To deny the SARS-CoV-2 virus easy options for sustained transmission, commanders should model adherence to, and ensure implementation of, social mitigation measures. While some measures can be achieved at the organisational level through policy, every Service person’s experience of the COVID-19 pandemic will have differed, affected by a range of personal, occupational and geographical factors. A successful recovery phase for each Service personnel (SP) therefore relies on localised assessments and individualised support plans. The return of SP to the physical environment must be safe, and the financial needs of their whole family must be considered. Commanders must understand the need for balance in supporting social reconnection both personally and in the workplace. Commanders have an important role in the development of SPs’ mental resilience; supporting mental well-being, early recognition of deteriorating mental health and signposting, and compassionate understanding of the needs of SP deployed or bereaved. Disruptions to healthcare service provision will impact the duration of medical downgrading, workforce capacity and operational effectiveness according to extant parameters, which must be understood by commanders. Likewise, functional fitness may have been adversely affected. Physical health and fitness recovery can be supported by time-based extensions to occupational health policy and graduated return to work physical training programmes.
- infectious diseases
- public health
- public health
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The UK Governments’ recovery strategy for COVID-191 sees progression and regression through a range of action plan phases,2 including the recovery phase. Defence organisations must also have a strategic plan to identify the tasks and operational requirements required during the recovery phase. It is equally important that commanders consider and risk assess the specific recovery needs of individuals. Each phase of the COVID-19 pandemic will not be neatly differentiated; therefore in order to prepare, many of the recommendations made need to be considered or implemented now.
The risks and outcomes of COVID-19 infection itself, but also the impacts of mitigation measures implemented, show significant disparity3 among individuals based on a range of wider social determinants of health,4 including occupational, personal and geographical factors. Therefore, no two individuals will have had the same experience or health outcomes of the COVID-19 pandemic. This paper considers how such factors may have influenced personal experience and ultimately health outcomes and provides some recommendations to what recovery measures individuals, commanders and the organisation might make. To do this, we use the Public Health England Emergency Planning Concept of Operations’ five spheres of recovery5: the physical environment, the financial environment, social health, physical health, and mental health and well-being.
Physical environment: ensure the safety of where Service Personnel work and live
Changing employment patterns and economic recession6 present a risk of disruption to water, utility, power and local infrastructure supplies. This could affect not only accommodation but also a safe return to the workplace. Workplaces and on-site accommodation vacated or unserviced during the earlier phases of the pandemic require a health and safety assessment prior to Service personnel (SP) returning. This should consider building damage, which may present a health hazard through trauma; risk from newly exposed mould, asbestos; and risk of Legionella following water system stagnation or air-conditioning unit disuse.7 Where appropriate, Environmental Health advice should be sought on mitigation measures. These health threats also exist for those in private or family’s accommodation, where maintenance work or safety tests have been postponed. Mental health can also deteriorate if safety fears for the individual or family exist. Individuals should arrange such works to be undertaken as soon as possible. Managers and the organisation should support this.
All countries have experienced periods of local and international travel disruption, and for some, this may have resulted in separation from partners or children for prolonged periods of time. The organisation should consider the welfare, support and mental well-being needs of SP and their families who have experienced this. The impacts of and recovery from natural disasters, such as the flooding in Ironbridge,8 have also been compounded by COVID-19, and it is likely that a mix of both short-term and long-term negative physical and mental health outcomes will be seen as a result. Geographical location during lockdown is therefore another important consideration in planning individuals’ return to work.
Financial environment: consider the whole family’s financial position
Socioeconomic status is a source of inequality for health outcomes for many health conditions, including COVID-19.3 UK SP are fortunate, unlike many, to have had full pay throughout the COVID-19 pandemic whether shielding, in self-isolation or undertaking caring duties. On-site civilian employees may only have been offered unpaid leave or statutory sick pay. Socioeconomic deprivation is associated with an increased risk of COVID-19 mortality9 and is likely to contribute to spread as the need for pay affects work attendance, health behaviours and adherence to symptomatic isolation. Risk of spread in defence establishments is not just between SP, but also from others who also work on-site. Defence policy must consider the risk from and to all on-site; SP, civilians, families and visitors alike.
While SPs’ wages were unaffected, other sources of family income and long-term financial security may have been affected: through partner job loss, economic recession,10 loss of rental property income or other income sources. This could cause financial difficulty, which commanders should be aware of. Lack of access to the furlough,11 or a similar scheme, whether in the UK or due to an overseas posting, or the potential perception of being disadvantaged compared with others can cause financial stress and anxiety. Financial anxieties can impact on physical and mental health, workplace concentration and overall effectiveness. These anxieties may be compounded by fears of financial debt, impacting security clearance. Commanders and welfare teams should prepare for this now, offering signposting advice to national support services, including Citizens Advice12 and single Service families support services.
Social health: find the right balance of personal and workplace social reconnectivity
Social distancing and self-isolation measures have affected the frequency and nature of personal and workplace social interactions. The longer such measures stay in place, or the frequency with which they may be eased and reimplemented, the more significant the impacts are likely to be on well-being. Social connectivity is an essential element of the five ways to well-being,13 giving individuals mental resilience to cope with changes and stressors in either the home or workplace. Individuals may rely on social support networks in either setting to manage stressors in the other. Work may be an escape for those experiencing domestic disharmony or abuse, but if this results in separation or divorce,14 mental resilience to manage additional work pressures may be limited.
