October, 2014, has seen unprecedented deployment of both US and British military personnel to support the efforts in west Africa against the Ebola crisis. Up to 4000 US troops could be deployed in Liberia as part of Operation United Assistance. The British Army commenced Operation Gritrock with the departure of a medical team on Oct 16 to Sierra Leone. “This unit has been the Vanguard medical regiment for the past 20 months which means we are on high readiness to deploy at short notice to anywhere in the world”, said Lieutenant Colonel Alison McCourt from 22 Field Hospital in Aldershot. This capacity to rapidly assemble highly trained personnel experienced in operating in extreme and dangerous conditions is just one factor that makes the military well suited to respond in such humanitarian crises, along with resources, expertise in logistics, transportation, and command and control.

Although countries like the UK and Australia contribute to humanitarian missions, by far the bulk of global support comes from the USA. Involvement of US military personnel in global health activities has increased substantially during the past decade, according to a report published on Oct 8 by the Center for Strategic and International Studies. The report, entitled Global Health Engagement: Sharpening a Key Tool for the Department of Defense, highlights the key role that the military health system could play in “the nation's health, diplomacy and development goals”, but also criticises previous activities in global health engagement carried out by the US Department of Defense (DoD).

Much of this criticism focuses on the poor coordination of DoD efforts alongside other civilian agencies, which still provide the vast majority of humanitarian global aid. Before the Ebola effort, DoD spending on global health engagement was estimated at US$600 million, compared with $9 billion from civilian agencies. The report describes an ad-hoc short-term focus, and accuses the DoD's global health efforts of poor appreciation of local cultural norms, little high-level oversight, and failure to properly assess effectiveness. However, the report acknowledges that since 2010, when a mandate for “promoting global health” was introduced into the US National Security Strategy, substantial developments have occurred in internal organisation, quality control, and inter-agency coordination. Specific examples include the formation of the new military position of DoD's global health engagement coordinator and efforts to undertake extensive outreach to civilian agencies.

The DoD has also released a report which discusses the increasing demands on the DoD to provide humanitarian assistance as a consequence of climate change. The report 2014 Climate Change Adaptation Roadmap describes climate change as a “threat multiplier”, with the potential to exacerbate existing challenges to US national security. This is the first report from the DoD that acknowledges that climate change-related global extreme weather events are already creating unstable conditions that affect national security, creating demands for more frequent disaster relief because of hunger, poverty, conflict, and population displacement.

The stated aims of the DoD have moved from just protecting the health of US forces and US citizens from security threats to “partnering with other nations to achieve security cooperation and build partner capacity”. But this concept reflects the challenges posed by placing military personnel in sites of public health emergencies: the goals of deployments are in support of military strategy rather than as a purely humanitarian action. The use of the military for humanitarian operations is not militarily, politically, or legally neutral. Peacekeeping with combat troops has often proved to be a complicated arrangement and at times at odds with humanitarian needs and sometimes a precursor to hostility.

The 2007 UN Oslo Guidelines clearly state that military assets should only be used as a last resort in situations where “there is no comparable civilian alternative…to meet a critical humanitarian need”—a position reinforced by AJP-9, NATO's doctrine on civil military cooperation. This situation is clearly the case with the Ebola epidemic, the scale and severity of which has outstripped the capacity of the humanitarian global health community. But should this involvement challenge the current position on military involvement in humanitarian catastrophes or prompt us to strengthen civilian global health systems?

As the DoD has recognised, the security of one nation's citizens is inextricably linked to others through both global health and climate change. Therefore, the military seem set to play a greater part in global civilian health in the future. The question is what should this role look like in the 21st century?

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Article Info Publication History Identification DOI: https://doi.org/10.1016/S0140-6736(14)61923-1 Copyright © 2014 Elsevier Ltd. All rights reserved. ScienceDirect Access this article on ScienceDirect