key: cord-0056168-ej59bwib
authors: Garza, Alexander Gerard; Dunagan, Wm. Claiborne; Starke, Keith
title: The Covid-19 War: Military Lessons Applied to a Public Health Campaign
date: 2021-02-09
journal: NEJM Catal Innov Care Deliv
DOI: 10.1056/cat.20.0549
sha: 8abcd43e1aa830651c73f1dde3b82b5801b33aeb
doc_id: 56168
cord_uid: ej59bwib

Leaders of major health care systems in St. Louis, Missouri, joined forces to form a pandemic task force grounded in military planning and decision-making protocols and processes to address needs and concerns related to the coronavirus.

It is remarkable how this pandemic resembles other threats to our national security, economic vitality, and public health, only by a different means. Were SARS CoV-2 a terrorist organization that claimed the lives of hundreds of thousands of Americans, we may have seen a different approach. However, this enemy turned out to be a strand of RNA, and the responsibility of combating it fell mostly on public health systems and health care organizations.

In early 2020, the chief medical officers of major health systems in the St. Louis Metropolitan area -first SSM Health, BJC HealthCare, and Mercy Health, and later St. Luke's Hospital -met to discuss how each organization was planning for the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. These health care systems spanned the urban, suburban, and rural areas in the counties of Eastern Missouri and Southern Illinois surrounding the City of St. Louis. The leaders of the health care systems quickly agreed that it made sense to work together as one to develop a regional strategy and speak with one voice in the pandemic. This led to the formation of the St. Louis Metropolitan Pandemic Task Force (PTF), which eventually included public health authorities, the business community, Federally Qualified Health Centers, and the local elected officials.

The MDMP has been used for decades in the military for planning operations and campaigns, both large and small, and brings an organized thought process to a complex issue. Planning for a pandemic is consistent with the aspects of military campaign planning:

• Planning is the art and science of understanding a situation, envisioning a desired future, and laying out effective ways to bring that future about.

• Planning is based on imperfect knowledge and assumptions about the future.

• Planning cannot predict exactly what the effects of the operation will be, how things will behave, or how people will respond.

• The understanding and learning that occur during the planning process have great value.

Several acronyms are used throughout the process (Table 1 ) and appear in accompanying figures.

The MDMP is seven distinct steps -Receipt of Mission; Mission Analysis; Course of Action (COA) Development; COA Analysis; COA Comparison; COA Approval; and Orders Production, Dissemination, and Transition -each with specific inputs, actions, and outputs ( Figure 1 ). 

In using the MDMP, the PTF leveraged the most appropriate steps in developing its plan while ignoring others ( Figure 2 ).

Here, we offer details on how the modified MDMP steps function in the health care context for Covid-19.

In this step, the staff would receive the higher headquarters order or plan, with the output being the commander's guidance. That guidance includes the time required to develop the plan, whether to go straight to the MDMP process or abbreviate the MDMP, any necessary coordinating functions required with others, and initial information requirements. An example would be for the commander to instruct his staff that he needs to be able to issue an operations plan within 2 weeks and would like to go right into the MDMP process and dispatch his staff to make requests for information from other units or federal agencies; the commander may request liaison officers from other units to supplement the planning process. The commander'sintent is dependent on multiple issues and is meant to convey what the commander believes are key aspects to planning, such as, "My intent is to dominate the battle space using combined XX forces, defeat opposing forces, and quickly establish an interim government." The subordinate staff then works on specific battle plans to support the overall plan and commander's intent. The challenge of the current pandemic is that there is no unity of command; instead, there is fractured and discordant strategy -from the U.S. Centers for Disease Control and Prevention and the White House Coronavirus Task Force at the national level, to state and local governmental leaders. At each level there has been different guidance and intent. This makes it incredibly difficult, if not impossible, to address the pandemic in any coordinated and effective fashion.

