibilities for this combination of enhanced traditional and relatively new advanced training are the Marine Corps Training and Education Command (TECOM), headed by Maj. Gen. Raymond C. Fox, and the Marine Corps Tactics and Operations Group (MCTOG), commanded by Col. Bill Mullen.

TECOM has the first element, from turning civilians into Marines to all of the formal education provided to both officers and enlisted throughout their military careers; in short, all requirements of Title 10 of the U.S. Code related to training the nation’s military force. With Marines rapidly cycling in and out of Iraq and Afghanistan the past decade, along with a wide range of other deployments around the globe, training and education have become both more critical and more difficult.

A U.S. Marine from 3rd Battalion, 3rd Marine Regiment, Lima Company, conducts counter improvised explosive device (IED) training on Marine Corps Base Hawaii, May 4, 2011. Concurrent Technologies Corporation, in accordance with Training and Education Command (TECOM)/Training Support Center Counter IED, assisted the Marines for an upcoming deployment in support of Operation Enduring Freedom. U.S. Marine Corps photo by Cpl. Jody Lee Smith

“When the OPSTEMPO [operations tempo] increases, as it has for Afghanistan, we have to accelerate the training cycle, sometimes moving up three or four months,” Fox noted. “We [TECOM] have been able to react to that – it’s usually harder on the units involved, which may not have completed other training they normally would get first.

“When we start reducing forces in Afghanistan and get to what we call steady state, with a hopefully more predictable OPSTEMPO, we will have more time to train individuals and units, including going back to redo an event on which they may not have performed [as well as expected].”

MCTOG was stood up in 2007, with immediate requirements to provide crucial predeployment training – especially in leadership – while also rewriting infantry company and battalion doctrine that had not been updated since the late 1970s.

According to Mullen, the Operations and Tactics Training Program (OTTP) has three primary goals:

1. Train and certify Operations Tactics Instructors (OTIs).
2. Put units prepared by the OTIs through the Battle Staff Training (BST) program, concluding with an exercise called Spartan Resolve.
3. Conduct the Operations Tactics and Training (OTT) program – reviewing or writing doctrine, updating training standards, and integrating tactical lessons from Afghanistan.

With only 150 personnel – about 50 government civilians and contractors, with the rest primarily senior officers and noncommissioned officers (NCOs) – MCTOG relies heavily on simulation in its training programs. But it also uses small groups who present the Marines with a range of human interaction, from local officials to villagers to enemy insurgents.

One of the most important components in predeployment leadership training – for both officers and NCOs – is something that has grown almost exponentially in the new century: information management, which includes acquiring, validating, and fusing data from a wide range of sources into useful information available when needed and in a format shared by leaders at all levels.

“They have to know not only who they are talking to, but understand what that person can or cannot do for them and the impact of that. We call it non-kinetic targeting, where they build a profile on the individual – who he knows, his background, his real influence – and develop a plan on what to talk to him about to get the best results,” Mullen explained.

U.S. Marines with 7th Marine Regiment, 1st Marine Division practice combat marksmanship on Range 105 at Marine Corps Air Ground Combat Center, Twentynine Palms, Calif., Aug. 1, 2009, during Operation Spartan Resolve. The operation was in preparation for upcoming deployments. U.S. Marine Corps photo by Lance Cpl. Christopher M. Paulton

“Part of that is information from other people. When you go into a new area, you don’t know all that, so you try to get as much information in advance as possible. But you remain noncommittal when you first sit down with locals, watching how others react to them. When someone enters a room and is ignored, that guy has no influence whatsoever; if all conversation stops, that guy has influence. But until you figure that out, you remain noncommittal.”

In Afghanistan, which has always been more a loose confederation of tribes and warlords with ever-changing alliances than a traditional nation-state, all that is further complicated by religion, culture, outside influences (such as al Qaeda), and a centuries-old distrust (at best) of foreigners. It is up to TECOM and, especially, MCTOG to give Marines on their way to Afghanistan the best possible knowledge and understanding of their host nation allies, civilians, and enemy.

“We’re doing a lot of work on lower-level development to make the best squad leaders we can, so they can make the right decisions in the environments they will be facing,” Fox said. “I’m not sure today’s young Marines are much different from those in World War II, but certainly they are challenged to do more and the world is a much more complicated place today. So basically it has ramped up our requirements to spend more time and use all the means of education and training we can. We use a lot of online training and have invested a lot more time teaching the cultural values and languages of different countries.

“The equipment is more sophisticated, which requires better education and training, as are the communications. So they need to understand how all that gear works before they go into combat. And that is what has produced the Marines we have today, from their desire to be Marines to their ability to grasp the technologies involved, the need to understand culture and language, and take those new skills out onto the battlefield.”

And while public attention has been largely focused on Afghanistan, Fox and Mullen emphasized Marines were heavily engaged in multiple other missions around the globe since January 2010, ranging from humanitarian relief after the Haitian earthquake and the Japanese tsunami to counterpiracy efforts off the coast of Africa and to training with allies worldwide.

“The type of operations the Corps has done in the past 18 months is something the nation should be proud of,” Fox said. “The Corps is justifiably proud of the versatility of our deployed forces. I think policymakers sometimes take for granted having those forces there without realizing what it takes to get them there.”

MCTOG’s Spartan Resolve exercise has multiple goals, including helping battalions prepare for their final test before deploying – Enhanced Mojave Viper (EMV), a grueling 35-day live-fire exercise conducted by the Marine Corps Air Ground Combat Center, Twentynine Palms, Calif. The “Block IV” component of the Corps’ Pre-deployment Training Program (PTP), it combines elements from two previous programs – the Revised Combined Arms Exercises and Security and Stability Operations training – giving warfighters a final, Afghanistan-focused “dress rehearsal” for what they soon will face in theater.

A role-playing Afghan National Army (ANA) soldier takes up a security position during an Enhanced Mojave Viper exercise at the Marine Corps Air Ground Combat Center's new combined arms, live-fire, Military Operations on Urban Terrain training range, Feb. 15, 2011. Role-playing ANA soldiers attach with squads throughout some of the training, giving Marines an idea what it will like when working with foreign militaries. U.S. Marine Corps photo by Cpl. Andrew S. Avitt

“Enhanced Mojave Viper is the last test for battalions before they head overseas, so we help them try to do better on it,” Mullen said. “Regiments do not go to EMV, so we set up two different Spartan Resolve exercises, one to work through the bugs and the second as an assessment, which really is another set of eyes looking at the regimental staff.”

