It was in late February 2020 that the first American military service member, a young soldier stationed at Camp Carroll near Daegu, South Korea, was infected with the novel coronavirus, SARS-CoV-2, that causes the disease now known as COVID- 19. By then, the Department of Defense (DOD) had already been working, for weeks, on the effort to protect service members and all Americans, at home or overseas, from the unpredictable and often deadly virus that has made its way around the world.

As the virus continued to sicken people in China, where the global pandemic began, the DOD’s earliest activities were directed at keeping military and civilian Americans safe. The federal officials, service members, and civilians evacuated from China in the early weeks of the pandemic, when many commercial flights had been grounded, were brought home on military aircraft, and many were temporarily housed at military bases. Civilian evacuees from China, or from passenger cruise ships that had suffered outbreaks at sea, were lodged at DOD facilities under an agreement with the U.S. Department of Health and Human Services (HHS).

The U.S. military and its federal and international partners were called upon to do more as the pandemic spread across the globe, and the Global Pandemic Campaign Plan issued by the Pentagon on January 30 has grown in scope and complexity to reflect the challenge of fighting a pernicious enemy that attacks indiscriminately. The DOD’s response to the coronavirus has been truly global in scale and comprehensive in scope, tapping into military expertise in everything from logistics to medicine to vaccine development.

Brian Lein, MD, joined the campaign in May 2020, as the Defense Health Agency’s new assistant director for health care administration. Before that, Lein spent 30 years in the Army, commanding some of the nation’s most important medical, research, and educational facilities before retiring with the rank of major general.

“In just about every aspect of the nation’s COVID-19 response,” Lein said, “you see the fingerprints of the Department of Defense. It’s been at the forefront of a lot of what’s been done.”

A HEALTHY AND MISSION-READY FORCE

From the start, the DOD’s response to the COVID-19 pandemic was focused on three priorities laid out by Secretary of Defense Mark Esper: first, to protect service members, DOD civilians, and their families; second, to maintain the military’s mission capabilities; and third, to provide full support to the whole-of-government interagency response to the pandemic.

The Pentagon’s first moves to protect the health of the armed forces were issued in a series of memos outlining force health protection guidance for service members and their commanders – focusing first on quarantines for those who had been to mainland China, and then on travel restrictions for service members and their families to and from countries based on risk classifications assigned by the U.S. Centers for Disease Control and Prevention (CDC). In March, all domestic travel, including duty travel and permanent changes of station, was temporarily halted, and in hard-hit countries such as Italy and South Korea, force health protection plans, which included modified training, quarantining, social distancing, and promoting good hygiene, kept infection rates lower at U.S. military installations than in much of the surrounding areas.

Communications technology has helped to keep many DOD personnel safe: Civilians have turned increasingly to telework, and a virtual recruiting environment has been established to protect recruiters. The pandemic has introduced significant changes to the way health care is delivered in the Military Health System. “Using digital solutions,” said Lein, “has allowed us to continue providing care but decrease the requirement of patients to actually come in and have a face-to-face encounter with the pharmacy or with a provider.”

At the same time, the Defense Department has striven to remain agile, flexible, and responsive, adapting to conditions as they emerge. Initial stop-movement orders – which involved mission-critical exemptions from the start – have been updated and altered as more has become known about the novel coronavirus and how it’s transmitted. Even as it battled COVID-19, the DOD continued global military operations: conducting counterterrorism missions in Africa and the Middle East; assuring freedom of navigation in operations around the world; monitoring and protecting U.S. airspace; monitoring North Korean weapons tests, and more.

Force health protection and readiness, Lein said, “go hand in hand. It’s not an either-or. We haven’t compromised one for the sake of the other; we’ve been able to do both to make sure we’re still able to respond to any international crisis.”

SUPPORTING THE INTERAGENCY RESPONSE

When the DOD issued its Global Pandemic Campaign Plan in January, it put the U.S. Northern Command (NORTHCOM) at the forefront of the battle. By early April, a major federal disaster declaration had been issued in all 50 states for the first time in American history, and the DOD’s support to the response nationwide was mobilized within several existing frameworks, including the National Response Plan.

“Under the National Response Plan,” said Lein, “DOD has certain requirements that we’re meeting – but we also have, through our liaison officers and through our trusted relationships that we’ve had with the Centers for Disease Control and Prevention, Health and Human Services, the Department of State, and others, […] been able to develop a really strong interagency platform at the secretary of defense level through the secretary’s COVID-19 Task Force.”

