"News from the Field" Pandemic Response: DoD, You’ve Been on the Front Lines for a While
By Lieutenant Colonel John Ringquist, U.S. Army
In late 2019 I was part of an after-action review that assessed the ability of an African state, and the U.S. embassy in that country, to respond to a pandemic. The review revealed that the embassy response plan was based on a lot of potentially flawed assumptions regarding the capabilities of the host nation, the international community, and the combatant command. The partner nation claimed to have capabilities and a quarantine plan that could encompass any pandemic threat. However, 90 days later that same country failed in this task, was closing borders and airports, and the U.S. embassy was issuing shelter-in-place directives for embassy personnel. What could have been done better or differently that would have ensured a more effective response? In hindsight it is easy to lay blame and point out what should have been done, but it is more productive to learn from the failings and pass that on to others. Pandemic response is not a new challenge for Foreign Area Officers, but it is a given that additional pandemics will challenge how we respond in the future. It is not enough to say that we will do better next time. We have been warned for at least two decades that we needed a better plan and a better way to help our partner nations prepare for and respond to potential pandemics.
The COVID-19 outbreak in 2019 forced the world to do what wasn’t done for prior 21st century disease outbreaks such as the Severe Acute Respiratory Syndrome (SARS) in 2004, the H1N1 pandemic in 2009, Middle East Respiratory Syndrome in 2012, the Ebola epidemic in 2014, etc. The Department of Defense was involved in responses to all these outbreaks, helping to provide early warning, providing transportation and logistical assistance, or serving as a tripwire to ensure global hot spots were being monitored through Walter Reed or other military programs. COVID-19 is a global pandemic that has the potential to rearrange how we conduct our security cooperation programs and what the DoD can be expected to do in response to the security challenges posed by pandemics.
Foreign Area Officers can play a key role in the DoD response to potential pandemics, and DoD has a long history of identifying, responding, and aiding partners to combat disease. The DoD has been a valuable partner in the ongoing war against disease in past eras, whether through attaché reports from locales where malaria, typhus, or yellow fever killed many, or in the aftermath of conflict where warring factions made medical interventions nearly impossible for containment efforts. FAOs now operate in a security paradigm that for many African partners places pandemic response efforts far behind the imperative to conduct counterterrorism campaigns against foes that don’t have to react to COVID-19. The tragic example of Chad’s military suffering hundreds of casualties from Boko Haram attacks in March 2020, during government efforts to implement a national quarantine, illustrates how governments must allocate security forces in accordance with well-designed national response plans. So how do FAOs work with partner nations to confront pandemic threats, despite our training offering little to prepare us for these unique security threats?
The first line of defense against a pandemic will always be effective programs to monitor potential outbreaks and the ways that the DoD can help contain them. Programs like the DoD HIV/AIDS Prevention Program (DHAPP) are a good starting point for building military medical capacity to monitor diseases, as are the episodic pandemic response plan exercises and training events that fall under the security cooperation portfolio. But there must be a first step for all these programs, and no response plan can be effective without knowing both our capabilities and those of our partner. The 2014 Ebola outbreak in Nigeria is an example of how lack of capacity and capability could have led to a massive death toll. Lagos in 2014 was a city of an estimated 15-20 million inhabitants, with one fire company, a woefully inadequate medical structure, and a government plagued by poorly coordinated agencies. Fortunately, the partner’s CDC and national medical leadership had just completed a tabletop exercise with U.S. DoD planners that emphasized pandemic response. The nascent plan became the blueprint.
The FAOs who coordinate medical programs and exercises must be willing to engage with their counterparts in the partner nation to get a realistic gauge of their ability to respond to a pandemic. As countries seal borders and impose quarantines, we should take notes and make contacts to keep information flowing. Security Cooperation officers and Defense Attaché Offices must do more than report information to Combatant Commands for spreadsheets. They must ask the hard questions that will help frame future discussions and response plans. How can that be done? Here are a few suggestions for FAOs in the areas of agreements, programs, and partnership efforts.
Know What is in Your Status of Forces Agreement and Other Agreements.
The SOFA isn’t going to spell out what you will need to ensure that the DoD can respond to requests for aid. Start by looking at what you have been able to do in the past and what will be needed soon. The DoD will need access to airfields and logistical support at those locations. If you send a diplomatic note clarifying what is required for a DoD aircraft to land and transit the country during a pandemic, that will be a start. If you have pre-positioned medical materiel that has been in place for response to Ebola or another pandemic, know its status. It is likely it will be requested for government response efforts if it lacks bed capacity and lab capabilities. It is highly likely that if your partner nation needs it, they will approach you with a zero-notice request for assistance. Since you will most likely not have the personnel in-country for that sort of response, you will need to know what the COCOM can do and what it has planned. Then ask yourself, How would I respond to this request? What are the interagency requirements? Is there a disaster declaration required, and have other agencies anticipated this?
