Larissa Forster, The Theoretical Soft Power Currencies of U.S. Navy Hospital Ship Missions in:

Sebastian Bruns, Sarandis Papadopoulos (Ed.)

Conceptualizing Maritime & Naval Strategy, page 281 - 294

Festschrift for Captain Peter M. Swartz, United States Navy (ret.)

1. Edition 2020, ISBN print: 978-3-8487-5753-4, ISBN online: 978-3-8452-9915-0,

Series: ISPK Seapower Series, vol. 3

Bibliographic information
The Theoretical Soft Power Currencies of U.S. Navy Hospital Ship Missions1 Larissa Forster The Tsunami in South-East Asia in 2004 prompted the largest military disaster response in history. Encouraged by the success, increasing attention has been paid to the various humanitarian assistance and disaster relief activities conducted by US armed forces. Since 2006, the US Navy has deployed one of its two large hospital ships regularly to either Central and South America or the Asia–Pacific region to provide people in need with free care. These missions offer many opportunities to increase the soft power capital of the United States by forging ties with host nation governments and improving the image of the United States within the local population. “What better way to knock down the hatred, the barriers of ethnic and religious groups that are afraid of America, and hate America, than to offer good medical policy and good health to these countries?” (Thompson 2004) Introduction The maritime strategy “A Cooperative Strategy for 21st Century Seapower” (United States Navy, Marine Corps, and Coast Guard 2007) lists humanitarian assistance (HA) and disaster relief (DR) among the core competencies of US maritime forces. While in prior years, these tasks were treated as an “extra,” they have since been promoted to being equally as important as the four traditional naval missions of sea control, presence, deterrence, and power projection2. 1 This paper is a shorter version of Larissa Forster, “The Soft Power Currencies of US Navy Hospital Ship Missions,” in International Studies Perspectives vol. 16: 4 (November 2015), 367–387. 2 In recent years, the focus has shifted again more towards great power competition and fighting and winning wars. The document A Design for Maintaining Maritime Superiority (Washington, D.C.: United States Department of the Navy, 2018) describes the USN as “a key enabler of the Joint Force’s ability to prevent China and 281 The US military has a long tradition of providing such humanitarian aid. During World War I, for example, President Woodrow Wilson used food supply as a form of disaster relief to counter the spread of Bolshevism and civil unrest (Zajtchuck 2003). A Center for Naval Analyses (Cobble, Gaffney, and Gorenburg 2005) study on US military responses to international situations between 1970 and 2003 identified only 22 combat operations compared with 366 HA/DR missions. These numbers show the importance and frequency of HA and DR, yet little has been written about the role and experience of military forces in these domains. With the unprecedented use of military assets during the Tsunami 2004 relief efforts, a new level of military involvement had been reached and continues to influence all future humanitarian operations. The often-cited success of US aid provided the impetus for more regular, scheduled, proactive humanitarian medical missions with US naval hospital ships as a platform. While traditional naval missions advance US interest, the contribution of HA/DR is still contested and needs to be more thoroughly evaluated. This article aims to explore the theoretical usefulness of military forces in the humanitarian arena by placing hospital ship missions in the context of the concept of soft power3. Defining the Concepts Hard Power and Soft Power: Coercion versus Attraction The term “soft power” was coined by Joseph Nye in Bound to Lead (1990) who offers the following definition: “soft power is the ability to affect others through the cooptive means of framing the agenda, persuading, and eliciting positive attraction in order to obtain preferred outcomes” (Nye 2011). Unlike hard power, which influences through coercion, soft power exerts a subtle influence. According to Nye (2004, 2011), the goal is to get others to want what you want without coercing them. Vuving (2009) suggests instead that getting others to accept what you want can be enough. After the terrorist attacks of 9/11, the United States had pursued a unilateral foreign policy and relied heavily on military means to resolve all security Russia from controlling the Eurasian rimland and its adjacent seas.” Nevertheless, military diplomacy remains an important contributor to advancing US interests. 