U.S. Military Assistance to International Health Emergency

U.S. Military Assistance to International Health Emergency
Banyan Analytics is an institute founded by Analytic Services Inc. that
aids the U.S. Government with the implementation of programs and
initiatives in the Asia-Pacific region. By combining ANSER’s rich analytic
methods with the expertise of scholars in Asian affairs, the institute
continues our corporate tradition by informing decisions that shape the
Nation’s role in the Asia-Pacific region.
U.S. Military Assistance to International Health Emergency Response:
Examining Frameworks for an Ebola-like Disaster in the Asia-Pacific
28-29 January, 2015
Quicklook Report
Outbreaks of Zaire ebolavirus and associated mass fatalities in Liberia, Guinea, and Sierra Leone have
elevated global concerns regarding the political, financial, social, and humanitarian challenges of a
virulent infectious disease. As part of its public-service mission, Banyan Analytics held a two-day exercise
and high-level discussion regarding international response to a future complex health emergency in the
Asia-Pacific, with a focus on the role of U.S. military assistance. The goals of the exercise were to
improve participants’ understanding of the use of U.S. military assets during an international health
emergency, identify solutions that increase the effectiveness of U.S. military support during
international health emergencies, and enable participants to understand and apply the basic principles
of risk communication.
In support of these goals, Banyan applied its broad capabilities and cross-domain expertise to provide a
forum that informed mission, policy, and doctrine decisions for future deployments to address disease
outbreaks, pandemics, and natural disasters. The exercise was organized into four “moves,” which
tracked the progress of an outbreak of Ebola in a fictional Asia-Pacific nation, Asiana. Each move was
prefaced by a learning module that deepened participants’ understanding of the issues and challenges
they would face in planning their response. This Quicklook Report summarizes the key takeaway issues
and action items identified by participants during the exercise. A final report with a full analysis of the
exercise findings will be released at a later date; please note that the findings and recommendations
within that report may differ from the key takeaways noted herein.
Move 1: Asiana in Crisis
An outbreak of Zaire ebolavirus has been confirmed in the nation of Asiana, one of the least
developed countries in the Asia-Pacific. With its population already suffering from widespread
poverty, malnutrition, and lack of access to clean drinking water and healthcare, Asiana is
quickly overwhelmed by the Ebola outbreak. Although Australia and Japan have sent medical
teams to help, international bodies such as the World Health Organization (WHO) and Médecins
Sans Frontières (Doctors without Borders) cannot provide significant support due to their
concurrent Ebola response efforts in West Africa. Recognizing that his country does not have the
capacity to mount an effective response, the Prime Minister of Asiana has convened a meeting of
foreign experts and U.S. Government and military officials to discuss how to request and
coordinate international assistance, with a focus on assistance from the U.S. Government and
U.S. Military Assistance to International Health Emergency Response
Quicklook Report
Participants were asked to identify the steps they can take to increase the effectiveness of
international aid and to request and apply U.S. Department of Defense (DoD) assets during a
health emergency.
Key Takeaways
Many countries lack resources to build requisite capabilities to fully implement the International
Health Regulations; this lack of capability will necessitate assistance from the international
community during a large disease outbreak.
Inherent complexities across the international health system impede rapid response to outbreak
or epidemic conditions.
The use of acronyms or jargon can disrupt communication and situational awareness,
particularly when English is not the first language of the host country.
The involvement of the Association of Southeast Asian Nations (ASEAN) would include
coordination of efforts with the U.S. Agency for International Development (USAID). ASEAN’s
decision to assist a nonmember country within the region involves consideration of whether the
assistance is the interest of ASEAN and its member states.
Participants identified confusion regarding roles, responsibilities, and mechanisms for
coordination of international and/or multinational humanitarian response efforts. The host
country needs to implement a coordination protocol to manage international providers.
With few exceptions, the USAID Office of Foreign Disaster Assistance (OFDA) is the lead
U.S. federal agency and will issue requests for proposals to meet requirements. As lead, USAID
engages in constant consultation with the U.S. Ambassador to the requesting nation and
remains integrated with the cluster system established by the United Nations Office for the
Coordination of Humanitarian Affairs (OCHA).
Responding organizations need assessments to determine requirements, yet they may lack the
capacity to perform these assessments.
The United States, when deciding whether to respond, should consider whether WHO has
declared a Public Health Emergency of International Concern.
USAID will keep in mind cultural considerations, such as relationships among the military, law
enforcement, and the public.
A disaster declaration cable from the U.S. Ambassador (or Chief of Mission) is needed to start
serious planning activities for the U.S. response.
Action Items
 Engage with ASEAN regarding provision of humanitarian and disaster response assistance.
 Educate all partners on the process for requesting U.S. assistance.
 Clarify a framework for coordination of international assets between the host nation and
international response partners.
 Pursue activities for public health preparedness prior to the onset of public health
U.S. Military Assistance to International Health Emergency Response
Quicklook Report
Move 2: Planning for Effective Response
The Prime Minister of Asiana decides to request U.S. assistance. The National Security Council
Staff and the lead federal agency, USAID OFDA, coordinate efforts regarding the request. USAID
OFDA begins assessing interagency capabilities to support Asiana. Given the situation and the
presence of military support to the response in West Africa as a precedent, use of U.S. military
assets in Asiana may be likely.
Given this situation, participants were asked to discuss which U.S. Defense Department assets and
capabilities are best suited for international health emergency response, and how U.S. assets can
address the cascading effects of infrastructure failures.
