Article: Lieutenant General (Rtd) Professor Martin Bricknell CB PhD
THE IMPLICATIONS OF THE COVID PANDEMIC FOR FUTURE MILITARY MEDICAL SUPPORT
I conducted a series of interviews with key leaders within the NATO military medical community to seek their reflections on their experience of the COVID crisis. These interviews have already been published on the military-medicine.com website. This article is my interpretation of the points made by our interviewees on the implications of the COVID pandemic for future military medical support. The editorial team and I are extremely grateful for the time afforded by our interviewees. Their insights provide a very senior perspective on the role of military medical services in support of their armed forces and the contribution of NATO to the overall response to the COVID crisis. This is also a unique collection of interviews for the historical record.
The interviews are:
- Major General Timothy Hodgetts GBR, Chairman of COMEDS and UK Surgeon General: Click here to read the interview
- Brigadier Zoltán Bubenik CZE, previous Chairman of COMEDS and Czech Surgeon General: Click here to read the interview
- Brigadier General Dr. Laszlo Fazekas Hun A, ACOS JMED/MEDAD JMED Division, Strategic Enablement Directorate, Supreme Headquarters Allied Powers Europe (SHAPE) and Allied Command Operations (ACO): Click here to read the interview
- Brigadier General Dr. Dirk-Friedrich Klagges DEU, Director NATO Centre of Excellence for Military Medicine: Click here to read the interview
- Brigadier Stefan Kowitz DEU, Director, NATO Multi-National Coordination Centre/European Union Medical Command: Click here to read the interview
- Colonel Sohrab Dalal GBR, Branch Head (Medical), NATO Allied Command Transformation: Click here to read the interview
Within this paper, points made by individual interviewees are attributed using their initials. The analysis and conclusions are my own.
The COVID pandemic has had severe consequences for the health of our populations in our countries. All governments mobilised the full spectrum of their national resources to mitigate these effects, primarily by reinforcing their entire health sector from procurement of supplies through to rehabilitation of COVID patients. The pandemic also affected the health of armed forces personnel, requiring radical changes to military working practices alongside new modes of healthcare provision by military medical services. In spite of these constraints, the whole Defence enterprise worked to ‘prevent the health crisis from becoming a security crisis’. This experience can provide insights into the potential types of force health protection practices required to mitigate the threat of CBRN warfare, new ways in which military healthcare can be delivered to beneficiary populations, and the unique contributions that military health services might make to augment civilian health systems in future health crises. It might also indicate some risks and vulnerabilities within military health services that need to be addressed for the future.
IMPLICATIONS FOR OPERATIONS
At both a national and an Alliance level, the mission was to keep military personnel and families safe whilst maintaining operational readiness and military outputs (LF, TH). At the beginning of the outbreak, military activity was reduced to the minimum necessary to maintain strategic security with many military training exercises and other events being cancelled to reduce the risk of COVID. These slowly resumed as the risks of transmission and effective mitigation measures were understood. Unfortunately, despite robust force health protection measures, there were several outbreaks of COVID in military populations. The outbreaks onboard naval ships were most public, though outbreaks also occurred amongst deployed forces, in training centres, and in army and air force units. Overall, military medical services need to learn from this experience so that they can provide technical advice and maintain clinical services in the event of a similar health emergency in the future, either naturally occurring or man-made.
The NATO medical plan to mitigate the impact of the pandemic was based on 4 lines of effort: information, reporting, prevention, and consequence management (LF). This might be a suitable structure for a contingency plan to mitigate a future health threat. Each of these topics will be considered in subsequent sections. There are also important observations about the wider military command and control adaptations to manage the response to the pandemic. The military approach to crisis management has been a factor in the response to the pandemic (ZB). Using the existing military operational planning process to respond to new situations, many military headquarters created integrated planning teams to focus on COVID, such as the COVID Action Team within SHAPE (LF). This also brought the headquarters’ Medical Advisers into the senior Command Groups (ZB, LF, TH) whilst changing the medical staff branch into a ‘supported’ function as an independent staff branch rather than subordinate to Support or Logistics (LF). Similarly military forces assigned to the COVID response were ‘brigaded’ into designated task forces, such at the NATO COVID Task Force (LF). The military approach to problem-solving at pace has also been recognised as a significant contribution to the overall response using military planning teams and liaison officers to support civilian planning and response.
