Under siege

On 4 March 1918, the first known cases of Spanish flu broke out in Fort Riley, Kansas. Within three weeks in the cramped barracks conditions, 1,100 soldiers had come down with the virus – and from there it spread across the world. Just over a century later, defence forces are facing similar issues in combating the spread of Covid-19 in close quarters. The US aircraft carrier USS Theodore Roosevelt was a particularly striking case in point. During its mission in the west Pacific in March 2020, its crew numbered between 4,500–4,800 personnel. After a stopover in Da Nang, Vietnam, the first case of Covid-19 was declared on board on 22 March. By 25 March, nine crew members who had tested positive had been evacuated and naval operations were suspended. Six days later, after an on-board quarantine had been implemented, there were more than a hundred confirmed cases on the ship.

By 13 April, the US Navy had mourned the first – and fortunately only – death linked to this vessel. And when 5 May came around and every member of the crew had been tested at least once, there were a total of 1,156 confirmed coronavirus cases among the crew, at which point the Navy stopped releasing new figures for further confirmed cases.

The extent to which Covid-19 took hold of the vessel was a shock to naval forces around the world, and one was to be repeated on the French aircraft carrier Charles De Gaulle just days later. There, 64% of the 1,800-strong crew ended up testing positive for Covid- 19. Again, naval operations were quickly suspended.

While the First World War saw some early attempts at biological warfare, it wasn’t until the Cold War that toxic agents were weaponised on a large scale. Since then, all military environments have been protected against ‘CBRN’ threats – chemical, biological, radiological and nuclear. Protocols were built around the idea that danger comes from the outside. Everything is closed and you create a high-pressure environment, and then you and your staff are safe from toxins trying to work their way in.

“The very hard lesson that militaries learned during the first wave of the pandemic is that biological risk doesn’t always work that way,” says Dr Benjamin Queyriaux, medical director at the Health Intelligence Protection Surveillance Agency (HIPS), which works with public and private organisations to identify, prevent and mitigate health and biological risks. “Once the agent – the virus – is inside, it’s too late, and it’s people that are bringing it inside. All the protections built against the CBRN threats were totally useless and even counterproductive.”

From April 2020, Queyriaux was contracted as a pandemic advisor to Nato, where he played a key role in advising high command and helping them plan for the second wave of Covid-19. “It was very interesting because they had never coped with an issue like this,” he recalls. While the response to the first wave was simply to remain resilient and hope to resume business as usual by summer 2020, their mindset completely changed in autumn.

“They understood that they were running a marathon, not a sprint, and realised the biological risk of a virus was something completely different,” says Queyriaux. “At that point they began saying that they were ready to tackle this problem, and take it into account in their planning and operational processes.”

Design changes and the end of the handshake

It may sound like an insignificant change, but Queyriaux hopes that the pandemic will lead to the end of the handshake in the military. “That would be an absolute revolution, and we really hope that they will keep it in the future,” he says. “We’ve been trying to promote [ending the handshake] for years without any success, but suppressing handshakes between military personnel [during the pandemic] has really improved the situation. It seems simple but it’s a critical point.”

Dr Nelson Michael is the director of the Walter Reed Army Institute of Research’s Center for Infectious Diseases Research. He says that once a decision like this is made at high command, it is likely to stick. “When you come into any military worldwide, you gain benefits but you lose some of your rights as a citizen to autonomy – that’s the deal,” he explains. “When my commander says you will physically distance and wear a face mask, there aren’t any personal decisions that come in. It gets done. We follow the rules. We are unique in our ability to execute those rules.”

In addition to the obvious measures that have been brought in during the pandemic – reduced handshaking, physical distancing and face masks – Queyriaux advises further training of crews and commanders in biological risk, not only in the Cold War sense of the term, but also taking transmissible diseases into account. These risks, he says, must be integrated into business continuity plans, which should include protocols on how to reorganise the crew in the event of an epidemic to avoid cross contamination.

In the longer term, design changes will also be necessary. In fact, one of the toughest lessons learned from the USS Theodore Roosevelt and Charles de Gaulle outbreaks, according to Queyriaux, is that it’s practically impossible to stop the spread of a virus and isolate contagious patients in buildings that have not been designed with a situation like this in mind, an issue his predecessors grappled with in 1918.

