Military Participation in Health Security: Analysis of Joint External Evaluation Reports and National Action Plans for Health Security

Abstract

Militaries around the world play an important but at times poorly defined and underappreciated role in global health security. They are often called upon to support civilian authorities in humanitarian crises and to provide routine healthcare for civilians. Military personnel are a unique population in a health security context, as they are highly mobile and often deploy to austere settings domestically and internationally, which may increase exposure to endemic and emerging infectious diseases. Despite the role of militaries, few studies have systematically evaluated their involvement in global health security activities including the Global Health Security Agenda. We analyzed Joint External Evaluation (JEE) mission reports (n = 94) and National Action Plan for Health Security plans (n = 12), published as of July 2020, to determine the extent to which military organizations were involved in the evaluation process, military involvement in health security activities were described, and specific recommendations were provided for the country's military. For JEE reports, descriptions of military involvement were highest in 3 of the 4 core areas: Respond (76%), Prevent (39%), and Detect (32%). Similarly, National Action Plan for Health Security plans mentioned military involvement in the same 3 core areas: Respond (58%), Prevent (33%), and Detect (33%). Only 28% of JEE reports provided recommendations for the military in any of the core areas. Our results indicate that military roles and contributions are incorporated into some aspects of country-level health security activities, but that more extensive involvement may be warranted to improve national capabilities to prevent, detect, and respond to infectious disease threats.

Introduction

In response to increasing risks of international spread of infectious diseases, countries around the world agreed to the revised International Health Regulations (2005) (IHR), which came into force in 2007. The goal of the IHR was to protect against the international spread of diseases while avoiding undue restrictions on international traffic and trade. The IHR require participating countries to strengthen their capabilities in 19 health-related technical areas, including disease surveillance and response capabilities. Despite the widespread agreement to participate, many countries have been unable to meet the goals established in the IHR.¹

In 2014, the Global Health Security Agenda (GHSA) was introduced to reinvigorate action toward reaching IHR goals and to establish partnerships to strengthen country capacities. The GHSA is organized around 11 “Action Packages” to prevent, detect, and respond to public health emergencies, particularly infectious disease threats, with goals that align with IHR objectives.^2,3 The GHSA explicitly encourages a multisectoral approach,⁴ with the goals of conducting a collaborative response to natural or intentional biological events, linking public health and security authorities, and developing and implementing a framework for sharing information across human and animal health, law enforcement, and the defense sector.

Global health security is relevant to the military establishment for multiple reasons, including the support that militaries can provide to the civilian sector during outbreaks of infectious diseases and other public health emergencies and the impact of infectious diseases on operational readiness. Militaries provide support to civil authorities domestically and internationally when civilian capabilities are exceeded, particularly in humanitarian relief or times of conflict, such as during the 2014-2016 West Africa Ebola outbreak.⁵ Militaries can provide a range of capabilities in security, transportation, logistics, and communications^6,7 and can direct patient care during outbreaks, as happened during the Middle East respiratory syndrome coronavirus outbreak in the Republic of Korea. The military also plays a critical role in national biodefense to prevent or respond to the potential misuse of biological agents as bioweapons.⁸

In addition to emergency response activities, many military medical clinics and hospitals provide extensive medical treatment to their countries' civilian populations on a routine basis, a relationship that is often overlooked in country-level health security initiatives. In many African countries, “the military has the strongest medical infrastructure and capability that should be leveraged.”⁹ Among African militaries surveyed, as much as 50% to 80% of delivered healthcare by military medical services is provided to civilians with no military affiliation.¹⁰ Similarly, the Jordanian military's Royal Medical Services runs 10 hospitals that serve approximately 30% of their civilian population.^11,12

While militaries have an important role in supporting civil authorities for health security, they also have a clear responsibility to provide healthcare and public health support to their troops. Infectious diseases have had, and continue to have, a profound impact on military operations. For example, during World War II, malaria infections affected at least 124,000 US military personnel in the Pacific Theater.¹³ More recently, HIV/AIDS reduced troop strength for countries across sub-Saharan Africa.¹⁴ In addition to these 2 large-scale examples, regular outbreaks of malaria and other febrile illnesses, diarrheal diseases, and respiratory diseases have been known to limit operational readiness for militaries around the world.^15-17 During the current pandemic, coronavirus disease 2019 (COVID-19) transmission has interfered with military training and operations globally, including an outbreak that removed the USS Theodore Roosevelt from service for an extended period¹⁸ and an outbreak at a military training center in West Java, Indonesia.¹⁹

