The first year of the pandemic was unprecedented for U.S. health care, and the Defense Department's medical system was called on not only to care for its own but to support the nationwide response, while also continuing to care for troops in overseas military operations.

U.S. Army North, the command responsible for supporting the Federal Emergency Management Agency's nationwide response to COVID-19, deployed more than 4,700 military medical personnel to 83 hospitals in 62 cities through October 2021, and more than 5,100 personnel supported 48 vaccination sites in 42 cities.

At the same time, medical personnel were deployed to support the withdrawal from Afghanistan and provide medical care for refugees through Operation Allies Refuge and Operation Allies Welcome.

By the end of 2020, there had been 157,798 cases of COVID-19 among military personnel and family members, with 1,633 hospitalizations and 26 deaths.

As of April 1, 2022, 455,650 military personnel and family members had contracted COVID-19, 3,149 had been hospitalized and 130 had died since the start of the pandemic.

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Military medical leaders have said the department was well positioned to respond to a pandemic, although perhaps not one on the global scale of COVID-19.

During a March 22 hearing before the Senate Appropriations Defense subcommittee, defense officials praised their personnel's response to the pandemic, which Defense Health Agency Lt. Gen. Ronald Place called "one of our top priorities vital to the medical readiness of our forces and the health and well-being of all Americans."

"Our health care professionals have demonstrated their dedication and readiness in response to the global pandemic for the last two years," said Lt. Gen. Scott Dingle, Army surgeon general. "We must monitor the impacts of the prolonged pandemic response on our health care workforce, our soldiers, and our families."

The military medical workforce's response to the pandemic, which included setting up field hospitals in major cities throughout the U.S., deploying to two hospital ships, and establishing and manning testing and vaccination sites left hospitals without enough personnel.

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Some facilities started the pandemic short staffed, according to the IG. As a result of "DoD-directed military medical personnel cuts" that were planned before the pandemic, positions slated for reduction were vacant after members transferred to other duty stations, leaving units without needed providers.

The military health system is in the middle of a massive reform effort that has shifted management of the military services' 51 hospitals and 424 health clinics to the Defense Health Agency while focusing the Army, Navy and Air Force's medical commands on providing health care primarily for military personnel.

The plan calls for trimming roughly 12,800 military health billets and moving many non-military beneficiaries to private-sector health care, but as the IG found, while the cuts were paused during the pandemic, some billets essentially have been trimmed, having gone unfilled.

In addition, competing demands of deployments; difficulty recruiting new staff during the pandemic and on a pay scale that couldn't compete with the private sector during a national emergency; and COVID-19 infections among health care workers, colleagues or family members caused remaining personnel to work long hours, sometimes as many as 16 or 17 hours a day, 7 days a week.

"We are stretched thin and exhausted," one service member told the IG team. "If we complain, we are seen as lazy and don't want to do our job. ... When the ones who you depend on most during this pandemic cannot function and do their job due to work stress and being burnt out, (leadership) knew that this has been a problem and still let it continue."

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The IG, which looked primarily at the military health system's pandemic response in 2020, found that some problems, like burnout, continued into 2021.

"Officials from 28 MTFs [military treatment facilities] continued to report that staff burnout due to personnel shortages and operational tempo is a challenge," the IG team wrote.

The inspector general made five recommendations to the assistant secretary of defense for health affairs to ensure that the Defense Health Agency and military medical commands solve ongoing issues and are ready for the next pandemic.

They include: developing a policy on maximum consecutive work hours and shifts per week, as well as a plan for coverage in the absence of team members; creating an advisory group to develop recommendations from DoD COVID-19 after-action reports: establishing a working group to address staffing challenges; crafting new manpower requirements for COVID-19 within military treatment facilities; and reviewing personnel requirements needed for future pandemic response and biological incidents.

In response, Dr. David Smith, who currently handles the duties of assistant secretary of defense for health affairs while the confirmation process is underway for a permanent nominee, agreed to develop policies to address staff fatigue and support a working group to track implementation of lessons learned from the pandemic.

He disagreed, however, with establishing manpower requirements within the MTFs for the ongoing mission and future pandemic or biological incident, saying that military treatment facilities are staffed for emergencies to meet national standards and the Defense Health Agency "does not establish manpower requirements to address a specific virus."