Conversely, many who have remained at work throughout the COVID-19 pandemic have seen increased workload and pressures. For some, this has been in isolation, away from family and support networks. Although SP are used to periods of separation, they are usually time limited and followed by postoperational tour leave. This supports reintegration into ‘normal’ life, a revitalisation of social and mental well-being, and re-establishment of physical and social contact. The need for SP who have been essential workers, or deployed for prolonged periods to operational theatres, to socially reconnect and take leave should also be considered. This is particularly pertinent to SP who have experienced a fatality and have not been able to collectively grieve as is usual in armed forces organisational culture. The long-term mental health impact of having to reintegrate and adapt to an atypical society should not be overlooked.
Social functions are an important part of military culture, and loss of this social network can negatively impact on the mental health and well-being of veterans.15 Re-establishing social connectivity in both personal and work settings is important; however, recommencing such functions must carefully consider national guidance, financial costs, availability of childcare and organisational reputational risk.16
Physical health: time is key in the recovery of both physical health and fitness
Retaining occupational fitness is an essential requirement for SP and is usually supported at the unit level, with access to functional training equipment, such as rifles and uneven or obstacle-laden terrain. During lockdown, exercise has been individual, undertaken in the home or local outdoor environment, without access to functional equipment or the motivational support of group exercise. On return to work, units which have not been able to maintain collective or individual functional fitness must implement a training programme to avoid excess new musculoskeletal injuries and/or climatic injuries.
Nationally and within defence, routine healthcare services, including primary care, secondary care, dental care and rehabilitation services, have also been interrupted, with appointments and investigations often postponed. In the UK, the number of people seeking health service appointments declined,17 and at the peak of the pandemic, access to routine care and specialist services had significant geographical disparities or, in the case of dentistry, ended.18 It is feared that as a consequence, many individuals, including SP and their loved ones, will now present to healthcare services with more progressive new-onset disease. This may impact on individual outcomes, the duration of medical downgrades and, ultimately, operational effectiveness.
Units must allow time, without penalty, for SP to receive routine vaccinations, access postponed occupational health and dental checks. SP on rehabilitation or mental health recovery programmes, although delivered remotely, will not have benefitted from specialist face-to-face expertise and may therefore need longer to recover. Allowances must be made for those who are downgraded, and extensions to temporary grades and medical discharge processes should be recommended.
The long-term sequelae of infection with COVID-19 remain unknown, and the impact of any long-term health outcomes on occupational grading and career are unclear. While such considerations must not impact on clinical care, long-term consequences must be considered as more evidence becomes available. National measures have focused on the impact of COVID-19 on attributable and excess mortality. Defence organisations should focus their attention on the impact of attributable and excess morbidity, a measure much more relevant to a younger and fitter military population. The potential clinical outcomes are not explored here as this paper focuses on wider social determinants of health as opposed to clinical treatments and outcomes.
Mental health and well-being: understand everyone’s differences and develop effective mental resilience
Personal experiences during the COVID-19 pandemic will have varied significantly. Balancing workplace duties, carer roles, or essential worker status can seem daunting and create significant stress, particularly if commanders are not understanding of these exceptional times. Commanders must therefore consider the workload demands and the impact of national policies, such as availability and provision of schools, early years or wraparound childcare. Others may have additional stressors of individual or family physical ill health, or the impacts of financial difficulty. If too many stressors are applied, this will impact mental resilience, and SP may experience a decline in mental health or well-being.
As well as occupational and situational stress, other feelings of mental ill health may present. Those who have been shielding for themselves or a household member may experience significant reintegration anxieties. SP who have lost a loved one will be managing the impacts of a culturally atypical bereavement process and possibly delayed grief. Those who experienced the lockdown phase in urban areas with poor air quality, with closed public parks or in flats with no access to green spaces can experience worse mental health outcomes.19 From life course epidemiological models, SP from socioeconomic deprived populations were at increased risk of mental ill-health even before the impacts of COVID-19 are considered.20 All the wider determinants discussed here and earlier, whether pre-existing or situational, contribute to mental health and well-being, and the COVID-19 pandemic can introduce new risk factors or exacerbate existing risk factors.
While the British Army has invested in developing soldier mental resilience and coping strategies,21 these focus on coping strategies for dynamic conflicts and taking offensive action. COVID-19 is different; SP can unknowingly carry and transmit it themselves, putting those they wish to protect at risk and making their behaviours the potential enemy. The preventative social mitigation measures which deny further spread are perceived as defensive, not offensive. This can make it difficult for SP to apply coping strategies they have learnt or to adhere to health behaviour messaging through a desire to ‘man up’ and push through. This, in turn, can increase their risk of infection, and biologically, SARS-CoV-2 itself may impact on mental health through postviral depression, mood disorders and potential increased risk of suicide.22
Returning to a workplace, fundamentally different from the pre-COVID-19 working environment, will present challenges at the individual, command and wider defence levels. While adapting to and modelling adherence to the social mitigation measures required to combat COVID-19 transmission, it is essential that commanders at all levels take time to consider the individual and different lived experiences and ongoing challenges of each SP and then offer appropriate support or signposting. This is particularly key in considering the financial and mental health and well-being needs of the SP.
Beyond this, some aspects can and should be delivered at the organisational and policy levels. Commanders must ensure safe physical environments and utility supplies on return to the workplace. Time-based extensions on occupational health policy and delivering a graduated return to work physical training programmes are vital in ensuring recovery of physical health and fitness. Commanders should also strive to find and support the right balance of safe social connectivity, both within the workplace through social functions and with personal support networks.
Contributors All three authors (HT, OQ and DR) contributed equally to the drafting and editing of the article. This is a personal view based on public health and occupational health knowledge and experience applied to recovery of individual service personnel.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Disclaimer This is a personal view that has not involved any research on human participants and therefore has not required study approval.
Competing interests None declared.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; externally peer reviewed.
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