Military personnel are a unique population from a health security perspective. They are typically highly mobile, self-sustaining, and able to deploy to austere settings, domestically and internationally, which may increase exposure to emerging pathogens. Recruits train in crowded conditions where the risk for pathogen transmission is higher. Some militaries have extensive immunization programs, but military personnel are often immunologically naive to circulating pathogens,²⁰ especially pathogens that have no widely available vaccines, putting personnel at an elevated risk for infections and diseases, such as malaria.²¹ Military personnel are at risk for infection during international deployment, which also poses a risk for host country populations due to transmission of infectious pathogens. Similarly, these pathogens may represent a risk for the military personnel's home countries upon deployment back to their country of origin.^15,22 Military personnel have often been involved in disease transmission events during international deployment and domestic exercises. Spread of pandemic influenza, both in 1918 and in 2009, was likely exacerbated by domestic and international travel of military personnel.²³ Notably, cholera was introduced in Haiti after the 2010 earthquake, most likely by Nepali peacekeepers,^24-26 which led to an outbreak of hundreds of thousands of cases of diarrheal disease among the highly susceptible host country civilian population. Mobility can be a concern even within a country's boundaries. For example, an outbreak of malaria along the northern coast of Peru, in a region where no malaria had been reported for 4 years, was linked to Plasmodium falciparum strains potentially introduced by military personnel returning from operations in the Peruvian Amazon.²⁷

Despite the military's role in global health security, few studies have systematically evaluated the involvement of military organizations in global health security activities. To better measure the incorporation of each GHSA member country's military into their health security activities, we analyzed 2 types of reports that aim to assess and strengthen country capacity for public health surveillance and response to meet IHR requirements, as proxies for military involvement in health security. First, we analyzed the World Health Organization (WHO) Joint External Evaluations (JEE) reports.²⁸ Through the JEE process, experts work with each country to assess the country's abilities to prevent, detect, and respond to all-hazards public health threats, including infectious diseases, and provide recommendations for improvement.²⁹ Second, we evaluated available National Action Plan for Health Security (NAPHS) plans,³⁰ which outline country priorities for addressing shortcomings identified in the JEE reports and improving public health capabilities.

Methods

We systematically screened and analyzed the available JEE reports^28,31 and NAPHS plans³² for mentions of country military involvement. Two analysts evaluated all reports and plans, with both analysts reviewing each document to verify the data collected. Any discrepancies between the 2 analysts were resolved by further review of the document in question. Documents were screened for mentions of military involvement, in part through keyword searches for the following terms: “military,” “defens(c)e,” “army,” “navy,” “air force,” “MOD,” “armed forces,” and any acronyms identified in the beginning of each report that represented the country's military. For documents available only in French or Portuguese, the equivalent terms in the respective languages were searched, which were compared against English versions generated through online translation tools such as Google Translate. Militaries were defined as organized armed groups tasked with providing defense and prosecuting war on behalf of the respective countries, similar to the definition used by Michaud et al.⁷ Only specific mentions of military organizations were considered, rather than security sector participation in general. Civil defense organizations and other domestic security agencies distinct from the country's military were not included.

Joint External Evaluation Reports

All JEE reports from the 6 WHO regions published online^28,31 as of July 2020 (n = 94) were analyzed; 76 were available in English, 16 were available only in French, and 2 were available only in Portuguese.

Reports were analyzed, in part using the keyword terms described above, based on the following metrics:

military participants included;

total number of military participants (if listed);

specific examples of military–civilian engagement;

role of the military in the 4 JEE core areas (Prevent, Detect, Respond, Other IHR-Related Hazards and Points of Entry);

recommendations for future military engagement in each of the core areas;

military policy documents related to global health security;

support from or partnerships and collaboration with militaries from other countries, including any regional cooperation; and

experts affiliated with the military or Ministry of Defense included on the evaluation team.

