Lessons learned in an emergency

Lessons learned in an emergency
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The coronavirus pandemic puts the country on a wartime footing. The alarm has been sounded for launching a campaign against a different kind of enemy. The usual playbook is not enough.

For the World War II generation, mobilization was total, reaching pretty much into everyone’s daily life. But the major conflicts since then — Korea, Vietnam, and the wars in the Gulf — rested on a national security state that was both less pervasive, more bureaucratized, and gradually more professionalized. Since the 1950s, relatively little has been demanded of civilian routines during armed conflicts. 

At exactly the same time, thanks to modern medical science and improved hygiene, the threat of epidemic diseases seemed a thing of the past. At too many levels, smugness set in as memory was lost.

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The social and political consequences of neglecting the threat of a pandemic for national security are now evident. The country needs to reorient itself to the advantages that the U.S. military can provide in this crisis. If we look at our recent history, we will find lessons that can help with tactics and strategy. 

That goes particularly for mobilizing the National Guard and Reserve (NGR) that give surge capacity for health care to the country. More than the resources and assets that are being mobilized, we need to act smartly on using them. To do that, we need to figure out creative solutions beyond those that have already been implemented. 

Most of the public attention is focused now rightly on mitigation strategies — social distancing, isolation, protection, etc. Depending on the success of the mitigation and suppression plans, the curve for the infection rate could flatten out substantially. 

Nonetheless, best planning includes contingencies for worst-case scenarios for the numbers of sick patients requiring hospitalization. And, unlike civilian medicine, the military posture is designed for the worst case.

By mobilizing the National Guard and Reserve, the country gets access to vast amounts of equipment and supplies including ventilators and masks. The NGR also has a number of field hospitals and the capability to reconfigure buildings to treat patients. Most importantly, it has a substantial pool of doctors, nurses, technicians, and other support personnel. 

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That's the tricky part because these professionals will be drawn from communities that may also need them. But this is not a new problem. The military has faced such challenges historically, in mobilizing for the Gulf War in 1990 and preparing for other contingencies. The rule of thumb for the leadership is developing the support plan to get “the right person, to the right location, to the right job.” It also entails leveraging technology and tools to solve problems creatively and improve operations.

Mobilizing the NGR is a complex process of personnel management and a host of other factors. The process is particularly complicated in allocating medical personnel and assets. Taking doctors and nurses out of their usual place of clinical practice has ripple effects. The movement and assignments need to be individualized, especially with doctors and many nurses in short supply in some areas. 

Good personnel management succeeds with hands-on administering, blocking and tackling, involving face-to-face conversations. It can be done, as long as the leadership has good data. The leadership needs to know the staffing needs of the hospitals and clinics that will be treating the patients, the locations of the facilities, and the capabilities that can be mobilized to augment and backfill them. 

The skeptics and critics opine that lessons learned from 1990 do not apply — the coronavirus pandemic differs from mobilizing for war — but the principles of making a plan and executing it have not changed. The planners and leaders need to get the best information, convene the decision-makers, and set up the means to coordinate their efforts. 

Another lesson from the Gulf War in 1990 was that leaders needed to push the envelope on leveraging technology. It's ironic to see now in 2020 that the White House is promoting telemedicine and relaxing rules and regulations

Such modifications were obvious to us fighting wars decades ago. We learned in action that necessity is indeed the mother of invention. It was clear that technology and off-the-shelf tools had to be leveraged and customized to improve the effectiveness and efficiency of operations in support of mobilization. 

The army could do that because it was not constrained by the rules imposed on the civilian sector. The strategies for leveraging technology apply the elements of requirements-based processes — identify the need or gap to be filled, survey available technology and tools that can be leveraged, and customize them to improve the delivery of health care.

For example, doctors with good basic clinical skills will need to rely on the ready consultation of experts to treat many patients in many locations not accessible to the experts — basic telemedicine, like the support that the army positioned in 1995 to support operations in Kosovo.

One key doctrine of the U.S. military has been that of giving the on-site commander the freedom to adjust to rapidly changing conditions. Similarly, it is often said that all health care is local. The leadership of complex operations, such as treating the victims of coronavirus, should be empowered to handle the local challenges.

Acknowledging the unique circumstances, each state must configure its leadership teams to best fit the communities being served. The various agencies that support those teams must coordinate their efforts to meet the needs of the front lines.

The pandemic is a test of bold leadership, a test for which the muscle memory of the Army National Guard and Reserve medical system must be revived and applied. 

Stephen N. Xenakis, a psychiatrist and retired Army Brigadier General, serves on the executive boards of The Center for Ethics & the Rule of Law at the University of Pennsylvania and is an Adjunct Professor at the Uniformed Services University of Health Sciences. Follow him on Twitter: @SteveXen

Jonathan D. Moreno teaches medical ethics and health policy at the University of Pennsylvania. His most recent book is "Everybody Wants to Go to Heaven but Nobody Wants to Die: Bioethics and the Transformation of Health Care in America."