Militarizing Global Health
November 11, 2014
Nov 11, 2014
14 Min read time
Epidemics are not security crises. But the army is often our only tool.
101st Aviators. Photograph: Virginia Guard Public Affairs
Using troops in a humanitarian crisis or to stop an epidemic is a seductive idea. Indeed, President Barack Obama dispatched the 101st Airborne Division to “fight” Ebola and the UN Security Council declared West Africa’s Ebola epidemic a threat to international peace and security. And on November 4, Sierra Leone’s President Ernest Bai Koroma declared a “military approach” to fighting Ebola, appointed his former defense minister, a retired army major, as head of the National Ebola Response Centre, and urged citizens to use force against those who resist public health directives.
This is worryingly authoritarian, bad for public health, and strategically counterproductive. Despite its impressive logistics, the army makes only a marginal contribution to international disaster relief—and often makes things worse. Nor do soldiers “fight” pathogens—and the language of warfare risks turning infected people and their caretakers into objects of fear and stigma. But, because of America’s politics of public finance, the army is the only tool we have. If civilian health programs were properly funded, they could have prevented the disaster.
Infectious Disease Is Not a National Security Threat
After the end of the Cold War, President Bill Clinton instructed national security analysts to focus on non-traditional threats to U.S. security. Vice President Al Gore focused on climate change. Another major theme was epidemics, spurred by the finding that infant mortality was one of the top three variables predicting state failure, and by the growing HIV/AIDS pandemic. In January 2000 the National Intelligence Council reported that “the persistent infectious disease burden is likely to aggravate and, in some cases, may even provoke economic decay, social fragmentation, and political destabilization in the hardest hit countries in the developing world.” That same month, at the initiative of the United States, the UN Security Council held a historic debate on HIV/AIDS, the first time it had ever discussed a disease.
Then came 9/11 and the anthrax scare. Rattled, the Bush administration began a $6-7 billion annual program for defense against bioterrorism. It is instructive to look into what the experts on smallpox, anthrax, and other potential weaponized germs did with that money. They already knew that a naturally occurring epidemic is much more probable than a bioterrorist attack, and that epidemics and bioterrorism require exactly the same response. So when the Centers for Disease Control was allocated $17.4 billion over ten years, it “put the vast majority into bolstering an underfunded public-health infrastructure. The rationale is that the nation has little chance of fighting a bioterror attack without a strong system for detecting, reporting and treating any emerging infectious disease.” The consensus was that spending for general population health is useful, but funds solely targeted at anticipated terrorist use of biological weapons are wasteful.
Public health advocates were grateful for the security alarm because it brought much-needed attention and funds. And they adopted martial language themselves. Calling for a Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria, Kofi Annan said, “The war on AIDS will not be won without a war chest.” International donors have increased their assistance to health fourfold since 2001, and in 2012, $28 billion was spent annually on global assistance programs for public health, with the U.S. government as the largest contributor.
Over the same period, researchers explored every connection between health and security in the history of disease. They found that modern epidemics do not cause security crises. For example, the influenza pandemic that followed World War I killed many more people than the war, but its political impact was negligible. John Barry concludes his account of the pandemic, “The fear, not the disease, threatened to break the society apart.” Many observers—including this author—predicted that Africa’s epidemic of HIV and AIDS would have far-reaching governance and security impacts—but those feared consequences failed to materialize. In fact, a human rights–based response to AIDS strengthened civil society and improved governance. Ebola may kill thousands of people and impoverish hundreds of thousands, but a nightmare of a new plague tearing down the pillars of social order is just that—a nightmare. Newly evolved pathogens are a constant threat, but a rerun of the near-total devastation of the native American populations by diseases entirely new to them is far-fetched for the simple reason that there are no longer any large populations wholly isolated from, and therefore at risk of, major infections.
Epidemics do not cause security crises.
The greater dangers come from panicked or coercive responses to disease. Margaret Chan, Director General of the World Health Organization, recently highlighted this: “rumors and panic are spreading faster than the virus. And this costs money. Ebola sparks nearly universal fear. Fear vastly amplifies social disruption and economic losses well beyond the outbreak zones. The World Bank estimates that 90 percent of economic losses during any outbreak arise from the uncoordinated and irrational efforts of the public to avoid infection.” Slapping travel bans or unjustified quarantine measures on the affected countries has a minuscule protective effect, and only makes it difficult to deploy health workers and maintain basic economic activities.
The National Intelligence Council revised its assessment in 2008. Gone were the predictions of social crisis and state collapse across Africa. Instead of scare stories, the new report concluded with a section entitled “Health as Opportunity: A New Look at a Successful Paradigm.” Global health, it suggested, is a fruitful field for diplomacy, including smoothing relations with adversaries, easing tensions between the United States and the developing world, and advancing economic development. The report was a parting gift from the Bush administration to its successor, a plea to maintain a rare example of a recognized success in foreign policy. It was also a plea to place U.S. global public health policy where it belongs, with health professionals. In turn, Obama’s 2010 National Security Strategy recognizes “Pandemics and Infectious Disease” as security threats, but its proposals keep national global public health programs with public health specialists, mostly civilian.