The next item to check is your file of agreements: interagency; COCOM; subordinate commands; allies; host nation. These agreements might pertain to access to fuel and airfield services, or they could be old and barely fleshed out, remnants of a prior emergency. Make sure that you are aware of such things as how to get TDY personnel out of country. If they are in remote areas you may have to request partner- nation assistance for transportation to some place where the TDY personnel can then be organized for departure. Make sure that you turn off TDY visits early in the pandemic response cycle. If you have questions about whether to host a visit, shut it off. You do not want to have a team in country when borders close and the airport shuts down. If you need to evacuate a team house, have a plan because there will be a lot to move and you will need major assistance.
Know What Your Embassy Partners Can Do.
It’s not going to be a DoD-pure response. Know your embassy partners and coordinate with them. Form working groups and meet regularly. If you are not in an ongoing pandemic response, a quarterly meeting should be adequate. However, if the WHO is issuing a pandemic warning, look at a weekly meeting apart from the inevitable Emergency Action Committee meeting. Nobody likes extra meetings, but you need to be situationally aware. Report the results to your higher headquarters and be sure to contribute to embassy cables. If you need to get more information from your partner-nation military health counterparts, then do so with the knowledge that what you learn will be incorporated into a response plan. If there is a national disaster or a pandemic response plan, read it and know where you need to be involved with planning. Ask questions about numbers of beds, laboratory capacity, where to read test results, and how to monitor things like curfews or quarantines.
It is never too early to learn about interagency health programs. USAID, and the Departments of Agriculture or Homeland Security may have programs in place that can provide early warning or valuable information that you will need to know. Be sure to also manage expectations about DoD capabilities, and operational methods. One of the worst things that the DoD can do is to forget their internal capabilities in a time of pandemic response. If the borders have closed and the DoD team is operating with minimal personnel, find out who can operate special equipment, or who may have a background in the medical field. Everyone in the embassy has a primary and a secondary function. This is the time to learn new skills. Be honest with yourself and improve your weak areas.
Do Not Assume that There Will Be Time to Respond.
We are all busy, and the workload at the COCOM or the embassy can be overwhelming at times. The potential for a compressed decision loop for all groups involved in the response will be high, as will be the potential for misunderstandings. For example, in one country where I have worked, the assumption that the French would provide disaster-response assistance was not met by the reality of the French response plan. If you think you will need to work with international partners – you will – then contact them early and make sure that you understand each other and your plans. Embassies are very poorly equipped to respond to a pandemic with the embassy clinic’s limited capabilities. Think about how you will assist with authorized and ordered departures. How do you request a chartered plane to do MEDEVACs in such an environment? What happens if the head of state succumbs to the pandemic or is rushed out of the country for medical treatment?
FAOs in those countries that have cooperative security locations (CSL) have an additional imperative to ensure that the locations can receive aid and store materiel. Ask yourself when was the last survey of the CSL electricity, air conditioning, bed-down, and physical security? If the CSL can serve as a reception point for regional contingency or pandemic response, survey the location’s ability to support 24-hour operations, and the partner-nation’s willingness and ability to support those sorts of operations. Do not assume anything.
Be Aware of Your Limits and Those of the DoD
As FAOs we are taught not to promise what cannot be delivered. Do not get into this trap. If you cannot provide something, make it clear why you cannot, but if the request is reasonable, be sure to seek guidance. Case in point: if the partner nation lacks medical gear for quarantine response, find out what is most needed and why. Communicate that to your desk officers and prioritize the need with quantifiable numbers and rationales. As of the time of writing this article, U.S. hospitals are asking for help with ventilators, masks, and surgical gowns. Some medical teams are making their medical gear from parts or asking for private donations in order to keep providing care. Know what can be reasonably expected of the U.S. and be prepared to answer the partner nation request with information.
Look to your own health and that of your fellow DoD members and families. If you are under an ordered departure, make plans accordingly. Know what you need to take with you and get those go-bags ready. Do not make the mistake of assuming that you will have time to adjust to the changing situation. In at least one case the chartered flight to take U.S. embassy personnel and families out of country departed in less than 48 hours. FAOs must anticipate this course of action, and be prepared to continue operations with minimal personnel, while ensuring that their families are well-prepared for evacuation to their follow-on locations.
