Over the past several weeks, medical personnel from multiple units across the combined joint operations area (CJOA) have come together to provide a better coordinated effort to protect the health and welfare of the 6,500 service members, Department of Defense employees and contractors in East Africa during the COVID-19 pandemic.“Overall, I believe that Camp Lemonnier and the outstations have robust prevention and response strategies in place, regarding COVID-19 preparedness,” said U.S. Air Force Col. (Dr.) James Eric Bermudez, Combined Joint Task Force-Horn of Africa (CJTF-HOA) Joint Force Surgeon and director of the Surgeon Cell. “For several weeks, the Camp and the outstations have been developing and implementing comprehensive health prevention measures, with a main focus on hygiene, sanitation and social distancing, in line with Centers for Disease Control and DOD guidance.”While commanders of the various operating locations have final determination over what measures are implemented for their installations, there are some fairly standard prevention measures that have been implemented throughout the CJOA. These include an increased focus on hand washing for 20 seconds; maintaining a minimum six-foot social distance or wear of a mask if that’s not possible; reduced hours or total closure of morale, welfare and recreation facilities; and a reduction in manning or alternate work schedules in non-mission essential areas.Another example is the disinfectant team established at Camp Lemonnier, Djibouti (CLDJ). At the request of camp staff, several of the 25 tenant command organizations operating at CLDJ provided a number of service members to be trained by CJTF-HOA Surgeon Cell public health personnel on how to properly sanitize high-traffic areas and objects around camp.“The team was taught how germs, such as viruses, can live on non-porous surfaces, such as metal, glass, plastic, and laminated surfaces, for up to several days,” said U.S. Air Force Maj. Leah Chapman, CJTF-HOA Surgeon Cell public health officer. “They were also taught the importance of cleaning and wiping down all such surfaces and objects, how to mix a bleach cleaning solution and how to apply it in the varying common use locations and the use of proper personal protective equipment for the job.”The areas the team is responsible for disinfecting include water filling stations, benches and doors at common use facilities frequently touched by multiple individuals, she said. The team is also responsible for disinfecting the medical isolation living spaces that have been set aside, should those spaces be needed.Even with the team disinfecting high-traffic areas, Bermudez said it’s important for everyone to do their part and wash their hands on a regular basis, as well as to regularly disinfect commonly touched items in their living spaces and work areas.“Contaminated common-use objects are a potential viral vector threat area,” he said. “If you are maintaining proper social distancing, but are neglecting hand hygiene and hand-contact awareness, then you’re still very vulnerable to infection transmission, since germs may be potentially lingering on many commonly touched surfaces such as door knobs, faucet handles, and light switches.”Because of the size of the CJOA, which includes 12 countries spanning 2.4 million square miles, or approximately two-thirds the size of the U.S., and the political diversity throughout the region, the CJTF-HOA Surgeon Cell has a mission essential role.The Surgeon Cell provides medical advice to commanders in the region, and coordinates health service support and force health protection for U.S. military medical operations across the CJOA. Its mission is to sustain the health of U.S. armed forces, support ongoing operations and strengthen partner-nation alliances.“In a number of ways, we each have a unique set of capabilities,” Bermudez said. “The surgeon cell specifically has more of a broad, dynamic view of the whole area of responsibility. There is a list of logistic, political and policy challenges that we are able to consider as part of a broader scope. We are able to use that knowledge to coordinate with our civilian partners to ensure a timely flow of communication, which better fosters trust between the U.S. and the countries in the Horn of Africa.”The surgeon cell also plays a key role in coordinating medical evacuation (MEDEVAC) of U.S. forces at the various contingency locations throughout the CJOA, being one of the primary organizations that would organize a MEDEVAC either to CLDJ or directly to an acute care hospital should the need arise.Thanks in part to CJTF-HOA’s ability to coordinate and set policy in conjunction with CLDJ and the other commands within the CJOA, the Expeditionary Medical Facility (EMF), located at CLDJ, has also seen a drop in the number of people who have unrelated viruses, according to U.S. Navy Capt. Paul Allen, EMF officer in charge.“For us, it's interesting because we see diarrhea spikes and common cold spikes here all the time, and all of our numbers for all those other diseases are way down,” he said. “It’s because now people are distancing, they're washing their hands and doing all the stuff that their mom taught them to do.”In addition to the ever-present challenge of keeping personnel in the CJOA healthy, the COVID-19 pandemic has presented several obstacles to essential missions that had to be resolved, particularly for the EMF at CLDJ.The EMF is the only Level 2 medical treatment facility in the U.S. Africa Command (AFRICOM) area of responsibility, which means it maintains a limited number of functions found at a typical hospital in order to treat trauma cases and to stabilize patients for medical evacuation to a full hospital at another location, such as Germany.