Medicine in Irregular Warfare

Medizin bei irregulärer Kriegsführung

Audrey Jarrassier^a, Mathieu David^b, Yann Le Vaillant^c, Pierre Mahé^d, Florent Josse^e, Pierre Pasquier^{f, g}

^a Department of Anesthesiology and Intensive Care, Military Teaching Hospital Begin, Saint-Mandé, France

^b Deputy Medical Advisor for Allied Special Operations Forces Medical Command, Mons, Belgium

^c International Medical Relations Office, Operations Division, French Armed Forces Health Service Headquarters, Arcueil, France

^d International Affairs, French Armed Forces Health Service Headquarters, Arcueil, France

^e Department of Anesthesiology, Critical Care and Emergency Medicine, Bundeswehr Hospital Ulm, Germany

^f French Military Medical Service Academy – École du Val-de-Grâce, Paris, France – Écoles militaires de santé, Lyon-Bron, France

^g Department of Anesthesiology and Intensive Care, Percy Military Teaching Hospital, Clamart, France

Summary

Irregular warfare disrupts conventional medical evacuation, requiring prolonged casualty care with limited resources. Damage control resuscitation, mobile surgical platforms, and prehospital transfusion strategies bridge the gap between injury and definitive care. Telemedicine, artificial intelligence-assisted triage, and medical intelligence enhance battlefield medicine, optimizing resource allocation and countering disinformation. Humanitarian engagement and defense medical diplomacy strengthen alliances and stabilize conflict zones. Future innovations in autonomous casualty evacuation and AI-driven decision-making will further adapt combat medicine to austere and unpredictable environments.

Keywords: irregular warfare; battlefield medicine; global health engagement

Introduction

Irregular warfare refers to conflicts that deviate from conventional engagements and are characterized by asymmetric tactics, decentralized forces, and hybrid threats [6]. These conflicts involve insurgency, cyber warfare, precision strikes, and disrupted logistics, posing significant challenges to military medicine (Figure 1) [5][43]. Recent conflicts, such as those in the Sahel-Saharan region and Ukraine, highlight how modern conflicts disrupt evacuation chains and require prolonged casualty care [8][18]. Enemies systematically and deliberately target medical treatment facilities. Unlike traditional battlefields, these environments demand adaptability in medical response as forces operate with limited access to advanced care [17][33]. Traditional tactical combat casualty care and mitigation strategies were designed for structured conflicts with rapid evacuation. In irregular warfare, medical teams must provide prolonged casualty care with limited resources, intermittent supply chains, and mobile resuscitation requirements [14].

This article examines the medical challenges of irregular warfare, the adaptations required in combat casualty care, and the strategic role of medicine in supporting military operations in austere and unpredictable conditions.

Fig. 1. Contrasting traditional and irregular warfare

Medical Challenges in Irregular Warfare

The medical challenges of irregular warfare are complex and multifaceted. On the battlefield, the absence of a defined front line and sometimes an undefined enemy presence complicate casualty care, as combatants often operate in small, dispersed units with limited access to immediate medical evacuation [20]. Under these conditions, prolonged care in the field becomes a necessity, requiring combat medical technicians and providers to care for severely wounded patients over extended periods [9][36]. Unlike conventional conflicts, where casualties are typically transported to advanced medical facilities within an hour, irregular warfare often compels medical teams to sustain life in austere environments with minimal resources.

The types of injuries seen in irregular warfare are also more varied than those on traditional battlefields. Blast injuries, penetrating wounds, burns, and polytrauma are common; however, these conflicts also introduce new threats such as drone strikes, electronic warfare, chemical exposure, and thermobaric injuries [30][42][48].

Cyber-attacks on medical infrastructure can further complicate care delivery by disrupting communications and logistics. The deliberate targeting of medical personnel and facilities in some conflicts represents a significant game changer, forcing military medical teams to remain mobile and adaptable.