And, of course, the pandemic is different because, unlike military operations, there was no invasion to plan or objective to take. Because of this, we supplemented the traditional Army Design Methodology (ADM)7 for establishing commander's intent. The ADM is usually used to formulate the commander's intent and helps develop the initial framework that then translates into the deliberate planning process using the MDMP. ADM frames the problem and develops anoperational approach to solving the problem. This includes describing theCurrent State as well as theDesired End State and then defining the operational approach, which features broad general actions to solve the problem. An example of a national campaign end state would be "An economically viable and stable Country X, without the capability to coerce its neighbors."

Just as in complex military campaigns, this pandemic has highlighted different societal and political issues, some of which continue today. The military typically addresses these in the planning process using the PMESII/ASCOPE method; this forces the military to identify and plan forPolitical, Military, Economic, Social, Infrastructure, and Information issues, which are then cross referenced with theArea, Structures, Capabilities, Organizations, People, and Events. As mentioned previously, because the pandemic "battle space" encompassed multiple different political jurisdictions as well as very diverse social, economic, and cultural areas, the PTF had to consider these different areas of operation while developing a course of action. As an example, the politically conservative elected officials in the more suburban and rural areas were more reluctant to shut down businesses or take proactive measures, such as mandatory masking requirements, and were more likely to "open" the communities earlier, and allow for more higher-risk situations, such as indoor dining and bars, whereas the more liberal officials of the inner suburbs and urban areas were more likely to take broader and more aggressive public health actions and refrain from higher-risk actions.

However, although the elected officials owned the battle space, they did not control the combat power, specifically health care assets. None of the public health departments had significant testing capabilities, nor did they control the fundamental war fighter, who, in this battle, was the health care personnel. The elected officials' most effective strategy and tactic is to "shape the battlefield" by instituting policies that will alter the enemy's effect in the battle. This includes things such as shelter-in-place orders, restricting activities, and mandatory masking policies for the general public.

The PTF agreed to certain principles at the outset of our planning, which was the guidance given by the health care CEOs. These included that we (the health care systems) would function as a single entity as much as possible. No one health care system would be allowed to fail because of issues such as an influx of Covid-19 patients beyond capacity, or a loss of personal protective equipment (PPE). In addition, we would coordinate policies and procedures as much as possible. This follows another axiom of military planning of unity of effort for the whole andautonomy of action for the parts.

The PTF also agreed to designate author AGG (who has significant military and combat experience) to serve in the commander role. In practice, however, the agreed-upon End State effectively served as the commander, given that there was no single commander as there is in the military model.

According to the process articulated above, we developed what we believed was a reasonable and inclusive end state of the pandemic. This was articulated broadly as reestablishing the vitality and vibrancy of the Greater St. Louis Region through:

1. Overall health and well-being; substantial decrease in new transmissions and deaths 2. Elimination of shelter-in-place orders

With the commander's guidance understood and the end state established, the PTF set out to do the deliberative planning using the MDMP.

This step serves as a method to clearly identify the problem and the tools available to solve the problem. This is the most important step in the MDMP because it helps leaders to understand the environment and define the plan. There are multiple sub-steps under mission analysis; only those relevant to our planning are mentioned here.

In this step, the commander is attempting to understand the enemy, such as: How many divisions of infantry does the enemy possess? What air assets do they have? What is their organizational structure? What do I have to bring to the fight? Where, when, and how can I dominate the battle space? This is coordinated through the planning cell and intelligence assets.

Although the elected officials owned the battle space, they did not control the combat power, specifically health care assets. None of the public health departments had significant testing capabilities, nor did they control the fundamental war fighter, who, in this battle, was the health care personnel."