Military medical support to regions of the country hard-hit by the virus have included embedding Defense Department providers directly into civilian hospitals or treatment facilities. Deployable augmentation teams from the Army, Navy, and Air Force have assisted providers in the fight against COVID-19. In the spring, as the pandemic accelerated throughout the United States, service branches put out a call to retired and reserve members to help shore up the capabilities of civilian medical providers. By mid-April, for example, about 25,000 former soldiers from various backgrounds had volunteered to join the Army team, either as medical providers or support staff.

 

DOD medical professionals have added modular capability to civilian health care facilities – staffing entire hospital wings, for example – and established alternate care facilities such as the field hospitals established by the U.S. Army Corps of Engineers in Seattle and at the Javits Convention Center in New York City. Overall, the Corps of Engineers added more than 15,000 beds to civilian health care facilities by converting hotels, dormitories, and convention centers into alternative care sites.

The Navy hospital ships Comfort and Mercy were dispatched to New York and Los Angeles, respectively, to add 1,000 additional beds each and expand those cities’ capacity to deliver care. The Navy also established its own expeditionary medical facility at the Morial Convention Center in New Orleans.

The military medical community shared generously from its stock of medical supplies and personal protective equipment (PPE) – an effort that has been aided nationwide with the assistance of as many as 45,000 National Guard service members, who transported and distributed supplies and food, set up and supported community-based testing sites, created additional medical capacity, and dispatched infection control teams to help nursing home staff prevent the spread of COVID-19. Specialists with National Guard Civil Support Teams were instrumental in augmenting the capacity of civilian laboratories in processing patient samples for testing.

THE LOGISTICS OF PANDEMIC RESPONSE

The importance of the National Guard to the domestic COVID-19 response helps illustrate an important aspect of the DOD’s pandemic campaign: logistics. The tasks of moving people and equipment around, and keeping personnel supplied with the material they need to fight the disease, have been monumental undertakings, and military expertise has been critical. NORTHCOM and the U.S. Transportation Command (TRANSCOM) have delivered millions of test swabs and N95 respirator masks, along with thousands of personnel, to where they’re needed, and their efforts have been supplemented by National Guard units – in April, for example, when airmen from the California Air National Guard transported 500 ventilators and medical supplies to New York and other states in need. Air Force aircrews moved hundreds of personnel and nearly 8 tons of cargo to the Army field hospitals set up in New York and Washington state, evacuated COVID- 19-positive patients from remote areas, and helped hundreds of American citizens return home from abroad.

By June, the Defense Logistics Agency (DLA) had procured a massive stockpile of material for the nation’s COVID-19 fight: more than 13 million nonmedical and surgical masks; 5.9 million N95 masks; more than 118 million exam gloves; 2.7 million isolation and surgical gowns; 8,000 ventilators; and more than 821,000 test components. According to Lein, the job of staying on top of where all this equipment goes, and when, is handled within the Office of the Secretary of Defense, by the COVID-19 Task Force established in February.

The Army, Navy, and Marine Corps also stepped up by producing critical equipment, partnering to produce 3D-printed face shields and test swabs to assist in the response.

MILITARY RESEARCH AND TECH AID THE FIGHT

From the beginning of the pandemic, when the DOD used its sophisticated disease modeling platform to inform its own planning and personnel decisions, military science and research have contributed to the national response. In May, when the White House announced Operation Warp Speed, the administration’s program to accelerate the development, manufacture, and distribution of COVID-19 vaccines and other countermeasures, the Pentagon joined the public-private partnership to lend support in diagnostics, therapeutics, vaccines, production, distribution, and security. By September, five DOD medical treatment facilities had been identified for Phase 3 COVID-19 vaccine trials.

In addition to the clinical research conducted at military medical facilities, Lein pointed out, the DOD also conducts basic bench research at its laboratories. For example, in May, the Air Force Genetics Center of Excellence at Keesler Air Force Base in Biloxi, Mississippi, joined with the CDC and the National Institutes of Health to begin sequencing the genome of the SARS-CoV-2 virus to track its evolution and identify targets for treatment and vaccines.

In addition to the vaccine trials being conducted at DOD medical facilities, said Lein, military laboratories are contributing to clinical research in various ways. “The research and development that goes on at the Army, Navy, and Air Force labs includes everything from vaccine development to working on various treatment algorithms and medications,” he said. “The Walter Reed Army Institute of Research has worked with the Food and Drug Administration [FDA] and other partners to get some of these testing devices up and available for testing across the United States.”

Several military-developed technologies have contributed to the COVID-19 response: The Army has used stand-off thermal imaging devices, for example, to create safe distance between operators and subjects being screened for fever. In May, the FDA authorized the emergency use of a device developed by the U.S. Army Medical Research and Development Command: the COVID-19 Airway Management Isolation Chamber (CAMIC), which had been used in the Military Health System as an extra layer of protection for health care workers. “The CAMIC has been used to prevent aerosolization of the virus during airway procedures and during treatment and intubation of patients,” said Lein. “And that came directly out of our research.”