In addition to the immediate challenges of trauma care, irregular warfare often involves prolonged medical operations in environments where the local health system is either non-existent or severely compromised. Military medical teams may need to treat both combatants and civilians, blurring the traditional boundaries of military medicine. Operating in such hybrid environments requires advanced training in prolonged casualty care, damage control, and medical strategies adapted to limited resources [37].

Medical Strategies in Irregular Warfare

Combat medicine in irregular warfare emphasizes damage control resuscitation, damage control surgery, and prolonged casualty care to bridge the gap between injury and definitive surgical intervention.

REBOA

In the last decades, one of the most significant advances in battlefield medicine has been the widespread use of tourniquets and hemostatic agents to control life-threatening bleeding [1][7][15]. The introduction of Resuscitative EndovascularBalloon Occlusion of the Aorta (REBOA) and junctional tourniquet has further improved survival rates in patients with non-compressible torso hemorrhage by allowing temporary hemorrhage control in severe conditions [10][39][41][46].

Blood Transfusion

Blood transfusion protocols have also evolved to meet the needs of combat casualties. The use of whole blood, particularly low-titer O whole blood, has revolutionized combat damage control resuscitation [29][38][44]. Field-adapted transfusion methods, including walking blood banks and lyophilized plasma, have been integrated into pre-hospital care to provide early blood compensation in environments where traditional transfusion facilities are unavailable [3][27]. These strategies have significantly reduced avoidable deaths from bleeding and have been successfully implemented in conflicts such as Iraq, Afghanistan, and Ukraine [4][35].

Mobile Surgical Platforms

Mobile and modular surgical platforms have become essential in irregular warfare. Deployable surgical teams now operate in forward positions, providing damage control surgery (“en route surgery”) closer to the point of injury [24]. Airborne surgical capabilities have also been developed, allowing critical surgery during medical evacuation [16]. These advances have redefined the concept of pre-hospital trauma care, ensuring that casualties receive life-saving interventions as early as possible.

Technology

Technology is playing an increasingly important role in irregular warfare medicine. Telemedicine, artificial intelligence-assisted triage, and high-tech tools are now being used to support decision-making on the battlefield when low electromagnetic signatures are not mandatory [22][25][26]. By integrating remote medical expertise, frontline personnel can enhance treatment strategies and allocate resources more efficiently. These innovations can potentially improve battlefield medicine by reducing delays in treatment and increasing the efficiency of medical resource utilization [19][47].

An often overlooked but significant medical challenge in irregular warfare is the emergence and spread of multidrug-resistant infections. Recent operational experience highlights the risk of military personnel returning to their home countries as carriers of highly resistant pathogens, potentially posing a significant public health threat to expeditionary forces and their home countries. These risks require a strategic approach similar to that used in biological risk management, including the use of specialized medical countermeasures during transport, such as portable diagnostic platforms (mini-PCR) for rapid detection and containment of multidrug pathogens [2][23]. In this context, multidrug-resistant organisms could be deliberately exploited as a biological threat to undermine morale, strain healthcare resources and impose significant societal and economic costs. Recent data, such as those described by Scott JC Pallett et al., underscore the alarming prevalence and potential strategic implications of such resistant pathogens in contemporary warfare scenarios [31].

Medical Applications in Irregular Warfare

Medical intelligence has emerged as a relevant component of irregular warfare strategy [42]. Understanding enemy medical capabilities, tracking battlefield injury patterns, and analyzing the medical logistical challenges of enemy forces can provide valuable insights that shape military operations [40]. Monitoring casualty evacuation routes and medical supply chains can reveal strategic vulnerabilities; however, such practices must strictly adhere to ethical standards, medical neutrality, and international humanitarian law, including the Geneva Conventions. While particular state or non-state actors may unethically exploit medical intelligence by deliberately targeting healthcare facilities, evacuation pathways, or medical supplies, these actions constitute severe violations of international humanitarian law and medical ethics. A clear distinction must, therefore, be maintained between legitimate medical intelligence, focused on optimizing medical support, preparedness, and protection of friendly forces, and unethical misuse (weaponization), which constitute war crimes. Medical personnel must uphold humanitarian principles, avoiding actions compromising enemy combatants’ or non-combatants’ health or survival [13].

