Further research questions

country’s government health system that is trained to be redeployed from their home location in crisis situations. The breadth and depth of this contribution has been determined by the size of each nation’s military medical system, their role in supporting armed forces personnel and other beneficiaries, and their existing capabilities and capacities.

All nations have used their military medical services to support expansion of civilian hospital services in response to local outbreaks. Countries with military hospitals have provided access to these for civilian patients (except for the USA). The exact method has varied from deploying field hospitals (France, Italy, Russia, or hospital ships, USA), building semi-permanent new hospitals (China, Russia), converting large public buildings into temporary hospitals (Belgium, Spain, UK, Italy, Sweden, Russia) and providing military medical personnel as augmentees (all nations studied). It is notable that Russia specifically trained its medical units for this role in March 2020 and may have used its deployment of medical personnel to Italy as a means of gaining knowledge about the clinical treatment of COVID-19 patients. Both China and Russia had pre-existing plans to build semipermanent hospitals to care for infectious disease patients and were able to rapidly construct these facilities. Russia has demonstrated its ability to move, deploy and operate field hospitals over ‘operational’ distances as part of their response to local outbreaks. Russia and the US Army Reserve pre-designated and trained teams of military personnel for augmentation to civilian hospitals. Spain and Brazil focussed their military medical augmentation on caring for low-acuity COVID-19 patients including ‘step-down’ for the elderly prior to discharge to care homes. No nation declared the use of a ‘biological warfare medical facility’ as part of their military medical contribution (in spite of some nations having this as a military medical capability). These choices could be analysed and formalised as military capability codes.

Many nations provided military personnel and equipment (ambulances, helicopters, and aircraft) to augment civilian pre-hospital care and patient transfer services. This included the movement of COVID-19 patients in an array of different ‘infection control’ modules. It is likely that this experience will have been additional to that gained from patient movement during the Ebola crisis and might provide lessons for the movement of casualties from biological warfare.

All nations have used their military medical logistics organisations to support civilian capacity including allocation of military stockpiles (PPE, drugs, and medical equipment) to civilian use. COVID19 testing has been incorporated into military laboratory services for both military patients and as part of national laboratory programmes. Military medical research institutions have conducted COVID-19-related medical research on military populations, been innovators in COVID-19 healthcare for wider populations, and been part of national vaccine research programmes within existing biosecurity research institutions (China, USA, and Russia).

The COVID-19 crisis has demonstrated the importance of the military health sector as part of national crisis response. It is notable that Russia and China have been very public in their COVID-19 military to military global health engagement programmes. It is important to consider this aspect of global health diplomacy as countries review their approach to international development assistance in global health.

Further research questions:

 How can the volume of physical patient-provider community services in garrison health services be restored in order to recover ‘personnel readiness’ in military forces?