Interview: Air Force Surgeon General Lt. Gen. Dorothy Hogg

Air Force Surgeon General Lt. Gen. Dorothy Hogg is leading the Air Force’s medical response to the COVID-19 pandemic and took time recently to speak with Air Force Magazine Editor in Chief Tobias Naegele and Digital Platforms Editor Jennifer-Leigh Oprihory. Her comments here have been edited for space and clarity.  

Q: Where are you right now on ensuring you have personal protective equipment for your Air Force medical personnel—masks and so on?

A: We are sitting in a pretty good place. We had a good stockpile of pandemic capability. We also have some other capabilities that we can dig into if needed. We have not had to do that. And we are part of the whole-of-government effort, so that when we need resupply, we do put in our request for resupply, and to date we have not run short. The other things that we’re doing with the PPE, along with the rest of the government, is looking at ways that we can safely and adequately extend the use of some of our PPE equipment, specifically our N-95 masks, since that has been the topic of a lot of discussion across the government. We have had some of our very innovative Airman come up with ways to safely disinfect our N-95 masks, such as using ultraviolet lights. And that has been looked at [by] the CDC, and they also are giving the green light to do that—if and when needed. So, we know that that is a capability that we have and we haven’t had to absolutely go that way yet. So in the PPE realm, we’re doing really, really well.

Q: And not just on masks but on gowns, boots, gloves, etc.?

A: Right, absolutely. It’s not just N95, we have capability and capacity for all the other PPE kinds of items that we would need.

Q: What lessons have you learned so far that would change the way you prepare in the future?

A: Obviously we’re still learning lessons, right? And because it’s a new virus, we don’t really know everything about it yet. Each day we get a little bit smarter about how it acts, how it affects, how it infects, how long it stays around, and those kinds of things. We’re continuing to learn lessons every day. Some of the lessons that we have learned to date is, No. 1, how do we operate in an environment where you have to reduce your face-to-face interactions? So we have done a lot with telehealth, which is something that we had been moving towards in the Military Health System, generally. But this event has helped us to move that faster, and to expand it across the Military Health System. And so that’s been working out very, very well. We have adopted systems that we can use and expect to continue to use those once we get back to whatever our new normal is going to be. We’ll never get back to really normal-normal, but whatever our new normal is. We’ve also looked at ways to utilize, as I said earlier, our PPE and how we can extend the use and wear of those. So that’s something that has been beneficial. Previous to COVID, pre-COVID I like to call it, we were pretty much a face-to-face organization. Today, we have figured out that there are a lot of things that we can do through teleworking. And so I do expect that some of those things will continue down the road, as well.

Q: One of the challenges in a lot of military environments—think about missile silos, airplane cabins, or command centers—is people working very, very close together. Do you anticipate this experience to change the way some of those things are designed? Would you anticipate advising changing the way some of those things might be designed?

A: I would anticipate that the way that they operate will change based on this environment. If and when they talk about design, absolutely, there would be a medical rep in on the design to help them go through that, as there is in a lot of the designing that goes on now in new capabilities. But yes, we are advising them now on how best to operate those systems, given the confines that they have, and reducing the rate of individuals having a positive COVID encounter. We are absolutely on the frontlines of advising on those kinds of issues.

Q: Similarly, do you anticipate changes in the way USAF approaches healthcare, medical missions, and aeromedical evacuation?

A: Well, I guess I would have to say, this isn’t just related to the Air Force, this is going to change how we all operate our lives from here on out. But for the Air Force specifically, I foresee that we will do a lot more kinds of interactions doing telehealth versus face to face. Certainly, it won’t replace face to face. There will still be a need for face-to-face visits with health care providers. But there are some instances where you could take care of a patient’s issues doing telehealth, and that can be anywhere from doing a virtual encounter, like a FaceTime kind of secure encounter, or just a telephone. We were doing this before COVID-19. We did a significant amount of telephone telehealth with our providers and patients, but this is just going to probably open up the aperture for that and allow us to do more of that and allow us to do more video telehealth.

On the [aeromedical evacuation] side of the house, we have been looking at how we would transport infected patients, whether it be chemical, biological, or whatever, for years. If you remember, during the Ebola crisis, that is when we developed our TIS—our transportation isolation system capability—to transport Ebola patients. Luckily, we didn’t need it for that environment, but then we looked at it for this environment. We made some adaptations to it, because it was not initially designed to do aerosol respiratory droplet kinds of containments. Now it is. The TIS has a limited capability of transport, so we are also looking at how do we transport patients safely at higher numbers, perhaps outside of a containment unit in the back of an aircraft, but with the crew being in PPE versus the patients being in PPE. There is a lot of research, a lot of studies going on to see how you could do that safely in the back of an aircraft, with air flows and, you know, those kinds of things. …. And then the third category is how the pandemic could change the services’ approach to medical missions in general. If it’s a mission-essential requirement, we’re going to do it, because that’s what we do. We walk into harm’s way on purpose because that’s what the nation asks us to do. So the essential missions will continue. So it might end up being that we do some added steps to ensure that these missions go off safely and we have the least amount of risk to having a COVID-positive member affecting the mission, such as restricting movement prior to stepping into the mission for a certain period of time.

Q: You have a pretty fit population, which is by and large less likely to succumb to this illness than the population at large. Do you anticipate this having any impact on who you would take in, in the future, or any changes in how you look at your Air Force population versus the population at large?

