Written evidence submitted by Professor Colin McInnes FAcSS FRSA
Colin McInnes is Professor of International Politics and Pro Vice-Chancellor (Research) at Aberystwyth University. Between 2007 and 2018 he was the UNESCO Professor of HIV/AIDS and Health Security in Africa, and in 2018-19 was consultant to the WHO in developing their framework for civil-military collaboration in health emergencies.
- The UK military possesses a range of capabilities which may be used to support health services when responding to an outbreak.
- The question for the UK is not whether the military should provide assistance in health emergencies, but how it might do this most effectively.
- It is necessary to shift from a culture of response to one of preparedness, including: clear guidelines on decision making; training; resource mapping; technical requirements; and quality assurance.
- International guidelines need to be revised to facilitate the effective assistance where appropriate of external militaries (such as thse of the UK) in national responses to disease outbreaks.
- There is a general consensus in the UK that major emergencies will require a multi-sectoral response, and there is a well-established pattern and widespread acceptance of military involvement in such responses. Although health emergencies, including disease outbreaks, may create particular sensitivities over military involvement (that the uniformed military have distinctive norms, values and organisational culture which often jar with those of health professionals), the experience during COVID-19 appears to have been largely successful in accepting a role for the military in responding to public health needs. The question for the UK therefore is not one of whether the military should provide assistance in health emergencies, but how it might do this most effectively.
- Military assistance to civilian authorities can provide an important boost in UK health capacity. As COVID demonstrated, capacity may be at risk during a major disease outbreak, but also during a bio-terrorist incident where specialist health provision may be required. Within the context of a multi-sectoral response, the UK military possesses a range of capabilities – from military medics through logistics, command and control, and surveillance to engineering assets – all of which may be used to support health services when responding to an outbreak. But it can also be more readily mobilized and moved to where need is greatest than other potential sources of support (eg civilian contractors, retired public health professionals).
- To maximize the effectiveness of military involvement in disease outbreaks, however, it is necessary to shift from a culture of response to one of preparedness. Although all three stages of a public health emergency - preparedness, response, and post-response/exit – are important, preparedness is critical in reducing risk and improving response. From a review of available documents, it is not at all clear that the UK has made this shift.
- Based on work undertaken for the WHO, effective civil-military collaboration in disease outbreaks would generally involve:
- establishing a means of collaboration at the strategic level for good governance and an efficient use of resources, avoiding duplication of effort, a lack of coordination in response and competition for resources;
- ensuring differences in norms, organisational culture, mandate, uneven distribution and/or use of resources, terminology, operational standards and data sharing do not hinder collaboration;
- establishing effective operational mechanisms, not least in the areas of logistical support, communication, media relations, and command and control, at all levels; and
- addressing questions of resourcing.
- To ensure that the UK is sufficiently prepared for future disease outbreaks requiring civil-military collaboration, the following therefore need to be considered.
- First, are the mechanisms to ensure a coherent civil-military response at the strategic level sufficient? Although the Gold Command structure is well established for ‘blue light’ and other civilian agencies, does this adequately engage with the military? Does the UK have – or require - formal agreements, established in advance of an emergency and including the engagement of devolved administrations to inform planning, or is it sufficient to rely on ad hoc arrangements developed during an emergency? In this respect it is important to note that civilian health collaboration with the military may pose different issues from that with other civilian agencies and cannot always be subsumed into generic multi-sectoral guidelines.
- Although ad hoc arrangements may have some benefits in being more readily adapted to particular circumstances, they risk inefficiency and ineffectiveness at a time when lives are at risk, through a lack of coordination, poor communication between sectors, and an inability to work together quickly. Rather, what is recommended here is a plan for civil-military collaboration in health emergencies. It is not clear from available documents that the UK possesses this; rather planning documents produced for health emergencies – which focus on pandemic preparedness rather than on infectious disease more generally –rarely if ever mention collaboration with the military.
