In the relentless battle the United States is waging against the “silent enemy” coronavirus, self-declared wartime president, Donald Trump, has been reluctant to deploy all the weapons needed to win the fight. This includes the healthcare resources, research expertise and facilities, and logistical capabilities of the US military and other uniformed services. In this article, the first of two on this topic, I look at the capabilities of these services with respect to tackling the coronavirus pandemic and how they have been used to date.
The extensive capabilities of the United States’ uniformed services
The United States has eight uniformed services.[^1] Of these, the military services of the Department of Defense (DoD) and the United States Public Health Service Commissioned Corps (USPHSCC) of the Department of Health and Human Services (DHHS) are trained and equipped to deal with medical crises and have the ability to scale up rapidly in order to do so. There are myriad examples, national and international, over more than a century, where this has been the case and the services have provided medical and trauma care, built temporary healthcare facilities and shelters, and transported food, medical equipment and people.
In addition, the 450,000 reservists in the US National Guard (Army and Air Force) can be brought in to assist in emergencies. These units are usually under the control of individual states, with the state governor acting as commander in chief. However, the president can activate the National Guard and place it under federal control; this means the costs will be borne by the federal government and units can operate outside their home states.
For national emergencies like the coronavirus pandemic, the military outlines its role as providing “support to prepare, prevent, protect, respond, and recover from domestic incidents”. Such support is “provided in response to requests from civil authorities and upon approval from appropriate authorities”. Thus, the military won’t start deploying around the country without DHHS or other government agencies requesting this.
The military is barred by a legal provision known as “posse comitatus” from using its capabilities to enforce domestic laws (for example, interdicting vehicles, conducting searches and seizures, making arrests, surveillance, investigations) and so its actions are limited to helping states with issues like emergency medical treatment and evacuations. However, this rule doesn’t apply to the National Guard which could perform law enforcement functions if requested by a state governor or the president.
In addition to its crisis management capabilities, the Defense Department has the Defense Health Agency (DHA) which provides comprehensive healthcare to 9.5 million services members and their families in the United States and overseas. The DHA operates some 375 treatment facilities in the United States, employs its own staff, trains clinicians, conducts global disease surveillance, and invests in research and development.
The Veterans’ Health Administration (VHA) operates one of the largest healthcare systems in the world, with 170 medical centres with 13,000 acute care beds and 1,800 ICU beds and 1,074 outpatient sites. Working alongside the DHA and the DHHS, the VHA is legally designated as the backup healthcare system in national emergencies. Legislation enacted in 1982 expanded its role into what has become known as the Department of Veterans’ Affairs “fourth mission”: to absorb non-veteran civilian or military patients in the event that hospitals are overwhelmed in an emergency, such as the coronavirus pandemic. The VHA also is a key participant in the National Disaster Medical System, a cooperative, asset-sharing program that augments local medical care when an emergency exceeds the scope of community resources National Disaster Medical System.
How have these services been involved to date?
From publicly available information, here is a list of contributions from the uniformed services thus far to combat the pandemic. This is almost certainly incomplete.
- At the request of the DHHS, beginning in early February, military bases helped with quarantining Americans returning from Wuhan, China and infected passengers from the Diamond Princess cruise ship.
- Military officials are stationed at the 11 feeder airports that passengers from abroad must go through for medical screenings before entering the United States and the military is providing needed quarantine facilities.
- A team of USPHSCC officers with clinical, scientific, international and public health backgrounds, was sent to Japan on February 15 to assist in the management of hospitalised American citizens with COVID-19. Their mission was to identify seriously ill patients for enrolment in a compassionate use trial for remdesivir, an investigational antiviral treatment previously used to treat Ebola.
- The USPHSCC has also announced plans to deploy 10 to 12 clinical “strike teams”. One such team was sent on March 6 to the Washington state nursing home that was the first epicentre of the nation's coronavirus outbreak to help care for residents.
- More than 28,400 National Guard troops have been deployed around the nation. On March 22 President Trump used the authority under Title 32 to activate the National Guards in five of the most affected states (New York, California, Washington, Louisiana, New Jersey) and the District of Columbia, which means the federal government will pick up the costs, and dozens of other requests for Title 32 status are expected to be approved soon. These troops are constructing emergency makeshift hospitals in conjunction with the Army Corps of Engineers, swabbing people at test sites, helping operate elderly care homes, providing medical care at prisons, delivering medical supplies and food, and retrieving the bodies of people who died at home.
- On March 18, the President announced that the Navy hospital ships Comfort and Mercy, with 2,200 medical personnel aboard would be dispatched to administer care to patients in New York City and Los Angeles, respectively. It took some time for this to happen; the Mercy docked in Los Angeles on March 27, the Comfort did not arrive in New York until March 30. Initially it was planned that these ships would manage non-COVID-19 patients, but that has not proved viable. On April 6, after an appeal from Governor Cuomo, President Trump gave permission for the Comfort to take COVID-19 patients. However these ships are not well designed for patients with infectious diseases; for example, although the Comfort has 80 ICU beds, they are in open bays.
- On April 4 the US Northern Command announced it was deploying 1,000 Air Force and Navy medical providers to New York City. About 300 personnel will work at the makeshift hospital at the Javits Center and others will be deployed to various hospitals that lack medical staff.
- On March 17 the Department of Defense offered up to 2,000 ventilators and five million masks from its own supplies and the ability of Defense laboratories to conduct coronavirus tests for civilians. It is not known if and where these resources have been distributed.
- The Army leads the military’s medical research, primarily at Fort Detrick in Maryland, where researchers who have previously worked on Ebola, MERS and SARS are working on developing faster diagnostic tests, finding new treatments and developing vaccine candidates. However, some of the containment laboratories were shut down by the Centers for Disease Control and Prevention (CDC) in August 2019 and were only allowed to reopen on March 27.
Using the uniformed services in these ways is necessary in times of crisis such as these. The responses above, however, have largely offered too little and been delivered too late. There is more that the uniformed services can do to assist the fight against the coronavirus but utilising them to their full capacity is contingent on effective leadership. Tomorrow, I will analyse what additional measures are needed, and why President Trump has seemingly been reluctant to deploy them.
This is part one of a two-part feature on the United States uniformed services’ response to COVID-19. Tomorrow: What are the limitations facing the uniformed services? And what more can be done?