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Coordination and relationships between organisations during the civil–military international response against Ebola in Sierra Leone: an observational discussion
  1. Colleen Forestier1,
  2. A T Cox2 and
  3. S Horne3
  1. 1Canadian Armed Forces Health Services Headquarters, Ottawa, Ontario, Canada
  2. 2Royal Centre for Defence Medicine, Birmingham, UK
  3. 316 Medical Regt, Colchester, UK
  1. Correspondence to Maj A T Cox, Royal Centre for Defence Medicine, Birmingham, B15 2SQ, UK; acox{at}doctors.org.uk

Abstract

The Ebola virus disease (EVD) crisis in West Africa began in March 2014. At the beginning of the outbreak, no one could have predicted just how far-reaching its effects would be. The EVD epidemic proved to be a unique and unusual humanitarian and public health crisis. It caused worldwide fear that impeded the rapid response required to contain it early. The situation in Sierra Leone (SL) forced the formation of a unique series of civil–military interagency relationships to be formed in order to halt the epidemic. Civil–military cooperation in humanitarian situations is not unique to this crisis; however, the slow response, the unusual nature of the battle itself and the uncertainty of the framework required to fight this deadly virus created a situation that forced civilian and military organisations to form distinct, cooperative relationships. The unique nature of the Ebola virus necessitated a steering away from normal civil–military relationships and standard pillar responses. National and international non-governmental organisations (NGOs), Department for International Development (DFID) and the SL and UK militaries were required to disable this deadly virus (as of 7 November 2015, SL was declared EVD free). This paper draws on personal experiences and preliminary distillation of information gathered in formal interviews. It discusses some of the interesting features of the interagency relationships, particularly between the military, the UK's DFID, international organisations, NGOs and departments of the SL government. The focus is on how these relationships were key to achieving a coordinated solution to EVD in SL both on the ground and within the larger organisational structure. It also discusses how these relationships needed to rapidly evolve and change along with the epidemiological curve.

  • PUBLIC HEALTH
  • TROPICAL MEDICINE

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Key messages

  • The international response to the Ebola epidemic in Sierra Leone was a multi-agency response led by the UK Department For International Development (DFID) and involved the British, Sierra Leonean, Canadian, Dutch and Irish Armed Forces, as well as numerous governmental and non-governmental civilian organisations.

  • The nature of the response evolved throughout the operation, with the military having a greater role early in the response, especially in the areas of leadership, logistics and engineering expertise and medical reassurance.

  • Understanding the human and organisational factors involved in the response, particularly those that were either helpful or detrimental, is key in understanding how similar operations may develop in future.

  • Military training should integrate aspects of interorganisational coordination in order to further develop an understanding of a range of actors and to facilitate an enhanced response during future operations of this kind.

Introduction

This paper aims to provide a synopsis of the involvement and relationships of various organisations in response to the Ebola virus disease (EVD) outbreak in Sierra Leone (SL). It is based on a combination of the personal experiences of the authors and the preliminary distillation of information gathered in a series of formalised interviews with key informants from the UK military, the Department for International Development (DFID) and a senior employee at a United Nations (UN) organisation. It provides comments on future considerations that may improve future civil–military engagements.

EVD background

The first casualty of the 2014/2015 West African Ebola outbreak was an 18-month-old child in Meliandou (a 31 household village in Gueckedou District, Guinea) on 26 December 20131 who died within 2 days of becoming ill. By the second week of January 2014, several members of his family as well as a number of community healthcare workers and staff at the receiving hospital had also succumbed. The first public health alert came on 24 January, but initial investigating teams found bacteria in the samples and concluded that the victims had died of cholera. Despite the ongoing development of cases, there were no further public health alerts issued until 1 March 2014. Later that month, a filovirus (Marburg or Ebola) was finally identified as the cause of the outbreak and on 23 March the WHO publicly announced the outbreak on its website; 49 cases and 29 deaths had been officially documented,2 and EVD had been imported into SL and Liberia. Ongoing delays in recognition of the outbreak allowed the virus to spread to neighbouring communities, across porous and frequently crossed borders and continue unabated due to the fragile public health and surveillance systems of all three countries; a result of political instability and conflicts over recent decades. Conditions were set for the disease to spread rapidly, facilitated further by high levels of poverty and cultural practices and beliefs.