Fundamental to a good battle plan is understanding the area of operations. The St. Louis Metropolitan Statistical Area (MSA) spans two states, Illinois and Missouri, and 15 different counties including the City of St. Louis, which is a separate political body. The MSA has a " population of 2.8 million and a geography of 7,863 square miles. The population is 52% female and 18% Black, with a median age of 40 years. The median household income is $66,000 with 10% of the population below the poverty line, although this is highly variable depending on the county. The health care systems in the PTF provide the vast majority of health care services throughout the MSA including in the rural areas outside of the urban jurisdictions. Several of the PTF systems also provide health care services across the state of Missouri. Therefore, the PTF hospitals had operational control over the primary war fighter and significant assets such as testing, hospitals, intensive care units, ventilators, and pharmaceuticals.

In addition to intelligence about the population, the systems began analyzing modeling data to help predict how the virus would impact the area of operations, including cases, admissions, hospital and ICU census, and ventilator demand, very similar to understanding the enemy's course of action and predicted movements, as well as anticipated casualties in the military. Prior to forming the PTF, each health care system had generated its own estimates for hospitalizations and deaths, each with different models and assumptions. The health systems recognized the need of a single source of truth for our data and analytics requirements. This resulted in the formation of the PTF analytics cell where all the data scientists, epidemiologists, and modelers from across the health care systems and the major universities within the area collaborated to produce a single model for the entire metropolitan area that everyone would use. For the PTF, this was titled Space, Staff, and Stuff. The PTF leadership assigned clinical and operational leaders into a planning cell to identify critical assets. These teams calculated the range and maximum bed and ICU capacity and the range of ventilatory equipment that might be required, as well as our staffing capabilities and PPE. The team also inventoried community assets that could be called upon in case of extreme measures.

The Pandemic Task Force agreed to certain principles at the outset of our planning, which was the guidance given by the health care CEOs. These included that we (the health care systems) would function as a single entity as much as possible." " This effort resulted in two different planning bounding assumptions. One included hospital beds and ventilators during non-Covid-19 normal operations and a second in extremecrisis pandemic operations. We estimated that we had approximately 5,000 medical/surgical beds and 1,000 ICU beds within the PTF on any given day. We further recognized that approximately 4,300 of these beds would be occupied on average and that just under 2,300 beds would be available for Covid-19 admissions. In extremis, we believed we could double our medical/surgical and ICU capacity using various methods. These numbers would be flexed incrementally depending upon which phase of the pandemic we were in and by hospital census status.

A fact is a "statement of truth or considered true at the time." An assumption is "a supposition of the current situation or a presupposition of the future course of events." These must be logical, realistic, and considered likely to be true.

For the combatant commander this may be something like, "We know country XX has GB and VX chemical weapons. We also know they have used these nerve agents before on their own population during uprisings." Therefore, an assumption would be, "We believe, if country XX was backed into a corner, they will use chemical weapons against our forces."

The PTF agreed to certain critical facts for our planning purposes. These included the limits to our space, staff, and stuff. Based on the modeling at that point in time, the PTF also made certain assumptions including the probability that there would be more patients than capacity, that we would not receive support from outside of the metropolitan area, that we would need to manage the messaging, and that our assets would degrade over time, including PPE and the workforce.

The CCIR refers to all the information elements the commander and staff require to successfully conduct operations. For the combatant commander, this could be something such as, "I need to continuously know the movements of country XX's elite force" or "I need to know the battlefield casualty rate." This element is key to understanding where the pandemic is in space and time in order to make decisions. Early on, the PTF health systems developed agreements to share data on a daily basis -including laboratory data, admissions, ICU, ventilator status, and hospital census data -and more complex data on a weekly basis. Data use agreements were executed, and data elements were added over the course of the pandemic to gain greater situational awareness.