- A framework for civil-military collaboration in health emergencies may draw upon existing legislation (eg the Civil Contingencies Act) or the experience of multi-sectoral responses to other civil emergencies, but the need to formalize this and designate responsibilities – ideally into an agreed National Plan – is paramount. Incorporating advice from both military and civilian health officials into high-level decision-making might be addressed by the appointment of a National Health Security Adviser.
- Second, is coordination at operational levels adequately established to ensure a smooth response? Once the decision to use the national military during a health emergency has been taken, civilian health and military authorities will need to work closely together if effective decision-making is to be maintained. This includes clarifying the different roles, technical requirements and limits of both sectors, as well as the role of the military in providing security during a health emergency (especially a bio-terrorist incident). More local decisions would likely involve issues of where resources would be deployed, community engagement, surveillance and monitoring, containment and providing treatment. How these day-to-day, operational decisions are made can be vital in the effective management of a disease outbreak.
- Where possible, existing arrangements should be built upon rather than negotiating new agreements. Coordination mechanisms for health emergencies may also be integrated into broader emergency preparedness plans and processes. Effective coordination might also involve adopting common risk assessment and communication procedures at both the national and local level, and may include not only those directly involved with a public health emergency on the front line, but also those with access to resources (such as social media sites which can influence community attitudes in an affected region). A coordinated civil-military media strategy – such as exists within the Gold Command system - would facilitate consistent messaging and engagement with both the general public, especially with communities at risk, and .
- Third, has the UK built sufficient mutual understanding between the two sectors, including on a one-to-one basis to ensure that there is a community of practice? Networking and establishing effective, working relationships before a disease outbreak is an essential part of preparedness and may involve formalized agreements and practices. This may also involve resource mapping and liaison on quality assurance requirements. Cooperation can also be embedded through involvement in training/professional development programmes; in placements; in sharing information on relative capacities pre-crisis (e.g. liaison officers and secondments); and in an awareness of who will be talking to whom, and working with whom, on an individual basis. Simple, small steps - such as joint seminars and table top exercises – complemented by regular liaison meetings at regional levels (so that ‘you know who you are talking to’), can make the process of cooperation routine rather than exceptional.
- Fourth, it is important to establish in advance how operations are to be financed, not simply for the duration of an emergency but also to cover preparedness (including any training and joint exercises) and in the aftermath of an emergency. Contingency funding may be available for an emergency, but for preparedness and recovery it is not always clear who has funding responsibility.
- Fifth, SARS, ‘swine flu’ and COVID-19 have shown that infectious diseases can cross borders with increased ease. As a result, ‘health is global’, and the UK has an interest in the control of infectious diseases worldwide and in promoting an effective global response to this threat.
- Internationally, the cornerstone to this response is the 2005 revision to the International Health Regulations (IHR), and at the heart of the IHR is the agreement by the State Parties to provide a certain level of core capacity to respond to disease outbreaks at the national level. However, in many instances, core capacities are not sufficient to meet the IHR expectations and therefore global bio-security is at risk. There is therefore a case that external militaries may be useful in supporting national responses to disease outbreaks, not only out of humanitarian concern but also to protect global bio-security – as we saw in the 2014-16 West African Ebola outbreak.
- However, not only have such responses been almost wholly reactive but the guidelines for international involvement in health crises were largely produced by UN agencies and INGOs in the first decade of the new millennium and are heavily influenced by the humanitarian crises of the 1990s. Pre-eminent amongst these international guidelines is UN Office for the Coordination of Humanitarian Affairs (OCHA) revised 2007 ‘Oslo Guidelines’, but other international guidelines include the ‘MCDA Guidelines’, and the IASC’s 2004 Reference Paper and 2011 Position Paper. These are consistent in emphasising that military assistance should be a last resort and that the different mandates between military and relief organisations create major – for some insurmountable – problems, risking the humanitarian basis of such actions.
- Even before COVID-19, these guidelines appeared somewhat dated and failed to recognize the changed context of global bio-security. They now provide a potential block to action and there is a growing case for their revision to reflect new circumstances. This should address not only general principles of collaboration – the when and why questions – but more practical aspects of how such collaboration should be achieved.
1 September 2020