A Spartan Resolve exercise was conducted in July and August for three battalions at Camp Pendleton, Calif., and a fourth at Marine Corps Base Hawaii (MCBH). MCBH was where the first Spartan Resolve was held in October 2008, when the 3rd Marine Regiment was activated as a special purpose Marine Air-Ground Task Force (MAGTF) to go to Afghanistan on fairly short notice.

“They were building a battle staff training program as part of our original charter and may have run one or two battalion-level operations before that, but that was the first real one,” Mullen said. “And since then we’ve hit every battalion going to Afghanistan – 7th, 2nd, 1st, 8th, 5th, and we’re getting ready to do the 6th Marines in September.”

The various training programs conducted by MCTOG address junior and senior officers, NCOs, and enlisted personnel equally, he added, with a goal to have leaders at all levels – from squads to headquarters – equally prepared to deal with whatever may happen.

“If you take the time to explain things to Marines of any rank, they understand. But it you don’t explain things to them in advance, their first instinctive reaction may create problems,” he said, “which is why we train officers and enlisted together in the MCTOG courses.”

While the culture, religion, politics, and tribal relationships of Afghanistan are far outside the world American military personnel know and understand, it is the Marines’ own technology that can be the most difficult obstacle MCTOG training seeks to overcome.

“The hardest part, by far, is information management and the compounding factor is integration: organizing all the incoming information, sifting through what is and is not important, then getting it to the decision-maker in time for him to make an informed decision,” Mullen said. “There is so much information coming in today, you could easily drown in it. You have people above pulling for information and people below you sending it up in vast volumes. So you have to be value-added to the people below you, even as you feed the beast above.

“A common comment in Iraq – and now Afghanistan – is information goes up, but nothing ever comes down. When pulling a new team together, you first have to get past the typical inward focus. One technique we use is the institution of a battle rhythm, a series of meetings that force you to pull in other folks, process information, establish human filters who are trusted members of the team. We have to sort all that out through the training exercises so they can get that out of the way before they deploy.”

Civilians, especially teenagers, may be surprised to learn one of the most common forms of communication in a combat operations center is “chat,” using everything from handhelds to laptops to desktop terminals. But just as in civilian life, while chat can provide a fast way to communicate among numerous users, it also can become part of the information management problem – and so part of the training program.

“People tend to get too focused on their chat windows – they can have half a dozen open at the same time – and that impacts situational awareness. So we get them to understand there are times when you have to say ‘stop,’ get everyone’s attention, explain what information has just come in and what needs to be done with it,” he said. “We explain to them how the whole information chain needs to be fed, how to properly resource everyone and make decisions on what has to happen.

“We operate all the way down to the company, putting advisors at the regiment, battalion, and company levels, which is where they really have to start pulling things together. A lot of our training is focused on the individual Marine, out there every day collecting information. But if no one responds to that when they come back from patrol, they will stop collecting as much.”

Marines and soldiers sit waiting at a Marine Corps Tactics and Operations Group (MCTOG) classroom for the first integrated Ground Operations Chief Course and Tactical Marine Air-Ground Task Force Integration Course graduation April 8, 2011. The class graduated 57 officers and 18 enlisted personnel. U.S. Marine Corps photo by Lance Cpl. William J. Jackson

While the current focus is on Afghanistan, TECOM, MCTOG, and the entire range of Marine Corps training and education components also are looking to what will be required in a post-Afghanistan world. The new company and battalion doctrine updates, as well as the length and structure of the OTI training course,  will incorporate both lessons learned from more than a decade of combat in Southwest Asia and some things critical to traditional Marine operations but overshadowed by the requirements of combat far from the sea.

“We are squarely focused on lessons learned. We’re great at observation, but less so at adopting them. So we need to make sure all that is pushed back into the doctrine so these things are not forgotten,” Mullen noted. “Even after Afghanistan, we will still have to train units to deploy. The only real change will be the exercises no longer will be fully focused on Afghanistan.

“In fact, the course we run for OTIs today, the final exercise, has nothing to do with Afghanistan; the actual details are classified, but it’s an amphibious MEF [Marine Expeditionary Force] landing for offense, defense, and stability operations. That is a core competency we have to make sure we maintain. If we lose our ability as Marines to do amphibious operations, then people will start asking why we need two land armies.”

There appears to be general agreement within the Corps that, at least for the next 10 or 15 years, any combat operations, wherever they may occur in the world, are more likely to resemble the asymmetric, counterinsurgency (COIN) battlespace of OIF/OEF and what were known as “small wars” in previous centuries than a full-blown conflict with a peer or near-peer nation-state. But future doctrine and training also will have to take into account both rapidly evolving technology and the increasing ability of even small terrorist groups to acquire and use that technology for communications, surveillance, and even precision weaponry.

At the same time, because the Marine Corps prefers a young, short-term enlisted force, leaving minimal time for training, courses and exercises will need to focus on what is known or expected regarding potential adversaries.

“We try to maintain focus on all the changes that are happening, but the only things we teach the students are what we know for a fact they will face once they get out and into their jobs. We want to make certain they are proficient on what they need to use now, not train them on things they may not be using,” Mullen said.

“Technology changes too fast; people are not even getting proficient in the systems we have now before new ones come out. We’re trying to put the brakes on that so people are at least 80 percent proficient; we’re not pushing for 100 percent. And that is not just for command and control, but also weapons, vehicles, etc. Every new system that comes online brings its own problems – who uses it, who maintains it, etc. The enemy also has a vote – and for all our vaunted technology to remove the fog of war, they find ways to get around it.”

Fox believes the training that has evolved for Marines since 9/11 has been crucial to their success, not only in Iraq and Afghanistan, but also in humanitarian relief efforts and other missions around the world. And what they have accomplished, from Fallujah in Iraq to Afghanistan’s Helmand province, has laid the foundation for future training, exercises, and deployments.

