After a careful identification and screening process as illustrated in the PRISMA flow diagram (Figure 1), forty-five publications were included in the analysis. Articles were published in English, French, or Spanish.
Three thematic clusters were identified in the phenomenological analysis (Table 1)
Reports covered five continents: Asia, Europe, North America, South America, Oceania. First authors of CIMIC field reports, role model reports, and (co-) authors for medical studies included 22 different countries. Further details on thematic and geographic distribution will be presented and discussed below.
4.1 Medico-scientific contributions with the participation of military medical personnel or institutions
For medico-scientific contributions to the literature within CIMIC, the military acted in three distinct roles: 1) as subject matter experts, 2) as clinical or experimental investigators or co-investigators, and 3) as co-funders for research (22–45). Military subject matter expertise included telemedicine, digital health technology, critical care medicine, respiratory care, transfusion medicine, as well as global and public health. Military clinical investigators or co-investigators contributed to COVID-19 relevant topics such as critical care medicine, radiology, neurology, burn medicine, public health, emergency and disaster medicine, and pulmonology. One experimental military investigator worked within the field of environmental and occupational sciences. A synoptic overview of each contribution is provided in Figure 2, detailed information about each publication is listed in Table 2.
The map in Figure 3 shows countries of military (co-) authors in medico-scientific publications with military contributions during the COVID-19 pandemic.
4.2 CIMIC field experiences or civil-military analyses
The following section reviews concrete CIMIC field experiences or analyses of such (3,46–62). Because disaster management during COVID-19 was generally guided by national frameworks and policies, pertinent reports in this section are reviewed grouped by country of first author in order to maintain this perspective (Figure 4), appearing geographically aggregated by continent and in descending order of overall numbers of reports per country. Further details, including time periods of reports covered, are provided in Table 3.
United Kingdom
Gad et al. analyzed civil-military cooperation in six European countries, i.e., UK, France, Spain, Italy, Belgium and Sweden, in the early phase of the COVID-19 crisis (46). For this analysis, they identified seven main analytical themes, i.e. 1) Recognition of health security threat from coronavirus spread in Wuhan, 2) detection and announcement of first cases as reported through military health functions, 3) invocation or announcement of national crisis, plans and/or military involvement, 4) how military support was incorporated into national crisis response, 5) how the military modified its activities, 6) dealing with rumors/allegations related to COVID-19, and 7) other—military and COVID-19, and divided these themes into 19 categories of civil-military cooperation (46). The armed forces and the military medical service were key components of early disaster response and strengthened resilience, while Italy and Spain had the most intense and Sweden the least intense level of CIMIC within this group of countries (46). Gibson-Fall identified three different trends of national military involvement during the COVID-19 crisis worldwide: 1) minimal technical military support, 2) blended civil-military responses, and 3) military-led responses (47). An interesting example for enhancing crisis management capabilities in the public sector is the British stabilization unit, which facilitates cooperation between agencies, civilians and the military and could serve as a training and capacity building model (48). Ten military critical care transfer teams assisted the London Ambulance Service and transported 52 ventilated civilian patients during a COVID-19 patient surge in intensive care units in London, UK, during the last two weeks in April 2020 (49). Each two-member team was composed of 1) a consultant/registrar in emergency medicine and pre-hospital emergency medicine or anesthesia and 2) an emergency nurse or paramedic (49). Main lessons identified centered around overcoming technical issues with the ventilation and measures to avoid transmission SARS-CoV-2 to the staff (49).
Germany
Roßmann et. al focused on systems innovation, analyzing the dynamic challenges of the emerging COVID-19 pandemic through a Cynefin lens; very similar crisis management problems were found in different areas of the public health service in Germany (50). They identified four key areas that necessitated systems innovation to strengthen disaster resilience, i.e. 1) information-management including crisis communication, 2) data- and information-visualization (dashboard), 3) training and education of supporting staff, and 4) a framework and evaluation concept (“scoring-matrix”), and developed novel tools to adapt, change and innovate the public disaster management system [38] .
