United Nations peacekeeping in South Sudan

The United Nations (UN) was founded in 1945 with the intent to ‘save succeeding generations from the scourge of war.’ Article 1 of its charter states that ‘the Purposes of the United Nations are to maintain international peace and security, and to that end: to take effective collective measures for the prevention and removal of threats to the peace, and for the suppression of acts of aggression…’1 This aspiration requires a spectrum of activity from: conflict prevention—stopping tensions from escalating into violence; peacemaking—finding the political agreement for peace; peace enforcement—making peace happen on the ground; and peacebuilding—reducing the risk of relapse into conflict.2 These activities do not all rely on the same tools. Conflict prevention is often thought of as a primarily political activity. Peacebuilding involves capacity building to support both society and state and so often involves political and development actors. Military peacekeeping missions usually sit in the middle part of this spectrum—enforcing peace agreements and ceasefires and ensuring a secure environment for early peacebuilding activities to take place. The primary responsibility for the maintenance of international peace and security rests with the United Nations Security Council (UNSC) and so only the UNSC has the authority to dispatch peacekeeping and peace-enforcing missions.3

The United Nations Mission to Sudan was established after the comprehensive peace agreement between the government of Sudan and the Sudanese Peoples Liberation Army in 2005. Despite the declaration of independence and establishment of a new government in Juba formally ending the civil war in Sudan, the peace in the new state was deemed sufficiently fragile that the first peacekeeping mission to South Sudan (United Nations Mission in South Sudan, UNMISS) was authorised under UNSC resolution 1996 on 8 July 2011. With appropriate pessimism given the bitter conflict that has followed, the peacekeeping mission started the day before the world’s newest nation state even came into being, on 9 July 2011. Its current mandate is to:

ensure the protection of civilians; to monitor and investigate human rights; to create the conditions conducive to the delivery of humanitarian assistance, and to support the implementation of the (peace) agreement.4

Large-scale fighting resumed in December 2013, and again in 2016. It is estimated that between December 2013 and April 2018, up to 4.5 million of the 10 million population were displaced and 383 000 killed.5 This combination of a humanitarian emergency in a region ‘where there is total or considerable breakdown of authority resulting from internal or external conflict and which requires an international response that goes beyond the mandate or capacity of any single agency and/or ongoing UN country program’ is the definition of a complex humanitarian emergency (CHE).6 This is a challenging space for civil–military relationships, but these relationships are vital. Aid agencies working to mitigate against the ravages of war and development agencies hoping to support sustainable increases in living standards and resilience to future shocks will be working in areas patrolled by blue-helmeted UN troops, international soldiers deployed under bilateral agreements, national government forces and militias. This philosophical and political no-man’s land is known as the triple nexus, where humanitarianism, development and security meet.

The UK deployed a Role 2 Medical Treatment Facility (a small hospital capable of damage control surgery) in 2017 as part of an Engineering Task Force in support of UNMISS, Operation (Op) TRENTON. This paper aims to describe the basic structure of UN missions as they pertain to CHE, and in particular the implications for civil–military relationships between medical units and other healthcare workers to inform future planning for UN missions.

Structure of the humanitarian response in CHE

At the beginning of the emergency, a Humanitarian Coordinator (HC) is appointed by the Inter-Agency Standing Committee’s (IASC) Emergency Relief Coordinator, based in New York. Typically, the Resident Coordinator (RC) of the UN Development Programme already in country becomes the HC as well—linking the UN and IASC roles. In a UNSC mandated mission, the UN Secretary General may also designate a Deputy Special Representative to the Secretary General (DSRSG). This is normally combined with the RC/HC appointment, called the ‘triple-hat.’ The RC/HC/DSRSG chairs the Humanitarian Country Team (HCT), setting the strategy for the humanitarian response and ensuring that the UN humanitarian crisis response, the ongoing development programme and the UN peacekeeping responses are coordinated at the highest level in country.

The HCT usually involves the lead agencies for some or all of the 11 UN clusters—coordination mechanisms for provision of relief across key domains such as logistics, nutrition and shelter (figure 1). There may also be representation from international non-governmental organisations, local non-governmental organisations (NGO) and the host government. While all relevant stakeholders will be closely engaged with the HCT, the actual make-up of the HCT itself varies according to the local context. The UN Office for the Coordination of Humanitarian Affairs (OCHA) acts as the secretariat to the HC, and has five key responsibilities: coordination, advocacy, policy development, humanitarian financing and information management. Within their coordination role, OCHA is also responsible for Civil-Military Coordination (CMCoord) and is the link from the HCT to the military.

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Figure 1

The United Nations (UN) cluster system showing the 11 clusters, each with the usual lead agency(s). IOM, International Organisation for Migration; WFP, World Food Programme. Reproduced with permission from OCHA19 .

