Original research BMJ Mil Health: first published as 10.1136/bmjmilitary-2020-001721 on 30 March 2021. Downloaded from Civil–military cooperation in the early response to the COVID-19 pandemic in six European countries Mohamed Gad ,1 J Kazibwe,1 E Quirk,2 A Gheorghe,1 Z Homan,3 M Bricknell 4 ► Additional material is ABSTRACT Key messages published online only. To view Background The COVID-19 pandemic has presented please visit the journal online many countries with significant health system and (http:// dx. doi. org/ 10. 1136/ This paper analyses the role of armed forces in economic challenges. The role of civil–military cooperation ► bmjmilitary- 2020- 001721). response to the COVID-19 pandemic, based on in a health crisis of the magnitude presented by COVID-19 1Global Health and case studies of six European countries. remains virtually unexplored. This review aims to detect Development (GHD) Group, We identified 19 distinct categories of and identify typologies, if any, of associations between ► Department of Infectious civil–military cooperation across seven main Disease Epidemiology, MRC security or military systems and the national response analytical themes. Centre for Global Infectious measures during the COVID-19, as adopted by six Euro- Results from Italy and Spain showed the Disease Analysis; and the Abdul pean countries during the early phase of the outbreak ► Latif Jameel Institute for Disease highest range and frequency of civil–military (January to March 2020). and Emergency Analytics (J- cooperation categories. IDEA), School of Public Health, Methods We designed a structured qualitative liter- Sweden showed the lowest range and Imperial College London, ature review (qualitative evidence synthesis), primarily ► frequency of civil–military cooperation London, UK targeting open- source grey literature using a customised 2Faculty of Medicine, Imperial categories. Google web search. Our target countries were UK, France, College London, London, UK ► The COVID-19 crisis has shown that the armed 3 Spain, Italy, Belgium and Sweden. We employed a ’best Centre for Science & Security forces and military medical services should Studies, Department of War fit’ framework synthesis approach in qualitative analysis be considered as key components of national Studies, King’s College London, of the result records. London, UK resilience. Results A total of 277 result records were included 4Conflict and Health Research Group, King’s College London– in our qualitative synthesis, with an overall search rele- Strand Campus, London, UK vance yield of 46%. We identified 19 distinct descriptive copyright. categories of civil–military cooperation extending across In some countries, the response to the outbreak Correspondence to seven analytical themes. Most prominent themes included during the spring of 2020 was believed to alleviate Dr Mohamed Gad, Global how military support was incorporated in the national part of this strain, especially on healthcare services. Health and Development (GHD) COVID-19 response, including support to national health However, the displacement effect of common lock- Group, Department of Infectious Disease Epidemiology, MRC systems, military repatriation and evacuation, and support down measures has left the global economy desta- Centre for Global Infectious to wider public systems. bilised. Baseline economic forecast from the World Disease Analysis; and the Abdul Conclusion Findings of this review show the significance Bank envisions a 5.2% contraction in global gross Latif Jameel Institute for Disease of military systems in supporting an expansive response domestic product throughout 2020, with many http://militaryhealth.bmj.com/ and Emergency Analytics (J- IDEA), School of Public Health, during the COVID-19 pandemic, and our proposed meth- countries already being pulled into economic reces- 6 Imperial College London, odological approach for capturing military health data in sions. As countries navigate their way through this London, W2 1PG, UK; m. gad@ a reproducible manner and providing a comparative view global health crisis, the expectation is that the global imperial. ac. uk on common types of interventions provided by civil–mili- response to COVID-19 may benefit from stronger tary cooperation to inform lessons from the use of military coordination and information sharing, both across Received 16 November 2020 7 Revised 2 February 2021 capacities during current COVID-19 outbreak. geographies and disciplines. Accepted 9 February 2021 In Europe, national decision- makers sought to engage with various domestic and regional stake- holders to respond to the threats posed by the INTRODUCTION outbreak. Policy responses have extended beyond on September 28, 2021 by guest. Protected The topic of civil–military relations during public health interventions.8 Notable examples include the health emergencies has tended to focus on the private sector scaling up manufacturing of personal relationship between international armed forces protective equipment and ventilators9; and the (including military medical services) and human- military or security sector support to healthcare itarian actors on overseas intervention opera- interventions and implementation of national © Author(s) (or their tions.1 While there has been increased emphasis COVID-19 measures such as enforcing lockdowns employer(s)) 2021. Re- use on the importance of national resilience and civil and maintaining public order.10–13 This coopera- permitted under CC BY- NC. No preparedness as a component of national security, tion was also evident across countries in the form commercial re- use. See rights and permissions. Published this has been perceived to be a civilian responsibility of international aid relief, regional fiscal policies 2 by BMJ. with military support as a last resort. and mutual assistance to deployment of front-line The COVID-19 pandemic has presented many healthcare resources. Such multisectoral coopera- To cite: Gad M, Kazibwe J, countries with significant challenges and extensive tion allowed governments to provide a rapid and Quirk E, et al. BMJ Mil Health 14 Epub ahead of print: [please system- wide effects across their society. Both public extensive response to meet urgent system needs. include Day Month Year]. and private health sectors seemed to have been Putting aside issues of COVID-19, the role of doi:10.1136/ overwhelmed, especially in countries worse hit by military health systems in contributing to popula- bmjmilitary-2020-001721 the virus or in resource- constrained settings.3–5 tion health and the domestic health policy tends Gad M, et al. BMJ Mil Health 2021;0:1–10. doi:10.1136/bmjmilitary-2020-001721 1 Original research BMJ Mil Health: first published as 10.1136/bmjmilitary-2020-001721 on 30 March 2021. Downloaded from to be poorly understood.15 It is often viewed as a distinct Godin et al27 highlight some inherent limitations in using entity from the civilian health system, though the armed forces Google search algorithms for literature review. These were miti- and wider security services could play a greater role in global gated by taking measures to standardise our method for easier health and national public health.16 17 The ALMANAC Mili- multiresearcher reproducibility of results and by a review of tary Medical Corps Worldwide collates some data on military a sample of each of the search results by a second reviewer to health systems; however, the depth and quality of the informa- minimise selection bias. A standard ‘step- by- step search instruc- tion is insufficient for international comparisons.18 With the tions protocol’ was developed and consistently used. This exception of complex emergencies linked to humanitarianism included using Google search by a generic access point (non- user and peace-keeping efforts, it is often neglected from main- defined), setting search language to native language of respective stream global conceptualisations such as United Nations devel- country, following exact order of insertion of search terms and opment system or WHO health system building blocks.19 20 adjusting search settings in Google search to display results by Nevertheless, in many countries, the security or military health respective local geographical regions. More information on the system is substantive. This is true across many domains such as search strategy is available in online supplemental material. budget, size (number of facilities, staff), throughput (number of We carried out two preparatory search rounds on eight coun- patients, population served) and endowment (higher than usual tries on 21 April 2020. These rounds enabled us to design our availability of high- performance diagnostic and therapeutic study by testing various search techniques and consequently equipment, medicines and consumables).21 The research that developing a search strategy suitable for our study objectives. has been done on the Ebola outbreak in West Africa (2014– This included refining the search criteria, time horizon, search 2016) emphasised the importance of military support in health language and target countries. provision to national population during epidemics. However, it is suggested that whatever cooperation occurred at the peak Target countries of the outbreak may have not been taken forward, in spite of Six European countries emerged as suitable candidates during 22–25 the increased profile of the global health security agenda. our preparatory search rounds. These were the UK, France, As a result, the nature of