The Lessons Learned and Innovation Branch of the NATO Centre for Excellence for Military Medicine (NATO MilMedCoE) has played an important role in collating information from individual member nations and sharing this through an ‘Innovation Portal’ (DK). This Branch might consider how the architecture, networks, and processes that were rapidly developed in response to this crisis are codified as lessons learned that can be identified and translated into changes in policy, procedures, force structure, and professional education for military medical services. This analysis will need further distillation into specific recommendations for action either through standardisation or medical force structures.
IMPLICATIONS FOR FORCE HEALTH PROTECTION – INFORMATION, REPORTING AND PREVENTION
Both at a national level and at a NATO level, it was critical to establish effective communication of force health protection measures across the whole force using a single version of the truth (TH). The COMEDS VTCs were very valuable to provide a shared view of the crisis across the NATO military medical community, which reinforced the value of regular meetings both physical and virtual across the COMEDS structure. The COVID crisis also emphasised the value of health intelligence as a shared, common intelligence picture underpinned by a comprehensive system for collecting, processing and analysing many sources of data. The Force Health Protection branch of the NATO MilMedCoE has clearly demonstrated its value for the NATO medical community.
The main lesson of the pandemic for military medicine is to re-emphasise the importance of basic public health in controlling the spread of infectious disease (DK). Disease knows no borders and may pose a substantial threat not only to public health and economies but also to military operational readiness (DK). In the first instance, military public health specialists were heavily tasked to provide technical advice on force health protection measures covering a large range of topics including: new business processes to enable remoting working, social distancing, wearing of face masks, hand hygiene, surface decontamination, ‘cohorting’ of groups of personnel to minimise the risk of widespread transmission, pre-deployment quarantine, asymptomatic COVID testing etc. This experience re-emphasises the value of specialists in preventive medicine and infectious disease within the military health system (LF), alongside the specialists in trauma care that were so important during NATO operations in Afghanistan. NATO member states might also consider how to ensure that they can contribute suitably qualified and experienced personnel for these roles within the NATO command structure.
IMPLICATIONS FOR MEDICAL SERVICES – CONSEQUENCE MANAGEMENT
The requirement for robust infection, prevention, and control (IPC) measures within health facilities to minimise the risk of nosocomial infections led to significant changes in the methods for delivery of healthcare. Telehealth was a game-changer to maintain access to health services whilst reducing the risk of disease transmission (SK). This has the potential to transform garrison healthcare services enabling remote consultations and increasing the exchange of data between military and civilian health information systems. Military health services also had to make new arrangements for quarantine and isolation for armed forces personnel living in military accommodation who were contacts or cases of COVID. This was especially challenging in deployed environments where social distancing within living spaces can be difficult to implement. However, it would seem sensible to maintain these arrangements as a contingency plan so that the risk of transmission of other contagious infectious diseases (such as influenza) within military communities can be minimised.
Health facilities also introduced rigorous IPC measures to reduce COVID transmission between patients and staff including pre-admission COVID testing, segregation of COVID and non-COVID cases, personal protective equipment (PPE), and discharge COVID screening to reduce transmission back into the community. These measures replicated the basic principles of contamination control in a CBRN environment. The methods used to mitigate the threat from COVID within healthcare will need to endure as a contingency plan to enable military medical field units to operate under the threat of CBRN warfare. The design of existing field and fixed military medical treatment facilities greatly limits the degree to which expansion can occur and the degree to which patient separation can be maintained (DK). This particularly means that military field hospitals will need to re-examine the process of patient flow within a facility to mitigate the risk of intra-hospital spread of contamination by separating infectious patients from non-infectious patients and the widespread use of PPE (DK).
The COVID crisis demonstrated the fragility of the medical supply chain for personnel protective equipment (PPE) and respiratory ventilators. It also reinforced the importance of strategic stockpiles and resilience in the military medical logistics system (LF, DK). There needs to be greater understanding of the risks within the military medical logistics system by engaging across the civilian, military, commercial, and supply sectors (SD). The new NATO Military Medical Modular Multipurpose Epidemic/Pandemic Stockpiling Concept may provide a framework for new STANAGS on this topic (SK).