Learn from the Experience and Document It.
A pandemic response situation is challenging and will force you to be flexible and creative in your solutions. Capture the lessons learned from the experience and ensure that you share them. Do not assume that weekly reports and COCOM emails will suffice for this. Make a book for the DoD team and update it daily as the response unfolds. Much like a battle book or a diary, the lessons-learned book will help FAOs account for unanticipated expenses, closed residences, meeting decisions, plans, and all the minutiae that will get shredded when the crisis passes. The DoD lives by SOPs, and the notes that you take will be part of new or changed SOPs.
Conclusion
It is a lot of work to add pandemic planning and event tracking to already heavy portfolios that include security cooperation and security assistance programs. However, it will help to ensure an effective response to a pandemic, or at least help expedite assistance to our partner nations. Further, keeping records and evaluating your response will help you to be a better FAO. Many of the response measures required for a pandemic will also be necessary in the case of a natural disaster or even a mass casualty event. Reach out to your foreign counterparts daily, and make sure that they know you are engaged. Work with your interagency partners and ensure that they keep you informed of their counterpart actions. Be sure to stay in contact with your desk officers, charge your communications devices, and validate those satellite phones before you need them.
About the Author:
Lieutenant Colonel Ringquist is the J53 Lake Chad Basin Branch Chief at AFRICOM. His assignments as a Foreign Area Officer include Security Cooperation Officer, Army Attaché, Senior Defense Official/Defense Attaché, and Senior Intelligence Analyst. He served as a member of numerous embassy working groups, and has helped to plan and implement responses to Ebola, Lassa Fever, and COVID-19. He is also a research consultant with the Army Research Labs and has written on topics as diverse as climate change, historical African disease outbreaks, and transhumant conflict in African settings. He is currently engaged in research into the intersection of security, cultural shifts, and climate change in African settings.
The author conducting a port survey in Guinea-Bissau
Appendix 1
Pandemic Capacity Survey Checklist
Treatment Capacity
Number of treatment facilities with isolation wards and their capacity
What level isolation ward – CDC biohazard level 1-4.
Does the isolation ward separate host nation and foreign cases?
Number of in-country labs capable of sample testing
Does the partner nation send lab samples to other countries, if so where?
What level of pandemic threat can the lab address? Use the CDC biohazard level 1-4.
Military and Civilian hospital bed numbers and expansion capability
Number of ventilators, hospital beds (not including gurneys), alternate medical sites
Medical evacuation capability
If the decision is made to isolate cases, where do they go?
If cases are kept in-home, how are they monitored?
Ambulance numbers and readiness status
How many medical transport vehicles are mission capable?
Number of air, ground, and water evacuation vehicles.
Number of military and civilian medical providers with disease treatment experience
Have the partner nation’s medical staff been part of a pandemic response in the past?
Does the partner nation have a training plan for medical staff and a plan to augment them?
Medical Supplies
Number and type of personal protective equipment (PPE) in military and civilian hospitals/clinics
Masks, gloves, suits
Disinfection and decontamination materiel, quantities, and storage sites
Methods for medical waste disposal, chemical disinfection methods, locations of materials, distribution plan
Storage sites for PPE and distribution strategy
Who owns and authorizes release of the supplies, where are the supplies, when were they last assessed (expiration dates of materials), who distributes them, who gets the supplies?
Strategic Preparedness
Last time pandemic response plan evaluated via exercise
Tabletop or field exercise
What agency or person is responsible for national response coordination?
Do you have a copy of the partner nation pandemic response plan?
When was it last updated? What are its key assumptions?
Do you have a copy of the partner nation disaster response plan?
When was it last updated? What are its key assumptions?
Does the partner nation have any mechanisms in the plan to help prevent human rights abuses during implementation and maintenance of quarantines and curfews?
Does the partner nation have a pandemic media plan– how will information get disseminated?
Does the partner nation plan to use social media to distribute information?
Does the partner nation have a history of press censorship or suppressing information classified as “fake news” or “rumors” during states of emergency?
Does the partner nation have pandemic aid agreements in place with neighboring countries?
Can the partner nation burden share border security and medical needs with neighboring states?
Can the partner nation rely on neighboring states to provide medical and materiel aid?
Does the military perform any exercises with their civilian medical counterparts?
Can the military and civilian medical infrastructure work together?
How will the security forces ensure the safety of medical providers and their facilities?