This could be more appropriately titled building relationships for the PTF. In the military, as described in the MDMP handbook, gaining and maintaining the trust of key actors are important aspects to ensure stable and successful operations. "Faced with many different actors (individuals, organizations, and the public) connected with the operation, commanders [must] identify and engage those actors who matter to operational success. These actors' behaviors can help solve or complicate the friendly forces' challenges as commanders strive to accomplish missions. . . . Commanders and their units coordinate what they do, say, and portray through themes and messages. A theme is a unifying or dominant idea or image that expresses the purpose for the military action."2 For the combatant commander this could be how to interact with the host nation government, a local militia force, or other "centers of gravity," such as a sheikh or other informal leader and what to say to reinforce why they are taking action. This was similarly true in the pandemic, where there were multiple different "actors" who could impact the mission.

The health systems recognized the need of a single source of truth for our data and analytics requirements. This resulted in the formation of the PTF analytics cell where all the data scientists, epidemiologists, and modelers from across the health care systems and the major universities within the area collaborated to produce a single model for the entire metropolitan area that everyone would use."

We recognized early on that pandemic-related efforts would need to adopt a notion known in the military as a whole of government approach, which translated into awhole of community effort for the PTF. In addition to the health care systems, the PTF expanded to include the Federally Qualified Health Centers, the business communities, the local health departments, and the elected officials. Developing appropriate themes and messaging for these influencers -as well as the general public and other stakeholders, including the media -is an important element in successfully managing the pandemic. Of course, it was very challenging to have an overarching theme or message due to the fragmentation of government and public health approaches. However, the health care systems were very consistent in messaging and had a singular voice in the pandemic when working with our various partners and the public or media.

A Course of Action Development (COA) is a broad potential solution to an identified problem that must be feasible, acceptable, and suitable ( Figure 3 ).2 "

The COA identifies multiple "lines of effort" to achieve conditions necessary to reach end state goals and assigns responsibility to each effort. Lines of Effort (LOE) link multiple tasks and missions to focus efforts toward establishing operational and strategic conditions. It describes and connects the major efforts/actions of the campaign. An LOE helps the commander visualize and articulate the "logic of the campaign" and how they might organize major efforts over the course of the campaign to achieve synchronize unified action. The subtasks were then developed by teams within the respective health care systems to ensure efforts were synchronized. These plans were briefed to the senior leaders of the PTF, where there was broad general agreement that this would be the approach. The Community Assistance component was led by our business organization partners to develop support mechanisms, such as food drives and other support, for those who would be potentially impacted by the pandemic. Public Health strategies were coordinated among the health department leaders and there was general agreement on some mitigation strategies and policies. However, due to the political nature of the different jurisdictions, there were not synchronized mitigation strategies. Emergency Medical Services was coordinated through the health care systems' emergency managers, as well as the local government Emergency Management structure.

We recognized early on that pandemic-related efforts would need to adopt a notion known in the military as a whole of government approach, which translated into awhole of community effort for the PTF."

After going through multiple iterations of the COA, the PTF agreed that the final plan had met the requirements of being feasible, acceptable, and suitable. Traditionally, multiple courses of action are developed for the commander to consider. However, because of the rapidly developing situation, a single COA was developed for all the participants in the PTF.

Just as in military planning, where there are phases to an operation, there are clearly different phases in the pandemic, and each phase has different levels of effort from the health care system, the public health system, and the community. And like in war, each phase requires different efforts and solutions (Figure 4 , Figure 5 ). " FIGURE 4

Phase names are driven by the activity in that phase and an emphasis on decisive tasks driven by what the planners intend to have occur in that phase. The phases in the pandemic were initially thought to contain these distinctive activities:

• Phase 0, Shaping operations. This helps to create a condition for successbefore the pandemic onset and continuing throughout the pandemic. Examples: shelter-in-place orders, mandatory masking policies, PPE conservation policies, and ceasing elective surgeries.

• Phase I, Initial surge. This ensures that the health care systems can handle the initial surge in patients. Examples: to ensure adequate staffing, PPE, negative pressure space, etc.

• Phase II, Critical mass/prevent failure. This period is focused on peak demands and stressors, such as handling maximum Covid-19 patient load, ensuring that the health care system is able to handle the load, with a whole of health care approach. Examples: maximize capacity, alternative care sites, federal assets, institute crisis standards of care.

