Why health needs to engage the guys with guns

When Red Cross midwives in Nigeria are killed by militants or hospitals in Syria are deliberately bombed, it might seem perverse, if not downright naïve, to call on the health sector to step up engagement with armed forces.

Yet this is exactly what epidemiologist Dr Nick Thomson says is needed to stem the human toll from disease outbreaks, urban crime, substance abuse and a host of other challenges.

Dr Thomson is leading a provocative call for greater engagement between the two sectors in a special series in The Lancet on security and health, along with eminent global public health experts and police strategists – among them a former Surgeon-General in the UK armed forces.

“We need to start working with security forces and treating them as key players in health, rather than intruders, because shouting at each other from a distance achieves little, and not working together is catastrophic,” says Dr Thomson, a human rights epidemiologist at the Melbourne School of Population and Global Health.

There have been some successful examples to date, but the problem, Dr Thomson explains, is “we’re not joining the dots”.

The 2014 Ebola outbreak in West Africa and Brazil’s crisis as a result of the Zika virus in 2015 highlight the unique ability of militaries to command and deploy significant resources, like mobile labs or mosquito eradication sprays, at lightning speed.

In Australia, partnerships between law enforcement, health and communities have brought about “the end of AIDS” as a public health issue, with HIV now considered a chronic, manageable condition. This is in contrast to other regions where HIV runs rampant as a result of crackdowns on sex workers, injecting drug users and men who have sex with men (MSM).

In cities like Amsterdam and Barcelona, pill testing at music festivals is now mainstream, supported by governments, and saving many lives. With police backing, Sydney’s supervised drug injecting centre has, since 2001, prevented countless deaths.

While police and health professionals working together in Glasgow, once known as the murder capital of Western Europe, have made it one of the safest cities in the UK.

But these lessons on effective cooperation have been slow to be reflected despite being a national core requirement of the World Health Organisation’s International Health Regulations 2005 specifically in the context of pandemic preparedness and response.

Perhaps the most serious of these is the new Ebola outbreak in the Democratic Republic of Congo’s North Kivu province – the first in a war zone.

Health workers have vaccines, which they didn’t have in 2014, but they are hampered at every step by violent distrust, rebel militias, conspiracy theories, and lack of access. UN peacekeepers are now guarding health workers as they go about tracing and quarantining carriers, and vaccinating villagers.

Dr Thomson was galvanised on the issue of security force and health sector relationships in the early 2000s. He was carrying out HIV prevention trials with people who injected drugs in Thailand just as the country was embarking on a Duterte-style program of extrajudicial killings of drug traffickers.

Predictably, many swept up in the net had no history of drug trafficking but were merely casual drug users. The researchers lost contact with many people who were enrolled in the studies.

“It was horrendous and confronting. We had no contacts with the security apparatus of the government, no ability to influence senior levels of policing or the interior ministry. This was a huge gap in our program, and we vowed we couldn’t let this happen again.

“We started asking questions like, ‘How do we find a way in here? How do we understand the potential levers these agencies have that, if tweaked, could deliver significant assistance in public health?’” Some of those levers turn out to be bringing the police in as partners with the government in the national HIV response. Police fostering an enabling environment for people to access HIV services, supported by top-level political commitment and partnerships has seen concentrated epidemics slowed.

“Rather than ‘sticking to their lane’, the best results come when the two sectors train together, work together, and set shared goals,” Dr Thomson says.

Dr Thomson says international security sector donors should apply a public health lens to their funding decisions, and if necessary, use their financial clout to push for security forces’ reform in the name of better public health outcomes.

“That new helicopter or counter terrorism training program might be better off accompanied by funding for a program to combat gender violence or the development of police strategies to support vaccine delivery in conflict settings.

“If you really care about public health you have to engage in places where public security dominates such as prisons for example. If you really care about asylum seekers in detention, you have to engage with Home Affairs.”

But to do that requires co-operation and a change of attitude on both sides.

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