“The thing we have carried forward, starting well before Fallujah, is it is the MAGTF that wins the fight, sustaining the individual Marine on the ground with ISR, firepower, communications, working with the coalition,” he concluded. “All those we constantly reinforce while taking into account lessons learned to do better the next time.”

This article first appeared in Marine Corps Outlook: 2011-2012 Edition.

But it is the Raiders with which MARSOC most closely identifies – a highly trained, lightly armed force that made initial amphibious landings on beaches considered inaccessible by a larger force, conducted surprise raids where swiftness and stealth were critical, and functioned as a guerrilla force behind enemy lines.

“Edson’s Raiders of the 1st Marine Raider Battalion and Carlson’s Raiders of the 2nd Marine Raider Battalion are said to be the first U.S. special operations forces to form and see combat in World War II,” Capt. Waiann W. Mai, Headquarters Battalion adjutant, said during MARSOC’s anniversary celebration.

The capabilities developed for and by the Raiders were carried to a new level in 1954 with the creation of Marine Test Unit 1, which gave the Corps an airborne capability with the still-new helicopter. Mai added, “This unit developed and performed innovative clandestine insertion methods before the Navy SEALs and the Army’s Green Berets [U.S. Army Special Forces].”

The Corps moved closer to today’s construct when Test Unit 1 and the Amphibious Reconnaissance Battalion were merged to create the first Force Recon companies, deployed to Vietnam in 1965 to conduct independent operations behind enemy lines, as well as deep reconnaissance and direct action through both helicopter and water – primarily riverine – insertions and extractions.

Marines with U.S. Marine Corps Forces, Special Operations Command, provide security during a medical engagement as part of a pre-deployment exercise at the National Training Center, Fort Irwin, Calif., May 15, 2011. The three-week exercise is designed to prepare MARSOC Marines for deployment to combat operations in Afghanistan by immersing them in an environment as realistic and comprehensive as possible. U.S. Marine Corps photo by Cpl. Kyle McNally

“An agreement between the Marine Corps and U.S. Special Operations Command [SOCOM] led to the activation of Marine Corps Special Operations Command Detachment 1 on June 19, 2003,” Mai continued. “As the Global War on Terrorism drew more and more heavily on special operations units, it was decided to formally incorporate a Marine special operations force element into SOCOM to ensure success in the long war ahead.”

In the first few weeks, MARSOC comprised a small staff and the Foreign Military Training Unit (FMTU), previously formed to provide foreign internal defense assistance. Under MARSOC, FMTU was redesignated as the Marine Special Operations Advisor Group (MSOAG). A few months later, the 1st and 2nd Force Recon companies were transferred to the new command, forming the 1st and 2nd Marine Special Operations Battalions (MSOBs). In April 2009, MSOAG was redesignated as the Marine Special Operations Regiment (MSOR), with the 1st, 2nd, and 3rd MSOBs as subordinate units.

“MSOR provides the primary command structure, oversight, advisement, and standardization for MARSOC’s three MSOBs. It also provides tailored military combat skills training and advisor support for identified foreign forces in order to enhance their tactical capabilities and prepare the environment as directed by SOCOM,” MSOR Commanding Officer Col. Edward Jeffries explained.

“MSOR Marines and sailors train, advise, and assist friendly host nation forces – including naval and maritime military and paramilitary forces – to enable them to support their governments’ internal security and stability, to counter subversion, and to reduce the risk of violence from internal and external threats.”

MSOB standardization is one of MSOR’s top responsibilities, enabling SOCOM to call on any available unit at any time and know exactly what to expect in terms of training, equipment, tactics, techniques and procedures (TTPs), command structure, and capabilities. It also facilitates a smooth transition between rotating teams and no interruption to host nation assistance.

“MSOR’s top priority is the preparation, deployment, and redeployment of our forces to and from combat, specifically in support of Operation Enduring Freedom-Afghanistan, as well as our other persistent presence missions in support of OEF,” he added. “This includes developing the SOTF [Special Operations Task Force] and preparing for its employment, as well as maintaining MARSOC’s two-company presence.

“We need to ensure that we maintain persistent presence in our nations of focus so we can better facilitate long-term relationships and trust. Only then can we hope to help host nations develop the capability, capacity, and vision necessary to achieve our common goals. The lessons learned from ongoing operations have enabled MSOR to adapt its structure, training, and operational cycle to improve force capabilities.”

Marines with U.S. Marine Corps Forces, Special Operations Command, walk through a village with Afghan role players during a pre-deployment exercise at the National Training Center, Fort Irwin, Calif. May 15, 2011. U.S. Marine Corps photo by Cpl. Kyle McNally

Giving MARSOC a SOTF capability early in its existence was a primary goal of MARSOC commanders and Corps commandants, setting the Marine special operations forces (SOF) up to become the core command and control entity for a joint SOTF. Having done that more quickly than many had expected, MARSOC SOTFs have provided command, control, coordination, and support to multiple SOF elements from both MARSOC and the Army Special Operations Command (USASOC) throughout CENTCOM’s Regional Commands West, Southwest, and North. Acting as a JSOTF, MARSOC would provide command and control for multiple SOTFs.

MARSOC’s current structure also includes the Marine Special Operations Support Group (MSOSG), which provides SOF units with combat and combat service support, and the Marine Special Operations School (MSOS), which screens SOF applicants, provides training and certification of special operators, and develops doctrine.

“We provide the ‘all other’ capabilities, everything from truck drivers and supply Marines all the way up to high-end SIGINT [signals intelligence] and HUMINT [human intelligence], Joint Terminal Attack Control [JTAC], and multipurpose canines,” MSOSG Commanding Officer Col. Richard Anders said. “The concept is not unique; the other services call them enablers. We don’t like to use that term because it builds a wall between operators and enablers and my job is to destroy that wall. So we do our support capability very differently, deploying a task-oriented group around a company, for example, and ensuring they are very highly trained tactically, with more of a holistic capability, and very much a part of the organization, not just an attachment.

“We take the first level of basic tactical training for general purpose Marines, which dovetails well with the need, for two months, to put them through enough fairly high intensity SOF-specific training to get them to where they can begin unit integration 210 days prior to deployment. During that time, they also have to get advanced MOS [military occupational specialty] training; pushing capabilities so far down to the team and element level, for most MOSs, it is not something you see in the general purpose force.”