Schulze et al. described lessons learned during the SARS-CoV-2 emergency vaccination roll-out campaign in Heidelberg in the year 2020. The following five strategic elements were important for success: 1) robust mandate, 2) use of established networks, 3) fast on-boarding and securing of commitment of project partners, 4) informed planning of supply capacity, and 5) securing the availability of critical items (3). Planning tools included 1) analyses through a VUCA lens, 2) analyses of stakeholders and their management, 4) possible failures, and 5) management of main risks including mitigation strategies (3). Lessons learned identified ten tactical leadership priorities and ten major pitfalls. The authors proposed that these methods which comprised VUCA factors combined with analyses of possible failures, and management of stakeholders and risks could be adjusted to any public health care emergency anywhere across the globe in the future (3).
France
Barreau summarized the French civil-military operation which was entitled “resilience” and launched on 25 March 2020. The military adapted their support to the local needs and circumstances, a permanent dialogue between the civilian and military partners was important (51).
The Netherlands
In a global analysis of military deployments in the COVID-19 crisis, Kalkman described circumstances, motivations and societal imitations of these endeavors. As such, the political framing of the pandemic as a “war”, e.g., in the US, in France, and in the UK, leveraged and triggered a military response as a logical consequence out of this narrative (52).Moreover, these deployments were also in the interest of the militaries, because they strengthened their operational readiness and societal standing as they assisted the population (52). Of note, Kalkman emphasized the necessity of civilian control and respect of civil rights for reasons of a cooperative leadership culture and balanced disaster management approach (52).
Czech Republic
Assessment of military preparedness for civil-military cooperation in a disaster situation can be challenging and complex. Therefore, Tušer and colleagues developed a capacity and capability assessment procedure based on questionnaires and a mathematical model which includes Saaty’s method (53). The goal was to determine the degree of preparedness of the Czech army for cooperation with civilian partners in disaster management including the COVID-19 crisis. and to identify specific areas for improvement (53). The four assessment criteria included 1) human resources, 2) technical security of allocated forces, 3) command and control of allocated forces, and 4) planning; these criteria were further subdivided into two or three indicators each (53).
Spain
Consistent with the report by Gad, Lopez-Garcia observed a high degree of visibility of the military and other security institutions in the crisis communication strategy of the Spanish government (46,54). The four key axes of the crisis communication in Spain were 1) continuous communication, 2) seriousness of the crisis, 3) feeling of control, and 4) unity (54). This highly visible presence was a result of the high degree of trust that the military was enjoying in Spain compared with other public, political, private, and religious institutions. Thus, an association with the military during the COVID-19 crisis had a protective function for Spanish politicians against critics from the opposition (54).
Sweden
Bacchus and colleagues emphasized the necessity of thorough inter-agency preparedness for disasters in advance (55). The report civil-military experience with the rapid deployment - initially a high readiness exercise in January 2020 - of a military mobile biological field analysis laboratory and the development of a polymerase chain reaction (PCR) test in order to facilitate the diagnosis of SARS-CoV-2 infections (55). This project was a collaboration of the Swedish Armed Forces, the Public Health Agency, and a civilian hospital (55).
Switzerland
In Switzerland, civilian pharmacists were enlisted as reserve officers in the military and supported the civil-military crisis response in hospital battalions and medical logistics battalions (56). Overall, 5000 mostly medical soldiers including pharmacists were mobilized 6 March to 30 June 2020 within the Swiss militia system (56). In the hospital battalion, they mainly managed supply of medical material to military and civilian entities and coordinated hygiene measures to reduce the risk of staff contamination with SARS-CoV-2 (56). Their main duty in the medical logistics battalion included pharmaceutical production support in civilian and military facilities (56).
USA
There were two remarkable project reports on civil-military cooperation from the US. First, Dutta et al. described the deployment of 500 Navy Reserve medical professionals to New York City (57). Some of these reservists supported eleven local hospitals that were overburdened with the COVID-19 surge which led to the exhaustion of the civilian staff. This civil-military mission was an example for successful rapid deployment of medical forces and cohesive cooperation in a diverse professional setting across all specialties (57). Likewise, the Army medical service supported New York City as well. They rapidly activated and operationalized a COVID-19 inpatient care facility in a civilian congress center in New York City, successfully integrating uniformed services, governmental agencies, and private healthcare organizations (58).