The interaction between militaries and humanitarians in CHEs

In 2004, the IASC of the UN issued guidance on the role of militaries in CHEs and their interaction with civilian agencies involved in the humanitarian effort.7 It recognises that the military will be delivering security, potentially placing them in conflict with one or more of the parties involved. This stands in opposition to one of the four fundamental principles of the humanitarian organisations (box 1)—neutrality—the others being humanity, independence and impartiality. Indeed, deployment is at the behest of the government, who may have other reasons than a simple humanitarian imperative, so militaries cannot, by definition, be independent either. Finally, with regard to medical services, care in a military facility may not be impartial (ie, non-discriminatory) as only certain categories of personnel have automatic right of entry. While these may seem semantic, humanitarian organisations rely on these fundamental principles to negotiate access to those in need, and also for their own security. The IASC guidance asserts that whatever military activities are undertaken, they must not compromise the position of humanitarian organisations. The key factor in this is distinction—the concept that military activities should be clearly separated from those of the humanitarians at all times. Militaries should not look like the humanitarians, should not undertake similar activities if it can be avoided and should operate separately whenever possible.

UN integrated missions are complex from this perspective, as political, development and military activities will be taking place concurrently under the umbrella of the same mission to achieve the stated mandate. While integrated missions do not claim to include humanitarians, it is inevitable within the cluster system that there will be a degree of interaction with them. In Bentiu, Medecins Sans Frontières and other civilian organisations such as the World Food Programme (WFP) and the WHO were closely colocated (within the same outer perimeter) with peacekeeping contingents from Mongolia, Ghana, India and the UK.

In highly charged, volatile settings the humanitarian component (including the HC who acts as the civil–military liaison) may need to be located entirely separately from the military component of the UN mission—the ‘two feet out’ approach (figure 2). In stable situations, the two may coexist comfortably, and the UN OCHA component may reside within or near the military mission - “two feet in”. In the final construct, the humanitarian component is kept near to the military one, and OCHA resides outside the military mission but with liaison officers reaching in both directions—‘one foot in.’7 The South Sudan model appeared to be a variant of the ‘one foot in’ model, with another agency (Relief, Reintegration, Protection) representing the D/SRSG’s office as military liaison within the mission command, and OCHA staying further away in the humanitarian compound. This use of an alternative agency within the UN is unsurprising—while OCHA holds the mandate for coordination it is a small organisation, and coordination occurs simultaneously in many regions and across many technical areas.

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Figure 2

The civil–military structural relationship in United Nations (UN) integrated missions. (A) Two feet in—stable operation, OCHA and humanitarians closely located with military mission. (B) One foot in, one foot out—OCHA located outside the military mission, D/SRSG in. (C) Two feet out—separate locations and operations, including OCHA. D/SRSG, Deputy Special Representative to the Secretary General; HC, Humanitarian Coordinator; OCHA, Office for the Coordination of Humanitarian Affairs (adapted from OCHA20).

Civil-Military Cooperation, CMCoord or Defence Healthcare Engagement?

The Op TRENTON medical mission statement did not explicitly require any interaction with agencies beyond simple provision of care, as the mission was to provide medical support to the UN mission. There was no mandate within the Medical Rules of Eligibility to treat any civilians who were not ‘card-carrying’ UN workers, unless in exceptional circumstances when so directed by the Force Medical Officer. However, interaction with other agencies was an implied task. It was absolutely essential to delivering the mission that there was effective communication with the supported organisations, including humanitarian organisations within the integrated UNMISS such as the WFP.

There are two commonly described classes of civil–military interactions, which are subtly but importantly different—Civil-Military Cooperation (CIMIC) and CMCoord. We outline this difference with regard to Op TRENTON below.

CIMIC is defined by the North Atlantic Treaty Organization (NATO) as: ‘The co-ordination and co-operation, in support of the mission, between the NATO Commander and civil actors, including national population and local authorities, as well as international, national and non-governmental organisations and agencies.’8 The key words here are in support of the mission, the reason why CIMIC is often regarded with such suspicion by humanitarian actors. It is closely associated with a ‘Hearts and Minds’ approach. Civilians often fear an encroachment into their space in order to achieve military objectives, undermining their principles, access and safety. Many past CIMIC projects have done just that, often because of poor understanding of what constitutes an appropriate relationship and boundaries.9 10