• Phase III, Maintain operations and prevent failure of the health care system. This period is focused on the post-peak period to continue operations during the pandemic while avoiding setbacks. Examples: sustainment the workforce, planning for phase IV.

• Phase IV, Stability operations. Here, health care systems transition back to more normal operations. Examples: decommission Covid-19 units, relax visitation policies, and restart elective surgeries.

The PTF held weekly meetings to help gain situational awareness of the different operational environments, attempt to synchronize efforts -especially with mitigation strategies -and advise on strategies. However, given the diversity of political and cultural ideology, once past the initial shutdown and reopening, there was little congruence in approach to mitigation of the pandemic. While there were attempts to have the region operate in a singular fashion, this was not possible. At a minimum, the group was able to share thoughts ideas and opinions about approaches to the pandemic and ensure that everyone was operating from a consistent set of data and recommendations from PTF health care systems. In addition to coordinating relevant health care operations, the PTF also became the trusted voice of the pandemic in the metropolitan area by performing daily press briefings via Facebook Live ( Figure 6 ).

The PTF reported hospital admissions and inpatient, ICU, and ventilator census for Covid-19positive and patients under investigation (PUI) and, beginning in December 2020, the number of vaccinations and vaccine planning. In addition, the PTF discussed current issues about the pandemic, such as different types of testing, mitigation strategies, mask wearing, and other topics of interest. As the pandemic progressed, the briefings included updates to forecasting and addressing any public policies and other important issues related to the pandemic, as well as stories from frontline health care workers regarding the impact of Covid-19.

The 2019 SARS CoV-2 is a novel virus that, in mid-January 2021, continues to spread rapidly around the globe with substantial morbidity and mortality. The entire community continues to be at risk, but especially vulnerable populations. This makes it unique from other disasters, which are more geographically discrete. The breadth of this disaster from a societal and economic standpoint was beyond anything experienced with natural disasters, such as tornados or hurricanes. In addition, this disaster would have a considerable duration, a so-called long war and not a short low-intensity conflict. As such, this war was bound to go through various phases, each with its own set of issues and challenges, before reaching an end state (herd immunity). The development and deployment of vaccines beginning in December 2020 adds new complexities and challenges. The fractured nature of the sociopolitical response that has plagued health care efforts throughout the pandemic is also challenging the vaccine deployment strategy. The MDMP would offer a model for building a vaccine "campaign," just as we used this for approaching the pandemic.

The pandemic shares remarkable similarities to military campaigns and war planning. We believe that using elements of the MDMP allowed the PTF to bring clarity in planning to the initial fog of war, and created an organizational environment to bring unity of effort across the metropolitan area and through the different phases of the pandemic that continue today.

As of February 2021, the Pandemic Task Force continues, and expects to maintain its operations until that end state is achieved.

The PTF has had multiple successes including assisting businesses with plans to decrease spread of the virus, reviewing and assisting local health departments with school and sports plans, as well as influencing local elected officials with the scientific and data resources to determine measures required to slow the enemy's advance. This is especially concerning given that Missouri is one of the few states with a governor that has refused to enact a statewide mask wearing policy.8

As with military planning, once a single operation reaches end state, you move to the next planning scenario, so essentially you start over from the beginning of the MDMP. Understanding that the Covid-19 pandemic has now become an even more insidious enemy, it will require an updated campaign plan, in which the PTF is currently engaged.

Chief Community Health Officer, SSM Health, St Louis, Missouri, USA

General Services Administration, National Archives and Records Service, Federal Register Division. Record Creation Date

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Department of the Army

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United States Army War College, Department of Military Strategy, Planning, and Operations

Explaining the Army Design Methodology. Infantry Online. U.S. Army Maneuver Center of Excellence (MCoE)

State-by-State Guide to Face Mask Requirements. Healthy Living