Military medical innovation and the Ebola response: a unique space for humanitarian civil-military engagement

Military contributions have featured prominently in the international response to the Ebola epidemic in West Africa. Médecins Sans Frontières (MSF)’s public call for civil–-military collaboration – a first for the organisation – has been echoed across the wider global public health community, and a variety of agencies have stated the need for military logistics, communications, planning and coordination capacities. In response, several countries have sent military deployments to West Africa. The US has committed 2,900 troops and military equipment to Liberia in order to assist in the construction of treatment centres and provide medical expertise. On 8 October 2014 the UK pledged 750 military personnel to Sierra Leone to establish treatment centres and an Ebola ‘training academy’ for medical practitioners.

Critically, these military forces are working alongside both international humanitarian and national medical staff. The US military, for instance, committed to training 500 local Liberian healthcare workers each week in Ebola prevention, containment and treatment. The Kerry Town Treatment Centre, an 80-bed facility built by the British military in Sierra Leone, was handed over to Save the Children but houses an additional clinic managed by the UK Military of Defence to treat local and international healthcare workers.

The scale and immediacy of such direct coordination between military and humanitarian actors represents an extraordinary – and, to some, extremely controversial – evolution in civil-–military coordination (CIMIC) during emergency humanitarian operations, and has sparked important discussions around the implications of military collaboration within the medical humanitarian space. K. B. Sandvik, ‘Ebola: A Humanitarian Crisis or a Crisis of Humanitarian Governance?’, HPN blogpost.

Although direct operational coordination between humanitarian and military actors is on prominent display in the West African response, a particularly interesting aspect of CIMIC has gone largely unnoticed: namely that humanitarians are actively drawing from key innovations in military medicine to combat the spread of the disease. The Ebola emergency response offers interesting examples of how military-derived scientific knowledge and product innovations related to infectious disease control can be adapted to medical humanitarian practice. This diffusion of military scientific knowledge and products highlights a distinct and under-explored area of active humanitarian–military engagement, and one that may hold potential for further exchanges of innovations valuable for medical humanitarianism.

Military medical innovations

The history of warfare is intrinsically tied to military medicine’s struggles against disease and trauma, and mili-taries around the world have historically devoted significant resources to infectious disease control and biomedical R&D as aspects of force protection. The massive size and scale of military investment in the development of new medical innovations, and the large supporting biomedical R&D infrastructures of several major militaries, have in turn provided generations of medical knowledge, products and processes with applications far beyond the military sector. These include many scientific breakthroughs with direct applicability to medical humanitarian operations.

US military drug research alone has made major contributions to the discovery and development of vaccines for a range of communicable diseases, including equine encephalitis, meningococcal meningitis, adenovirus respiratory disease, Rift Valley fever and anthrax, as well as leading experimental vaccine candidates for malaria and HIV/AIDS. A. Artenstein, ‘History of US Military Contributions to the Study of Vaccines against Infectious Disease’, Military Medicine, 170 4(3), 2005.  In parasitology, key US military contributions include foundational epidemiological research into, among others, schistosomiasis, trypanosomiasis and gastrointenstinal parasites. N. Crum et al., ‘History of US Military Contributions to the Study of Parasitic Diseases’, Military Medicine, 170 4(17), 2005. US military researchers have also been responsible for establishing the efficacy of the anti-malarial drugs Malarone, primaquine and weekly tafenoquine, and the development of DEET and permethrin. L. Kitchen et al., ‘The Role of the United States Military in the Development of Vector Control Products, Including Insect Repellents, Insecticides, and Bed Nets’, Journal of Vector Ecology, 34(1), 2009; J. Peake et al., ‘The Defense Department’s Enduring Contributions to Global Health’, Center for Strategic and International Studies.

US military medicine in the Ebola response

Much of the current knowledge of Ebola comes directly from the US military, which prioritised research into the virus as a result of bioterrorism and bio-warfare security concerns long before the current outbreak. One major output of US military biodefence R&D into Ebola is the drug ZMapp, which at present is the leading global candidate for a potential Ebola treatment. ZMapp is a direct result of efforts by the US Army Medical Research Institute of Infectious Disease (USAMRIID) and the US Defense Threat Reduction Agency, in partnership with the Public Health Agency of Canada, which together have supported two pharmaceutical companies, Mapp Biopharmaceutical and Defryus, Inc, in the development of the drug for years.

