Enmity then empathy: How militarisation facilitated collaborative but exclusive exchange in Sierra Leone's Ebola response.

In the autumn of 2014, with the 2013-16 West Africa Ebola epidemic spiralling out of control, the United Kingdom announced a bespoke military mission to support-and in some ways lead-numerous Ebola response functions in Sierra Leone. This study examines the nature and effect of the civil-military relationships that subsequently developed between civilian and military Ebola response workers (ERWs). In total, 110 interviews were conducted with key involved actors, and the findings were analysed by drawing on the neo-Durkheimian theory of organisations. This paper finds that stereotypical opposition between humanitarian and military actors helps to explain how and why there was initial cooperative and collaborative challenges. However, all actors were found to have similar hierarchical structures and operations, which explains how and why they were later able to cooperate and collaborate effectively. It also explains how and why civilian ERWs might have served to exclude and further marginalise some local actors.

Militaries and global health: peace, conflict, and disaster response.

Many countries show a growing willingness to use militaries in support of global health efforts. This Series paper summarises the varied roles, responsibilities, and approaches of militaries in global health, drawing on examples and case studies across peacetime, conflict, and disaster response environments. Militaries have many capabilities applicable to global health, ranging from research, surveillance, and medical expertise to rapidly deployable, large-scale assets for logistics, transportation, and security. Despite this large range of capabilities, militaries also have limitations when engaging in global health activities. Militaries focus on strategic, operational, and tactical objectives that support their security and defence missions, which can conflict with humanitarian and global health equity objectives. Guidelines-both within and outside militaries-for military engagement in global health are often lacking, as are structured opportunities for military and civilian organisations to engage one another. We summarise policies that can help close the gap between military and civilian actors to catalyse the contributions of all participants to enhance global health.

Chemical Weapons and public health: assessing impact and responses.

BACKGROUND: The recent use of Chemical Weapons (CWs) in armed conflicts and terror attacks highlights the importance of understanding their full impact in order to inform an effective response. This article argues that while the consequences of CWs on individual health have dominated our understanding of the impact of these weapons, far less attention has been directed to their impact on public health. METHODS: A review of the literature on the health impact of CWs was conducted, and two case studies of their use in urban settings were explored - Halabja in northern Iraq in 1988 and throughout Syria's ongoing conflict. RESULTS: The importance of considering the long-term health consequences of CW use and their impact on healthcare and health systems was demonstrated. CONCLUSIONS: This article highlights the importance of supporting future research on the topic and proposes a framework for assessing the public health impact of CW use.

Global health security: the wider lessons from the west African Ebola virus disease epidemic.

The Ebola virus disease outbreak in West Africa was unprecedented in both its scale and impact. Out of this human calamity has come renewed attention to global health security--its definition, meaning, and the practical implications for programmes and policy. For example, how does a government begin to strengthen its core public health capacities, as demanded by the International Health Regulations? What counts as a global health security concern? In the context of the governance of global health, including WHO reform, it will be important to distil lessons learned from the Ebola outbreak. The Lancet invited a group of respected global health practitioners to reflect on these lessons, to explore the idea of global health security, and to offer suggestions for next steps. Their contributions describe some of the major threats to individual and collective human health, as well as the values and recommendations that should be considered to counteract such threats in the future. Many different perspectives are proposed. Their common goal is a more sustainable and resilient society for human health and wellbeing.

Medical services policy in respect of detainees: evolution and outstanding issues.

Alleged and confirmed abuse of civilians arrested or detained by the UK Armed Forces has been the subject of four formal enquiries, and all have used medical evidence and/or addressed medical issues. After the first three, robust policies were put in place to ensure that all those arrested had appropriate medical examinations and that healthcare personnel acted appropriately. However, by the time of the Second Gulf War, the training and medical processes had lapsed and were found to be a contributory factor in not preventing abuse. The fourth enquiry has endorsed most of the lapsed policies but is ambiguous in two areas-on medical certification of fitness for interrogation and the timing to the first medical examination. This article summarises the medical aspects of the four enquiries and discusses the two ambiguous areas, arguing that to diverge from the policies eventually put in place in Northern Ireland is a retrograde step. It also discusses how training put in place to avoid the very events which occurred in the Second Gulf was discontinued.

Travel restrictions and infectious disease outbreaks.