3 For a more detailed discussion of important areas of research to actually measure the effectiveness of HA/DR missions see Forster (2015). Larissa Forster 282 problems (Feste 2003; Nye 2011). The preemption doctrine of that time had removed any distinction between imminent and potential future threats. It assumed that grave threats were now always imminent. This thought process led to the devaluation of diplomacy and negotiation and shifted the emphasis to the use of immediate force, thereby failing to distinguish between short- and long-term threats and different adversaries. After many years of neglecting soft power approaches, a policy shift became visible with the release of the National Security Strategy (NSS) 2010 and the Quadrennial Defense Report (QDR) 20104. Both strategic documents emphasized a renewed US interest to invest in soft power. “As a global power, the United States has a broad range of tools for advancing its national interests (…). Whenever possible, we seek to pursue those interests through cooperation, diplomacy, economic development and engagement, and the power of America’s ideas and values” (QDR 2010). Nye (2011) argues that while hard power is and will remain important, alone it is not sufficient. Power has different aspects and faces (Dahl 1961). The first face5 uses coercion or incentives to reach the desired outcome. The second controls actions to limit possible choices. The third face—soft power—creates and shapes beliefs, perceptions, and preferences. Only the first face of power is directly felt, while the two other faces exert a more subtle influence on their target but are allegedly nevertheless effective. More recently, Nye (2004) defined the combination of the hard power of coercion and payment with the soft power of persuasion and attraction as “smart power.” With their capability to exercise both soft and hard power, naval forces are a unique tool of smart power. This is also reflected in the 2007 naval strategy (United States Navy, Marine Corps, and Coast Guard 2007). According to Elleman (2007, quoted in United States Navy 2010), “during the nineteenth and most of the twentieth centuries, the very thought that sea powers might regularly use naval platforms to deliver humanitarian aid, as opposed to cutting off and starving an enemy’s supply lines, would have seemed alien. In the twenty-first century, however, na- 4 The unclassified National Defense Strategy Summary (United States Department of Defense, National Defense Strategy Summary ,Washington, D.C.: Department of Defense, 2018) describes inter-state strategic competition as the primary challenge to US prosperity and security with the competitive military advantage of the United States as eroding. In this increasingly complex security environment, soft power and diplomacy remain important to sustain influence and power. 5 Incentives can come in the form of payments or inducements. Another form is negative sanctions, for example, taking away economic assistance previously provided. The Theoretical Soft Power Currencies 283 tional power and prestige are more and more characterized by soft power. UNIFIED ASSISTANCE [the Tsunami relief operation in South-East Asia] showed that hard power assets like aircraft carriers can also be the best providers of soft power.” Soft power has also attracted much criticism. Joffe (2006) cautions that soft power is still a form of power and “does not necessarily increase the world’s love for America.” And like all forms of power, it can still create enemies. Another weakness of soft power is that it lies within the people to decide how much influence it will have, and there is little to no control over how the actions will be perceived by the target population. Gray (2011:vi–viii) argues that “an important inherent weakness of soft power as an instrument of policy is that it utterly depends upon the uncoerced choices of foreigners. Sometimes their preferences will be compatible with ours, but scarcely less often they will not be.” In general, the concepts of attraction and persuasion and their translation into soft power are difficult to measure. But when trying to convince others to pursue soft power approaches, it is important to be able to demonstrate their effectiveness. Peacetime Deployments of Naval Forces The US Navy (USN) has been the predominant American military instrument of diplomacy, due largely to its greater mobility and flexibility compared to the other services (Turner 1974; Till 2009). Army and Air Force are more likely associated with posing a greater threat and destruction. Naval forces are less intrusive and offer a more subtle influence. This offers unique opportunities to create soft power. The diplomatic potential of navies has long been recognized by nations and can be traced back to the heritage of colonial powers that would dispatch their fleets to boost their prestige and to influence events ashore (Davidson 2009). While some argue that the use of coercive diplomacy is a thing of the past, others see an increasing need in an era in which the focus of the USN is shifting away from large-scale conflicts (Nailor 1984; Booth 1985; Ghosh 2001; Le Mi'ère 2011). Naval diplomacy acts as a signal demonstrating US interest and concern in particular regions and countries; any naval deployment demonstrates US commitment and capabilities (Sanders 2007). At the lower end of the diplomatic spectrum are measures such as goodwill visits, exercises, and other confidence-building activities. At the higher end, armed