The NATO response to the COVID-19 pandemic – interview with Brigadier General Dr. Laszlo Fazekas

Bricknell, Martin: 

What is your current role?

BG Laszlo Fazekas SHAPE MEDAD:  

I am the Medical Advisor to the Supreme Allied Commander Europe (SACEUR). As a special advisor, I have a direct access to the Commanding General (CG) and I provide recommendations and advice in all health and medical support matters that require their attention, decision or action. I represent SACEUR’s medical interests across the breadth of NATO and conduct appropriate liaison with external and non-NATO military or civilian organisations and institutions to further develop eventual medical partnerships and facilitate interactions. I am also Assistant Chief of Staff (ACOS) and Chief of the Joint Medical Division (JMED) within the Strategic Enablement Directorate (STREN) of SHAPE HQ.

Under my supervision, my team provides cross-cutting medical authority, direction, and sets the requirement at strategic level for all aspects of military medical support in accordance with NATO Military Committee’s policy. We coordinate all medical functions at the strategic level including medical oversight and situational awareness. We provide medical direction and guidance to the subordinated Headquarters (HQ) Medical Advisors (MEDADS) and their medical staff including deployed medical units. My team also supports all internal SHAPE Divisions to facilitate medical input to strategic planning, policy and medical capability development, force generation, resource and assets management and implementation in the domain of the collective training, as well as supporting and advising NATO HQ.

Bricknell, Martin: 

What has been your involvement in the military response to the COVID pandemic?

BG Laszlo Fazekas SHAPE MEDAD: 

The COVID pandemic has already killed several million human beings. It represents the greatest medical threat the Alliance has encountered since its creation. NATO’s overall objective was to keep its personnel and dependants safe and to protect the men and women who are engaged in NATO missions. Alongside this, NATO’s fundamental security tasks must be maintained. While we had to define and take all the necessary measures to protect our armed forces, NATO’s operational readiness remained undiminished. The Alliance continued to deliver effective deterrence and defence. Our forces remained vigilant and prepared to respond to any other threat. Collective defence is at the heart of the Alliance and creates a spirit of solidarity and cohesion among its members. The pandemic has not challenged this and it even created opportunities to show support between NATO nations and partners.

My primary role has been to provide evidence based medical advice to SACEUR, SHAPE Chief of Staff (COS) and Command Group (CG) on managing NATO Allied Command Operations (ACO) pandemic response. I also have had to provide medical direction and guidance to all ACO subordinated commands, units of the NATO Command Structure (NCS), the NATO Force Structure (NFS) and ACO Operations and Missions (AOMs) across time in four continents. In addition, due to the fact that SHAPE COS is responsible for the SHAPE compound, I also became responsible for the pandemic response in the SHAPE HQ and compound.

The content of the above roles changed during the different phases of the pandemic. The phases were from my point of view:

Initial Response Phase: January 2020 – May 2020 (first wave in Europe)

General Response Phase: June 2020 – May 2021 (second and third wave in Europe)

Specific Response Phase: June 2021 – present (mass vaccination)

My role in the Initial Response Phase was, in close coordination with SHAPE COS, to lead NATO ACO’s pandemic management efforts as a NATO operation under the guidance of SACEUR. The strategic goal of NATO was identified by SACEUR and is still in place: to prevent the health crisis from becoming a security crisis. The medical objective for ACO was to mitigate the impact of the pandemic on ACO’s personnel and consequently protect ACO’s ability to accomplish our mission. Four lines of effort were established to achieve it: information, reporting, prevention, consequence management.

It has been a unique experience and a huge challenge for a MEDAD/ACOS JMED to acquire the ‘supported role’ by all the other stakeholders in a strategic HQ in place of acting in a ‘supporting role’ to a different staff element. One of the biggest challenges was that the CCOMC (strategic operations centre) and SHAPE Command Group required the same quality and quantity of outputs which are usually provided by other command elements (e.g. intelligence, operations etc) that were 10-15 times bigger than the JMED prior to the pandemic. The workload and the available time for it were manageable only by applying fast military decision making and staffing process with JMED itself. Stricter measures were applied in the ACO than in civilian setting and the compliance with reporting requirements was also better in the military command structure.