From individual critical skill operators (CSOs) to 48 authorized 14-man Marine Special Operations Teams (MSOTs), 12 Marine Special Operations Companies (MSOCs), and three MSOBs, the Corps’ special operators spend nearly every minute not in combat training for combat. It is a regimen that ranges from MSOSG’s provision of specially trained warfighters, to the MSOBs and MSOR’s ability to train and support allied command and tactical capabilities, to the spiritus invictus (unconquerable spirit) goal of the Performance and Resiliency (PERRES) program.

“With the PERRES program, we are successfully integrating a holistic approach capable of rehabilitating and enhancing physical, mental, and spiritual performance, while maintaining overall resilience,” MARSOC’s commander, Maj. Gen. Paul E. Lefebvre, said. “That is, the individual and unit’s capacity to withstand stress and hardship and remain functionally and holistically able to group and self-renew.”

Training becomes especially intense in the months leading up to deployment, despite the rapid cycle and short dwell time between deployments MARSOC units have experienced from day one.

A U.S. Marine pulls security near a poppy field in Peyo as Marines assigned to Marine Corps Forces, Special Operations Command, and Afghan soldiers patrol through the village in the Bala Baluk district in Afghanistan's Farah province, March 29, 2010. U.S. Air Force photo by Staff Sgt. Nicholas Pilch

In May, for example, the 2nd and 3rd MSOBs went through an intensive two-week immersion exercise at the Fort Irwin National Training Center in California’s High Mojave Desert – what one training evaluator termed “the backbone of counterinsurgency.”

Operating in “Potemkin villages” populated with largely Middle Eastern volunteers portraying all elements of Afghan society – including Taliban and al Qaeda insurgents – the Marines sought to enhance, while being graded on, their language and cultural skills. They also had to demonstrate an understanding of and ability to deal with what is considered SOCOM’s top counterinsurgency strategy in Afghanistan – foreign internal defense using village stability operations (VSO).

“This exercise provides MARSOC’s commander the opportunity to certify his deploying forces,” one command officer explained. “It also provides the opportunity for the exercise force to assemble all of its special operations combat support and combat service support personnel, and to work out their procedures and command relationships.”

The goal was to connect the villages to the Afghan district and provisional governments while simultaneously eliminating and preventing insurgent operations. Because MARSOC Marines in-country are tasked with determining which villages are suitable as VSO sites, the exercise provides a foundation on which the success or failure of the MSOBs’ real-world mission rests.

“That’s why it’s crucial that they know how to interact with the locals – that’s where this familiarization training comes into play,” the training evaluator added. “We try to replicate as closely as possible the dynamics they will find in the villages and also the interaction they will encounter when working with higher headquarters.”

The exercise also brought in other U.S. agencies MARSOC Marines typically encounter in Afghanistan, such as the Drug Enforcement Administration, State Department, U.S. Agency for International Development (USAID), Navy Criminal Investigative Service (NCIS), and the FBI. How each encounter evolves varies from exercise to exercise, which typically are conducted three or four times a year.

“Each cycle, the component is able to determine where they can improve, support, or provide additional capability. In turn, the lessons learned are fed back into our training pipeline, all the way back to the Individual Training Course, the direct support courses, all of the communications courses, and the Special Operations Training Course,” another MARSOC observer noted.

“This exercise is the cauldron for which that can be done. The program requires considerable support and effort from the entire MARSOC component and the respective commands. But the shared responsibility ensures that our forces are as ready as possible for deployment to combat operations.”

A joint terminal attack controller (JTAC) with U.S. Marine Corps Forces, Special Operations Command communicates with a Navy MH-60S helicopter during takeoff as part of Carrier Airwing Training conducted by the Naval Strike and Air Warfare Center aboard Naval Air Station Fallon, Nev., April 7, 2011. During the exercise, MARSOC JTACs practiced their critical skills and renewed their currencies and qualifications. U.S. Marine Corps photo by Cpl. Kyle McNally

MARSOC Marines also participate in sister service exercises, especially the Navy’s, where specific unit or individual skills can be tested, evaluated, and improved before being called on in combat. An example in April was the participation of 10 MSOT JTACs in the Naval Strike and Air Warfare Center’s carrier air wing training exercise at Naval Air Station Fallon, Nev.

In general, JTACs direct the actions of aircraft involved in close air support (CAS) and other air-to-surface operations. In MARSOC, however, the JTAC provides his 14-member team with a full range of expertise in every facet of aviation support. That includes planning, briefing, and executing almost any aviation-related mission, from Army Assault Support helicopters to Navy EA-6B electronic attack and Air Force C-130 aerial resupply. Because MSOTs operate almost entirely cut off from other friendly forces and logistics chains, the JTAC provides crucial mission capabilities.

Each service providing air support has slightly different TTPs the MARSOC JTACs must know. Added to rapidly changing equipment (including the enemy’s), JTAC skills are considered especially perishable. As a result, they are required to conduct at least six controls every six months, complete an academic package each year, and pass an intense evaluation every 18 months.

In their role of “bringing fire from the sky,” as one JTAC put it, they must successfully integrate complex shoot-move-communicate scenarios while maintaining positive control of all aircraft overhead, deconflicting the routes of both manned and unmanned aircraft, and integrating fires on the objective – all to achieve his commander’s intent while ensuring the safety of his team and reducing negative collateral effects of the attack he has designed.

As the Department of Defense tries to meet major cuts in its budget, a new Marine Corps Force Structure Review has called for an overall reduction of 15,000 Marines. MARSOC, however, along with the special operations community in general, will grow larger, primarily in combat support and combat service support.

According to Lefebvre, the planned 44 percent increase in his command is part of an effort to “right size” both the big Corps and its special ops component. It also reflects the growing demand for SOF capabilities, not only in Afghanistan, but in more than 15 other nations where MARSOC has conducted missions, many of those joint training exercises with the host nation, but also counter-narcoterrorism, humanitarian assistance, and disaster relief.

“The commander of SOCOM has assigned MARSOC focus areas that have allowed us to tailor the pre-deployment training for MARSOC operators in order to maximize our capabilities in languages and become more culturally attuned to the areas we believe are key today and for the future,” Lefebvre said. “Because we are deployed around the globe with a variety of mission sets, the Leaders Course instructors [returning from deployment] bring a breadth of experience and valuable lessons learned to capitalize on for the new MSOR leadership about to gain teams and companies.

