On Protection of U.S. Forces From Global Health Threats: The Role of Health Security Advisors.

The coronavirus disease 2019 pandemic has exposed a health security gap within our nation and around the world. Recent national laws and policies have outlined the ends and means to improve health security. A decisive way is to achieve this objective is through health-related security cooperation efforts by increasing Health Services Support capacity. Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2022. This work is written by (a) US Government employee(s) and is in the public domain in the US.

The preservation of a soldier’s health should be [the commander’s] first and greatest care

Excerpt from the first regulations for Troops of U.S. (1792)[1]

The most disastrous fire in Philadelphia’s history started from a ship on the riverfront that quickly spread and burned all the warehouses on the wharf. Benjamin Franklin recognized the importance of raising public awareness of the need to improve the city’s firefighting capabilities. In a 1733 Pennsylvania Gazette article, Franklin noted that firefighting efforts relying on untrained and unequipped Philadelphians were insufficient. He encouraged the formation of a ready firefighting force “whose Business is to attend all Fires with it whenever they happen.”[2]

Like firefighting, enhanced protection of U.S. Forces’ health in the face of unpredictable health security threats can be accomplished by placing Department of Defense (DoD) health professionals with specific skill sets in forward locations around the world, prepared to recognize and respond to emerging threats. The DoD can proactively utilize its Global Health Engagement (GHE) professionals as “Health Security Advisors” (HSAs), embedded in U.S. embassies’ Security Cooperation Offices, to enhance the DoD’s roles in health security while supporting Combatant Command objectives.

Frontline HSAs who understand DoD’s unique operational requirements can help aggregate biothreat data across health domains and recommend early response plans to mitigate risk from biological threats. They can deliver real-time and actionable advice to Combatant Commanders to inform decision-making about how to best protect the forces and, most importantly, how to “stay in the fight.” These HSAs would be an especially valuable distal node of a hub-and-spoke model in resource-constrained settings, where full DoD overseas biodefense capabilities are unavailable. As GHE professionals, HSAs would guide security cooperation efforts to build partner nation health capabilities and increase regional health security. Admiral (Ret.) James Stavridis, the longest serving Combatant Commander and Supreme Allied Commander at North Atlantic Treaty Organization (2009-2013), said “at both U.S. Southern Command and U.S. European Command, I would have been thrilled to have Health Security Advisors at both the Combatant Command level and individually in key embassies.”[3]

The current pandemic underscores this necessity. In late December 2019, an invisible virus first identified overseas created a volatile, uncertain, complex, and ambiguous operational area for the DoD. The Military Health System’s (MHS) role to foster, protect, sustain, and restore health to support the mission was put to the test globally. A specific challenge was a coronavirus disease 2019 (COVID-19) outbreak on the USS Theodore Roosevelt (TR) in March 2020. The DoD’s joint medical capabilities, grouped under the joint functions of sustainment (health services support [HSS]) and protection (force health protection), were fully employed to support the TR.[4] Despite TR’s best effort to contain the outbreak, over 1,000 of TR’s 4,800 crew tested positive for COVID-19, 6 were hospitalized, and 1 sailor died.[5] The DoD has the most capable MHS in the world that can provide the full spectrum of HSS from point of injury to rehabilitation through its own network of military treatment facilities. However, when faced with a novel biological threat that can quickly overwhelm the finite resources of the MHS, steps should be taken to preserve capacity and increase readiness to fulfill additional medical requirements. Relationships and agreements with host and partner nation medical systems, achieved via GHE efforts facilitated by HSAs, can increase options for HSS, such as alternative quarantine sites for U.S. Forces. Interoperability of military medical capabilities, developed through GHE activities, increases coalition HSS readiness for contingency operations.

United States fatalities from the pandemic now exceed 900,000,[6] which surpasses the deaths from USA’s bloodiest war.[7] The COVID-19 impacted military operations, halting USS TR’s freedom of navigation without firing a single bullet or detonating any bomb. Acknowledging the potential impacts of future biothreats on our national security, the following recent national laws and policies outline how to improve health security: (1) The National Defense Authorization Act for Fiscal Year 2021[8]; (2) the interim U.S. National Security Strategy Guidance 2021[9]; (3) Global Health Security Act of 2021[10]; (4) the Secretary of Defense’s Biodefense Vision Memorandum,[11] and (5) National Defense Authorization Act for Fiscal Year 2022.[12] Although focused primarily on the ends and means of how U.S. government agencies and the DoD can be better prepared against future biothreats, they also highlighted the importance of collaborating with international agencies and our allies and partners to deliver a synchronized approach to prevent and counter global health threats.

Such collaboration efforts can be achieved by HSAs assigned at strategic U.S. embassies to help increase global health security, facilitate access and influence, strengthen alliances, and enhance Joint Force readiness, all while supporting Combatant Command Campaign Plans. The HSAs could synchronize DoD activities aimed at enhancing partner nation health security preparedness (e.g., cooperative threat reduction and security cooperation) and ensure coordination with related interagency efforts such as the Global Health Security Agenda.[13] Streamlined efforts can help develop a global network of health service nodes that incorporates ally and partner’s sustainment capabilities to support U.S. Forces overseas with minimal, if any, prepositioned U.S. MHS support. These agile and interoperable medical capabilities can rapidly mobilize to increase the overall global capacity to deliver comprehensive HSS to deployed U.S. Forces conducting highly distributed and special operations around the world.

We cannot go back in time, but we can learn from history. In 1734, Benjamin Franklin sent an anonymous letter to his own newspaper titled “On Protection of Towns from Fire,” where he coined the famous phrase “an ounce of prevention is worth a pound of cure”[14] to remind his beloved city that the 1730 fire of Philadelphia would likely have been contained if people were provided firefighting instruments. Readiness for future biothreats to our nation and protection of our forces can also start at the source—with a global network of interoperable medical capabilities with our allies and partners. Forward deployed DoD HSAs can be a key instrument to help quickly extinguish the flame of a future health security threat.