After all reports were analyzed and reviewers reached concordance in their responses, each metric was evaluated across all reports and across reports within each WHO region*—Africa (AFRO), Americas (AMRO/PAHO), Eastern Mediterranean (EMRO), Europe (EURO), South East Asia (SEARO), and Western Pacific (WPRO)—to determine proportions for each metric.

National Action Plans for Health Security

All NAPHS plans from the 6 WHO regions published online (https://extranet.who.int/sph) as of July 2020 (n = 12) were evaluated using the same keyword search methodology as the JEE reports to determine whether military involvement was mentioned in any of the JEE core areas: Prevent, Detect, Respond, and Other IHR-Related Hazards and Points of Entry. Involvement of militaries from other countries was also examined in each report.

Results

Joint External Evaluation Reports

To conduct this analysis, we analyzed a total of 94 JEE reports (Table 1). The reports were divided between 6 WHO regions, with AFRO publishing the largest number of reports (n = 44), followed by EMRO (n = 17), EURO (n = 13), WPRO (n = 10), SEARO (n = 8), and AMRO/PAHO (n = 2). For the 86 reports across all WHO regions that listed participating organizations, slightly over half (n = 48, 56%) included military participation in the assessment process. Not all of these 48 reports included a list of individual participants; among the 25 that did include a list, the median number of military participants was 1 per report, with 10 (Thailand) as the highest number of military personnel interviewees.

Table 1.

Mentions of Military Involvement in JEE Reports, by WHO Region

Mentions of Military Participation	Total N = 94 n (%)	AFRO n = 44 n (%)	AMRO/ PAHO n = 2 n (%)	EMRO n = 17 n (%)	EURO n = 13 n (%)	SEARO n = 8 n (%)	WPRO n = 10 n (%)
Military participation in JEE process^a	48/86 (56)	19/40 (48)	2/2 (100)	10/15 (67)	3/12 (25)	6/7 (86)	8/10 (80)
Military-civilian engagement mentioned	74 (79)	32 (73)	2 (100)	16 (94)	10 (77)	6 (75)	8 (80)
Role of military/MOD mentioned in at least 1 core area:	84 (89)	40 (91)	2 (100)	16 (94)	12 (92)	6 (75)	8 (80)
Prevent	37 (39)	14 (32)	2 (100)	9 (53)	8 (62)	2 (25)	2 (20)
Detect	30 (32)	12 (27)	2 (100)	10 (59)	1 (8)	3 (38)	2 (20)
Respond	71 (76)	35 (80)	1 (50)	12 (71)	10 (77)	6 (75)	7 (70)
Other IHR-Related Hazards and Points of Entry	36 (38)	13 (30)	2 (100)	7 (41)	6 (46)	3 (38)	5 (50)
Recommendations for military/MOD provided in at least 1 core area:	26 (28)	14 (31)	0 (0)	2 (12)	3 (23)	63% (5)	2 (20)
Prevent	7 (7)	4 (9)	0 (0)	1 (6)	0 (0)	2 (25)	0 (0)
Detect	5 (5)	1 (2)	0 (0)	1 (6)	1 (8)	0 (0)	2 (20)
Respond	14 (15)	8 (18)	0 (0)	1 (6)	1 (8)	3 (38)	1 (10)
Other IHR-Related Hazards and Points of Entry	6 (6)	3 (7)	0 (0)	1 (6)	1 (8)	0 (0)	1 (10)
Mention of relevant military/MOD policy documents	31 (33)	15 (34)	1 (50)	4 (24)	6 (46)	1 (13)	4 (40)
Any mention of involvement of militaries from other countries, including regional cooperation	8 (9)	1 (2)	0 (0)	3 (18)	1 (8)	1 (13)	2 (20)
JEE team included individuals affiliated with a military organization	6 (6)	5 (11)	1 (50)	0 (0)	0 (0)	0 (0)	0 (0)

Eight of 94 did not list participating organizations and were, therefore, not included in the denominator.

Abbreviations: AFRO, Regional Office for Africa; AMRO, Regional Office for the Americas; EMRO, Regional Office for the Eastern Mediterranean; EURO, Regional Office for Europe; JEE, Joint External Evaluation; MOD, Ministry of Defense; PAHO, Pan American Health Organization; SEARO, Regional Office for South-East Asia; WPRO, Regional Office for the Western Pacific; WHO, World Health Organization.