“This ensures the team and company leadership are receiving the most relevant and important training prior to deployment. These Marines are also gaining valuable professional development by having to produce the course content, period of instruction, and interaction amongst superiors, peers, and subordinates alike.”

A Marine with 3rd Marine Special Operations Battalion, U.S. Marine Corps Forces, Special Operations Command, conducts a high altitude, high opening (HAHO) jump at dusk as part of a double-bag static-line parachute course in Wendover, Utah April 9-21. The course was taught by personnel from the 2nd MSOB paraloft and the Airborne Mobile Training Team (AMTT), designed to give Marines a basic understanding of HAHO operations. U.S. Marine Corps photo by Cpl. Kyle McNally

Overall, the MARSOC commanding general is pleased with what has been accomplished to date in standing up a major new command in the midst of war, creating and employing multiple training sets and organizing and reorganizing various components in response to changing requirements and lessons learned.

“We have made great progress in our contributions to SOCOM in the last five years. We have and currently are consistently deploying to a number of priority locations in support of our nation’s security objectives,” Lefebvre said. “We have established great relationships with a host of individuals and established superb rapport with a number of host and partner nation militaries. Our language and cultural exposure and appreciation have risen substantially, which will better serve us in the future in various regions throughout the world.”

MSOR and MSOSG are critical to that rapid evolution, a role that will become even more important – and difficult to maintain – in the uncertainties of a post-OEF environment.

“There is no indication the world will soon revert to a place where large armies fight across open fields or even to a place where the enemy can be easily identified. Marines as a whole thrive in irregular warfare and uncertainty and this is no different in the future generation of our MARSOC warriors,” Jeffries observed. “We can certainly fight on a kinetic level, but we must also use finesse, tactical patience, and understand the non-kinetic fight.

“We are very adaptive and flexible – and still very capable of knocking down doors. As such, we are more capable today than ever. A top priority for us [is and will continue to be] the preparation, deployment, and redeployment of our forces to and from combat.”

For MSOSG, Anders added, it has meant becoming an organization with a “laser beam-like focus” on giving highly capable volunteers from throughout the Marine Corps both the advanced tactics and basic SOF capabilities they will require on the battlefield and advanced MOS training needed to support Marine special operators.

“A critical element in the future MSOSG is our evolution into the MARSOC Total Force, building significant capacity and capability where little exists today, such as creating and sustaining a true expeditionary Combat Service Support capability, deepening our employment of intelligence to support every MSOT on the battlefield, providing JTACs and multipurpose canines to every MSOT as needed, and preparing these capabilities sets to support MARSOC missions outside of the OEF construct,” he said.

“That’s our vision – to have a holistic MARSOC concept of employment, where all SOF Marines are very much a part of the fight, both support group and the critical skills community. We’re most of the way there and I think when my command ends in July this year [2011], my successor will be able to achieve that dream.”

As with its more recent specialized sister command – Marine Forces Cyber Command (MARFORCYBER) – MARSOC stands apart from the “big Corps” with respect to its chain of command (both report to joint commands), training, equipment, and task. But both also are imbued with the central theme of the Corps – “every Marine a rifleman” – as described by MARSOC’s motto: “Marines are who we are, special operations are what we do.”

At the same time, Lefebvre does not downplay the value and significance of a special operations component in a service that has always considered itself the nation’s special ops contingent.

“Although we are relatively young, we bring 235 years of ethos that has thrived in chaos and friction and is comfortable in the uncertainty of combat,” he concluded. “Our goal will never be to merely participate, it will be to lead the effort. We will never be happy with the status quo – we are fixers and innovators and we must keep pressure on the system.”

This article first appeared in Marine Corps Outlook: 2011-2012 Edition.

The Coast Guard national security cutter (NSC) Waesche conducts at-sea refueling operations with the USNS Yukon for the first time in the cutter's history, May 25, 2011. Coast Guard photo by Petty Officer 1st Class Adam Eggers

Working to share resources and maximize opportunities to leverage the capabilities and larger budgets of other services – primarily the U.S. Navy – is even more important in the current fiscal environment, where budget constraints are forcing government agencies to make tough choices. The Coast Guard is taking steps to ensure that it is equipped with the capabilities to continue to meet its 11 mandated missions.

“It is a wide-ranging term, but our motto is, ‘Mission execution starts here.’ We have to provide the Coast Guard with the platforms required to execute its missions,” noted Mike Tangora, the civilian deputy assistant commandant for acquisition. “The Navy starts with a threat assessment; for us, it’s a mission area and for all of our platforms it means multi-mission capable.”

To obtain the assets needed to accomplish each of its missions, the smallest military service initiates requirements development, acquisition strategy, preliminary design, execution, and building the platform. Then, the asset is delivered, and operationally tested to ensure it’s performing to standards. The process also necessitates setting up life-cycle management, with all the tools required to support an asset from cradle to grave.

The Acquisition Directorate oversees more than 20 acquisition programs, including 17 major acquisitions, meaning they cost more than $300 million from acquisition to maintenance throughout their useful lives. A few of these projects are:

There are many aspects of Coast Guard missions that provide opportunities for effective partnerships with other federal agencies. U.S. Coast Guard graphic

• The offshore patrol cutter (OPC) is currently in the pre-acquisition stage. The Coast Guard has released its draft specification and is currently reviewing comments from industry. Under its acquisition strategy, the service is preparing the request for proposal (RFP), assembling/drafting the statement of work, and conducting some upfront systems engineering.
• Production under the national security cutter (NSC) project is well under way and the Coast Guard is incorporating delivered assets into its existing surface fleet. The third NSC, the Stratton, was delivered in September and the production contracts for NSC 4 and 5 were awarded in fiscal year 2011.
• Other assets, such as the response boat-medium (RB-M), are in full-rate production, and approximately one-third of the 180 scheduled to be acquired have been delivered, with another one-third under contract.

The Acquisition Directorate is comprised of approximately 600 civilian and 400 military personnel, including accountants, logisticians, engineers, program managers, operators, and contracting officers. Since the directorate stood up in July 2007, the Coast Guard has established a robust, disciplined, and proactive certification process to ensure personnel are appropriately trained and certified.