The most common construct of a humanitarian crisis response

The textbook humanitarian crisis response involves the United Nations Office for the Coordination of Humanitarian Affairs (UN OCHA) coordinating the activities of major organisations using a ‘cluster’ system to structure the response. The explicit intent of UN OCHA is to improve accountability, capacity, predictability, leadership and partnership within the humanitarian response.3

The humanitarian coordinator (often the most senior UN representative in the country) is usually responsible for overall response coordination as well as the oversight of the 11 clusters, each one representing a key area of activity. Each cluster is managed under the direction of a lead agency (Figure 1). Cluster leads are responsible for gathering the key stakeholders, including host nation government departments, international organisations (IOs) or non-governmental organisations (NGOs), and coordinating their activities.3 This cluster response did not happen in the case of the Ebola outbreak, perhaps because of the perception that it was just a health issue and other pillars were not required.

Figure 1

The characteristic Office for the Co-ordination of Humanitarian Affairs (OCHA) cluster system of humanitarian and emergency relief. FAO, Food and Agriculture Organization; IFRC, International Red Cross and Red Crescent Movement; IOM, International Organization for Migration; UNDP, United Nations Development Programme; UNHCR, United Nations High Commissioners for Refugees; WFP, World Food Programme.

Civil–military support to a humanitarian response

Within the UN OCHA system, the UN Humanitarian Civil–Military Coordination Section (CMCS) specifically outlines how military actors are best employed and provides best practice guidance for military–civilian (particularly NGOs) interfacing.4 The fundamentals of these best practices are encapsulated in the Oslo guidelines,3 which recognise the value of Military and Civil Defence Assets (MCDA) in the delivery of assistance; however, it also recommends that the military should be used only as the last resort to fill a capability gap that humanitarian agencies are not able to deliver.

The use of the military to augment the civilian response in the context of a disaster is not new. Military contributions have been part of many humanitarian responses, including the floods of Mozambique in 2000, the South Asian tsunami in 2004, the Haiti earthquake in 2010 and the Typhoon Haiyan in the Philippines in 2013, to name just a few, but the use of the military in such situations does remain controversial. The well-known international non-governmental organisation (INGO) Médecins Sans Frontières (MSF) has stated that they believe that military forces and NGOs can never truly coexist and can at best converge in their objectives.5 The UN OCHA suggests that civil–military coexistence should be the baseline and the two should aspire to effective cooperation. This implies primarily verbal contact on a regular, but potentially informal basis, without an underlying contract or agreement, so as not to threaten the autonomy of either organisation.6 The interorganisational ties that help develop effective networks in humanitarian emergencies rely on past experiences with other agencies, previous working relationships with other actors and an observed track record of delivery, consistency and goodwill, all of which can be developed by effective civil–military coordination before the disaster.

Features of the EVD epidemic that made the response unique

Responding effectively to the EVD epidemic was challenging for all organisations involved because EVD is unique in many ways. It is one of the most virulent pathogens in the world with a high mortality rate, is non-selective in its choice of victims, but often preys on human kindness by infecting those caring for others.

The scale of this particular EVD outbreak was unprecedented. With every passing week, the response seemed more unmanageable, case numbers persistently climbed reaching over 200 cases per day at its peak and the healthcare infrastructures of the affected countries were overwhelmed. Within SL, the local NGO's, limited INGO's, the SL military and local healthcare workers made tremendous efforts to curb the spread of EVD, but they simply did not have the capacity, leadership or expertise to meet the ever-growing challenge. Based on the opinions of some interviewees, the SL Ministry of Health (MoH) was unable to coordinate the response required and was slow to accept the scale of the problem.

