On 2 September 2014, Dr Joanne Liu, International President of Médecins Sans Frontières (MSF), made an urgent appeal to United Nations member states to deploy biohazard containment teams to support the response to the Ebola epidemic in West Africa.+The quote in the title of this article is taken from Dr Lius 2 September briefing to UN member states. See http://www.msf.org.uk/article/msf-international-president-united-nations-special-briefing-ebola. For MSF, this call was unprecedented since the biohazard response capacities of powerful states are typically a military capability developed in response to biological or chemical warfare, rather than epidemic control. Despite the strong consensus within MSF that led to this call, it was not without operational and reputational risks.
August 2014: an epidemic out of control
The Ebola outbreak in West Africa was on a scale never seen before. What began as an outbreak in a remote, rural region of Guinea in December 2013 had, by the summer of 2014, snowballed into a global security concern. In the Liberian capital Monrovia the disease was spreading rampantly, violent social unrest was increasing, contact tracing was impossible, healthcare workers were contaminated and dying in shocking numbers, surveillance was spotty and no spaces remained in overflowing case management centres. MSFs resources were pushed beyond their limits; rather than proactively working on all pillars of the epidemic, as in past interventions, including contact tracing, safe burial and social mobilisation, field teams in Monrovia were only able to maintain a basic level of case management, and we feared that this terrifying situation could become a reality for an increasing number of densely populated urban centres.
Local capacities were not strong enough to face the crisis without substantial international support. Sierra Leone had just one doctor for every 50,000 people; Liberia had one for every 100,000. To make matters worse, healthcare workers were being infected (and dying) at alarming rates, further diminishing capacity and increasing stigmatisation and fear. Despite the World Health Organisation (WHO)s (late) announcement of a public health emergency of international concern and the elaboration of a regional response plan, a meaningful response was not forthcoming, and the epidemic left most aid agencies and donors paralysed. In-house expertise to deal with an epidemic such as Ebola had not been developed in most agencies, and the slim margin of error and severe consequences of any mistakes, whether in running a case management centre or in doing any form of outreach work, meant that engaging in a meaningful response was well outside the acceptable risk norms within the sector. Most INGOs draw almost entirely from local capacities to do the hands-on work, but in this case more hands were needed alongside them, inside the high-risk zones, rather than facilitating or managing from a (safe) distance. Some other international agencies in addition to MSF had deployed, but the scale of the overall response was far short of the needs. Decision-making had to be quick and clear, operational models had to be direct and involved rather than simply empowering local actors to work, and the ensemble could not be weakened by unclear chains of responsibility or inflexibility in grant funding.
While the INGO- and donor-led Ebola response was scaling up, MSF estimated (more or less accurately) that the process would take around three months, during which time the epidemic might well have continued to expand. The world was in uncharted territory from an epidemiological perspective and, despite attempts at modelling, no one was able to project how catastrophic the situation might be in three months time. Essentially, MSFs call for UN member states to deploy biological hazard containment teams was a last resort, in the hope of bringing about rapid and concrete action at the field level while aid actors and local authorities scaled up their response.+From an interview with Brice de la Vigne, Director of MSFs Ebola Taskforce, Brussels, 3 February 2015.
The risks of calling for foreign military assistance
Militaries operate with independent logistical capacity and have field-deployable medical resources. They also have a strong command and control style of management and a culture of discipline, both of which are a tremendous advantage in maintaining rigorous standards of infection control. However, despite internal consensus on making the appeal for biohazard teams to help with patient treatment, many within MSF feared that the deployment of foreign troops would militarise the response. MSF is opposed to a security-dominated approach to outbreak response that favours the imposition of safeguards such as lockdowns and the use of force to compel compliance. Rhetoric the world over employed a conflict/military lexicon to describe the outbreak: fighting the outbreak, hunting the virus, healthcare workers on the frontlines and so on. In Monrovia, a muscular, military-led quarantine backfired catastrophically, leading to violence, increased suffering due to lack of access to food, services and livelihoods and loss of trust in government-backed efforts to combat the epidemic; ultimately it may have amplified transmission rather than reduced it.+As Ebola Grips Liberias Capital, a Quarantine Sows Social Chaos, The New York Times, 28 August 2014. If tactics such as quarantines were encouraged, defended by foreign troops, what rules would govern their use of force when imposing them? No framework exists within International Humanitarian Law, as there is no conflict under way in the most affected countries, although the use of force is specifically rejected in the Oslo Accords, which offer a framework for the use of military assets in disaster relief. In addition, we feared that our appeal would be misconstrued or taken as a call for armed intervention amid fears about the deteriorating security environment and state collapse. Regardless of how military assets would be engaged, how would they be perceived by locals? Negative perceptions proved harmful to the aid effort during the earlier stages of the response, and led to the murder of outreach workers in Guinea in September.+Ebola Outbreak: Guinea Health Team Killed, BBC News Africa, 19 September 2014.