Some promising technologies are still in the experimental phase. The Defense Threat Reduction Agency (DTRA), for example, is adapting a technology it has been developing in partnership with the company Royal Philips – a wearable device programmed to detect, with the use of artificial intelligence and machine-learning algorithms, the early signs of bacterial or viral infection – to be COVID-19-specific.

AN INTERNATIONAL EFFORT

As part of an international effort to mitigate the effects of SARS-CoV-2, both in terms of public health and global security, the DOD has been involved in several international efforts. The DTRA’s Cooperative Threat Reduction (CRT) Program supported requests from more than a dozen nations seeking help with COVID-19 – an extension of the international partnership to mitigate weapons of mass destruction related threats to the United States and its allies. Laboratories built or renovated in partner nations through this program are playing a crucial role in COVID-19 testing or research. Through the CRT program, the DOD also contributed other forms of support – including subject matter expertise, diagnostic support, and PPE – to foreign partners.

The DOD has also extended aid to allies and partners through its humanitarian assistance programs. By October, the Pentagon, through its Humanitarian Assistance and Response Operations Team, had contributed more than $105 million overall to 139 countries to aid in testing, diagnostic support, infection control, PPE, contact tracing, and more.

Each of the six combatant commands has played a role in this process. In September, the U.S. Southern Command (SOUTHCOM), for example, transported a large mobile field hospital to Kingston, Jamaica, as a donation on behalf of the American people to support Jamaica’s ongoing COVID-19 response. NORTHCOM shipped a field hospital to Mexico and helped Mexican officials reconfigure it to handle COVID-19 patients, and both the European and African Commands (USEUCOM and AFRICOM) contributed funding and subject matter expertise to Italy and the African Union. The U.S. Indo-Pacific Command (USINDOPACOM) worked with the U.S. Agency for International Development to deliver ventilators to Indonesia and train field epidemiologists in Cambodia.

MOVING FORWARD: LESSONS LEARNED

Everyone who joins the Department of Defense, active duty or civilian, takes an oath to defend the nation “against all enemies, foreign and domestic.” The DOD’s fight against SARS-CoV-2 has deployed 61,000 people – including about 4,400 doctors, nurses, and other medical personnel – around the country to fight the pandemic and lend support: to deliver health care, manufacture PPE, distribute equipment and food, create and staff alternative care sites, support community-based testing, and more. Eventually, the United States and its allies will defeat SARS-CoV-2, and the efforts of service members and DOD civilians will have played a critical role in keeping the already grim death toll lower than it might have been.

But the fight is far from over: By the end of October 2020, as military and civilian medical research communities worked apace to develop vaccines, treatments, and other countermeasures, American public health officials continued to struggle in their efforts to contain the virus. On Oct. 23, the United States reported its highest ever number of new COVID-19 cases – more than 83,000. Health officials warned of a long, dark winter.

As the DOD and its partners redouble their efforts, Lein and the DHA remained focused on the priorities initially outlined by Secretary Esper. The Military Health System will continue to refine how it engages with patients, after its early experiences in expanding its telemedicine capabilities. “We’re building a digital patient platform that will be standardized across all the Department of Defense,” he said, “because when this hit, we had lots of pockets of excellence, and now are trying to standardize that excellence across the Department of Defense.” This platform will be used not only for routine appointments, Lein said, but for critical care. “When you have a critical care patient, the ability to reach back to a subject matter expert, especially during COVID, is crucial.”

The mobilization of Guard and Reserve units called forward to help civilian health care organizations, Lein said, will likely be more streamlined in the future – as will nearly every aspect of the DOD response. “We’re still learning as we go,” Lein said. “A lot of these things were unknown: How do we quarantine people with COVID? How do we isolate people? What are quarantine and isolation, and how long do we need to do them? Using all the science, we’re continuing to learn these things.” Every military branch, in conjunction with the DHA and the Uniformed Services University of the Health Sciences, is working through discussions of medical lessons learned – all the challenges and issues identified during the COVID-19 response so far – and developing long-term solutions for them.

“This has been an opportunity for us to integrate what we’ve learned in the Military Health System with our civilian partners, and vice versa,” said Lein. “It has been an incredibly collaborative process between the Department of Defense and all of the other agencies, in support of the soldiers, sailors, airmen, Marines, and their family members. Ensuring the readiness of our troops has been a priority. I really want to thank our nation for its continued support to the military throughout, because they’ve been doing a lot of the heavy lifting behind the scenes for COVID- 19, while continuing to serve on the front lines around the world.”

 

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