By the time WHO declared EVD to be a ‘Public Health Emergency of International Concern’ (PHEIC) in August 2014, there were three severely affected countries in West Africa: SL, Liberia and Guinea.7 The infrastructure and human resource capacities of all three countries were limited due to a paucity of training, leadership and financing, causing them to be overwhelmed, while fear continued to spread. The perception was that as an infectious disease outbreak, the crisis was different from ‘normal’ disaster relief or humanitarian emergency situations.8 No agencies felt prepared to deal with the personal protective equipment and training requirements to handle this contagion, especially as the rates continued to climb. In reality, no single agency had the capacity to respond decisively and it became clear that a successful response would require multiple international agencies to be involved.

It took an unusual move by the internationally known and respected MSF to really get the world to pay attention. On 2 September 2014, MSF President Joanne Liu spoke up in support of military intervention in the crisis, a request that had not been made by this NGO in nearly two decades.To curb the epidemic, it is imperative that States immediately deploy civilian and military assets with expertise in biohazard containment. I call upon you to dispatch your disaster response teams, backed by the full weight of your logistical capabilities. This should be done in close collaboration with the affected countries. Joanne Liu, President of Médecins Sans Frontières9

The request by MSF along with the PHEIC declared by WHO got the world's attention and key agencies began to look at how they could take action. Unfortunately, the response continued to be challenged by paralysing fear, resulting in an overwhelming reluctance of governments to commit personnel to the task and the inability of NGOs and INGOs to ensure the safety and health of their workers. This was particularly problematic as healthcare workers were experiencing an EVD fatality rate significantly higher than that of the general population.7

The agencies involved in the emergency response

With the growing number of EVD cases and difficulty in mounting the necessary response from UN agencies in SL,8 the UK government's DFID stepped in and pledged assistance. This agency had the ability to rapidly fund a large-scale response and housed the expertise necessary to analyse the requirements for the EVD response in SL. What DFID did not have was the manpower reservoir to deliver their response. While INGOs and NGOs slowly trickled into the country, they were not arriving quickly enough to manage the ever-growing number of cases. These agencies were also limited in their capacity to deliver sustainable manpower to meet the needs in an organised way.

According to discussions with DFID personnel in SL, when the EVD response scaled up in September 2014, many new agencies quickly discovered just how challenging the situation was. Local NGO's, local healthcare workers and other aid organisations were doing their best to manage the outbreak, but the lack of coordination, command and control as well as the overwhelming burden on the already fragile SL healthcare system created a chaotic situation. In what can best be described as a ‘whack-a-mole’ operational approach, every time DFID experts came up with a solution for a problem, another new challenge reared its head. For example, a first priority became getting the infected corpses off the streets and provision of a safe and dignified burial. Ambulances were the obvious solution for the task. However, this meant that there had to be training for the drivers and cleaners to disinfect the vehicles after transporting the bodies, logistics to ensure fuel tanks were filled, management of the fleet and a programme to increase public awareness of the need for these tasks (Figure 2). From each task grew others. For example, if ambulances were arranged, then there needed to be a mechanism by which the crews could be informed of each death, so a call and dispatch system needed to be developed. Once the system was in place to handle the dead, a system to handle the sick and symptomatic was required. Each step required a system of command and control and the infrastructure for this did not exist. Effective command and coordination infrastructure was a key element required to enable the delivery of a multilayered and comprehensive response.

Figure 2

Ebola signs near Freetown and Kerry Town, Sierra Leone (SL), May 2015. Some examples of the many different types of public health messaging clearly displayed along major roads and on posters throughout SL. These messages clearly encourage people to be vigilant, watch for signs and symptoms, to avoid unsafe burials (one of the most common cultural practices to overcome) and to call the national ‘117’ helpline.