But this expert consensus is not reflected in federal spending priorities. Global public health is small change: $7.4 billion last year, down from $8.3 billion in 2011, with global health research and surveillance budgets at the Centers for Disease Control and the National Institute of Health of just $464 million and $527 million, respectively. By contrast, as the size and power of the Department of Defense have grown, so too has its involvement in global public health. According to a thorough review of its labyrinthine $650 billion budget, the “DoD dedicated no less than $579.7 million in identifiable funding to global health-related activities” in 2012, plus considerable other monies in other accounts.
The Pentagon’s public health officers are professionals—but they work for a department with other priorities. One review politely notes that the “DoD has long made significant contributions to science through military medicine, but its strategic thinking about global health and security issues is evolving very slowly.” It further observes that “Some short-term DoD activities risk undermining the longer-term objectives of civilian development agencies.” Another review describes how the “DoD at times fails to give due consideration to the methods and principles that define successful global health programs.”
The DoD has tried to learn. On paper, there are guidelines for how to engage with civilians, and these adopt many of the best practices of aid programs. The logic is the same as for biodefense, where the job is best done by investing in civilian research, surveillance, infrastructure, and response capacity. So why do U.S. voters ask soldiers to be involved? If the administration were serious about infectious disease as a security threat, it would spend far more than and re-allocate some of the DoD budgets for that purpose.
The Military Has Limited Value in Humanitarian Response
Ebola is not merely an epidemic, but a humanitarian crisis. The weak health services in Guinea, Liberia, and Sierra Leone are overwhelmed, people are frightened, and everyday activities such as bringing food to market are affected by fear of infection. Emergency humanitarian operations to stabilize food prices and maintain essential services are needed. The army can carry out some useful tasks—but it must know its place, and that is not in charge.
As the United Nations geared up to declare that Ebola was a threat to international peace and security, Obama announced “Operation United Assistance,” and dispatched the 101st Airborne Division to Liberia. He said: “Our forces are going to bring their expertise in command and control, in logistics, in engineering. And our Department of Defense is better at that, our Armed Forces are better at that, than any organization on Earth. We’re going to create an air bridge to get health workers and medical supplies into West Africa faster.” His words are surely true—after all, $650 billion a year should buy some impressive logistics—but a military-led response is still cost-inefficient and ineffective.
When Air Force planes carry out airdrops of emergency relief, they are invariably much more expensive and less effective than their humanitarian counterparts. Army engineers have the equipment to construct flood defenses or temporary accommodation for people displaced by fire or water, but there is invariably much wastage and learning on the job (by definition, too late). Experienced relief professionals can list many of the downsides of bringing in the military: they utilize vast amounts of oversized equipment, clogging up scarce airport facilities, docks and roads; their heavy machinery damages local infrastructure; they use more equipment and personnel in building their own bases and protecting themselves than in doing the job; their militarized attitudes offend local sensibilities and generate resentment; and they override the decision-making of people who actually know what they are doing.
In the days after the Haitian earthquake in January 2010, the U.S. Army was efficient at clearing debris, setting up an air traffic control system, and getting Haiti’s ports and airport functional. One third of the emergency spending in Haiti was costs incurred by the military. (The costing includes only additional or marginal costs for the deployment.) When the army moved into other relief activities, such as general health and relief programs, even those marginal costs were disproportionately high. Trained for battlefield injuries, army surgeons weren’t skilled at treating the crush injuries common in an earthquake zone. In West Africa today, militaries are providing an important air bridge, given that commercial airlines have stopped flying. But the United Nations could do the job more cheaply and efficiently—if it had the resources.
Invariably, military commanders want to be the ones giving orders. In a humanitarian crisis, relief operations are best run by civilians who understand relief. Some humanitarian workers actually refuse to be seen with soldiers—even peacekeepers—who are ostensibly there to support their activities. The army can carry out some useful humanitarian tasks—but it must know its place.
The Legacy of Public Health and Colonialism
There is another, deeper problem with the militarization of public health: the legacy of colonialism and coercive medicine. Best practices in global health include efforts to be sensitive to national histories and cultures and to overcome the suspicions induced by outside health programs. Medicine in khaki is not only inefficient, it is bad practice.
British, French, and American armies have a history of imposing control in the name of hygiene, cordoning off a city or as-yet-insufficiently governed parts of the global borderlands. After the opening of the Suez Canal, the British and French regulated migration in the Muslim world in the name of controlling infectious diseases, especially cholera. For pilgrims to Mecca, the vaccination card preceded the passport. Hubert Lyautey, the French general who conquered Morocco, famously saw public health as a tool of counter-insurrection: “the physician, if he understands his role, is the most effective of our agents of penetration and pacification.” Migrant laborers for South African mines were the focus of intense medical screening and control; rural populations in central Africa were forcibly relocated in the name of controlling sleeping sickness; traditional migration routes across the Sahel were strictly regulated ostensibly to stop transmission of infection.