This phase was characterized by quickly changing pandemic situation resulting in need for quick adaptation of policy and guidance in all four lines of effort. Several new working elements were established in NATO and SHAPE in this phase to facilitate coordinated response to the pandemic. The NATO COVID Task Force was responsible for NATO support to nations or other organizations and ACO subordinated elements. The COVID Action Team was the coordination body on internal SHAPE actions. SHAPE JMED’s very close coordination with the CCOMC was essential in providing to ACO a recognized Covid picture. We defined a health surveillance reporting process for the ACO chain at all levels (strategic, operational, and tactical) in order to draw the most accurate operational medical picture. We also set up a wastewater surveillance protocol for our compound. This is experimental but other experiments in Europe show a strong link between the presence of SARS-Cov-2 genetic material in wastewater and the local epidemiologic picture. The Euro-Atlantic Disaster Response Coordination Centre (EADRCC), NATO’s main civil emergency response mechanism, expanded. The Centre operates on a 24/7 basis, coordinating requests and offers of assistance. It is helping to coordinate assistance, including medical and financial support, to NATO members and other countries. In June 2020, NATO Defence Ministers decided on a new Operation Plan to ensure that the Alliance continues to be ready to help Allies and partners. This included the creation of a NATO Pandemic Response Trust Fund to quickly acquire medical supplies and services. It maintains an established stockpile of medical equipment and supplies to be able to provide immediate relief to Allies or partners in need.

The General Response Phase was characterized by the existence of already established and well-functioning structures and processes. As a result, the usual chain of command could be exercised with very strong medical input and the direct MEDAD-COS chain changed to ACOS JMED-STREN-COS chain in SHAPE. The pandemic still required a tailored-to-the-activity medical conditions-based response. The military medical objective was to eliminate the pandemic impact on NATO’s personnel and operational capabilities in every level. However, some other military objectives within NATO rose to the same priority as the pandemic response in the second half of this phase.

The Specific Response Phase is characterized by massive availability and administration of vaccines in NATO forces. The high vaccination rates among military service members facilitate the application of the same measures as in the civilian setting without high risk of outbreaks. No change to objectives was necessary, but a new line of effort for vaccination was created.

Overall, you can see that NATO’s response not only concerned the medical community but the entire NATO community. We literally built a plan to fight against COVID. To that end, this compelled us to assemble subject matter experts from a variety of disciplines, such as operational, logistics, communication and more!

More specifically in the medical domain, we had to quickly write and promote evidence-based recommendations and provide rapid guidance to the ACO medical community. We created forums to exchange our experiences, resolved difficulties and promote best practices within our medical community of interest that included all medical advisors in our subcommands and single service commands but also willing nations and partners’ representatives.

We based all our recommendations on very strong scientific facts and publications. Highly recognised institutions and organisations such as WHO, CDC and ECDC were our main references but because we work in a multinational environment, we also reviewed analysis and recommendations from several national and international health authorities such as the US Federal Drug Agency (FDA), the European Medicine Agency (EMA), the UK Medicines and Healthcare products Regulatory Agency (MHRA), the FRA Haute Autorité de Santé (HAS) and many more! We also regularly reviewed the scientific literature.

Bricknell, Martin: 

Let's move on to the third question, what contributions have military medical services made towards the response to the pandemic?

 BG Laszlo Fazekas SHAPE MEDAD:

Our objective was keeping the force operational, capable of accomplishing the mission. Our primary contribution was to help keep personnel healthy and able to perform their duties. We were doing it through the SHAPE COVID Action Team by issuing the necessary guidance through orders issued on behalf of the Chief of Staff.

The situation was assessed regularly using the Pandemic Resilience Index developed by SHAPE JMED. It includes information on healthcare capacities (number of beds, ICU, nurses, physicians) and pandemic response (incidence, number of tests, positivity rate, number of active cases and later vaccination rates) One of our main challenges was to build tools in order to predict epidemiologic trends and medical resilience index for NATO countries and areas of interest. We identified relevant and reliable sources of data and created mathematical formulas to present our medical risk assessment in the most effective way even for non-medical personnel. The military authorities could then make informed decisions based on our products.  