suasion is the most forceful aspect of coercive diplomacy (Stocker 1998). Further traditional diplomatic peacetime activities center on cooperation and exercis- Larissa Forster 284 es, military-to-military contacts, officer training, and access agreements as means of demonstrating and building positive relationships. All these activities can contribute to US soft power capital. During port calls, deployed sailors frequently help communities on land. Examples include volunteer work such as supporting school construction and maintenance, helping to build hospitals, and inviting foreign nationals aboard a US Navy ship. While such assistance activities are the by-product of routine port calls, humanitarian operations are sometimes deployed for the sole purpose of delivering assistance. By delivering aid, the United States demonstrate goodwill, reassure support, shape perceptions, build relations, and thus generate soft power. For example, the disaster relief aid delivered in response to the Tsunami in South-East Asia resulted in a more positive attitude toward the United States, suggesting a positive effect of this display of soft power, as opposed to the traditional hard power use of military assets. After realizing the potential of health diplomacy, the United States decided to deploy the hospital ships USNS Mercy and USNS Comfort in regular missions to countries of interest in the Pacific Commands (PACOM) and Southern Commands (SOUTHCOM) areas of responsibility (AOR). In addition to “winning hearts and minds,” these missions serve as a training and relationship building opportunity for US and foreign forces as well as engage in capacity building for future disasters. These ambitions beyond improving the health of the target population make humanitarian assistance a tool for politics. This has triggered much criticism and remains controversial. US Hospital Ships Today the USN operates two hospital ships. The USNS Comfort and the USNS Mercy are both converted San Clemente-class supertankers re-fitted into floating trauma centers. Both vessels are commanded by the US Military Sealift Command (MSC); one is maintained on each coast (Mercy is stationed in San Diego, CA, Comfort in Norfolk, VA) with a small civilian crew and an embarked core naval medical team. The ships are 894 feet long and when fully operational have 63 civilians, 956 naval hospital staff, and 258 naval support staff. Both hospital ships are equipped with a 1,000bed hospital facility, 12 operating rooms, and a helicopter deck and side ports to take on patients when at sea. This is important as many ports lack infrastructure for the docking of such large vessels, which often have to an- The Theoretical Soft Power Currencies 285 chor off the coast. Thus, the majority of patients arrive by helicopter and a smaller number by boat. The hospital ships’ primary mission is to provide emergency medical support for US armed forces deployed in combat (Wayne 2008). Their “secondary mission is to provide full hospital services in support of US disaster relief and humanitarian missions worldwide” (United States Navy 2008). The USNS Mercy deploys nearly biannually to the Pacific as part of the mission PACIFIC PARTNERSHIP (2006, 2008, 2010, 2012, 2015, 2016, 2018), the USNS Comfort to the Caribbean Basin and Central and South America in mission CONTINUING PROMISE (2007, 2009, 2011, 2018)6. US Navy hospital ship missions are organized by PACOM and SOUTH- COM, respectively, but many different actors are involved in the planning phase and the mission itself. The country choice is based on a complex decision-making process and is heavily supported by the US ambassadors to the countries in the region. While cooperation between all actors needs to be improved in the future, the visits are increasingly characterized as “whole-of-government interagency missions” (United States Department of Defense 2012). As part of every mission, medical staff from foreign countries and an increasing number of NGOs join the crew. Both the US government and NGOs benefit from this collaboration. The hospital ship provides the latter with transportation and housing, and NGOs are often better informed about the needs of the populations, as well as local customs and traditions, and might even have worked on the ground before. However, despite this increased collaboration, civilian agencies remain critical of these missions, and support does not extend far beyond the involved NGOs. Concerns such as the short-term focus, militarization of aid[?] and lack of integration with other HA programs remain. While the disaster relief after the Tsunami came in the form of an aircraft carrier, hospital ships are not warships. They are white hulls with a red cross, recognized as protected platforms in whatever capacity they serve (Grunawalt 2005). Whereas the use of aircraft carriers for disaster relief shows a hard power tool fulfill a soft power function, health diplomacy by US Navy hospital ships does not involve hard power warships. Yet hospital ships convey US military might and power. A Navy capable of 6 In addition