Misinformation and medical disinformation are increasingly used as tools of psychological warfare [28]. False reports of chemical attacks, exaggerated casualty numbers, and misinformation about the availability of medical resources can affect morale and disrupt military operations [33]. Military medical teams must use these narratives to disseminate accurate information. Medical strategy can be used to strengthen alliances, build trust with local populations, and counter insurgent propaganda. Global Health Engagement, which could be humanitarian operations, is critical in irregular warfare. Providing medical care to civilians and local allied forces helps to build stability and legitimacy in conflict zones and the acceptability of the force [11]. Training local medical personnel in trauma care and public health measures increases regional resilience and reduces dependence on foreign military support [12,34]. Medical diplomacy is a powerful tool that extends beyond the battlefield, fostering long-term relationships and reinforcing the broader strategic objectives of military operations.

Military hospitals treat repatriated foreign war casualties, reinforcing cooperation with allied nations and fostering long-term defense partnerships. Furthermore, they provide medical support for foreign VIPs, including diplomats and national leaders, either military or civilian, as a strategic tool of defense diplomacy. These actions enhance geopolitical influence, build trust, and integrate medical capabilities into broader military and diplomatic objectives.

Fig. 2. Medical challenges and strategies during irregular warfare

Medical Prospects in Irregular Warfare

The future of medicine in irregular warfare will be shaped by technological advances, medical innovation, and the changing nature of warfare [33]. Artificial intelligence is expected to play a decisive role in medical decision-making [21]. AI-based diagnostics and predictive analytics will improve casualty management by enabling faster and more accurate injury severity assessment [45]. Robotics and remote surgical systems will facilitate casualty management in secluded or inaccessible battle zones.

Autonomous casualty evacuation is another promising field of development for irregular warfare. Unmanned aerial vehicles equipped with medical evacuation capabilities are being tested to move casualties from the battlefield to higher levels of care without putting additional personnel at risk [32]. These systems can revolutionize medical evacuation by providing rapid and safe transport in contested environments. Interoperability between allied forces will be essential in future conflicts.

The standardization and interoperability of combat casualty care protocols and improved multinational medical training programs will ensure seamless cooperation in joint military operations. Ongoing research using a trauma registry, data sharing, and international collaboration will further enhance medical outcomes on the battlefield. Strengthening partnerships between military medical communities will be essential to prepare for the complexities of modern and future warfare.

Conclusion

The evolving nature of irregular warfare requires constant adaptation of battlefield medicine (Figure 2). Future advances should refine existing trauma care techniques and explore new approaches to autonomous casualty evacuation, AI-driven decision support, and decentralized medical logistics. As conflicts become more complex, military medicine must embrace interdisciplinary collaboration, integrating expertise from data science, engineering, and humanitarian operations to improve strategic effectiveness and ethical considerations. Beyond the battlefield, innovations developed in war medicine will have broader implications for global emergency response and disaster relief, bringing military and civilian medical preparedness closer together in austere environments.

Key Messages

• Irregular warfare requires adaptive and innovative medical strategies.
• Damage-control strategies and prolonged casualty care are critical to improving the survival of war casualties.
• Civil-military cooperation improves casualty management and increases strategic impact.
• Medical intelligence plays a role in battlefield operations and countering disinformation.

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Manuskript Data

Citation

Jarrassier A, Mathieu D, Le Vaillant Y, Mahé P, Josse F, Pasquier P: Medicine in irregular warfare. WMM 2025; 69(6): 265-268.

Also published in WMM 2025; 69(6E): 3.

DOI: https://doi.org/10.48701/opus4-502

Author

Dr. Audrey Jarrassier

Department of Anesthesiology and Intensive Care,

Military Teaching Hospital Begin, Saint-Mandé, France.

E-Mail: jarrassieraudrey@gmail.com