By Dr Ian Davis, Director, NATO Watch
The current Ebola outbreak has so far claimed the lives of thousands in West Africa. The rate of contamination is snowballing, with some predicting that more than 500,000 could be infected by the end of January. Small numbers of infected cases are also now appearing outside of West Africa, including in Europe and North America. The World Bank has said that the international community is not doing enough.
Two prominent British doctors, Professor David Southall and Dr Rhona MacDonald, have suggested that a possible way forward might involve the transfer of Ebola positive patients from West Africa to suitable "isolation hospitals" in well-resourced countries for treatment. At this point I should declare an interest. The two doctors work for a charity, Maternal and Childhealth Advocacy International (MCAI), to which I am a trustee. However, because of MCAI's recent experience in Liberia, as well as in medically evacuating critically ill children from Bosnia to the UK during the Balkans conflict in the early 1990s, I feel in strong position to back their judgement. In short, they believe there is too little time left to create and staff sufficient local Ebola Treatment Centres (ETCs) to control the epidemic. Instead, they suggest that ETCs be opened in well-resourced countries, either in existing isolation hospitals or in newly established military field hospitals.
In order to create a totally secure process of medical evacuation and treatment, they also suggest that military transport planes containing international health workers wearing appropriate protective clothing could care for Ebola patients during their journeys to these internationally based ETCs. Of course, such a suggestion raises many questions. And at this stage the idea is just that, an idea up for urgent discussion. Some may argue that the response needs to continue to be at a local level rather than taking the problem outside for it to be dealt with in the west. Gaining either popular or governmental support may also be problematic. There may also be concerns about the military further straying into the humanitarian and development fields. The purpose of this article therefore is to explore further the possibility of military support for such an initiative and in particular whether NATO might have a role.
Two NATO member states have already involved their militaries in the crisis. The Pentagon has been steadily growing its Ebola effort, with 350 US troops already on the ground in West Africa and another 3,000 on their way. One of the US military's infectious disease labs has been operating in Liberia for years and Washington is planning to build 17 ETCs in Liberia, each with 100 beds, although they are not expected to be ready until mid-November. In addition, the US military is deploying a 25-bed field hospital to Monrovia for health care workers to use if they contract the disease.The total Pentagon budget over the next six months for this initiative is $750 million. The UK is sending 750 troops and a hospital ship to Sierra Leone to help combat the spread of Ebola.
The US Agency for International Development and the Centres for Disease Control and Prevention, which are leading the US effort, say that if 70 percent of the people infected with Ebola can get into a treatment centre the disease's spread can be brought under control. However, the growing numbers of victims suggests that the Ebola outbreak will probably outpace current US and British efforts at containment. In which case, might NATO coordinate and oversee a medical evacuation and the setting up of ETCs in member states, along the lines proposed by Professor Southall and Dr MacDonald?
Close to the UK city of York, for example, 22 field hospitals have been set up in a hangar where they are training to look after health workers in Sierra Leone. This suggests that similar isolation hospitals could be set up within other NATO member states within a matter of weeks. Old military bases, hospital and other isolated locations could be identified where there is no public traffic and the risk of contamination is very low.
NATO forces should be well prepared to set up state of the art field medical facilities, are trained in the management of chemical and biological warfare and have the equipment ready to isolate and treat patients. Most NATO member states also have medical professionals within their militaries who could potentially treat Ebola. Pre-deployment training, personal protective equipment, strict medical and hygiene protocols, and constant monitoring would mitigate the soldiers' risks of becoming infected.
NATO also has a Centre of Excellence for Military Medicine (MILMED COE) located in Budapest, Hungary, which is tasked with facilitating interoperability between the military medical services in NATO. It has eight member nations (Czech Republic, France, Germany, Hungary, Italy, The Netherlands, Romania and the UK) and the Centre has four medical branches: Deployment Health Surveillance Capability (DHSC) – a satellite branch located in Munich, Germany; Interoperability, Lessons Learned and Training. The DHSC, in cooperation with the German Medical Intelligence, published a risk assessment of the Ebola outbreak in West Africa on the 24 September. While not an official NATO document, the authors conclude that it "makes sense to apply the principles of 'collective response' and the doctrine of 'smart defence' to combat the outbreak of Ebola”. They add:
From an epidemiological point of view, self-limitation of this outbreak in the near future (to use this euphemism fully aware of its ethical implications and long-term consequences) is apparently not a likely scenario. Doubtlessly, robust and urgent actions are needed to prevent such a catastrophe. In this context, the answer how far the NATO should and can be involved is not to be answered in a technical risk assessment. Nevertheless, this report supports the position that it could be in the best (security) interest of NATO nations and in perfect accordance to their fundamental values to substantially and jointly assist UN and the affected countries in their effortsto contain the outbreak and to protect the world peace.
In an earlier statement released on 11 September, the Chairman of the Committee of the Chiefs of Military Medical Services in NATO, LTG Gérard Nédellec, MD, PhD, said that, as a result of the Ebola outbreak, NATO needs "to be prepared to address existing or emerging bio defence threats up to Bio Safety Level (BSL) 4 which may pose a risk to NATO members, and overall global stability and security".
However, the specific challenges associated with naturally occurring epidemics have never been the focus of any sustained NATO activity. Hence, whether NATO has or is able to coordinate among its member states the necessary laboratory diagnostic capabilities up to BSL 4, specific outbreak investigation capabilities, medical evacuation transport, isolation/quarantine facilities, and appropriate infection prevention and control, required for an Ebola containment mission remains an open question.
But at a time when questionable missions are being contemplated to address threats from the so-called Islamic State in the Middle East, NATO boots on the ground to fight infectious disease seems like a more urgent and appropriate response for a military-political Alliance. Gérard Nédellec says that NATO must be prepared to provide a coordinated and unified response to the current Ebola threat in addition to any future communicable disease threat. He recommends that current deployable and domestic capabilities (both civilian and military) need to identified, with a view to greater sharing and coordination of such capabilities. He also calls for a realignment of NATO planning and funding priorities to focus on developing an efficient, effective and sustainable response to future infectious disease outbreaks. Detailed guidelines for Ebola management by NATO are expected to be released later this month. Not a moment too soon for the people of West Africa.
In the longer term, of course, there needs to be greater emphasis on strengthening already fragile health systems in West Africa. But in the current crisis, the idea of setting up emergency systems in NATO member states appears to have merit.