“I have a very good staff that was put here to handle trauma patients from here in Djibouti, from downrange, and patients from the fleet as the fleet goes around us,” Allen said. “We normally have a limited holding capacity for patients, and my staff is just large enough to deal with our trauma mission, because that’s what we are here to do.”If the EMF staff were the only medical personnel at CLDJ, Allen said they would run the risk of being overwhelmed should a COVID-19 bloom occur on camp. Fortunately, there are several other organizations on camp with their own medical staff that can help augment the EMF.For example, the EMF was able to utilize medics from the 433rd Civil Affairs Battalion (CA BN) to distribute additional malaria medication, rather than have 100 or more people come to the EMF one or two at a time.In addition, the EMF staff has been able to rely on an existing relationship with CJTF-HOA’s Task Force Guardian (TFG), which oversees medical stations at Chabelley Airfield, Djibouti, and other contingency locations in East Africa.According to Col. (Dr.) Jonathan Park, TFG battalion surgeon, all of the TFG providers have worked at the EMF so they could be accredited to work in the facility should the EMF staff need to be augmented due to a large number of incoming patients.“The Task Force Guardian aid station staff has an amazing working relationship with the EMF,” Park said. “All of the providers and staff are really good at taking care of people. For any issues like this that come up, we serve as their medical backup if they need assistance.”The other main issue preparing for COVID-19 presented was the EMF building itself, which is approximately 50 years old. Allen said while the facility had all the necessities to treat most patients, it doesn’t have a room in which the air wouldn’t be recycled into the rest of the building, potentially resulting in infecting the rest of the building.To solve that issue, one of the first things the CLDJ incident management team did when it was stood up in March was to provide another building to the EMF specifically for any COVID-19 cases that required hospitalization.“If there's one entity that should get a ton of credit for all this, it is really public works. I've never been any place where a public works department stepped up like they did here,” Allen said. “They went in there and basically made an old office building into a makeshift hospital and altered the ventilation so that certain areas could be cold zones, while others could be warm or hot zones. And they had the whole thing up and running in just 72 hours, and that was all before COVID even hit Africa.”The main issue with having the second facility is if a single patient were to need to be placed in the facility, the EMF would end up losing at least nine personnel, some of whom are from critical positions within the hospital, in order to be able to man the facility 24 hours a day, Allen said. Once the facility no longer had any patients, those staff members would still have to remain on a restriction of movement for 14 days as a precautionary measure.When the EMF admitted a patient with respiratory issues from a suspected COVID-19 infection shortly after the pandemic began, Naval Forces Africa (NAVAF) gave a short-notice tasking to a four-person team from Naval Hospital Rota. Team members, who included an anesthetist, a nurse and two corpsmen, received initial notification they would be coming to CLDJ just two hours prior to their aircraft’s departure.“Having the four come down from Rota was great,” Allen said. “I called the CO (commanding officer) of Navy Hospital Rota to say thanks, and his response was great. He just said ‘I knew you guys need help.’ It wasn't even a thought.”Both NAVAF and AFRICOM have been able to dedicate additional resources to the EMF as well in the form of increased logistical support and additional medical personnel on top of the four-person team.“We say we're the tip of the spear, but we are at the end of the supply chain and the MEDEVAC chain,” Allen said. “Our supply chain for the EMF can take up to three months some times. Since this all started though, we have been getting supplies within 24 or 48 hours of requesting it.”The increased logistical support was particularly important because any COVID-19 tests collected here originally had to be frozen and then be sent to the Landstuhl Regional Medical Center in Germany. To do that, an aircraft colloquially dubbed the “COVID Express” was dedicated to run from CLDJ, to Rota, Spain, and then to Germany, Allen said.That process changed recently when the Navy Marine Corps Public Health Center in Rota sent CLDJ what is known as the BioFire FilmArray 2.0, a molecular infectious disease diagnostics equipment, which has since allowed the EMF to complete testing locally. Navy Marine Corps Research Unit Three, located at Naval Air Station Sigonella, Italy, was also able to provide a microbiologist to train the staff at CLDJ in its use.The largest contingent of additional medical personnel supporting the EMF is a critical care team which is made up of 13 U.S. Air Force airmen that AFRICOM requested. All of the team members are here temporarily from their home duty stations.“With the staff I have right now, we would be tapped manpower-wise before we ran out of (Intensive Care Unit) beds,” Allen said. “Having a critical care team come in will really give us a lot more ability if we're to receive a lot of critical patients.”Allen said he was thankful for all the help he and his staff have received from all the organizations across the CJOA, as well as higher headquarters, but it’s important everyone remain vigilant in their protective measures.“The real trick to this whole thing is COVID is out there. COVID isn't going away,” he said. “It's now in the community at large in the world; the genie is out of the bottle, so to speak,” Allen said. “The thing with COVID is 80 percent of the people walking around will be fine if they catch it. What we are worried about is the one to two percent of people who become critical.“Really, this is about getting back to the basics of what everybody knows they're supposed to do. This will likely go on for a while, and it's going to hurt for a while. But this is better than having a bunch of our shipmates, airmen and soldiers with tubes down their throat breathing for them. Eventually, though, we will get back to full operations and a normal lifestyle that allows for things like chocolate chip cookies in the galley again. Everyone just needs to continue to live up to their social responsibilities to protect each other.”(U.S. Air Force Senior Airman Gage Daniel contributed to this article)