There were many genuine examples of appropriate activity on Op TRENTON that could be regarded as CIMIC, and the chain of command was persuaded of the value of these activities as the mission developed. These included reciprocal visits to nearby healthcare facilities, such as the UNMISS Role 1 (primary care facility)and the WHO Headquarters in Bentiu. These publicised our capability to those we were supporting, improving their knowledge of what could and could not be delivered, and how to access our services. This in turn facilitated the military mission—resulting in more appropriate and consistent attendance patterns, and better use of UNMISS resources. It also enabled the unit to develop a clear picture of the medical capabilities in the area—information which was limited prior to deployment—allowing the identification of potential areas of support if the facility became compromised through resupply or equipment issues. Finally, it allowed early warning of changing trends in disease and non-battle injury presentations in other areas of the camp. The latter might be described as medical intelligence, although this term should be used cautiously in mixed audiences as it implies that it will be used in the wider intelligence context. ‘Medical situational awareness’ is a more neutral term, perhaps more appropriate for use with an already sensitised humanitarian population and makes clear the purposes behind such information gathering.

In contrast to CIMIC, CMCoord is a UN term, defined by OCHA as ‘the essential dialogue and interaction between civilian and military actors in humanitarian emergencies that is necessary to protect and promote humanitarian principles, avoid competition, minimize inconsistency, and, when appropriate, pursue common goals.’11 Activities are to promote humanitarian principles, not the mission. Arguably, the CIMIC-type activities already described may be subsumed into this definition. Although they did further the military mission, they were also aiming to promote these same humanitarian principles by allowing us to better support UNMISS; pursuing common goals and allowing us to understand the work of other agencies better—minimising competition and disruption.

Basic strategies for CMCoord range from cooperation to coexistence. Coexistence is the most minimal interaction with an emphasis on reducing competition and deconflicting activities. Cooperation aims to improve the effectiveness and efficiency of the combined efforts. Humanitarians are understandably anxious about the latter, fearing the impact that the implied shared responsibilities and interests may have on perceptions of their distinction from the military. OCHA seeks to manage some of these frictions by suggesting appropriate taskings depending on the security situation, expressed in the ‘cookie-truck-bridge’ analogy.12 They suggest delivery of aid items (the cookie) MUST be carried out by the humanitarians in all but the direst of circumstances, so that the face of the response is civilian. The bridge is infrastructure support—be it building roads, running an air traffic control or helping with planning. These activities are likely to benefit the whole humanitarian effort while blurring the lines between humanitarians and militaries far less, and so appropriate in most situations. The truck, or forward logistical support, sits halfway between the two and may be appropriate in permissive environments but could compromise humanitarian neutrality and safety in non-permissive environments.

One example of CMCoord was the development of the Bentiu Protection of Civilians (POC) major incident plan. The UK was asked to provide support given their expertise in major incident planning and response. UNMISS had a plan for the peacekeeping mission part of the compound, and the humanitarian actors, led by the International Organisation for Migration, had a plan for the POC Camp. Both plans contained key elements necessary for an effective response but no agreement for an integrated plan needed to ensure a predictable response no matter who the incident affected, or where. The UK facilitated a common language and framework for stakeholders, based loosely on Major Incident Medical Management and Support principles.13 Ongoing engagement and encouragement allowed a UNMISS owned and led plan to be developed with the full support of the humanitarian agencies over the next 4 months. ‘Train the trainer’ education ensured that the Ghanaian contingent rolled out training to other troop contributing nations providing a consistent activation and ‘Bronze’ area response regardless of the location of the incident and organisation responding. This kind of capacity building requires long-term contact to maintain and develop to the point of self-sustainment, but the initial effect was achieved easily, and was maintained through subsequent tranches of Op TRENTON.

However, we discovered that there are a range of areas where the pursuit of common goals seemed entirely appropriate, was not driven by the mission and rigorously maintained distinction. While these included some typical capacity-building activities such as support to planning and training, we also discovered the potential for atypical engagement facilitated by our shared health agendas—including joint education, research and mutual support through specialist medical capabilities and these may be best described under Defence Engagement (DE) as they do not fit easily into either CMCoord or CIMIC.

DE is ‘the means by which we use our Defence assets and activities, short of combat operations, to achieve influence.’14 It is further expanded to include activities such as upstream capacity building that prevents future conflict and instability, protecting UK national interests in the long term. Defence Healthcare Engagement (DHE) refers to DE undertaken by medical units.15 DE is normally considered to be a military to military activity although civilian interactions are not precluded. The difference between DHE in the Bentiu context and CMCoord is that it brings about long-term influence, relationships and capacity that are predominantly in the interest of the UK. Many of these will have no tangible benefit to the immediate mission on Op TRENTON, and so are not CIMIC, nor are they essential to the delivery of the immediate UNMISS humanitarian objectives and so are not CMCoord.