It is correct to recognise that military medical services are usually well experienced in specific domains of the medical field such as emergency and trauma care, CBRN medicine and medical assistance. However, for most NATO members, military healthcare professionals represent a very small percentage of the entire healthcare professional population. Some nations owned military hospitals when others entirely rely on their national health service. That means that no nation could only rely on its military health service to face the consequences of the COVID outbreak. Although the primary responsibility of military medical services is to preserve and maintain the health and fighting strength of the military, they played and still play a vital role in supporting their national civilian responses across the Alliance. The cooperation between civilian and military has been fundamental to fighting the pandemic. You can find military personnel in a wide range of medical activities; it is not only providing medical care but also coordinating national efforts or providing pharmaceutical and biological assets for example.

Bricknell, Martin:

What do you think are the lessons from the pandemic for national military medical services? 

BG Laszlo Fazekas SHAPE MEDAD:

It is far too early to finalise and conclude the ‘lessons learned’ process, however I believe that are 3 major Lessons Identified.

The first concerns the logistics of medical supplies. All nations, civilian and military, competed for the same medical products and personal protective equipment (PPE) in a time of disruption of the global logistic chain. We cruelly faced the consequences of strategic dependencies and ‘just in time’ market rules. Pandemic preparedness must include stockpiles of medical supplies at readiness: surveillance, diagnostics, evacuation, treatment, medical supplies including PPE, vaccines, disinfectants, antidotes etc.

The second concerns the scarcity of medical personnel. Only a very limited and small pool of medical personnel is available. And I am speaking of fully certified and trained personnel. Some medical specialties or specific medical skills are very rare. And in this domain again, military and civilian compete for the same resources. It takes a lot of time and costs a lot of money to obtain highly trained and efficient medical personnel.  

The third concerns the importance having sufficiently trained medical personnel who can make rapid evidence-based decisions and sufficiently communicate that to potential medical advisors and staff members.

Bricknell, Martin: 

What do you think are the lessons for international or multinational organisations?

BG Laszlo Fazekas SHAPE MEDAD:

I will concentrate on NATO though noting that, because NATO works closely with other international organizations, we interacted with the European Union, the United Nations Office of the for the Coordination of Humanitarian Affairs, the World Health Organization and the United Nations World Food Programme.  

Throughout the COVID-19 crisis, we have strengthened our cooperation with external partners, notably the European Union. NATO and EU staffs have been exchanging information on steps taken by both organisations to support NATO Allies and partners during the crisis. This ensures that our efforts are coherent, complementary and transparent. It is important that training of the medical leaders and medical staff across these organisations cover the same principles to get fast decisions with evidence based medical advice.

 Bricknell, Martin: 

What do you think of the risks to military medical services arising from the pandemic?

BG Laszlo Fazekas SHAPE MEDAD:

I see some limited risks arising from the pandemic specifically directed to military medical services: primarily there is a risk of forgetting and not learning our lessons effectively.

The biggest risk is burning out our personnel since the workload has been sustained since Jan 2020. Similar, to our civilian counterparts, the fight against the pandemic is huge and medical personnel are literally overburdened. Yes, flexibility, resilience and adaptation are in the DNA of military personnel, however only medical personnel have had to fight that long and with such intensity for a still ongoing unknown duration. I am legitimately concerned, I think, about the mid-term and long-term consequences on their commitments.

There are opportunities, too. Indeed, I prefer to remain optimistic and foretell an extraordinary opportunity to develop a high level of cooperation across the whole civil-military medical community. We can imagine that our experience gained during the pandemic could improve our preparedness to respond to another threat.

 Bricknell, Martin: 

The final question is what do you think are the specific implications of the pandemic for the COMEDS community?

BG Laszlo Fazekas SHAPE MEDAD:

The Committee of the Chiefs of Military Medical Services in NATO (COMEDS) is the senior body for military medical advice within NATO. COMEDS (in close cooperation with the Medical Advisors of the NATO HQ, ACO and ACT) is the central point for developing and coordinating military medical matters and for providing medical advice to the Military Committee. COMEDS is composed of seven Working Groups (WG) and several Panels (P) that cover a vast field of medicine such as the medical intelligence panel, the NRBC Medical WG and the Biomedical Panel for example.  For COVID-19, COMEDS is helping to coordinate military medical aspects of the pandemic among members and partner countries in order to identify issues that require harmonisation, immediate attention, decision or action. As a result of this success, the COMEDS advisory role to the NATO Military Committee has definitely been strengthened.

Date: 12/17/2021

Source: Martin Bricknell