A: The COVID virus does not discriminate against who it infects. However, the severity of [those infections] varies because of either age and or comorbidity, so if you are not a healthy individual, you have a tendency to not do as well with the virus. Now, again, this is a virus that does resolve and goes away, so it’s not like a chronic condition that you’re going to have for the rest of your life, that could potentially worsen as you get older. So, [in that sense], this is like getting the flu: You get the flu, you recover, and it doesn’t impact your ability to continue doing the things that you like to do. So I do not foresee this virus having any impact on my ability to access individuals into the military.

Q: Have any Airmen, who’ve recovered, become ill once again with the same virus?

A: I have no reports of that in my Active-duty or in my DOD population. We have had individuals who have recovered, and then gotten ill, again, but it was not COVID related. We’ve not seen any different trends than what we are seeing across the nation. So again, if you’re young, you tend to weather it pretty well. And now that’s not to say that some individuals have not done well, and have required hospitalization, but that’s the norm for all of the United States.

Q: Let’s talk about your medical supply chain, including the issue of testing. Do you have access to the things that you need in the quantities that you need? And, if you were to look forward and say, what do we have to do to change our supply chain in the future to ensure better access, what kinds of things would be in mind?

A: For testing, there’s somewhat of a misunderstanding on what our current capability is. And that is diagnostic only. I can test you into COVID, but I can’t test you out of COVID right now. So in other words, if you have a positive test with the current testing capabilities that we have, I can be pretty sure that you have COVID. If you have a negative test, I can’t be pretty sure that you don’t have COVID, because it is a point in time. It could be that your viral load has not increased enough for me to detect it on the test, and therefore come up with a positive. Hence the reason we have to continue with our public health measures, right? So testing is not a screening test. It’s not something that I can do, test everybody and go, “You’re good, you’re good to go go back to work.”

The testing will just help me mitigate the risk in areas such as mission-essential capabilities and in those tight spaces, like the missile silo. It will help me mitigate those risks in combination with my public health measures, like the restriction of movement, and then, you know, testing at the end of 14 days. . . . None of the nation—none of the U.S.—has enough testing capability right now. That’s something we are working hard on with the Defense Production Act to help industry to boost up its ability to produce more testing supplies, such as the cotton swabs, and reagents, and all that kind of stuff. As far as testing machine capability within the Air Force, I have enough machine capability, I just need to get more testing supply. And we need to advance our testing capability forward so that we’re not just doing a diagnostic test, which is a point in time, but where we get to where we can do a serology or surveillance or screening test, which would give us much more, much better information on whether or not somebody has been exposed and whether or not they have developed immunity to the virus. There are a lot of studies out there right now that are trying to figure that out, and once we would get to that point that would help me reduce the risk of our forces getting COVID.

Q: The military is supremely good at organizing supply lines and supply chains, yet you’re struggling with the same things as civilian hospitals with tight supplies of cotton swabs and other other kinds of basic gear. Do you have changes in mind for how to better be prepared next time?

A: We do have a very good supply chain, and it works very well. But you need to understand that this pandemic is very much like a mass [casualty] situation. Oftentimes you end up not having enough of anything for everybody, and so you end up tiering and saving resources as much as you can. So that’s what’s happened in this pandemic. Not only is it affecting the military, but it’s affecting the entire globe, the entire nation. Nobody, nobody is going to have enough supply to give everybody [everything they want or need] at one time. So I think that’s something we need to understand first and foremost. As we move forward, out of this pandemic, our ability to [understand] what we need to do better will absolutely be something that we will move forward with.

Q: Is it too soon though to be doing that now?

A: We’re actually figuring that out now. How much should we keep on hand? What do we need to do better? So it’s not too soon, but it’s probably too soon to be specific about what exactly we’re going to do.

Q: Have you seen an uptick in Airmen reaching out for mental and psychological health support since the stop movement order fell into place?

A: No, I haven’t seen an uptick. But we have been very cognizant that that most likely might be the case. And so we have put together a commander’s toolkit, when we went into social distancing, and gave them tools on how they could reach out to their Airmen during this time of physical distancing, and the way they could reach out to ensure that they were doing well. On the mental health side of the house, all of my mental health providers are doing telemental health. And so if they had any high-risk individuals prior to the COVID virus, we are maintaining contact with those individuals on a regular basis to make sure they are still doing well. If somebody needs some help, we’re doing it via telemental health, or if it needs to be face to face then we do it with the proper precautions. So, I haven’t seen an uptick, but I am very, very aware that that might be something that a lot of people are struggling with, even individuals who weren’t struggling before the social isolation period. We are working very hard on that. We just recently also released a resiliency capability, or toolkit, if you will, for Airman…. So a little bit of self-help, if you will.

Q: We’ve seen hotspots around the country, we’ve seen hotspots within the Navy, with the carrier in Guam. Has the Air Force experienced anything you would consider a hotspot? And if so, how are you managing that differently than the rest of the force?

A: We’re not experiencing anything like that, knock on wood. …. What we are experiencing is very similar to what we’re seeing in the rest of the country. So if there is a hotspot in a community, and I have a base in that community, or that county, then I’m also seeing an increase in cases in my DOD members—Active duty, Guard, Reserve, dependents, contractors. So we’re watching those very, very closely. Remember, a lot of my military treatment facilities are outpatient-only in the Air Force. They’re not bedded facilities. So I have to rely on the civilian health care system to help me when I need that. And so far, all of the places in my analysis are hot, have adequate inpatient capability in the surrounding communities.