Michael Tangora, the U.S. Coast Guard's deputy assistant commandant for acquisition, talked about the Coast Guard partnerships developed through foreign military sales during the spring 2011 Sea-Air-Space Expo. U.S. Coast Guard photo by PAC Sarah B. Foster

In the past four years, the service has spent a considerable amount of money hiring professionals and putting hundreds of people through rigorous course work in contracting, engineering, program management, and other education required for certification.

With this certification process active and in place, one of the primary focus areas of the directorate turned to what might be considered the most basic element in the acquisition process … the contract.

“In acquisition, what you really worry about is the requirements, acquisition strategy, and ultimately the contract – don’t take your eyes off the contract, actively manage it. That’s how we hold the contractor accountable. Where we make mistakes, industry and government, is when we miscommunicate our mutual expectations via the contract, with wrong expectations or statements of work,” Tangora said. “But it all comes down to the contract, which is the capstone document in any procurement and at the center of any acquisition program. It is our agreement with the platform manufacturer, and to modify it after award can be very costly.”

The Coast Guard has established itself as the system integrator over all of its acquisition projects and continues to move away from the commercial lead system integrator (LSI) construct employed earlier under the legacy Deepwater contract.

Deepwater was envisioned as a turnkey contract to do everything, bringing all programs and platforms in the Coast Guard transformation under a single umbrella, and according to Tangora, those expectations were misplaced. Four years later, he hopes that a strong contract focus and the professionalism of his directorate will push the memory – not the lessons learned but the memory – of Deepwater into the past.

H-65C Dolphin crews conduct their "first operational" Deck Landing Qualifications on the CGC Bertholf off the Southern California coast. Crewmembers were from Air Stations San Francisco, Calif.; Humboldt Bay, Calif.; and North Bend, Ore. U.S. Coast Guard photo by Lt. Matt Udkow, Air Station San Francisco

“You have to match your requirements to your resources; you have to know the requirements really well to cost it out. If you thoroughly understand them and know your engineering, then you should know with a good confidence factor what the platform will cost. But if there is an imbalance between cost and resources, then you have increased risk,” he explained, adding the worst version of that is to outsource everything.

Tangora goes on to explain that agencies should never buy technology without first having the intent to understand how it is built and maintained. If an agency doesn’t possess the knowledge of how technology functions, it cannot then assess the legitimate costs involved.

The smallest branch of the armed forces isn’t large enough to go it alone, so the Coast Guard relies on partnerships. For example, in building the NSCs, part of the oversight was conducted by Navy employees on lease to handle inspections and governance.

“If I tried to run this acquisition without the Navy, I would need another 1,000 people, all with the core competencies and facilities that the Navy brings,” he said. “We certainly couldn’t have accomplished the successes to date for most of our surface vessels and aircraft without the Navy. And the relationship between the Navy and Coast Guard has never been better – wherever we can assist the Navy, we do.”

Using Navy expertise – such as flight deck certification – means the Coast Guard does not need to create and maintain that capability internally. The list of programs leveraging Navy acquisition and capabilities for economies of scale is extensive: All Coast Guard combat systems, including all aircraft and gun systems; computer support, information assurance and global command, control, communications, computers, or C4; initial combat system training; supply support; and engineering support for larger ship programs. In addition, the Coast Guard Research and Development Center is tied to the Office of Naval Research.

This 82-foot patrol boat was decommissioned by the U.S. Coast Guard and transferred to Azerbaijan through the U.S. Department of Defense's Excess Defense Articles program, which offers U.S. assets declared excess to foreign partners in support of U.S. national security and foreign policy objectives. U.S. Coast Guard photo by PA3 L.F. Chambers

The same approach is also carried out with other agencies, from U.S. Customs and Border Protection to the Army Corps of Engineers; all C-130 Hercules aircraft are bought through the Air Force; work on the medium-range H-60 Jayhawk helicopter, especially the cockpit, is done in close cooperation with the Army.

When the Coast Guard has an acquisition requirement, it looks for a well-run program of record and attempts to combine its efforts when possible, especially the more well-run programs. If the Coast Guard can deliver commonality, that reduces its life-cycle costs and potentially those of other agencies. The Army/Navy, for example, buys rotors and blades for their H-60 fleet in bulk, but they have hundreds compared to about 42 in the Coast Guard fleet. If the service can leverage their economies of scale, then it can obtain parts and services as if the Coast Guard was a larger customer.

“We apply our acquisition discipline across the board consistently,” Tangora concluded. “We strive for the best deal we can get and fight against the urge to rush the process. Some of our programs are early and have more challenges; others are past the first article success and are in serial or full-rate production, which tend to be easier than delivering the first asset. When you look across the board at Coast Guard acquisitions, even where we have risk areas in some of our programs, all of them are running great and delivering assets to the fleet that is anxiously waiting for them. We are executing at least $1.3 billion in acquisitions per year, which is a great achievement for a workforce of our size.”

This article was first published in Coast Guard Outlook: 2012 Edition.

It all began with a change in attitude and perspective among doctors, both those in the battlespace dealing with wounded warfighters in the “golden hour” after injury and those at advanced treatment and rehabilitation facilities in the United States and at Landstuhl Regional Medical Center in Germany, the first stop between combat and CONUS for most severely wounded warriors.

“Early in the war there were issues related to the salvaging of limbs. When we discovered better ways to do that, we got that information to the field to ensure all limbs that can be saved are saved,” Dr. Jonathan Woodson, the assistant secretary of Defense-Health Affairs, said. “So the system has done a good job of being a learning organization and improving strategies for care.”

Like Woodson (an Army Reserve brigadier general), Air Force Lt. Col. Michael R. Davis, chief of Reconstructive Surgery & Regenerative Medicine at the Army Institute of Surgical Research (ISR) – has served as a combat surgeon. His experiences in theater and at USAF hospitals in the United States led him to focus on finding faster and less painful ways to improve both functionality and aesthetics for warfighters with extremities loss or severe damage.