The majority (n = 74, 79%) of reports mentioned some level of military–civilian engagement in at least 1 section and mentioned the country's military in at least 1 of the 4 core areas—Prevent, Detect, Respond, and Other IHR-Related Hazards and Points of Entry (n = 84, 89%). Across all reports, military engagement was most commonly mentioned in the Respond core area (n = 71, 76%), followed by the Other IHR-Related Hazards and Points of Entry core area (n = 36, 38%), the Prevent core area (n = 37, 39%), and the Detect core area (n = 30, 32%). Most military mentions were only cursory or included as part of a list of national institutions (eg, for Moldova: “more than [10] national authorities/institutions are involved in biosafety and biosecurity, including the Ministry of Defence”).³³

In addition to the 4 core areas, 19 technical areas of capability are included in the JEE reports. Military involvement was mentioned most often within the “linking public health and security authorities” technical area, part of the Respond core area (53% of all JEE reports). Other technical areas with the highest level of military engagement described were “chemical events” (21%; Other IHR-Related Hazards and Points of Entry core area), “medical countermeasures and personnel deployment” (19%; Respond core area), “emergency preparedness” (19%; Respond core area), and “radiation emergencies” (18%; Other IHR-Related Hazards and Points of Entry core area). Within the Prevent core area, “biosafety and biosecurity” (12%) and “IHR coordination, communication, and advocacy” (10%) were most common, and within the Detect core area, “national laboratory system” (15%) and “reporting” (10%) were most common (Table 2).

Table 2.

Military Participation Mentioned in JEE Reports and NAPHS Plans, by Technical Area

Core Areas and Technical Areas	Mentions of Military Involvement in JEE Reports (N = 94) n (%)	Recommendations Involving Military in JEE Reports (N = 94) n (%)	Mentions of Military Involvement in NAPHS Plans (N = 12) n (%)
Prevent
National legislation, policy, and financing	7 (7)	0 (0)	0 (0)
IHR coordination, communication, and advocacy	9 (10)	2 (2)	0 (0)
Antimicrobial resistance	6 (6)	2 (2)	2 (17)
Zoonotic disease	7 (7)	0 (0)	0 (0)
Food safety	1 (1)	1 (1)	0 (0)
Biosafety and biosecurity	11 (12)	2 (2)	2 (17)
Immunization	2 (2)	0 (0)	0 (0)
Detect
National laboratory system	14 (15)	1 (1)	2 (17)
Surveillance (real-time surveillance^a)	2 (2)	0 (0)	2 (17)
Reporting	9 (10)	0 (0)	3 (25)
Human resources (workforce development^a)	8 (9)	4 (4)	1 (8)
Respond
Emergency preparedness (preparedness^a)	18 (19)	3 (3)	4 (33)
Emergency response operations	14 (15)	1 (1)	3 (25)
Linking public health and security authorities	50 (53)	7 (7)	5 (42)
Medical countermeasures and personnel deployment	18 (19)	2 (2)	3 (25)
Risk communication	7 (7)	1 (1)	0 (0)
Other IHR-Related Hazards and Points of Entry
Points of entry	6 (6)	0 (0)	1 (8)
Chemical events	20 (21)	3 (3)	2 (17)
Radiation emergencies	17 (18)	4 (4)	5 (42)

Note: All technical area names are based on the 2018 version of the JEE tool³¹ except where noted.

Technical area names are based on the 2016 version of the JEE tool.³⁴

Abbreviations: IHR, International Health Regulations (2005); JEE, Joint External Evaluation; NAPHS, National Action Plan for Health Security.

Recommendations for enhanced military engagement in any of the core areas were infrequent across all reports: only 26 (28%) mentioned enhancing military collaboration in any of the core area recommendation sections (Table 1). Such recommendations were most commonly seen in the Respond core area (n = 14, 15%), particularly related to the “linking public health and security authorities” technical area (7% of all JEE reports), and least commonly seen in the Detect core area (n = 5, 5%).