“We know perfectly well that we can control pneumonia absolutely if we could avoid crowding the men, but it is not practicable in military life to avoid this crowding,” Army Surgeon General Gorgas had said during the First World War, recommending that army housing provide 60ft2 per soldier to prevent such an issue, but was all too often ignored.

Fast forward to the present and there is still a lot of work to do, according to Queyriaux. “Medium term, we’ll be looking at modification of the architecture, and the ventilation and air conditioning systems will be essential,” he says. “Longer term, we will also need modifications to the architecture of buildings and ships that give space to allow having different shifts that don’t cross contaminate each other.”

Improved testing

Michael was recently involved in reviewing two research studies on the transmission of Covid-19 throughout confined spaces. The first, an analysis of the crew on the USS Theodore Roosevelt, found that 77% of the infected crew members showed no signs of disease at the time of the initial diagnosis and 55% did not have symptoms at any time. “It was one of the first and definitive pieces of information that said [while] young people are going to get infected, they’re not going to be particularly ill and they’re likely to continue to transmit the virus throughout the whole crew,” he says. The second examined the effect of a phased quarantine of 1,848 recruits reporting to a land-based facility, a Marine Corps recruit depot in South Carolina, involving a two-week quarantine period at home followed by a two-week supervised quarantine on a college campus. It revealed that screening procedures to detect infection before and after quarantine needed to be strengthened, especially if the quarantine location is not highly secured. “18-year-olds are really good at sneaking out,” Michael notes with a smile.

The occurrence of late infections during the supervised quarantine period also suggested that quarantine periods should probably be longer than two weeks. “If you do the standard test where you swab people’s noses, in some bases you find virus in people 30 days after they’ve been infected. Tests have led us to conclude that some people have a lot of dead virus around and some have a lot of live virus,” Michael explains. His institute is now working with partners to commercialise more sensitive and specific diagnostics, which can better assess who is going to be contagious and when. “If we can now make those available to commanders as well as university deans and so on, we’re going to be in a much better position to decide who stays in quarantine and for how long,” he says.

On top of improved testing, Michael advises that procedures in the navy must include strict pre-deployment quarantine of crew members, isolation of infected individuals after a ship has left port, highly restricted shore leave, increased hygiene measures in common areas and continual risk assessment.

Balancing operational readiness with the health of the crew

It’s one thing to lay out the steps that need to be taken, but any decision to suspend operations in a military setting is a complex one; commanding officers need to balance operational readiness with the physical and mental health of their staff in a confined environment. As Michael explains, “On the USS Theodore ‘Teddy’ Roosevelt, you’ve got 5,000 sailors on a steel hull floating around the Pacific and they’re not there for a pleasure cruise. There are consequences to a cruise ship going back into port that are financial and there are consequences to a warship going back into port in terms of degrading national security, so this has to be balanced.”

In addition, when crew members are sick or at risk of falling ill, and they are not interacting with each other because they are afraid of being infected, they are not going to be doing their work to the best of their ability, Queyriaux stresses. “Of course, in this case, you have to redesign your mission,” he says.

What has struck Michael over the past year is that even with these financial and security considerations, the military has put its people first. To illustrate the point, he mentions the email signature of the current chief of staff of the army, General McConville: “People first, winning matters, army strong”.

“The last bit is old but the first bit is his and the amount of concern that senior army commanders have put into Covid to me has been really remarkable,” he says. “It’s a clear signal that the military cares about its people and that its people are the most valuable asset. I believe moving forward that the military will remain focused on data-driven solutions to find the balance between taking operational risks and taking public health risks.”

As for Queyriaux, he says every case is unique. But he is convinced that the commanders of the USS Theodore Roosevelt and the Charles de Gaulle made the best decisions they could at a challenging and complex moment. “Your point of view can change from hour to hour sometimes. The key point is the readiness of your crew and the awareness of the commanders and the top management. If they are aware of the different dimensions of the question, they can take the proper decision. Covid has allowed us to make a lot of progress on that.” Only time will tell whether the lessons that have been learned will effectively prepare the military for the next pandemic. It’s unlikely we will have to wait another century to find out.