Kaiya Capuchino (left), United States Army Medical Research Institute of Infectious Diseases (USAMRIID) combat medic, helps a student don personal protective equipment during hazardous material training in 2014, at Tripler Army Medical Center in Hawaii.

Is the Military Prepared to Handle Covid-19 Within Its Ranks?

The Covid-19 pandemic is plaguing the American military. The virus has spread in aircraft carriers and infected Marines in basic training in South Carolina, as well as airmen in basic training in San Antonio. As cases have continued to rise in military communities across the nation, the Department of Defense has asked bases to stop publicly reporting their individual numbers, citing security threats.

There have been several reports of a “readiness crisis” and doubts that the military can protect its own, including a Los Angeles Times article suggesting that the Pentagon is struggling to contain infections in the active duty ranks while also helping civilians in hard-hit states and cities. As of May 5, nearly 5,000 military personnel had tested positive for Covid-19. While the Department of Defense plans to test all of its members by this summer, in a press briefing last month, Thomas McCaffery, the Assistant Secretary of Defense for Health Affairs, acknowledged that it is fair to assume that there are many more service members who have the virus but have not been tested thus far.

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As a result, the military has been unable to maintain some of its core activities. The Army stopped taking new recruits at basic training for two weeks before resuming training “at reduced capacity.” Meanwhile, the Marine Corps closed the Parris Island Boot Camp to new recruits on March 30, before reopening three weeks later. The Department of Defense also delayed all military moves, halted deployments to Afghanistan, and delayed the return of troops currently deployed there. Some returning troops are faced with quarantines in under-resourced facilities.

On April 27, 10 Senate Democrats wrote to Secretary of Defense Mark Esper, arguing that the Department of Defense’s “slow and disjointed response put service members at risk and undermined readiness”.

The reduction in operations “is becoming a big issue,” said Mark Cancian, a senior adviser for the International Security Program at the Center for Strategic and International Studies (CSIS) in Washington D.C..

The military wasn’t always in such a vulnerable position. It has a long history of success in confronting infectious disease, dating back to the Revolutionary War, when George Washington inoculated his army against smallpox because his troops were more susceptible to the disease than the British. In fact, from the military’s earliest days its doctors have led research into infectious disease to keep its personnel healthy and prepared to defend the country.

The military has a long history of success in confronting infectious disease, dating back to the Revolutionary War, when George Washington inoculated his army against smallpox.

But today, with better vaccinations and other health measures in place, the assumption has become that infectious diseases have been brought under control. As a result, preventive measures in military medicine related to pandemic response have not been “forefront in most folks’ minds,” said Thomas Crabtree, a retired Army colonel and surgeon who is the group medical director for AMI, a company specializing in delivering health care solutions in remote and challenging environments. Instead, in 2017 Congress outlined a plan to eliminate about 18,000 medical positions and refocus military medicine on the so-called “trauma mission” — that is, treating burns and combat injuries from conflicts in places like Afghanistan and Iraq.

Yet as Covid-19 sweeps through the various branches, some military experts are rethinking that strategy, with the medical corps struggling to keep its active duty troops healthy while providing assistance to civilians.

“Today’s crisis should be a wake-up call to rethink any effort to downsize military health care,” wrote retired Air Force Lt. Gen. Orville Wright and retired Air Force colonel Keith Zuegel in a recent opinion piece in the Military Times. “Our nation has been caught ill-prepared for this pandemic. We lack both ready stockpiles of critical equipment and trained personnel to help respond.”

“Imprudent cuts to military health care,” the authors noted later, “pose risks that reach far beyond the military and include the nation’s greater health system.”

Infectious disease has always been a risk within the close quarters of the military rank and file. Smallpox was especially grievous during the Revolutionary War, and for every soldier who died of combat wounds during the Civil War, two more died of typhoid and other infectious diseases. “Armies are notorious petri dishes for disease outbreaks,” said Carol Byerly, a historian of military medicine and author of the “Fever of War,” a book about the influenza pandemic that spread across the globe and swept through American military camps during World War I.

The 1918 influenza pandemic was particularly traumatic for medical officers because “they couldn’t save the lives of thousands of the healthiest people in the country — young soldiers, Byerly said. “They just failed, and they couldn’t deal with it.”

American combat deaths in World War I totaled 53,402, but about 45,000 American soldiers died of the flu and related pneumonia by the end of 1918. The commanding officer of one training camp, Byerly said, killed himself after 500 young men died of influenza in one day. In all, more than 675,000 Americans (civilians and military) died of the flu in 1918.

Infectious disease has always been a risk within the close quarters of the military rank and file.

In an effort to prevent future catastrophic infections, medical officers set up high-level infectious disease committees during World War II to monitor outbreaks. Military scientists led the way in infectious disease research and developed the first flu vaccine in 1943.

At the same time, another disease emerged as a major health risk: “Malaria almost stopped the war in the Pacific,” Byerly said. General Douglas MacArthur, realizing that he would not be able to fight a war under such a threat, briefly stopped all operations until military scientists could get an antimalaria program going.

Virtually all antimalarial drugs currently used in civilian medicine came from research during World War II at the Walter Reed Army Institute of Research. Walter Reed, after whom the national military medical center is named, was a military physician who identified the vector for yellow fever, which was a devastating problem for American troops during the Spanish American war in 1898.

“The U.S. military has this proud tradition of focus on infectious diseases,” said Dean Winslow, a retired Air Force colonel and surgeon and current professor of medicine at Stanford University.

In recent years, the Military Infectious Diseases Research Program has been in charge of developing vaccines and drugs for infectious illnesses likely to impact military operations. Most of this work is carried out at the Walter Reed Army Institute of Research, the Navy Medical Research Center, and the Army Medical Research Institute of Infectious Disease. Yet even as research continues today, critics have noted that preparation for responding to pandemics has not been prioritized by the current administration.