Only 31 (33%) of the reports mentioned any policy documents with titles clearly related to the country's military. Eight (9%) reports mentioned the involvement of militaries from other countries (which included the mention of funding support to conduct activities in core areas as well as joint exercises and outbreak collaboration), and only 6 (6%) reports included individuals on the JEE assessment team who held positions specifically affiliated with military or defense organizations.

Regional and Cross-Regional Findings

We explored the metrics used in our analysis from a regional and cross-regional perspective (Table 1). Military participants were included in the majority of country assessments in the SEARO (86%), WPRO (80%), and EMRO (59%) regions and were less frequently included in country assessments in the AFRO (48%) and EURO (25%) regions. Consistent with the overarching findings across all regions, military–civilian engagement was mentioned in the majority of reports in each region, with the greatest mention of military–civilian engagement identified for the EMRO (94%), AFRO (73%), and SEARO regions (75%).

The role of the military was mentioned in at least 1 core area in over 80% of all country assessments in each region, except SEARO (75%). Also consistent with overarching findings across all regions, military involvement was most frequently mentioned in the Respond core area in most regions. Recommendations for enhanced military engagement were infrequently made in country assessments in each region, except SEARO (5 out of 8 countries, 63%). The highest proportion of reports including at least 1 mention of any clearly military-related policy documents was seen in the EURO JEE reports (46%).

National Action Plans for Health Security

NAPHS plans from 12 countries (N = 12)—Australia, Benin, Eritrea, Indonesia, Liberia, Myanmar, Nigeria, Sierra Leone, Sri Lanka, Tanzania, Uganda, and the United States—were available for evaluation. Overall, 73% (8 out of 11; 1 did not list participants) listed some level of military participation in the NAPHS development process. Plans for military involvement were included for at least 1 core area for 67% (n = 8) of NAPHS plans, including 33% (n = 4) for Prevent, 33% (n = 4) for Detect, 58% (n = 7) for Respond, and 42% (n = 5) for Other IHR-Related Hazards and Points of Entry (Table 2). The most common technical areas addressed were “linking public health and security authorities” (n = 5; 42%), “radiation emergencies” (n = 5; 42%), and “emergency preparedness” (n = 4; 33%). All countries with NAPHS plans also had JEE reports available for evaluation (n = 12); military involvement was mentioned in 67% (n = 8), including 17% (n = 2) for Prevent, 8% (n = 1) for Detect, 58% (n = 7) for Respond, and 17% (n = 2) for Other IHR-Related Hazards and Points of Entry core areas.

Discussion

While militaries' contributions were mentioned in at least 1 core area for the large majority of JEE reports (89%) and NAPHS plans (67%), most mentions were brief and limited in scope. Few (28%) JEE reports provided recommendations for further military involvement in at least 1 core area, most of which (56%) were in the Respond core area. While the limited mentions of military contribution may reflect the possibility that there is no need for improvement in military capabilities or collaboration in prevention and detection, it is more likely the result of a lack of emphasis on military engagement in these areas. GHSA, JEE, and NAPHS guidance documents advocate for linking public health with the security sector to ensure a multisectoral rapid response, including defense and other stakeholders, but they do not address incorporating military involvement more broadly into the Prevent and Detect core areas, which include priorities such as antimicrobial resistance, immunization, surveillance, and human resources. Although recommendations for multisectoral engagement may intend to include the military, where military involvement is not clearly specified may limit a country's ability to respond to JEE recommendations in a meaningful way. In addition, the limited mention of military involvement was also found in the NAPHS plans, which are intended to drive country global health security activities for several years.³²

Within the Prevent core area, military participation was mentioned in only 10% or fewer of JEE reports and NAPHS plans and was notably lacking in technical areas such as “national legislation, policy, and financing,” “IHR coordination, communication, and advocacy,” and “immunization.” Within the Detect core area, “reporting,” “surveillance,” and “human resources” technical areas mentioned military involvement in 10% or fewer of JEE reports and 25%, 17%, and 8%, respectively, of NAPHS plans. It is interesting to note that “biosafety and biosecurity” and “national laboratory system” included military involvement in 15% and 12% of JEE reports, respectively, and 17% of NAPHS plans, which may reflect military involvement in biomedical research for emerging pathogens.