“As a surgeon stationed in Afghanistan, I witnessed firsthand the impact of that on our troops and, back here, I have seen an increasing capability in being able to care for these injured soldiers,” he said. “We have a great responsibility to develop techniques and technologies for those in need. And with the conflicts drawing to a close, there will be a heavy emphasis within the military medical community to further those advances.

U.S. Marine Corps Sgt. Jordan Pierson climbs a 30-foot rock-climbing wall during a therapy session in the new Comprehensive Combat and Complex Casualty Care (C5) facility. C5 is a program of care that manages severely injured or ill patients from medical evacuation through inpatient care, outpatient rehabilitation, and their return to active duty or transition from the military. Prosthetics today must be designed with active-duty personnel in mind, because many amputees are choosing to remain in the armed forces. U.S. Navy photo by Mass Communications Specialist 2nd Class Greg Mitchell

“In the past, the standard was to reconstruct everyone, salvage every possible limb. But over time, as prosthetics have become more advanced and the benefit of a prosthesis has gone up, we have seen many cases where patients are more debilitated than they would have been with primary amputation. That has caused a paradigm shift in the orthopedic and reconstruction communities about how they feel about reconstruction versus primary amputation and prosthesis.”

The new prosthetics provide more than just better functionality, added Lt. Col. John M. Scherer, director of the Army’s Clinical and Rehabilitative Medicine Research Program (CRMRP), they offer the prospect of a return to duty or a far more “normal” civilian life.

“Most prosthetics before were not designed with a highly active 20-year-old amputee in mind. In addition, we now are looking at them from a combat environment requirement, because we have deployed people back into the combat zone with lower extremity prostheses,” he explained.

“Outside the military, they normally don’t have to be waterproof or sandproof because, if the weather is bad in the U.S. and you have a powered prosthetic limb, you either don’t go out or make sure it is protected from the weather. You can’t do that in combat, so there have been changes to make the batteries last longer and function in harsh environments – sand, heat, water, exposure – as well as giving them additional functions, such as the ability to go backwards.”

CRMRP is working with the Military Amputee Research Program to capitalize on advancements in neural interfaces, nanotechnology, and prosthetic design to improve foot and knee prosthetics, knee prosthetic control, and haptic [touch] feedback. Their coordinated research is designed to improve prosthetic performance through advanced clinical practices and strategies, but also will contribute to the overall advancement beyond prosthetics.

The vast majority of advances during the current conflict have involved replacing amputated feet and legs.

“Microprocessors in the knee have replaced control by the physics of the prosthetic movement. Basically, that makes you fall less and your gait is closer to normal, so you don’t injure the healthy limb. From that perspective, there has been a huge improvement in the ability to walk in a normal way compared to how you would have moved prior to these advancements,” Scherer said.

“There really has not been a lot of effort in changing the current state of the art for upper extremities – which includes the ‘hook’ that has been used for quite a while. There are lots of reasons for that, but DARPA’s [the Defense Advanced Research Projects Agency’s] prosthetics program has brought a lot of robotic improvements to upper extremity devices and we hope to go into clinical trials soon. Most of the biomechanical neural interfaces to prosthetic limbs also are being done by DARPA. And that is the holy grail – making the prosthetic work with a neural interface, with feedback, so you can actually feel in your ‘fingertips’ what you are touching and do direct movement.”

Advancements in lower limb prosthetics that have enabled many amputees to regain a more normal life also have resulted in a new development that concerns many in military medicine: Warfighters whose damaged feet or legs were saved by advances in battlefield and follow-up surgery asking to have the limb amputated anyway because they believe a prosthetic would give them greater functionality than their reduced capability real foot or leg. Those advances also give warfighters other “positive” arguments for amputation.

“Someone who undergoes primary amputation will heal and get through the process of rehab much faster. Someone who undergoes limb salvage could face 10 or more operations over a period of years before they see adequate healing and rehabilitation – if they ever get to a point of full functionality. So it requires very careful patient selection for complex reconstruction and who we recommend for primary amputation and fitting of an advanced prosthesis,” Davis said, but added new options are becoming available. “You can’t compare a prosthesis to a natural limb, but you can compare it to a reconstructed limb using techniques such as free tissue transfers and bone grafting.”

Sgt. 1st Class Leroy Petry salutes former Chief of Staff of the Army Gen. George W. Casey Jr. with his prosthetic hand at the Center for the Intrepid on Fort Sam Houston, Texas, Nov. 17, 2008. Prety received the Medal of Honor on July 12, 2011. U.S. Army photo by D. Myles Cullen

Historically, medical research has been an isolated pursuit, both in terms of competition in academia and industry and in a single-issue or application focus, such as brain injuries, orthopaedics, dentistry, etc. In recent years, however, the U.S. Military Health System has sought to bring multiple university and commercial researchers and disciplines together to pursue specific issues but also to share knowledge and find new applications for what works in one area to the needs of another.

Col. Robert G. Hale, commander of the Army Dental Corps’ Dental and Trauma Research Detachment (DTRD), spends the majority of his time on issues related to regenerating bone, tissue, muscle, and nerves, including face transplants, and ways to block or kill biofilm, which causes plaque and gum disease in the mouth but also keeps open wounds from healing. Tapping into DoD-sponsored multidiscipline research has brought new solutions to his concerns, while DTRD advances are finding applications in amputation and prosthetics – and moving beyond both.

“Advanced bone regeneration biomaterials, better than our most recent capabilities, could improve patient outcomes with fewer and less invasive surgeries, both for craniofacial and limb salvage. Another advance is adipose fat, which regenerates very quickly. If we can tap into the regenerative abilities we know exist in fat and place that into a wound, it can heal with less scarring and improve mobility anywhere on the body there is movement,” he said.

“A follow-on, perhaps starting next year, will be a stem cell-enriched fat. We may not be able to regenerate an arm muscle in the next 10 years, but maybe in 15 or 20 years we can slide a scaffold under the skin, then inject stem cells that will homein on that scaffold and help patients recover better.”

Tissue scaffolds are considered the medical implants of the future. Made of fully degradable biomaterials, they support cells at the site of injury and assist the body in growing new, functional tissue. Once that new tissue has successfully replaced damaged or lost tissue, the body’s natural systems will dissolve and recycle the scaffold.