Key Takeaways
The U.S. military is only one of many potential providers that may be identified to respond,
depending on USAID OFDA’s assessment of needs and available capabilities. U.S. Pacific
Command (USPACOM) has medical and nonmedical assets that could be applied to international
health emergencies, such as wholesale logistics support, military airlift and sealift, training,
situational awareness and military-to-military command and control, and some limited
infrastructure support. Providing direct patient care is not considered a unique DoD capability,
which is why it was not done in West Africa; other bodies, such as nongovernmental
organizations (NGOs) would be used. The U.S. military does the wholesale movement and
distribution, but is not responsible for dispensing to populations (for example, moving pallets of
water, not handing out bottles).
The USAID Executive Secretariat Memorandum for DoD response will include mission,
implementation concept, and exit strategy.
USPACOM would not report directly to USAID OFDA, though efforts would be coordinated
through OFDA; USPACOM would work through OFDA liaisons.
It will be necessary to determine whether standing rules of engagement are in force or whether
special ones are needed; it is likely that U.S. military forces will not come into the host country
armed. The host country is responsible for the security of responding organizations, including
military responders—but the country may have limited capacity to provide security.
USPACOM has a tradition of holding back its larger assets to balance with the “last in, first out”
concept: create a small footprint first ensuring civilians are seen leading.
Establishing relationships with host nations and partners in advance of an incident is critical to
effective response.
Action Items
 Work with embassy teams, USPACOM’s Pacific Outreach Directorate (J9), the State
Partnership Program, and other organizations to establish working relationships with
partners in the Asia-Pacific.
U.S. Military Assistance to International Health Emergency Response
Quicklook Report
Move 3: Managing In-Country Support
The U.S. Government mounts a major interagency response that includes USAID OFDA, the
Centers for Disease Control and Prevention (CDC), the U.S. Public Health Service, and DoD. The
U.S. military deploys over 2,000 troops in various support capacities, including logistics support,
command and control, engineering support, and public health and medical training. The U.S.
assists in constructing outpatient clinics to expand medical capacity, although local populations
not presenting at these facilities hamper response. During the course of the response, deployed
personnel express concerns over whether the level of personal protective equipment (PPE) is
adequate. In addition, incidents of civil disorder erupt in Asiana, disrupting response efforts and
increasing the likelihood of disease spread.
Participants discussed how the United States could develop and adapt intervention strategies to ensure
that both U.S. and host country objectives are met. Participants also addressed considerations for
providing deployed military assets the equipment, training, and guidance needed to ensure their safety.
These situations stimulated a discussion of what external support might be needed for effective disease
mitigation efforts.
Key Takeaways
DoD provides PPE as a standard medical practice, but the military does not stockpile civilian PPE
as recommended by the CDC for Ebola. There is a current worldwide shortage, with the priority
being directed towards the West Africa response.
In health emergencies, the media can present inaccurate assessments and misrepresentations
of risk.
Fear or uncertainty regarding Ebola or other communicable diseases may depress interest from
the traditional humanitarian assistance responders.
Hospital ships would not be a proper platform for a communicable infectious disease.
Mission evolution should not become mission creep; however, continuing and ongoing
assessment of the situation should inform decisions by OFDA or the lead federal agency and the
U.S. Ambassador. Before the military is reassigned in-country, USAID OFDA would assess
whether others are more appropriate to fill that role. The system allows some flexibility, but
there is a defined process to ensure that changes are agreed upon; being too adaptable can
create chaos.
There may need to be an operational pause if the situation deteriorates from permissive to an
uncertain or opposed environment—very high-level risk discussions need to be held.
Expect that foreign policy would drive a desire to maintain an intact state as part of national
security and foreign policy—but any changes to the military posture need to be initiated by the
host country, and there may be other implications.
Political and popular support for U.S. involvement will fade quickly if a soldier is killed or if
soldiers start getting sick.
If part of the U.S. military mission requires working with NGOs, the U.S. military must remain
cognizant that some NGOs do not wish to be seen with armed military due to organizational
policies and potential conflicts with international law governing their status as neutral and
impartial humanitarian providers.
U.S. Military Assistance to International Health Emergency Response
Quicklook Report
Action Items
 Familiarize responding staff and organizations within DoD and the interagency with
processes for coordinating foreign disaster response and allowing for reasonable adaptation
when in-country.
 Review implications of having or not having established status-of-forces agreements on
foreign disaster assistance processes, considerations, and timelines.
Move 4: Risk Communication
Families of deployed soldiers are concerned about their military loved ones. They ask what
precautions were taken to prevent deployed soldiers from becoming ill, and what procedures
would ensure their return without putting families at risk.
Discussion followed on what communication strategies would be needed to inform stakeholders and
communities. Participants developed risk communication messages regarding the U.S. military mission
in Asiana, discussing what risk communication messages should be sent to deployed assets, in-theater
forces, families, and the general public, and when and how they should be delivered.
Key Takeaways
The U.S. military has methods to communicate with families to help build trust and
understanding about the role of their loved ones in the military.
UN OCHA has a risk communication checklist for Ebola divided into four phases, with most tasks
in the preparedness phase.
DoD has a strategic communication annex to its plan for pandemics and emerging infectious
The CDC Message Mapping Diagram can guide messages and question-and-answer sessions.
One consideration for communications is to convey a message of hope.
Listening and monitoring are in UN OCHA guidelines. One cannot formulate a message until one
knows the situation on the ground and the cultural context.
Action Items
 Develop hazard-specific risk communication messages and strategies prior to events.
 Identify appropriate risk communicators and provide training to leadership on key principles.
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