The challenges involved with joint civilian and military medical support operations
When dealing with disaster relief operations and humanitarian crises, including logistics support and aid during civil wars and infectious disease outbreaks, non-governmental organisations (NGOs) and militaries inevitably face a number of challenges.
Ahead of the Medical Support Operations summit taking place in London between 26 - 28 April, Defence IQ analysed the key challenges facing NGOs, international militaries, and government aid agencies dealing with the broadened scope of overseas medical support operations. Medics are put to work in increasingly remote, diverse, and dangerous environments, understanding the challenges and finding solutions is vital to improve the planning and execution of medical support operations in the future.
When handling a disaster relief operation or humanitarian crisis one of the most fundamental challenges centres around collaboration – NGOs might have to work with the military and vice versa. The extent of this issue will vary from country to country – one might have a friendly government with a benign military, others may not – but it usually presents an early stumbling block for stakeholders. Clearly frameworks such as the Oslo Guidelines on the Use of Foreign Military and Civil Defence Assets in Disaster Relief play a part in smoothing the path for NGO and military collaboration, but this does not eliminate the issue.
There is a great deal of reluctance for people in NGOs to interact with the civilian military sphere because they associate them with being expeditionary forces fighting in, potentially, contested environments around the world. There is a real danger when working with militaries that NGOs are tarred with the same brush – both by themselves and with other local stakeholders – as the wider activities of that military force.
Jon Barden, a humanitarian and civil-military advisor in the Conflict Humanitarian and Security Department for the Department for International Development (DFID), discussed this issue in an interview with Defence IQ. He said some NGOs during the humanitarian operation in the Philippines after the 2013 typhoon questioned why civilian medical teams were being transported by military vessels. The answer, quite simply, was that the military had big ships with helicopters, and they didn’t. The issue lies in the concept of last resort. As soon as reports were coming through that NGOs had managed to hire their own vessels for disaster relief the military was put on other tasks or moved to different locations, because it was no longer a matter of last resort.
The real problem is that some NGOs believe all military forces are hawks and some military personnel believe all NGOs are full of tree huggers. Clearly neither is absolutely true, but dealing with these pre-conceived notions and educating all parties involved would go some way to assuaging this challenge. There is also the problem of acceptance and deterrence. Most NGOs base their security strategy on a policy of acceptance in that they work with the local community forming a trust-based relationship over time. Armed military forces work with the deterrence model based on their potential to use force. In the UK, civilians can sign up to be military reservists. So when considering medical support operations, civilians are brought in to work in military field hospitals as part of the reserve force. It is more difficult to make this work the other way round although mechanisms to allow for this are being looked into.
Civilian field hospitals are reliant on an acceptance approach for their security in the field. So for example, there might be a field hospital with unarmed guards and then a truck will roll up with wounded militia and the staff will say ‘of course we’ll treat you, we don’t care which side you come from, but you must leave your guns outside’.
“But as soon as they turn up and there are armed guards at the field hospital the situation has huge potential for escalation.
“If you have the weapons you have to be prepared to use them, in which case you are in danger of creating patients for yourself.
“And further to that the message will soon get out that there are armed forces at the field hospital, people will ask why and the potential for it to be attacked has increased.”
Twenty years ago this was less of an issue. The white vehicles and blue helmets of the UN Peacekeeping forces were a more accepted and respected presence in conflict regions than they are today as the nature of warfare and the hybrid threat has evolved.
Another potential problem with the military being shipped in to assist in aid efforts is that some serving personnel will not – nor would they be expected to – understand the nuances of aid delivery. Natural enthusiasm to help isn’t always beneficial to communities in need; even small changes can have long-lasting effects on the local economy. If a boat load of buckets is left on an island it could put the local man who has been selling buckets for 20 years out of business. Pre-deployment training for aid operations may be required but not always possible.
Adequate and timely funding and resources
One of the biggest challenges for NGOs is securing its supply chain and investing in appropriate resources in a timely fashion. Essentially, it’s an issue of funding. “NGOs don’t know if they have guaranteed funding – they might only know that a few days after a disaster happens,” said Mr Barden.
Ideally organisations would have funding pre-approved and sat in the bank waiting so that it could respond straight away following a disaster. Some of the larger ones do have stockpiles but to provide that for all in sufficient quantities would cost a fortune. NGOs have gone bust because they invested in and planned for relief efforts that didn’t happen.”
In the same way that the UK does not need to invest in expensive and seldom needed measures to keep its roads and airports open in severe weather conditions like Finland or Sweden, NGOs cannot always have that guaranteed funding because of the indeterminate nature of disasters.
The military are mandated to keep some capabilities at high readiness in order to support their personnel in the field. This means that they have a band of dedicated personnel committed to doing whatever they are instructed to do wherever that may be; it’s their duty.
In the civilian world there is far more room for disagreement and therefore uncertainty. Even finding time for training, which is part of the military way of life, is complicated in the civilian sphere.
“Pulling an NHS worker out of their job so they can come on a week long training course without it being a continued professional development (CPD) accredited course means that they have to take leave,” says Mr Barden.
“So if they do that two or three times a year then they will have no leave left to take with their family, which isn’t fair. We’re working hard to get that accredited but there is a limit.
“And even though we train our medical teams that will deploy as a team, when it comes to being needed some of them might be sick or have unbreakable family commitments. In the military there is someone on standby to fill that position immediately but this is much harder on the civilian side.”
Lessons learnt from Ebola – insurance premiums
The Ebola crisis in West Africa last year is a good example of when military and civilian organisations can work well together to provide effective aid and support.
“One of the problems with Ebola was that we were suddenly going to put our medics and aid workers right in the worst place they could be, an Ebola Treatment Centre Red Zone. This is something we rarely, if ever, do,” said Mr Barden.
“All organisations from DFID to the UN and NGOs we fund spend a lot of time and energy devising safety and security plans to keep people safe and away from flash points.”
Although it took a while to set up the field hospitals and start treating patients, that time allowed the various organisations to identify what the real problems were. Traditional burial practices were a major driver in the infection and spread of the disease, so the UK and others were able to focus on education to change behaviour in the affected areas and provide properly trained and equipped safe burial teams. In this instance time allowed the UN and aid agencies to tackle the root cause.
Another duty of care issue is insurance and this is an area where much thought and investment is required.
“Normally NGOs use a commercial insurance provider to medevac people with broken legs or those who have had a heart attack,” explained Mr Barden, “but none of those providers would touch Ebola. If the person starts secreting on the plane then the plane is out of action for a month while it’s cleaned.
“It’s a big challenge but there needs to be a dialogue with the major insurance providers because in the future we need an off-the-shelf product that will allow for high risk evacuations to happen.
“Insurance premiums went up and up and up and we couldn’t budget for it. So how does the insurance industry come up with a product that organisations can buy that will make a special evacuation flight possible?
“We need to think about that because it costs nearly £1 million to use the excellent services of the RAF.”