to these regular deployments the two hospital ships have responded to natural disasters (USNS Comfort 2017 hurricane Marina in Puerto Rico) and the USNS Mercy engaged in a subject matter expert exchange with personnel from the Chinese hospital ship Peace Ark during the military exercise “RIMPAC” 2014. Larissa Forster 286 maintaining a hospital ship of this size is no doubt capable of large-scale operations. The size of the ship can both demonstrate a larger commitment to politicians and trigger admiration by the patients and observers. This argument also helps to underline the signaling power these large vessels convey that individual Department of State initiatives cannot provide. The Soft Power Potential of Hospital Ship Missions7 Soft Power Currencies There are different ways to measure the soft power potential of military humanitarian assistance. Vuving (2009) suggested replacing the question, “What constitutes soft power?” with “What generates attraction?” thereby focusing on the attraction component of the definition. He defines three power currencies that generate attraction and thus soft power: gratitude, admiration, and shared ideals, values, causes, and visions. The first form of soft power currency is created through the positive attitude of agents when engaging with the clients. Soft power is generated by gaining gratitude and sympathy. The second soft power currency is concerned with the actual work done to create soft power, where the client learns from the success of the agent resulting in the power of admiration. The third soft power currency is represented by the shared ideals, values, causes, and visions of the agent. The need for moral support and the tendency to join forces with those who pursue the same goal are thought to work toward generating this currency of soft power. Thus, for this currency, the power lies in inspiring the client. These three elements can be applied to hospital ship visits to better understand their value to the United States. The power of being benign can take many forms but mostly lies in “doing good to others.” The service recruiting slogan already presents the US Navy as “A Global Force For Good.” The mission of hospital ship visits in particular is to do good and offer free help and care to people in need. Ad- 7 The United States is not the only country to deploy military hospital ships. China has also recognized the power of health diplomacy and the soft power potential of humanitarian assistance. The first deployment of the Chinese hospital ship Peace Ark to the Gulf of Aden in 2010 underscored the Chinese soft power interests in Africa (Peter Mackenzie, Red Crosses, Blue Water: Hospital Ships and China’s Expanding Naval Presence, Alexandria, VA: Center for Naval Analyses, 2011). Since then, the Peace Ark, in almost yearly deployments named “Harmonious Mission,” has visited various countries in Latin and South America, Asia and Africa. The Theoretical Soft Power Currencies 287 miral Jim Stavridis (2010), former commander of the US Southern Command, observed the positive influence US naval forces exerted in Latin America and the Caribbean and the capability of military humanitarian assistance to improve the national image of the United States and its military forces in particular. He found that initiatives to improve health security demonstrate that the nation cares and is willing to help the people in the region, whereas counter-narcotics and terrorism activities are largely perceived as focusing on narrow US interests. Bonventre et al. (2009) conclude that “hospital ships’ visits to Central and South America have paid dividends not only for the skills of military medics but also in influencing both populations and government leaders to view the United States and its military in a more favorable light.” The presence of US NGOs and civilian actors in addition to the military can possibly help to further enhance the perceived benignity of these missions. Another important factor is the level of global attention. Hospital ship missions are planned months in advance and are not “dependent” on natural or artificial disasters and are thus less under the watch of global community. After a large natural disaster or war, the global community expects US support and aid. Hospital ship missions, while still helping people in need, seldom make a difference between life and death. Because only limited attention is paid to these visits, it can be argued that the level of goodwill is even higher because the United States is less likely to receive any of the benefits from the positive global recognition generally associated with disaster response. Yet the population and government may interpret proactive humanitarian assistance as indicative of a stronger commitment and sign of goodwill. Admiration can be triggered by a variety of attributes, among them a strong military, a wealthy economy, advanced science and technology, or success. The fact that the United States can deploy large vessels to help people in need demonstrates capability, an important indicator for the potential to