Recommendations

Based on our findings, recommendations are both specific to GHSA engagement and speak more broadly to military engagement in global health security. Military participation should be considered beyond the Respond core area to include all technical areas within the Prevent and Detect core areas. For example, vaccination and prophylaxis plans, guidance, and requirements could include Ministry of Defense-generated policies for their military personnel, and surveillance for infectious diseases among military personnel before and during deployment could be a point of emphasis,^16,17,35,36 particularly because militaries were mentioned in the “immunization” and “surveillance” technical areas in only 2% of JEE reports and 0% and 17%, respectively, of NAPHS plans. Additionally, because military health systems often support civilian populations, where applicable, military staff should be included in the workforce development aspects of GHSA to have the capacity to respond and recover properly.⁸ Yet, military staff were mentioned within “human resources”/”workforce development” technical areas in fewer than 10% of JEE reports and NAPHS plans.

The Respond core area contained the most mentions of military involvement, likely reflecting militaries' strengths in security, transportation, logistics, and communications.^6,7 However, descriptions of military involvement were often vague and included recommendations for the military specifically for few (15%) countries. Planning around the security sector should be specific about military involvement in health security activities, which might include support for logistic, medical, and transportation capabilities related to preparedness, emergency response, medical countermeasure deployment, and recovery activities, where appropriate.³⁷

We noted that few JEE reports listed policy documents that (based on the document titles) were explicitly linked to the military, which indicates that military roles and military-civilian engagement may need to be clearly codified within government policies. Additionally, military response plans could be integrated into civilian government agencies plans and joint exercises could be established to ensure effective collaboration.⁷ While initial points of in-country military–civilian engagement may revolve around biodefense issues and risk reduction of a particular disease or pathogen, these initial engagements could serve as springboards and building blocks for broader military–civilian health security engagement.

Overall, we found that military personnel were involved in the JEE process and NAPHS plans for a majority of countries (56% and 73%, respectively). However, military participants and experts affiliated with defense organizations were rarely part of the visiting JEE teams. Military authorities should be considered for involvement as experts on host country and external reviewer panels in future GHSA activities. Additionally, military–military engagements between GHSA partner countries should be considered to advance capabilities, because military–military partnerships may be more politically feasible in many instances. As an example of such activities, the US Department of Defense has been actively engaged with partner militaries on health security activities aimed at countering biological threats and improving surveillance data for force health protection.^38,39 These collaborations enable partner militaries to enhance their own capabilities to mitigate threats.¹⁶ In Africa, an example of such collaboration is the African Partner Outbreak Response Alliance, in which partner militaries have increased coordination to improve national and regional responses to infectious diseases. In Southeast Asia, there is a specific opportunity and need for military–military coordination related to malaria because militaries operate in endemic regions and could collaborate to support elimination efforts in remote settings.²¹ To ensure the effectiveness of military–military engagements, metrics should be developed to monitor and evaluate military involvement in global health security,^40,41 since by and large, the effects of military investment in global health have not been quantified.⁶

Challenges to Involving Country Military Organizations

Involving military organizations in global health security is not without challenges, particularly with regard to political concerns, operational security, and funding. Further study is needed to understand to what extent the JEE reports and NAPHS plans truly reflect military involvement in global health security, and if further military engagement is needed, how best to increase participation and collaboration. The defense sector will likely always struggle to engage the broader public health community because the primary mission of militaries is not global health. While this is a legitimate concern, militaries bear responsibility for the health of their troops and often the health of civilian populations. Additionally, the perceived militarization and “oversecuritization” of public health activities could cause alarm among the public and other stakeholders, including nongovernmental organizations, thereby reducing buy-in, creating public resistance, and jeopardizing long-term implementation of global health security activities.⁴⁸ Cultural differences between the public health and defense sectors and policy restrictions may also complicate communication and limit military participation in civil affairs in many countries. GHSA helps to address these issues by creating a platform for collaboration across sectors, under civilian leadership using shared language and common goals. Some of these concerns could also be addressed by maintaining and supporting health security responsibilities within the civilian sector rather than relying on the military for these roles.

