A new civil-military health collaboration framework by the World Health Organization (WHO) suggests better pandemic preparedness in the future can be achieved by establishing and maintaining collaboration across these two major sectors.
The publication of this guidance document is an acknowledgement that militaries should be incorporated into national preparedness and planning for managing major infectious disease outbreaks where appropriate, and is a marked transition from using the military reactively to seeing them as a core part of a system to prevent or limit the extent of an outbreak.
But this transition will require a significant investment by both the military and health communities in an understanding of each other’s capabilities and limitations, as well as a wider acceptance by the civilian population and civil society that this is an appropriate role for the military.
The role of militaries in responding to natural disasters is well-documented, but there is little evidence that either militaries or civilian health services have systematically considered how militaries could contribute to preparing for, or responding to, infectious disease outbreaks.
Cementing a culture change
The role of national and some foreign militaries in the response to the Ebola and Zika outbreaks did contribute to a change in perception and, although this new guidance comes during the COVID-19 pandemic, its genesis was actually in 2017 in Jakarta, Indonesia, when more than 160 public health and security representatives from 44 countries, international organizations, and donors came together.
This cemented a culture change, as the civilian health services – who had frequently sought to distance themselves from the military – recognized the need to include military resources when addressing major outbreaks. Critically, the guidance seeks to provide a framework on how to involve the military proactively in planning for future outbreaks rather than using them in an ad hoc manner after an outbreak has already become critical.
The effect of ad hoc responses is seen in the wide variation between countries in how they have used militaries in responding to COVID-19. Partly this reflects national legislations, cultures, and political realities, but arguably it mainly arises from a lack of understanding between the two sectors of each other’s capabilities together alongside the absence of a stimulus to work together in advance.
Although the guidance document promotes and outlines a rational approach to civilian-military cooperation, its implementation will not be without difficulties especially as, philosophically, militaries may not see involvement in preparing for infectious disease outbreaks as a priority if they are expected to fund such involvement themselves.
There is also likely to be significant opposition by humanitarian and public health professionals if they perceive this as a ‘militarization’ of health which undermines humanitarian principles and could lead to a transfer of funds from civilian health services to the military.
And politically it will undoubtedly raise issues in states with significant suspicion or distrust of the military by the civilian population, or where ministries are headed by competing ministers of differing political persuasions. To its credit, the guidance document does highlight these challenges and does not suggest the military should always be involved.
It addresses a logical high-level approach to developing a partnership, carefully avoiding blanket recommendations. The most significant recommendations are those to overcome a lack of mutual understanding by the civilian health services and the militaries of each other’s capabilities and limitations.
Research by Chatham House and the Johns Hopkins Center for Health Security shows even health ministries which currently do incorporate militaries into their planning only have a superficial knowledge of the scope for cooperation.
There is a good understanding by health ministries of fixed military health facilities, of the contribution militaries make to logistics and engineering, and the availability of human resources. But there is a lack of understanding of how the military can use resources dynamically and flexibly, leading to a risk of both overestimating and underestimating its capabilities.
The military may have five fixed hospitals and five field hospitals, but only one set of personnel to work in the fixed hospitals when the field hospitals are not in use, thereby requiring planners to make choices on the use of resources. In many countries, the impact of outsourcing military supply chains – such as for personal protective equipment (PPE) – may not be obvious until both the military and civilian communities expand their demand level and find both are dependent on a single chain.
Overcoming reluctance and hesitation
The most important recommendations are around partnership, regular training exercises, and exchange of personnel, supported by an informed mapping of the capabilities, capacities, and limitations of military and civilian resources for health emergency preparedness.
Understanding requirements also helps overcome a reluctance by some militaries to share details on their capabilities with civilian ministries, and a hesitation by some health ministry officials to be seen as too inquisitive for security reasons.
Crucially, the guidance does not provide a blanket recommendation for the use of the military in every setting, but instead makes suggestions where improved collaboration between the two sectors is both appropriate and desired.
The recommendation is that the way forward is complemented by an appropriate strategic policy, and that sub-national plans should result in countries better leveraging existing capacities and capabilities for implementation of the International Health Regulations.
Although desirable, incorporation of the military into health emergency preparedness plans must be complemented by a ‘whole of society’ approach – to include other sectors – of a nation’s capabilities, both public and private.
But with increased urbanization, population growth, geo-political developments, and climate change, the risk of future pandemics is now increasing to the extent of being almost inevitable. Governments around the world need to improve preparedness plans in the shadow of the current pandemic, and military resources must become part of this planning where appropriate.