elicit admiration. Similarly, only a wealthy economy can afford to undertake proactive humanitarian assistance. This show of capability and goodwill can generate admiration which positively translates into imitation and respect. Vuving (2009) also argues that admiration can help to overcome suspicion and hostility, while working toward cooperation and understanding. Ideally, clients would seek US advice in other matters and show respect for other American decisions by their support of them. Of course, it is difficult to determine in practice how this support should manifest itself as it becomes manifest on different levels and venues. Activities can range from backing of small-scale US diplomatic initiatives in the host country or region to United Nations voting. Depending on the de- Larissa Forster 288 sired outcome, an increase in bilateral diplomatic activities may be enough. Imitation is even more difficult to measure, and certainly respect does not have to translate into support for US policies. Shared ideals, values, causes, and visions are very important in international relations. Striving for a common goal is said to encourage cooperation and friendship. It builds confidence in moral authority and legitimacy of the agent. By caring for the health of the local population, the US and the host nation government share a common goal. This again can translate into stronger relations and support for the United States and a more favorable attitude toward the country overall. Ideally, cooperation during the mission translates into cooperation in other matters and shared ideals, values, causes, and visions encourage understanding and foster trust for future interactions. Hospital Ship Mission Challenges Hospital ship missions carry some of the risks described above. As mentioned earlier, one of the weaknesses of soft power is that it lies within the recipient people to decide how much power it will have, and there are limits on how the actions will be perceived by the target population and host government. Because payoffs are not immediate and are rather manifested in “storing up political capital” (Nye 2004), it is difficult to attribute favorable outcomes to specific missions as results may be years away. “Nonetheless,” Nye (2004) argues, “the indirect effects of attraction and a diffuse influence can make a significant difference in obtaining favorable outcomes in bargaining situations. Otherwise leaders would insist only on immediate payoffs and specific reciprocity, and we know that is not always the way they behave.” The United States, Nye says (2004), effectively used soft power after the Second World War to form alliances and institutions with common goals. Gratitude, admiration, and shared ideals, values, causes, and visions all helped to forge these coalitions. These developments take time, and similarly it might take time before hospital ship missions to translate into soft power. Conversely, however, it is also possible that host nations reciprocate favors immediately after the visit, rather than storing political capital, resulting in only short-term influence. The problem of perception is very relevant to humanitarian assistance. While hospital ship missions offer many opportunities to attract and persuade, the potential negative effects should not be overlooked. Problems The Theoretical Soft Power Currencies 289 include the limited time spent in each country8, the resulting restricted number of patients receiving treatment, and unavailability of necessary follow-up care, which, in the worst case, may worsen health problems. Additionally, unrealistic expectations can trigger dissatisfaction with US efforts and consequently negatively affect public opinion. Furthermore, the population could be frustrated that the United States might not come back to the same place, meaning after a few days of top-level care, they have to rely on the local capacities again. Such considerations might turn the gained trust into anger. From a government’s perspective, problems can arise when the population becomes dissatisfied with the current health services prompted by the high-level care during the hospital ship visits. For example, while Bonventre et al. (2009:18) found positive effects of the deployments to Central and South America, they also observed that “the Mercy’s visit to Indonesia was more problematic, because the standard of care delivered far exceeded what the Indonesian government was able to provide after the ship departed, and Indonesia claimed that this had undermined its legitimacy and authority.” Similarly an article in the Tico Times (Williams 2011) from Costa Rica described how many patients had voiced complaints about inattentive national hospitals. While they often have to wait for years to get appointments at the local hospital, one woman is cited saying “The gringos come here and give me a check-up in 2 days.” Such considerations might reverse the positive effect of gratitude from a government’s perspective. As it is argued that soft power currencies take time to develop and even more time to translate into