BACKGROUND: A key purpose of the International Health Regulations (IHR) is to prevent unwarranted interruptions to trade and travel during large and/or transnational infectious disease outbreaks. Nevertheless, such outbreaks continue to disrupt the travel industry. This aspect of the IHR has received little attention in the academic literature despite its considerable impact on affected States and commercial activity. This article outlines the challenges and gaps in knowledge regarding the relationship between outbreaks and the travel sector and discusses the opportunities for further research and policy work to overcome these challenges. METHODOLOGY: We conducted a literature review on the relationship between outbreaks and travel restrictions, with a particular focus on the 2014-16 Ebola epidemic in West Africa. This review was complemented by an expert roundtable at Chatham House and further supported by case studies and qualitative interviews. RESULTS: Numerous travel stakeholders are affected by, and affect, large-scale infectious disease outbreaks. These stakeholders react in different ways: peer pressure plays an important role for both governments and the travel sector, and the reactions of the media and public influence and are influenced by these stakeholders. While various data sources on travel are available, and World Health Organization is mandated to work with States, there is no recognized coordinating body to disseminate timely, consistent, reliable and authoritative information and best practices to all stakeholders. CONCLUSION: This article highlights the interdependent relationship between various travel stakeholders. The reasons for interruption of travel during the 2014-16 Ebola outbreak were complex, with decisions by States only partly contributing to the cessation. Decisions by non-state actors, particularly the travel industry itself, contributed significantly and were based on a variety of factors. Further research, analysis and policy development are required to mitigate the health and economic consequences of infectious disease outbreaks. Any further research will also need to take account of COVID-19 travel-related issues.

Strengthening Public Health Leadership in Africa: An Innovative Fellowship Program.

PROBLEM: The Ebola virus disease crisis in West Africa revealed critical weaknesses in health policy and systems in the region, including the poor development and retention of policy leaders able to set sound policy to improve health. Innovative models for enhancing the capabilities of emerging leaders while retaining their talent in their countries are vital. APPROACH: Chatham House (London, United Kingdom) established the West African Global Health Leaders Fellowship to help develop the next generation of West African public health leaders. The innovative program took a unique approach: Six weeks of intensive practical leadership and policy training in London and Geneva bookended a 10-month policy project conceived and carried out by each fellow in their home country. The program emphasized practice, site visits and observation of U.K. public health organizations, identifying resources, and networking. Strong mentorship throughout the fieldwork was a central focus. Work on the pilot phase began in June 2016; the fellows completed their program in September 2017. OUTCOMES: The pilot phase of the fellowship was successful, demonstrating that this "sandwich" model for fellowships-whereby participants receive focused leadership training at the start and end of the program, minimally disrupting their lives in-country-offers exciting possibilities for enhancing leadership skills while retaining talent within Africa. NEXT STEPS: On the basis of this successful pilot, a second cohort of eight fellows began the program in October 2018. The expanded African Public Health Leaders Fellowship has become a central activity of Chatham House's Centre on Global Health Security.

Patterns of civilian and child deaths due to war-related violence in Syria: a comparative analysis from the Violation Documentation Center dataset, 2011-16.

BACKGROUND: Since March, 2011, the Syrian civil war has lowered life expectancy by as much as 20 years. We describe demographic, spatial, and temporal patterns of direct deaths of civilians and opposition combatants from conflict-related violence in 6 years of war. METHODS: We analysed conflict-related violent deaths with complete information on date, place, and cause of death and demographic group occurring from March 18, 2011, to Dec 31, 2016, recorded by the Violation Documentation Center (VDC). We included civilian and combatant deaths in all Syrian governorates, excluding government-controlled areas. We did not include detainees and missing persons, nor deaths from siege conditions or insufficient medical care. We categorised deaths based on VDC weapon type. We used χ2 testing to compare deaths from different weapons in civilian men, women, boys, and girls and adult and child combatants. We analysed deaths by governorate and over time. FINDINGS: The VDC recorded 143 630 conflict-related violent deaths with complete information between March 18, 2011, and Dec 31, 2016. Syrian civilians constituted 101 453 (70·6%) of the deaths compared with 42 177 (29·4%) opposition combatants. Direct deaths were caused by wide-area weapons of shelling and air bombardments in 58 099 (57·3%) civilians, including 8285 (74·6%) civilian women and 13 810 (79·4%) civilian children, and in 4058 (9·6%) opposition combatants. Proportions of children among civilian deaths increased from 8·9% (388 of 4254 civilian deaths) in 2011 to 19·0% (4927 of 25 972) in 2013 and to 23·3% (2662 of 11 444) in 2016. Of 7566 deaths from barrel bombs, 7351 (97·2%) were civilians, of whom 2007 (27·3%) were children. Of 20 281 deaths by execution, 18 747 (92·4%) were civilians and 1534 (7·6%) were opposition combatants. Compared with opposition child soldiers who were male (n=333), deaths of civilian male children (n=11 730) were caused more often by air bombardments (39·2% vs 5·4%, p<0·0001) and shelling (37·3% vs 13·2%, p<0·0001) and less often by shooting (12·5% vs 76·0%, p<0·0001). INTERPRETATION: Aerial bombing and shelling rapidly became primary causes of direct deaths of women and children and had disproportionate lethal effects on civilians, calling into question the use of wide-area explosive weapons in urban areas. Increased reliance on aerial bombing by the Syrian Government and international partners is likely to have contributed to findings that children were killed in increasing proportions over time, ultimately comprising a quarter of civilian deaths in 2016. The inordinate proportion of civilians among the executed is consistent with deliberate tactics to terrorise civilians. Deaths from barrel bombs were overwhelmingly civilian rather than opposition combatants, suggesting indiscriminate or targeted warfare contrary to international humanitarian law and possibly constituting a war crime. FUNDING: None.