The Air Force is invariably much more expensive and less effective than their humanitarian counterparts.
The United States imposed a similar securitized epidemiological control on Central America and the Caribbean after completing the Panama Canal. Its concerns were yellow fever and malaria. Army engineers developed skills and capacities in draining swamps and relocating communities to settlements where they, and their health status, could be monitored and controlled. The civil engineering skills were useful, but the military apparatus was problematic.
In much of Africa, public health has struggled to free itself from the way it was implicated in coercive colonial control measures. A foreign doctor arriving in an African town with poor health service is always openly welcomed, but there is also suspicion about whether he or she harbors a hidden agenda. Every time there is an epidemic that demands unpopular measures—HIV/AIDS and Ebola are examples—rumors spread that the infectious agent was introduced with the aim of controlling the African population. Frustrated physicians may stigmatize the local societies in which an epidemic has arisen, coming to believe that it is local misbehavior and irrationality that allows infections to spread. Such mutual resentment can quickly become the greatest impediment to public health, greater than the pathogen itself. Restrictive and unpopular measures may be needed to contain an epidemic, but they will only be effective if people understand why they are imposed.
National armies are often modeled on their colonial forerunners, and further shaped by military cooperation programs run by the United States, France, or Britain. The Armed Forces of Liberia, one of the few functioning institutions in a weak state, has been the government’s instrument of choice in responding to Ebola. President Ellen Sirleaf Johnson has declared a state of emergency, postponed elections, and deployed troops against demonstrators. Now Sierra Leone is following suit.
Ebola will be overcome by West Africans—with international help. This is a statement not of pious hope but of fact. Ebola is both an infectious disease and a societally based epidemic. Any health program in a country such as Guinea, Liberia, or Sierra Leone needs to apply best medical practices and make them work in the country’s own social environment.
Health policy experts know that foreign aid can only support national health programs and not substitute for them. Liberia is a sad case in point. A huge international aid program there did not generate the kind of public health infrastructure necessary for controlling infectious disease. In Sierra Leone, Koroma’s Free Healthcare Initiative, launched in 2010, immediately ran into enormous problems of capacity, corruption, and distrust, inherited from decades in which the health services were deprived of even the most basic resources.
One of the great, under-recognized successes of the response to HIV and AIDS in Africa was that the spread of an incurable sexually transmitted infection did not lead to repressive measures or massive stigmatization. On the contrary, the United Nations and donors insisted that public health be linked to human rights, and civil society organizations and people living with HIV and AIDS be represented in the governance of UNAIDS and the Global Fund.
That is the polar opposite of the war-like approach to Ebola. The Sierra Leonean journalist Oswald Hanciles drew out the implications of Koroma’s “war” on Ebola, comparing it favorably with the weak government defenses against the rebel attacks fifteen years ago: “This strategy of energizing and mobilizing youth to ‘comb’ their neighborhoods to ferret out ‘Ebola suspects’ could be the most potent in this Ebola War. We are optimistic that the President would use the security forces to back up the youths who the President said should be ‘hard.'” That would be a frightening prospect. Vigilante mobs dragging people from their homes or sealing off neighborhoods would destroy the public trust and community involvement at the heart of good public health practice.
The Ebola epidemic today demands a response that combines logistics with management of a social crisis. We need to dispatch front-line health workers; supply protective suits; provide safe means of disposing of the dead; staff the existing health infrastructure for regular (non-Ebola) health activities; and expand that infrastructure with special attention to isolation wards and evacuation facilities. We need to fund emergency epidemiological research on the transmission of Ebola and the development of a serum or vaccine. We also need to maintain social services and establish confidence in public health measures that may be undignified, alien, impoverishing, and unpopular. These demand the types of skills and relationships that only local health providers possess, combined with public education, community consultation, and a clear commitment to human rights.
The comparative advantage of the military lies in a few niche activities, such as airport infrastructure, transport helicopters, and—uniquely for this case—medical facilities to treat health workers when they themselves fall sick. All other activities are done far better by civilians.
The only rationale for sending the troops is that they and their equipment are available and already paid for, and would be doing nothing of significance otherwise. And, as a supplementary justification, that the U.S. Congress and taxpayers are ready to spend vast amounts of money on the military over modest amounts on global health.
This argument has a dreadful circularity; we are in this trap because we have paid for a bloated military and a threadbare global health system. It would be sickeningly wrong for the army’s role in responding to Ebola—inefficient, largely ineffective, but nonetheless better than nothing—to become a justification for why the Pentagon should continue to consume limitless resources. Soldiers can perform some useful tasks in West Africa. But their role should be brief, limited, barely visible, and subordinate to civilian control.
Militarizing public health is a strategic error. Security and public health experts know this and have tried to steer global health and security policies in a direction that is informed by the best evidence and analysis. But somehow, the beguiling metaphor of sending soldiers to fight pathogens still wins out, fueled by our deepest fears of disease, and by our uncritical acclaim for soldiery. It is time to discard misleading military metaphors and spend real money on real global public health.
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November 11, 2014
14 Min read time