National sovereignty may also be an issue when a military operating internationally experiences or detects an infectious disease outbreak. For example, during the influenza A (H1N1) pandemic, the United States deferred to host countries regarding official reporting of cases among US military personnel. However, based on the IHR, the United States would be obligated to report if the host country did not.²³ Clearly, military forces operating as peacekeepers or during exercises need to collaborate with the host country in reporting infectious disease cases, and they must be aware of the potential for carrying pathogens back to their home country.^15,49

Operational security poses another challenge. During drafting of the IHR, the United States agreed to (ratified) the regulation to notify WHO of public health risks occurring outside of its territory that may result in the international spread of disease, with the caveat that “any notification that would undermine the ability of the [US] Armed Forces to operate effectively in pursuit of [US] national security interests would not be considered practical for purposes of this article.”³ Notably, the Islamic Republic of Iran objected to this caveat, appealing to the universality of the treaty and stating there is “no room for exempting the American Armed Forces, in particular those operating abroad.” Further, Iran claimed that the majority of WHO member states rejected the caveat. This concern about operational security, and controversy about the topic, no doubt applies to GHSA-related activities. Even WHO member states that disagreed with the caveat in the IHR may be unlikely to fully comply with the notification requirements if operational security is jeopardized.

Funding represents a particular challenge for supporting military participation as part of strengthening global health security capacity. Funding for militaries may be perceived as military aid and may have legal restrictions at the federal level.²¹ For example, financial support from the United States Agency for International Development to militaries for HIV and malaria is indirect and dependent upon integration with larger public health initiatives.^10,50 Military participation in such programs may depend on cooperation with often resource-restricted ministries of health, which may serve as a barrier to access. Additionally, multinational and nongovernmental organizations may shy away from providing funding to the military for public health activities.

Limitations

Among the limitations of this study is that the analysis depended on the content of the JEE reports and NAPHS plans and was qualitative in its assessment of military involvement, without considering the depth of involvement for each country. In the JEE reports, the descriptions provided by external reviewers may not reflect the full scope of the country's military participation, and thus our analysis may underestimate military involvement in technical areas within the Prevent and Detect core areas. The JEE reports are also subjective and largely qualitative⁴² and are not designed for comparisons across countries and regions. However, the JEE reports reflect the priorities of the JEE and country team, which shows that militaries were not a major focus. This lack of involvement may have been due to the limited representation of military organizations on the JEE panels or a limited understanding of the defense sector's potential role in health security. Further, other studies have demonstrated the validity of the JEE reports. For example, JEE scores are generally representative of other health outcomes and align with measures associated with public health system capabilities,^43,44 and JEE reports corresponded with response capabilities during an outbreak.⁴⁵ Additionally, they provide a different perspective from self-evaluation,^46,47 and our results from the JEE reports are largely confirmed in the country plans laid out in the NAPHS plans.

Another limitation is that we used policy document titles mentioned in the JEE reports and NAPHS plans to determine whether they referenced military involvement, rather than reviewing each policy reference in detail. A deeper dive into the referenced policy documents may shed light on country policies that guide military engagement.

Finally, the small sample size (n = 12) of NAPHS plans presents a challenge in drawing conclusions about whether the documents exclude recommendations for military involvement to address shortcomings identified in the JEE reports. Follow-on studies that analyze all NAPHS plans when they become available are recommended.

Conclusions

Despite challenges and concerns about the defense sector's role in global health security, it is important to recognize that militaries throughout the world are already engaged in health security, with increasing involvement both domestically and internationally.^7,48 As emerging infectious disease threats are increasingly considered a national security and economic development concern,⁸ as seen during the current COVID-19 pandemic, the role of militaries will likely continue to increase. The question, therefore, becomes how to constructively incorporate the military's capabilities into each country's framework to improve whole-of-country capability, without undermining capabilities within civilian institutions and while remaining consistent with national priorities and international guidelines.⁷ Additionally, military personnel are part of an increasingly connected world—United Nations peacekeeping operations alone involve more than 85,000 uniformed personnel from 122 countries deployed in countries such as Haiti, Kosovo, and Mali⁵¹—and can be a potential source of infectious disease transmission across international boundaries.¹⁵ During future GHSA activities, military roles and contributions need to be considered in all aspects of global health security and whole-of-government approaches to prevent, detect, and respond to and recover from infectious diseases and other public health threats.

Footnotes

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