Reputational risks for MSF were easily identified. Factors that could influence external perceptions of MSF ranged from how information about our appeal was used or understood to the consequences of what actually happened on the ground when or if military assets were deployed. In many conflict zones around the world, including in West Africa, international aid agencies are considered by some armed groups to be instruments or proxies of hostile states, and thus not neutral or impartial. Regional examples include northern Mali and Nigeria, both of which experienced outbreaks of Ebola. Our call for the deployment of military assets ran the risk of confirming false suspicions that MSF is part of a Western security agenda. This could have created even more barriers to access in conflict-affected areas. Beyond this, if military assets were deployed and had a negative and damaging effect, for whatever reason, MSF could be blamed for having called for them in the first place.
MSF always endeavours to keep a safe distance from the trend in the aid industry whereby security, state-building and stabilisation agendas are conflated with humanitarian relief efforts. Even in the event of a natural disaster, MSF can choose to maintain a strict distance from military-assisted relief efforts due to existing conflict in the area, drawing exclusively from its own internally developed technical and logistical capacity. Unlike the earthquake in Kashmir in 2005, where MSF benefited from the use of military transport to participate in a well-received aid effort, MSF refused to work directly with the military in the response to the floods in Pakistan in 2010 due to ongoing conflict between the government and Taliban forces in the region. If the military is seen to be successful in managing Ebola cases in West Africa, this may fuel popular support for their engagement in supporting humanitarian relief in situations of armed conflict, which may put both aid workers and aid recipients in the firing line of opposing forces.
What did these militaries do?
Following MSFs call in early September, both the US and UK governments announced that they would support the epidemic intervention using military assets. Much to MSFs disappointment and the frustration of many military medics their role was not as a care provider to the general population, but rather to provide support, coordination and logistics for INGOs and local authorities. Even the facilities that were built, supported and operated by the military for the treatment of local and foreign healthcare workers (which we had also asked for and which were greatly appreciated) were provided to help ensure that others could treat patients within the general population, rather than offering care themselves. In Liberia risk aversion, either within or imposed upon the US military, led to inflexible and restrictive biosecurity protocols. For example, US helicopters would not assist in transporting laboratory samples, and would not transport healthy personnel back from areas where they had worked in treatment centres, meaning that the US military was actually more risk averse than the commercial airlines still operating in the region. Likewise, military vehicles were never used in a significant way for patient referral. In the end, even though formally under the auspices of USAID and the UKs Department for International Development (DFID), decisions, including on the use of personnel and assets, seemed to have been previously established at higher political levels, whether within the military or by politicians.
Informal discussions with military personnel at various levels suggest that our understanding of their biohazard containment capabilities was at least somewhat accurate, but ultimately it was unlikely that we would see the full extent of such resources given that any capacities developed for this kind of warfare would be highly classified. Perhaps fear of the political cost of something going wrong for instance a soldier getting sick and dying, or deploying a specialised response force that might draw scrutiny limited the use of resources and exposure to risk despite eagerness on the part of many soldiers to do much more. In the end, supporting activities remained the only option, and could equally have been performed by existing international aid agencies.
The real added value and unmet gap
While MSFs appeal for the deployment of biohazard teams was not met, the deployment of military actors was not without value or meaning. Essentially their engagement marked the symbolic beginning of the deployment of a substantial international response, and seemed to help people understand that an intervention was under way. Providing treatment facilities with a European or US standard of care for healthcare workers also reassured international agencies, allowing them to offer stronger assurances about fulfilling their duty of care standards when deploying international personnel and local workers and authorities. In the case of Liberia, where a more serious security force was deployed (with stabilisation in mind), soldiers were not rejected, and people on the ground seemed reassured that help had arrived.
By late February 2015, positive trends had emerged in the regions struggle with the epidemic, as transmission rates and new cases decreased. MSFs fears about the possible negative consequences of the military presence did not seem to have materialised operationally, yet neither did MSF get what it asked for in making its appeal to use military resources to curb transmission in the earlier phase. As institutions, aid agencies and governments reconsider global health security and epidemic response, we must hold existing institutions to account and affirm that responses to epidemics can mobilise quickly and effectively, particularly in periods of crisis. When the story of the management of this epidemic is written, we need to view foreign military engagement critically and accurately, rather than simply assuming that their added value was a game changer in a material sense on the ground.
André Heller Pérache is Head of Programmes at MSF UK. He tweets as @hellerperache. This article draws heavily on discussions and collaboration with Brice de la Vigne (MSF Operational Director) and Seco Gerard (advocacy manager for Ebola).