Currently, the cells used in that process are either produced synthetically or taken from the patient’s body and processed for application to the wound or transplant area. That process is expected to become substantially more successful with the use of stem cells – unspecialized cells with the ability to transform into specialized cells in the body. Adult stem cells, recently found to be both more plentiful and more adaptable than previously thought, are at the center of many medical research programs.

While those efforts cannot regenerate entire limbs – yet – in combination with bioactive factors and biomaterials, stem cells can form new bone, nerves, and soft tissue (skin, tendons, muscles, blood vessels) to replace damaged tissues and speed recovery. Even if salamander-like limb regrowth does become possible, however, growing a new hand, arm, foot, or leg that would be a true part of the patient’s body may have more drawbacks than advantages.

“There are studies under way to figure out how other organisms can regenerate body tissues and hopefully translate that into a human ability to do the same. The answer probably will lie with stem cells, but to regenerate something as complex as a hand is still science fiction,” Davis said.

“In another hundred years, will we be further along in terms of that kind of capability? Yes. The problem is, when someone needs a functionalized limb, growing one can cause substantial delay. So even if that becomes possible in the future, the time involved to complete the process may be prohibitive.”

Continued advances in limb salvage that return the damaged hand or leg to an acceptable level of function and appearance are seen as the best hope to avoid future amputations. For those who already have lost a limb or future wounded warriors whose limbs cannot be saved, if full regeneration is not a viable option, the ultimate answer may lie in improved biomechanical interfaces and – for hands, at least – transplants, from human donors or using hands cloned from the patient’s DNA.

Rear Adm. Elaine Wagner, director of Medical Resources Plans and Policy Division and chief of the Navy Dental Corps, is shown the advanced features of various prosthetics by Dr. Joanne Smith, president and chief executive officer of the Rehabilitation Institute of Chicago, during a Chicago Navy Week 2011 event. U.S. Navy photo by Valerie A. Kremer

Because a cloned limb would take as long to grow into adult size and appearance as the original, that source for a hand transplant would be a long-term solution, requiring some other approach immediately after amputation. While using a donated hand for transplant appears to offer the best choice, as with any surgical procedure, it has drawbacks, including an average 16-hour operation – twice that of a heart transplant. Finding a match also is more difficult than with a heart – in addition to all the usual blood and tissue match requirements, it also has to match the recipient’s age, sex, hand size, and skin color.

“There is a debate over what would make a hand transplant standard care. For a bilateral hand amputee, there is no better way to rehabilitate someone than through a transplant. But what if it is a single hand – either dominant or non-dominant? Those questions are still subject to determination, and whether they are still experimental or part of standard care is still a great debate within the military and civilian medical communities,” Davis explained.

“There needs to be great collaboration among the facilities doing these procedures to answer those questions and advance the field. And we are seeing that, with centers coming together and forming groups to answer these questions. We really need to go forth responsibly, not just doing transplants because we can, but because we should. Ultimately, those are patient decisions, but we need to be in the best position to recommend a course of care.”

One of those facilities is the Atlanta VA Medical Center and its affiliate, Emory University, where Dr.  Linda Cendales performs hand transplants and is conducting a new VA study tracking transplant patients.

“In my experience, patients report the new hand has been better for them than the prostheses they were wearing,” she said. “It’s a human hand, not a device. The hand recovers sensation and patients are able to perform activities such as turning doorknobs, holding the newspaper, tying their shoes. It’s not a life-saving organ – it’s a quality-of-life transplant.

“We have a multidisciplinary team that is patient-centered. Our program aims to provide another option for a selected group of patients and to provide the best options overall for our amputees. If it’s a prosthesis, the best prosthesis; if it’s a hand, the best-matched human hand.”

The other leading option for the future is a greatly improved biomechanical interface – linking the amputee’s living tissue to a prosthesis. Some elements of that already are available, some are in or close to beginning clinical trials, some are still in the lab, and, for a few, science and technology have not yet advanced far enough to move them from science fiction to science fact.

One that recently did make that transition is 3-D bio-printing – similar to industrial fast prototyping, where a solid object is built, layer by layer, from special plastics or other materials. In this case, researchers at Wake Forest University have successfully “printed” human skin. While a revolutionary leap in current technology, it may be years from wide-scale clinical use for other body parts.

“Being able to print biological materials, such as skin, will greatly advance our ability to create functionalized synthetic reconstructive tissues. It holds a lot of promise, but bio tissues are complex and much more difficult to synthesize and print than industrial materials,” Davis noted. “So I think that capability will come, but not in the near term.”

In the meantime, tissue regeneration in vitro, using processed body cells or adult stem cells, may be combined with new titanium bone implants to resolve a number of problems with the interface of prosthetics and human bodies. First on that list is bacteria entering the space where the prosthetic connects to the body; second is the body’s tendency to reject the prosthetic as a “foreign body.”

Both are being addressed by VA-sponsored research led by Thomas Webster, associate professor of engineering and orthopaedics at Brown University. Webster’s team has developed two techniques, which may work together: first, modifying the surface of titanium leg implants to promote cell growth and create a natural skin layer to seal the gap; second, covering the implant connection point with a molecular chain of proteins to hasten skin growth.

“You definitely have a complete layer of skin,” Webster said of the process. “There’s no more gap for the bacteria to go through.”

Improving prosthetics and how they connect to and work with the body, and developing new techniques to replace prosthetics or even avoid the need for amputation are subjects of active and intense research across the DoD, VA, academia, and industry. While spurred by a modern record number of severe combat limb injuries and amputations, it is an effort that will continue long after the last U.S. warfighter leaves Afghanistan.

“The biggest point to all this is we have a responsibility to get the best possible outcome for our wounded service members, who risk their lives every day and many suffer devastating injuries. I’ve seen these injuries firsthand while stationed in Bagram [Air Base, Afghanistan] and, knowing our current capabilities, realized the long-term outcome was not nearly as good as we could achieve. And they deserve the best outcome possible,” Davis concluded.

“Many within the military have the capability to advance these techniques, which in combination with top-level support and funding for this research, creates an environment where we can help them. What this does is create hope for our warfighters, which is one of the most positive outcomes of what we do, that a wounded service member can regain functionality they lost to injury.”

This article first appeared in The Year in Veterans Affairs & Military Medicine: 2011-2012 Edition.