ZMapp remains the front-runner candidate for further Ebola treatment, although a trial in Switzerland was recently put on hold. The drug was successful in treating several Ebola patients, and a clinical trial may soon commence in West Africa. Several other potential Ebola treatments – including TKM-Ebola, AVI-7537 and the GSK/ NIAD Ebola vaccine – are also outputs of USAMRIID-supported development by the pharmaceutical industry. Indeed, at the time of writing efforts to develop vaccines and experimental treatments for Ebola currently rely more on US government funding and innovation than they do on the private pharmaceutical sector.

Several new products currently in use as part of the Ebola response also offer examples of medical technologies with military roots. One is the FilmArray BioThreat Panel, a rapid-test Ebola screening kit currently used by US military medical staff on deployment in West Africa and in US hospitals. The kit was initially developed through a Defense Department-sponsored competition to elicit next-generation diagnostic systems for infectious disease. The winners, BioFire Diagnostics, received a $240 million contract from the Defense Department to support the kit’s development. P. Tucker, ‘The Military’s Ebola Screening Machine Just Got Approved for US Hospitals’, Defense One, 16 October 2014.  Likewise, product testing of a new antiseptic skin product, Provodine, was provided over the last four years at USAMRIID and is now being deployed by the US Army and provided to healthcare workers and emergency responders at risk of contracting Ebola in Liberia. Microdermis, ‘US Army Adopts and Deploys Provodine From Microdermis to Fight Ebola’, Press release, Microdermis Corporation, 2 December 2014.

Another area of medical technology led by US military research are mobile health platforms, also called mhealth, which utilise networked technologies to track and report health emergencies. These have proven particularly valuable in the fight against Ebola. Often in the form of smartphone applications, mobile health platforms collect, share and manage data for research and remote patient management. The Nigerian government has credited mobile health technology with helping to contain an Ebola outbreak in Nigeria, with Minister of Communication Technology Omobola Johnson noting that mobile phone systems ‘helped in reducing reporting time of infections [related to Ebola] by seventy-five percent’. E. McCann, ‘WHO Credits mHealth App with Helping Nigeria Get Rid of Ebola’, mHealthNews, 24 October 2014.

Mobile health platforms, in turn, belong to a broader category of telemedicine technologies which are a result of advances in military R&D. For example, the US Army Telemedicine and Advanced Technology Research Center (TATRC) developed the Global MedAid Engagement Toolkit for health data collection and training. It is currently undergoing field testing in West Africa as part of the US Ebola response. The toolkit integrates mobile learning, foreign language machine translation and mobile data collection into a service available on mobile phones. It is intended to support troops deployed in humanitarian disasters, and could potentially be adapted for humanitarian use.

Opportunities for military-–humanitarian innovation exchange

These examples demonstrate a distinct form of interaction between military and humanitarian actors that is rarely discussed within the traditional CIMIC debate – the exchange of innovative dual-use products and processes developed by militaries and employed for humanitarian practice. How militaries manage the R&D cycles that lead to innovations, and how these strategies differ from traditional humanitarian approaches to R&D and industry, are themselves important areas of comparative study that hold learning opportunities for improving humanitarian practice.

This point is especially pertinent to recent efforts to improve the humanitarian sector’s capacity to find innovative solutions to current and emerging challenges in the delivery of aid. While the value of engagement between humanitarians and non-traditional players in the humanitarian space, such as private sector actors, is becoming better recognised in the ‘humanitarian innovation’ debate, the military has not been seriously considered for study or engagement, critical or otherwise. Military medical innovations and their relevance in humanitarian work are evidence of the value of examining this engagement further. The Ebola response demonstrates an unprecedented recognition of the military’s potential in medical humanitarianism; as Julie Fischer, an expert on infectious diseases at George Washington University, says: ‘What we’ve already seen is a sea change in the receptiveness of many international health workers to military engagement’.

West Africans quickly adopted a cautious new way to greet each other in the midst of the current outbreak – the elbow-to-elbow ‘Ebola handshake’. It is an apt metaphor for any attempt to explore learning engagement between military and humanitarian actors around the theme of innovation. Like any other aspect of CIMIC, established core humanitarian principles must be preserved. Nonetheless, examples of military-derived scientific knowledge and infectious disease control innovation within the medical humanitarian Ebola response demonstrate that exploring innovation in the military world holds real potential for advancing humanitarian innovation and expanding the range of tools that humanitarians can utilise during crises. Understanding how the military and humanitarians already exchange knowledge is an important first step towards this goal.

Josiah Kaplan is a Research Officer with the Oxford Humanitarian Innovation Project. Evan Easton-Calabria is Research Assistant at the Project and a DPhil candidate at the Oxford Department of International Development (ODID).