DHE effects may increase the capacity of international (civilian) organisations too—enhancing UK reputation and influence, but also securing UK national interests by capacity building in partner organisations. DE through international civilian agencies is not described in the literature describing how the UK military does its business (‘Doctrine’). Examples include military field testing of new equipment that may add to future capabilities. The BioFire FilmArray, one such example, is able to use multiplex PCR testing to analyse samples rapidly for the presence of specific pathogens. This was first fielded by the UK during the Ebola epidemic in 2014/2015 and found to be valuable.16 In Bentiu, the WHO stood ready to start an enormous containment campaign should cholera re-emerge, as there had been 1800 cases in 2016. Systems currently in place could take up to 14 days to confirm cholera in a suspected index case—leaving the responders in limbo for that period, uncertain whether this was a cholera outbreak or not. The BioFire can do the same in under 2 hours. Clearly there is value in being able to share experiences of equipment and procedures, and demonstrate their capabilities in the field, as many of our requirements overlap. This is separate from the obvious opportunity to lend actual diagnostic support to agencies around us—which does not build capacity in any meaningful sense and runs the risk of a capability disappearing as we redeploy but might in carefully considered circumstances be entirely appropriate.

Several other activities undertaken on Op TRENTON fall outside the normal scope of CIMIC, CMCoord or even the normal definitions of DHE—although they lie closest to this as they will have generated some reputational and influence benefits. Instead they seem to relate more to the shared ethos of healthcare, with its associated professional norms, ethical frameworks and professional requirements. An excellent example, familiar to UK clinicians, would be the initiation of joint continuing medical education meetings. These occurred fortnightly, and food and refreshments were provided by the UK at the beginning. The topics chosen were non-threatening, starting with major incident planning, then moving on to malaria and cholera. The purpose initially was to encourage everyone to bring their own experiences and contribute from the outset. Within three iterations, attendees included all the UNMISS troop contributing countries, the Russian aeromedical team, the UNMISS civilian Role 1, the WHO and several major NGOs. Key WHO messages, for example, aligning all malarial treatment regimens so that they complied with the regional WHO recommendations and were disseminated into the military sector, and functional relationships within the health network were built and developed. Educational opportunities like this also increase medical situational awareness, develop UK understanding of diseases that we do not regularly see, share best practice and enhance our reputation significantly.

These examples would all appear to represent ‘safe areas’ for civil–military relationships—distant from direct delivery of care to the affected population, and so unlikely to impact to any degree on the NGOs’ ability to operate freely in the humanitarian space. They are not infrastructure support in the sense espoused by OCHA—rather capacity building within our own and other responding organisations, developing the overall response with potential to impact on a humanitarian response far distant from South Sudan. In the most volatile areas even these minimal contacts might be inappropriate, but the safe areas concept offers important opportunities for improvement in medical care in integrated UN missions and beyond.

How we can build on the Op TRENTON experience

The OCHA guidelines repeatedly suggest that joint training between military and humanitarian actors before the disaster is essential to better understanding and cooperation when they do deploy: ‘Coordination is a shared responsibility facilitated by liaison and common training.’17 However, such engagement is extremely limited, with most personnel (75% of civilians and 50% of UK military) responding to a questionnaire in South Sudan stating that they had little or no knowledge of the OCHA guidelines, and had never trained with their counterparts at all.18

A network of contacts with organisations that we will engage with in future would allow us to raise issues such as training, shared research, best clinical practice and equipment while still in the UK—far distant from areas where our agendas and principles might conflict. Here the limits of these safe areas can be explored. These discussions could influence current guidelines to strengthen the whole system, while recognising the individual needs, perspectives and boundaries of various actors. This requires ongoing dialogue and needs to start soon to build on recent successes in relationship building in Sierra Leone and South Sudan. The Centre for Defense Health Engagement is ideally placed to lead on this.

To make the most of these opportunities, contacts should be developed before the deployment. We should engage with organisations already working in the area at an early stage and should develop understanding of the strategic priorities for the Ministry of Health and WHO in the region, as well as the capabilities and perspectives of the key health and health-related actors. Areas where our unique skill sets have a significant contribution to make to capacity building should be identified a priori, and the mission should be explicit about whether we wish to develop these projects or not, and if so, how they will be resourced and the likely limits of exploitation. This will prevent the opportunistic and potentially harmful ‘knee jerk’ DE projects that have been so well documented in the past.

Whenever possible, contact with representatives on the ground should occur within days of arrival, maximising our situational awareness from the beginning. In other words, civil-military education should be part of our training pathways, planned into our deployments from the outset and should take place on the ground immediately we arrive.

In conclusion, the South Sudan experiences of the Defence Medical Services highlighted several areas of civil–military interaction that are of particular interest to healthcare workers. It highlighted gaps in the doctrine and areas that should usefully be developed for both civilians and military personnel. There is now a clear opportunity to build on this new understanding through policy development and training, ensuring that as an organisation we are able to mesh effectively with such structures in future.