The military has dealt with epidemics in recent decades, although none became pandemics. In 2003, during the SARS outbreak, the commander of U.S. forces based in Korea quickly recognized the threat and formed a crisis action team that implemented health surveillance, screening, contact tracing, and quarantine for suspected cases. As a result, not a single case emerged among U.S. military personnel in Korea. More recently, the U.S. military deployed to West Africa in 2014 in response to the Ebola epidemic to help establish treatment units, increase laboratory testing capacity, and train health care workers.

Nonetheless, experts say, the military is not designed to respond to a national pandemic, a fact that is not always well understood by planners responding to natural disasters. It is a common assumption that “if you have problems and you don’t have capacity, you can call in the military and they’ve got the capacity to do anything anywhere in unlimited numbers,” said Tom Cullison, a retired Navy orthopedic surgeon and rear admiral who served as deputy surgeon general of the Navy. In fact, “the military is designed for combat operations overseas. They have many plans and concept plans to do this and the the size of the various parts of the military, including the health part of it, is based on that. And there’s a finite capacity there.”

A mock patient getting prepped and placed into an isolation pod during an Ebola response exercise in 2014. Visual: SFC Rodney P. Horner / Army Medicine / flickr

The Army and Air Force reserves have been essential to the country’s response to Covid-19, but leveraging them often means taking medical workers out of one community to send them to another; the total capacity remains limited.

So even as Esper tried to reassure the public that the military medical system is up to the dual tasks, he also tempered expectations about its capacity. At a town hall meeting on March 24, Esper said that he anticipated that the military medical facilities could face shortages with personal protective equipment “like everybody else.” In addition, the field hospitals are “geared toward treating trauma patients” and not “supporting persons with infectious diseases,” Esper told NPR on March 25.

That capacity was already in the process of being reduced in 2017, when Congress mandated sweeping reforms intended to do two things: bring all military medical facilities (Army, Air Force, and Navy) under one centralized administrative structure — the Defense Health Agency — and improve medical “readiness” specifically to treat combat trauma, while starting to outsource non-trauma care to civilian facilities.

The restructuring is anticipated to eliminate an estimated 18,000 military medical jobs. Even the Uniformed Services University, which graduated doctors and nurses early this year to send them to assist in hospital ships and field hospitals is threatened by the cuts. Congress has put a pause on those cuts for now, but the plan remains.

Some argue this restructuring could make the nation less prepared to respond to a pandemic in the future. “The Military Health System is arguably among the most effective medicine systems in the world and is our nation’s strategic medical reserve. This recent pandemic highlights the imperative to maintain such capacity rather than risk reducing it in size and scope,” wrote Wright and Zuegel in their recent op-ed.

Cullison adds that such cuts could also negatively impact the recruitment, training, and retention of top military physicians, many of whom remain in military medicine for the opportunity to teach.

It is preferable to train military surgeons “in house,” he argues, because they’re able to “learn in the environment in which they will practice from faculty who understand both the medical specialty and military culture.”

The Accreditation Council for Graduate Medical Education requires a variety of medical specialties — not just surgery — to be included in the military medical training programs.

If those programs begin getting shut down, Cullison said, “I am really afraid that military medicine will set itself back and it will be extremely difficult to recover.”

“One of my biggest fears,” he added, “is that we shut down the training programs and our major medical centers, and we lose our capability based on that.”

Instead, Cullison and other experts are urging the nation’s civilian and military leaders to “embrace health security as a DOD mission priority.” In a report last year, the CSIS Commission on Strengthening America’s Health Security recommended restoring health security leadership at the White House National Security Council after a directorate was disbanded a year earlier by former National Security Adviser John Bolton. That decision led to the departures of highly respected leaders in the field: Rear Admiral Tim Ziemer, the NSC’s senior director for global health security and biodefense, and Homeland Security adviser Tom Bossert.

Cullison argues that planning for a pandemic threat should be considered on par with a threat of nuclear attack or terrorist attack. “It’s never gotten the visibility across the country that many of us think that it should,” he said.

“One of my biggest fears,” one expert says, “is that we shut down the training programs and our major medical centers, and we lose our capability based on that.”

Cullison and others also cite the urgent need for conducting preparedness exercises. In 2009, the Department of Defense developed a concept of operations plan for an influenza pandemic. And Politico revealed a more recent National Security Council playbook for responding to pandemics, yet found that it had not been followed and that it was unclear if senior officials were aware of it. “The plans have been there,” said Cullison. “The question is, have they been exercised on a regular basis? And do the people who would actually be using those plans understand how they work to a level that they can immediately respond to use them?”

The military does prepare troops to respond to major threats like anthrax attacks, nerve gas, and other biologic warfare, says Crabtree, who described training exercises that he conducted in preparation for deployment to deal with mass casualties, plane crashes, bombs, and biologic and chemical threats. But infectious disease was not in that playbook.

“So people are very aware of the science associated with this stuff, but no one practiced ‘Oh, here’s how we deal with a pandemic,’” Crabtree said.

“If you asked a hundred people that understood the term readiness, in the military or out of the military, five years ago, ‘What does readiness mean?’” Crabtree said, he predicts “not a single one would have said, ‘Be prepared to assist and defend the country against a pandemic threat.’ Nobody was going to say that. Now I’ll bet that will be a different answer in the future.”

Viviane Callier is a science writer whose work has appeared in Science, Nature, Scientific American, Quanta, Wired.com, Smithsonian.com, and The Atlantic.com, among other publications. She lives in San Antonio, where her husband is an active duty Air Force physician.