Hospital ship USNS Comfort (T-AH 20) pictured off the coast of San Juan, Puerto Rico, Oct. 6, 2017.

Hospital ship USNS Comfort (T-AH 20) pictured off the coast of San Juan, Puerto Rico, Oct. 6, 2017. U.S. Coast Guard photo by Petty Officer 2nd Class Meredith Manning

It Took Comfort 39 Days to Get Pierside in Puerto Rico. That's a National-Security Problem.

The hospital ship's poor utilization suggests that the US military's biomedical support doctrine needs shoring up.

It took USNS Comfort two full weeks to reach Puerto Rico after Hurricane Maria cut power to every hospital on the devastated American island. Once it arrived, the 70,000-ton hospital ship spent three more weeks underutilized offshore, connected to the injured population by a thin stream of helicopters and seemingly forgotten by FEMA and the Joint Staff alike. With just 33 of Comfort's hospital beds occupied in mid-October, Military Sealift Command sadly tweeted advice to “contact your local health provider if you need care.” When the medical vessel finally came pierside at the Port of San Jose on Saturday — 39 days after the hurricane made landfall — most of the ship's 200-plus available beds filled up within hours.

The Navy and Joint Staff have plenty of experience putting America’s floating hospitals, USNS Comfort and USNS Mercy, to use. Over the past three decades, Comfort alone has made two planned deployments and five unplanned deployments to the Caribbean, aiding sick and wounded after hurricanes, earthquakes, and migration crises. The confused response to Maria suggests the Navy’s biomedical support doctrine has fallen into disarray. And that is a national-security problem.

Biomedical care — the treatment and prevention of illness or injury — is a key part of U.S. military operations, from war to humanitarian relief. If the Navy is unable to put its floating hospital to good use after a slow-moving hurricane strikes U.S. territory, what will it do in a sudden Korean contingency, where casualties would be far more numerous and potentially complicated by exposure to chemical, biological or nuclear contaminants? If Japan is closed to contaminated or contagious casualties, hospital ships may be the only option.

Hospital ships have long been a defining characteristic of a modern navy, and America has reflexively bought and built them since the Spanish-American War. But they are treated as mere tactical assets, with little thought of integrating these ships into wider national security strategies. Occasional rushed deployments identified critical usability issues like modern vessel CONOPs, ship-to-shore civil-military integration, and hospital/ship cross-decking questions, but without a sustained presence in a defined military strategy, these problems have gone unanswered.

That is unfortunate. Comfort and Mercy were built to a grand old 1980s-era wartime playbook to serve as the biggest offshore combat trauma centers in the world. But decades of use have demonstrated that the Cold War playbook won’t work. The Mercy-class ships have several shortcomings, with the most vexing being that these world-class floating medical facilities have the offshore receiving capability of a small-town physician’s office. The ships lack a hangar and flight deck big enough to handle a surge of casualty-carrying helicopters. They can’t safely receive injured by boat while at sea, and they are simply too large to operate in many areas of the world. Efficient command and control of these civil-military hybrids continues to be a problem.

Everybody wants to provide the best casualty care, but few have the stomach to apply the lessons learned from three decades of hospital ship operations. Once the disaster-of-the-day is over, the hospital ships go into reserve status and become a problem for somebody else. Without a coherent medical strategy, the utility of any Navy medical asset risks being frittered away and the ships left to reinvent the wheel time and time again.

This story has been repeated ever since America’s first hospital ship, the USS Red Rover, entered service in 1862. During World War II, the Navy struggled to employ its baker’s dozen of Patrol Craft Escort (Rescue), or PCE(R)s, stubby little 185-foot boats crammed with 80 hospital beds. An informative review of these vessels is here, but listen to one PCE(R) skipper describe his experience aboard the USS Rockville. In a 1951 essay for the U.S. Naval Institute, Navy Cross winner Cmdr. F.S. Bayley Jr, wrote that the ships’ 1944 arrival in the Pacific theatre was less than heralded:

"No one in authority seemed to have heard of the ships and no specific task was designated...At Leyte, the ships lay empty and idle off Dulang until, after two days, the commanding officers of the '51 and '52 (USS Brattleboro) went ashore and briefed the beachmaster on where their ships were and what they could handle."

Having convinced the Army of their ships’ value, the PCE(R) skippers labored in vain to similarly persuade nearby admirals. Then disaster struck:

"The first naval personnel handled by the ships came with the sinking of the Gambier Bay and its escorts [in the Battle off Samar]. As a result of a direct appeal to the 7th Fleet Surgeon, the Fleet Medical Department became aware of what was anchored so close by on this day, and by nightfall the PCE(R)s were loaded to capacity..."

But fleet commanders didn't share knowledge, and so the PCE(R)s were generally misapplied or simply ignored for the rest of the war.

"The 851 joined the Iwo Jima landing force off Saipan, and patrolled off Iwo for a few weeks with empty hospital spaces. The Fifth Fleet at the time had the usual lack of knowledge of the PCE(R), and a commentary on its staff attitude was the fact that when the commanding officer started to tell a captain what his ship was equipped for and how it was used in the Philippines, he was cut off with the remark, "That was the Seventh Fleet, son—now you're in the Fifth Fleet".

This tale should sound familiar to those aboard Comfort.

Now pierside, the Comfort can apply its mass to help Puerto Rico directly. The ship can add staff to help backstop the island’s power-strapped and exhausted hospitals while boosting local public health laboratory, diagnostic, and waterborne-disease-surveillance infrastructure—capabilities that will be very important over the coming months. The ship can even ramp up from its current 250-bed configuration to as many as 1,000 beds, perhaps providing some cost-effective short-term housing for aid officials or supporting personnel from civilian non-profit aid agencies. It could even help power-strapped hospitals with mundane but critical tasks like cleaning soiled bedding.

When the time come to study the lessons of Hurricane Maria and the response to it, the Navy and Joint Staff should think hard about this missed opportunity to bring USNS Comfort to bear early and effectively. More concretely, their planners should take note of the ships’ functional shortcomings — for example, a small flight deck that restricts the arrival of patients by helicopter — and plan for them.

One way to help would be by employing medical support ships more often in domestic contingencies, during Fleet Weeks or in CONUS familiarity tours. Sustained operations would force usability fixes and help spur creative thinking on the strategic employment of America’s biomedical power-projection capabilities. But even if mistakes happen, humanitarian medical work, employed to advance defined national security priorities, helps the warfighter; in a big contingency like a Korean conflagration, America won’t have time to fumble about in applying the Navy’s floating biomedical forces.

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