International agencies continued to be reluctant to commit to the disaster response due to their concerns for their personnel and ability to fulfil their duty of care. It was apparent that only the military could provide the immediate access to logistics, personnel, training and coordination expertise that could be mobilised in a timely fashion and a decision was made to involve the UK Ministry of Defence (UK MOD). The UK MOD and later other allied nations such as the Canadian Armed Forces (CAF) and the Irish Defence Forces (IDF) were placed in the unique situation of supporting DFID. From the autumn of 2014, the UK MOD responded and proved that they had the ability to deliver quickly and flexibly with the support needed. Funded by DFID, the Armed Forces rapidly provided a training centre for local healthcare providers, built multiple Ebola treatment units (ETU's), including the Kerry Town Treatment Unit (KTTU), a healthcare facility designed specifically for potentially EVD-infected healthcare workers and originally run by 22 Field Hospital. In addition, the Armed Forces provided both military and civilian personnel involved in the response with force protection measures to mitigate the EVD and non-EVD risks involved in such a large operation. While the KTTU was particularly important, because it provided the necessary reassurance that many NGO's needed, to bring in personnel to work at the ETU's,10 additional reassurance was provided by the Royal Navy who deployed Royal Fleet Auxiliary Argus as a logistics and role 2 non-EVD hospital platform and the Royal Air Force who provided a capability in the form of an Air Transportable Isolator to aeromedically evacuate casualties, including those with EVD, to the UK.

The SL MoH was struggling to manage the coordination of the EVD response at a national level. To improve coordination, a dedicated National Ebola Response Centre (NERC) and multiple District Ebola Response Centres (DERCs) were created. The NERC was located in the capital city of Freetown, and the DERCs were located in all 14 districts. With operational planning and coordination integral to military training, along with the military's comfort with directive and hierarchical command relationships, their ability to integrate and run the command centres at the beginning of the EVD response was beneficial. Military personnel working under civilian leadership therefore played a vital role in the command and control of the NERC and the multiple DERCs, manning most of the key positions when the centres became operational.

Delays beget opportunity

Although the delay in the international response was in many ways problematic, it also provided a unique opportunity for the local government. The SL government was able to take part in the NERC and DERC command development and to take the lead in directing and coordinating the INGO and NGO responses. According to experienced humanitarian workers in SL who were interviewed, in most humanitarian responses such as Haiti in 201011 and Nepal in 2015, NGOs, IOs and other humanitarian agencies tend to rapidly overwhelm the local governments’ ability to coordinate the response. This can create a situation in which the humanitarian agencies end up operating in parallel rather than in support of the local government.11 This was not the case in SL during the EVD response. Organisations coming into SL were asked to take on preidentified DFID-funded roles in the EVD response and were expected to maintain the standard set out by the lead agency of that particular pillar.

The way the NERC was designed was based on local government oversight through a presidentially appointed chief executive officer (CEO) (Figure 3). SL line ministry representatives headed the technical pillars and were coordinated by the UN Mission for Ebola Emergency Response (UNMEER). The INGOs/NGOs participated in these pillars and in some cases took on a co-coordination role. The situation room provided the command and control functions. In concept, each DERC had a similar design with some minor alterations depending on district requirements (Figures 4 and 5). Each DERC was to feed information up to the NERC. At both the NERC and the DERCs, the military provided advisors and Chiefs of Staffs to help coordinate the functioning and to assist the CEO when required. DFID also provided civilian UK leads within the infrastructure. These relationships had to remain fluid and flexible to meet the rapidly changing response that reflected the evolving epidemiology.

Figure 3

National Ebola Response Centre (NERC) reporting structure diagram. Courtesy of Gp Capt F. Clifford.

Figure 4

Flow chart of patient process for live case management based on information from Western Area Ebola Response Centre (WAERC), May 2015. def'n, definition; DSO, District Surveillance Office; EVD, Ebola virus disease; pt, patient.