Chile
In the context of the socioeconomic tensions, the military was deployed in the streets during nightly curfews based on two government decrees in Chile, reported Dragnic, a sociologist at the University of Chile (59).
Indonesia (from an Australian perspective)
Fealy, a scholar from The Australian National University published a critical but important analysis of the role of the Indonesian armed forces in the COVID-19 crisis. The Indonesian armed forces and state intelligence service had very prominent roles during the pandemic - which he considered disproportionate – that resulted in weakening democracy in Indonesia (60). Specifically, despite lacking expertise, they were involved in the production of anti-Covid-19 medicine and Covid-19 testing (60). Furthermore, the military was tasked with the enforcement of restrictions mandated by the spread of the virus in the society and were given the authority to impose punishment on citizens (60).
Iran (from a U.S. perspective)
In Iran, Revolutionary Guards and the affiliated militia supported the COVID-19 disaster response by building field hospitals and enforcing quarantine (61).
Iraq (from a U.S. perspective)
Of interest, in Iraq, paramilitary forces and militia took over roles and responsibilities that one would expect being led and fulfilled by the government as well as the public health sector. Specifically, Iraqi paramilitary units and militia contributed to mitigating the impact of the pandemic by providing logistic support, i.e., transporting medical supplies, personal protective equipment, and food (61). They supported hygiene measures by sanitizing public spaces, but also covered typical public health activities such as medical information campaigns (61). Their approach appeared to be comprehensive and covered mental health support to medical personnel and the construction of field hospitals including a 200-bed hospital in Baghdad (61). In addition, these groups helped burying the deceased while respecting diverse religious rituals including both Muslim and Christian faith (61).
Pakistan
Jabbar and Makki analyzed civil-military cooperation during the COVID-19 pandemic from a leadership perspective (62). They focused on four themes, i.e., 1) the significance of CIMIC in disaster management, 2) challenges associated with CIMIC during the COVID-19 pandemic, 3) the role of a common civil-military comment operation center, and 4) government policies and practices related to disaster management (62). Of interest, most funding is spent into measures responding to a disaster rather than in prevention (62). This is not an isolated phenomenon, but a frequent global shortcoming, which is being addressed by the Sendai Framework for Disaster Risk Reduction 2015-2030 (63). Tasks of the Pakistani army included support in SARS-CoV-2-testing, logistics (i.e., distribution of medical equipment including testing kits, ventilators, personal protective equipment and drugs), disaster response coordination, and information management (62). In Pakistan, overcoming a communication gap and fostering collaboration between civilian actors was important during the COVID-19 crises (62). In the absence if international guidelines for CIMIC, a definition of the overall framework and guidelines are helpful (62). Joint training of civilian and military stakeholders improved functioning and mutual understanding, and increases trust, while previous military training of civilian actors proved to be beneficial in this regard (62).
4.3 The military as a role model for crisis management
In a New England Journal of Medicine editorial, Michael emphasized a tradition of influence from of military medicine on to its civilian partners (64). Two recent examples in the COVID-19 pandemic corroborated this relationship and dialogue. Successful management of SARS-CoV-2 outbreaks on a ship and in a Marines boot camp delivered valuable insight into virus transmission, disease understanding, diagnosis, tracking and tracing as well as appropriate quarantine measures in the early phase of the pandemic that could be extrapolated into civilian community settings such as schools, dorms, or other shared living environments (64). Katz and colleagues considered items of military medicine such as preparedness, team-based care, echelons of care, augmenting the effort, effective triage, and servant leadership as important lessons learned for adaptation into cardiac critical care during the COVID-19 pandemic (65). While hierarchical top-down, command-and control structures in healthcare may have worked well in the past in military operations, crisis management, and certain healthcare settings, they do not meet today’s standards due to generational value change and complexity issues in the operational environment (66). There has been a slow shift in healthcare leadership culture towards the emphasis on emotional intelligence in order to 1) foster respect and civility to empower teams, 2) lead with transparency and open communication to promote psychological safety, and 3) lead with compassion when tackling severe problems. This change process may now experience push-backs and regression into the old-school system because of the pressure during the pandemic (66). Role model articles originated from the U.S. and Canada.