As national health systems became overwhelmed, it became necessary to establish a strategic patient evacuation command and control (PECC) function for both pre-hospital MEDEVAC and inter-hospital TACEVAC. Military medical operations personnel are very familiar with this concept and these personnel were used in many countries to help set up and run PECCs at regional and national level. Military medical personnel, ambulances, helicopters, and aircraft were also used to augment civilian MEDEVAC capabilities. It will be important to increase understanding of civil-military cooperation for the evacuation of patients in large scale emergencies and health crises (SK). It might be appropriate to maintain a military presence in national civilian ‘PECCs’ in the future so that military medical operations personnel can learn from the civilian system and advise on the use of military assets. This may also be important if large numbers of armed forces casualties from military operations need to be received and distributed within national civilian medical systems in the future.
IMPLICATIONS FOR ALLIANCES AND COALITIONS
The COVID crisis re-established the importance of managing health services capacity and medical evacuation at the strategic level. All interviewees highlighted the increased importance of civil-military relations across national and international actors within the overall health economy. The detailed relationships between the civilian and military parts of a Ministry of Defence and the co-operation between military health services and civilian Ministries of Health and other civilian institutions varies between countries. However, the COVID situation has reminded us of the importance of military medical services at the national strategic level (ZB, TH). The involvement of the military medical services in support of the civilian health system was very important at the national level, in bilateral support to partners, and as part of international organisations including NATO and the EU (ZB). There was much greater civil-military cooperation in the sharing of information, sharing a common operating picture, resources, and patients than ever before (SD). Senior military personnel were placed into liaison and planning roles within national Ministries of Health (TH). The development of scenario-based contingency plans and civil-military exercising will be needed to achieve and maintain readiness for the response to a future health emergency (DK). It is important that the training of medical leaders and medical staff across these organisations cover the same principles and decision-making processes (LF). It is also important to consider how to use placements for military planners within national health systems as part of their professional development in the same way that military doctors, nurses and allied health professionals have clinical placements within civilian hospitals.
Whilst these international organisations and partnerships provide a mechanism for burden-sharing, when COVID started to affect all countries equally, there was limited capacity to exchange medical personnel and equipment between countries. This has important implications for the use of military forces to mitigate risk during health emergencies in case they are needed concurrently in support of military operations. This is a particularly relevant in deciding the balance between active duty and reserve personnel in the medical services and how they are embedded within the civilian health system.
2020 could be considered as the ‘year of the Military Medic’ due to their broad utility across internal and external tasks (TH). They have been used in a range of para-‘medical’ roles such as ambulance driver, ambulance technician, healthcare assistant across the breadth of employment within hospitals, COVID sample collectors, or vaccinators. The COVID crisis also illustrated the value of military medical personnel as a national strategic reserve that can be deployed to reinforce local civilian medical services that are under stress. However, it is forecasted that there will be a significant shortfall in the national and global health workforce. Military health services will need a strategic approach to solving the problem of scarcity of medical personnel (LF). Military health services will have to make sure that their terms of employment are competitive in this increasingly challenging market.
COVID has re-emphasised the value of Standardisation Agreements to facilitate inter-operability between NATO military medical services and to highlight important areas of difference between nations. New standardised protocols are needed for the transfer of patients between civil and military health systems, standard formularies, and credentialling to increase interoperability (SD).
It is notable that NATO is developing a series of strategic bio-response documents covering not only military medical services but also wider military capabilities and civil-military decision-making at the NATO and European level (ZB).
This set of interviews from senior leaders within the NATO medical community is an important source of insights for both the facts of the military medical contribution to the response to the COVID crisis and also future implications for military health services. This crisis has been a valuable reminder of the importance of infectious disease, both natural and man-made, as a risk to military capabilities. There are important lessons for the development of medical intelligence, a medical common operating picture, garrison health services, field medical services, and international co-operation for the future. These insights provide guidance on topics for deeper analysis and interpretation as the COVID experience is translated into Lessons Learned.
Lieutenant General (Rtd) Professor Martin Bricknell CB PhD
Professor of Conflict, Health and Military Medicine
King’s College London