Figure 5

Western Area Ebola Response Centre (WAERC), May 2015: photograph shows the WAERC headquarters with multiple agencies working closely together and different pillar groupings as identified by the banners on the walls.

As clear as these relationships were on paper, it was not always simple or straightforward. Based on interviews and discussions with personnel working in advisory roles, the inner workings of the command centre relationships were difficult to define and to clarify. This was due in part to the many different types of organisations involved, different organisational cultures and different levels of comfort with command and control relationships and evolving nature of the disease and response. While the military is comfortable with a hierarchy, they do not have authority over civilian organisations. By contrast, civilian organisations, particularly NGO's and INGO's, are used to a great deal of individual and organisational autonomy. This situation was further aggravated by a rapid turnover of staff and loss of institutional knowledge, as well as political and funding pressures. For several of the individuals interviewed, an essential part of what made the interagency relationships effective was the vagueness with which they were defined allowing a high degree of flexibility to partners.

The establishment of the initial command and control elements at the NERC allowed the design of the distinctive EVD pillar structure to take shape. These pillars included: social mobilisation, safe and dignified burials, live case management, quarantine, contact tracing and surveillance and psychosocial support. By identifying these key pillars early, incoming INGO's and NGO's could be provided with important information about gaps in service provision, allowing them to assist in one of these areas and meet the local government requirements rather than having to do their own needs assessment and determining what it was they intended to provide. The INGO's and NGO's were essentially stepping in and providing required services where it was most needed and in some cases, to a predetermined standard. This standardisation of services proved to be important in coordinating the response. For example, one large INGO was identified as the lead agency for the dignified burial pillar at the NERC level. That large INGO determined the way in which the burials would be provided, based on developed best practice, and this standardised process was set out as a requirement for all the smaller organisations supporting that pillar across the country. By linking funding to the requirement to meet a particular standard, compliance with the standard could be achieved.

Understanding relationships between key organisations

A number of unique interagency relationships developed within the SL EVD response. The intense focus on a common goal drove the EVD response in a way that most experienced field workers had not previously experienced; each organisation involved had a common end goal of ‘getting to zero (EVD cases)’. There were no competing interests, priorities or drivers. The response was also heavily influenced by the rapidly evolving epidemiology, a situation that those interviewed had not previously encountered in humanitarian responses. This led to weekly and even daily evolutions in response planning and coordination.

Agencies that had not previously worked closely together suddenly found themselves working side by side. Military, INGO's and NGO's were co-located in the same headquarters, local government alongside DFID and the MoH. INGO's and NGO's were a vital part of the response and were engaged in a unique way: taking on difficult roles in the response and being faced with the need to become experts in areas of the response they had often never even previously considered within their expertise.

The relationships between the INGOs, NGOs and the military were mostly indirect. Autonomy was respected, and everyone understood they had a job to do. According to those interviewed, the INGO's and NGO's delivered an effective response on the ground. There seemed to be minimal friction between INGOs, NGOs and the military according to those interviewed, in part because the INGOs and NGOs arriving into SL understood that the military was an integral part of the response, and in part because there was a general understanding between the organisations that differences would be put aside as they worked towards a common goal.

This is not to say that friction did not occur. Interviewees commented that military personnel tend to be directive in their approach to making decisions, while civilian organisations tend to rely on consensus. At the outset of the EVD responses, there was not enough time to manage decision-making by consensus and the directive approach was necessary. According to those interviewed, as the response evolved, more organisations arrived, EVD rates slowed and the response became systemised and accepted, the leadership style of military directedness became more challenging for civilian organisations. In some cases, the military directedness was seen as a ‘dictatorship’ that caused relationship setbacks despite the best of intentions from all parties. While both military and civilian organisations are goal oriented, civilian ones often rely more heavily on relationship-building; an important and fundamental difference in how these organisations operate.