power, one single hospital ship visit is not likely to trigger host nation support for US policies or long-lasting positive attitudes toward the United States in the host population. Gratitude and admiration for example can still be felt but may fade after a few weeks. It may thus be important to provide a certain continuity of aid and consider a return of the hospital ship during the next deployment. If, however, the United States wants more immediate payoffs, continuity is not as important and “renting” current influence can be sufficient. Up to now, the United States largely has relied on measuring efforts rather than using effectiveness to evaluate hospital ship missions. Success is measured by counting the numbers of surgeries or treated patients. While 8 This issue was addressed in the 2012 PACIFIC PARTNERSHIP mission. Unlike in earlier years, the vessel spent almost two weeks in every port. Thus, instead of visiting as many countries as possible, the focus lay on extending each stay for as long as possible (see PACIFIC PARTNERSHIP 2012, artnership/2012/). Larissa Forster 290 these numbers are certainly important, they fail to capture the bigger picture about enduring impacts and how these missions can increase US soft power and support national security objectives. Thus, if one wants to answer the question whether, in a fiscally constrained environment, military humanitarian assistance should be continued, more measures of effectiveness have to be defined and evaluated. Conclusion My goal has been to position hospital ship missions in the context of soft power. Hospital ship visits are a good tool for signaling that the United States cares about the well-being of a specific group or of people in need and attaches importance to the forging of partnerships. Such operations have the power to influence both populations and governments and offer soft power benefits to the United States in addition to providing medical aid to people in need. Given the increasing importance of global health, this is a timely approach to advance cooperation and security. In theory, these visits offer the possibility to increase US soft power capital with the help of the currencies of gratitude, admiration and shared ideals, values, causes, and visions. In the future, more research should focus on supporting these theoretical conclusions in form of data measuring the actual effectiveness of these missions. Works cited Bonventre, Eugene, Katherine Hicks, and Stacy M. 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The 21st century is witnessing renewed tension as conflicts between major powers, serious concerns about future security alliances and global, even generational, security policy challenges arise. In the light of this, naval forces and maritime security, and understanding their underlying strategic rationale, are gaining momentum and importance. What are the roles and missions of naval forces, and how have states and the institutions themselves sought to frame their goals and methods? This book brings together experts from the United States, Europe, and Asia to reflect on how maritime and naval strategy is conceptualised and how it has been used. It celebrates the life and work of Peter M. Swartz, Captain (US Navy) ret., who since contributing to ‘The Maritime Strategy’ of the 1980s as a young Pentagon officer, has been a mentor, friend, intellectual beacon and the foremost purveyor of maritime expertise to the global naval community. With contributions by James Bergeron, Sebastian Bruns, Seth Cropsey, Larissa Forster, Michael Haas, John Hattendorf, Peter Haynes, Andrzej Makowski, Amund Lundesgaard, Narushige Michishita, Martin Murphy, Sarandis Papadopoulos, Nilanthi Samaranayake, Jeremy Stöhs, Eric Thompson, Geoffrey Till, Sarah Vogler, Steve Wills.


Großmachtkonflikte, die Zukunft von sicherheitspolitischen Institutionen sowie transnationalen Generationenherausforderungen bergen eine neue globale Unsicherheit. Vor diesem Hintergrund bekommen maritime Sicherheit und Seestreitkräfte sowie deren Einordnung im außenpolitischen Werkzeugkasten eine zunehmende Bedeutung. Was sind die Rollen und Einsatzaufgaben von Seemacht, und wie haben Staaten und ihre Institutionen maritime Ziele, Mittel und Wege konzeptualisiert? Dieser Sammelband bringt ausgewiesene Experten aus den USA, Europa und Asien zusammen, die ihre Perspektive auf maritime Strategie teilen. Das Buch dient gleichzeitig die Festschrift für Peter M. Swartz, Kapitän zur See a.D. der US-Marine, der seit seiner Arbeit als einer der Autoren der „Maritime Strategy“ (1980er) als Mentor, Freund, intellektueller Leuchtturm und vor allen Dingen als Spiritus Rektor wesentlich zur Schärfung des Verständnisses von Seestrategie in den globalen Beziehungen beigetragen hat. Mit Beiträgen von James Bergeron, Sebastian Bruns, Seth Cropsey, Larissa Forster, Michael Haas, John Hattendorf, Peter Haynes, Andrzej Makowski, Amund Lundesgaard, Narushige Michishita, Martin Murphy, Sarandis Papadopoulos, Nilanthi Samaranayake, Jeremy Stöhs, Eric Thompson, Geoffrey Till, Sarah Vogler, Steve Wills.