DFID provided the vital role of funding, as well as providing expertise in the areas of international development to develop a holistic plan for the response. DFID also managed the high-level coordination with local government and leveraging of strategic and political level relationships in order to ensure the response happen quickly. DFID did have challenges with sustainment of expertise over the longer term of the response and there were times when the rapid turnover of staff became difficult for continuity of information and knowledge management. In order to address some of these gaps, they relied on experienced and tested contracted personnel, but in reality, there were not many of these key players available to deploy, creating ongoing personnel and knowledge transfer challenges.

Not surprisingly, many interviewees commented on the importance of personality, emotional intelligence and personal flexibility on interagency relationships within the civil–military context. Due to the military's inherent hierarchical nature and the fact that the majority of time they deal in a solely military context, personality styles do not tend to influence the outcome of decisions when working in a military-only situation. Within civilian agencies, personalities can have a greater influence on decision-making and working relationships. This requirement for the military to ensure that personalities can adjust to a more civilian-style working relationship is a fundamental shift in how the military works on a day-to-day basis. It was observed that this key difference meant lower ranking officers and soldiers within the DERCs worked better with civilian agencies than higher ranking ones because they seemed to be better able to negotiate with the various agencies and had less expectation of making decisions and less need to demonstrate individual success.

While military ethos is all about leadership, and leadership styles are often personality driven, it suggests that there is actually a specific style of leadership best suited to this type of civilian–military engagement. It seems that a flexible, open-minded and collaborative leadership style needs to be taken into account when selecting key positions.

Future considerations for effective civil–military relationships

Civil–military engagements are likely to become more common in future for both organisational and political reasons. The Stockholm International Peace Research Institute12 recommended that the military should train to assist in humanitarian crises and that humanitarian actors should be involved in the design of this military training nearly 7 years ago after their study of military assistance to relief effort. Military disaster management training should incorporate the integration of other large civilian agencies. This will assist with the development of a better understanding of respective organisational structures, mandates, goals and missions and will help assist with more effective engagement.

DFID took on the lead role in the SL EVD crisis response. Their ability to flexibly fund such a massive undertaking and the expertise they provided were vital to the successful outcome. Having the military work in support of DFID worked well in this particular health crisis environment, but the SL EVD response may not be applicable to other crises where UN agencies play a more central role. Military training should therefore consider the different scenarios that may arise and the different structures and organisations that may potentially be involved in future humanitarian responses.

The roles and relationships of agencies participating in the EVD response evolved along with the epidemiology. The military role was critical at the beginning of the crisis response, providing planning and coordination expertise that most other agencies did not possess. As the response evolved and the epidemiological curve rapidly declined, the directive nature and hierarchical relationships that the military is familiar with became increasingly challenging for civilian agencies who depend on consensus decision-making style. This is important for military leadership to consider in prolonged responses, to ensure handover to civilian and development agencies happens as quickly as possible.

Individual personalities played an important role in how well organisations worked together, thus highlighting the importance of ensuring the right people partake in the right roles at the right time, particularly when it comes to interagency relationships. Unfortunately, at this time, no specific criteria exist to determine who might be best suited to these key roles, but this is an area for potential future research.

Communication between and among agencies was a challenge. Different agencies have different ‘chains of command’ and institutional mandates thus creating information ‘silos’ that made genuine interagency operational integration difficult. Understanding that there will always be political and cultural sensitivities around information sharing between agencies, this issue could have been ameliorated with clear high-level direction and consideration for common information networks.

The EVD response alone is unlikely to significantly alter the common challenges that civil–military engagements face when working together, but the experience may allow us all to better understand what each agency brings to the table, and what organisationally unique factors to consider when working together.

Acknowledgments

The authors would like to thank the interviewees who contributed the material used in this paper and in particular Kate Foster at DFID for her input and advice on the manuscript.

References

Footnotes

  • Contributors All authors contributed to the planning and writing of the manuscript.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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