Peace Operations at the Intersection of Health Emergencies and Violent Conflict: Lessons from the 2018–2020 DRC Ebola Crisis

I. Introduction

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Dirk Druet
Rethinking the Humanitarian Health Response to Violent Conflict

In many fragile and conflict settings around the world, humanitarian responses overlap with the work of international peace operations.1 United Nations (UN) “mission settings” range from the UN special political mission in Afghanistan (UNAMA), to the long-standing military observer mission between Syria and Israel (UNDOF), to the large, well-equipped stabilization mission in Mali (MINUSMA). These missions are not neutral; they are mandated to help end a violent conflict, restore normal state functions, and protect civilians from physical violence. In these same settings, humanitarian organizations provide food, shelter, medical supplies, and other forms of immediate assistance. Each of these humanitarian organizations operates on principles of strict neutrality and independence grounded in the conviction that life-saving assistance and dignity are rights to be enjoyed by all and that affiliation with one or another side of the conflict risks politicizing the organization’s presence and impeding its safe access to people in need.

While these two types of crisis intervention are interdependent, they also exist in an uneasy relationship with each other. For humanitarian actors, a baseline of security is necessary for their work. Peace operations—along with national security forces and even some nonstate armed groups—can provide a degree of protection. However, the humanitarians’ principles require them to maintain a distance from political and military actors, invoking an ongoing debate over how close is too close. For international peace operations, whose mandates are negotiated by the UN Security Council, the life-saving assistance provided to populations by humanitarian actors is often seen as complementary to the pursuit of longer-term solutions such as negotiated political settlements or better governance. Yet humanitarian objectives do not necessarily contribute to these longer-term pursuits in a linear way. In some cases, immediate life-saving needs clash with the political interests of peace operations or may even exacerbate the conflict dynamics in the short term; for example, when humanitarian aid is used by armed groups to bolster their legitimacy in areas where it is distributed.

The complex relationship between humanitarian responses and international peace operations was brought into sharp relief during the Ebola vector disease outbreak in the eastern Democratic Republic of the Congo (DRC) in 2018. The World Health Organization (WHO) described the situation as a “perfect storm” in which this highly infectious disease arose in an area of active conflict, in a country with weak governance and often predatory national armed forces, and in a dense, highly mobile population near two porous international borders.2 The potential global threat posed by the outbreak prompted an enormous national and international health response aimed at stemming the wider spread of the disease while also treating those infected.

This perfect storm and the health response to it played out within the theater of the UN’s largest and ostensibly most robust peace operation, the UN Organization Stabilization Mission in the Democratic Republic of the Congo (MONUSCO). MONUSCO was mandated to aggressively neutralize armed groups in the east of the country, first among them the notoriously violent, Ituri-based Allied Democratic Forces (ADF), while protecting civilians and supporting crucial national elections. The unique nature of the health emergency and the unique characteristics of the peace operation raised unprecedented questions for both humanitarian actors and MONUSCO about how the mission could, should, or should not work to support the Ebola response and/or pursue its mandates amid the health emergency.

Not all of these questions were new, however. Over the years, the overlap between peace operations and humanitarian action has invoked sharp debates over the appropriate boundaries of missions’ relationships to humanitarian actors, the application of humanitarian principles to these relationships, and the consonance and dissonance between peace operations’ political and security mandates and humanitarian objectives. In many mission settings, armed escorts provided by peacekeeping missions are considered by some agencies as critical for enabling humanitarian access across the country and panned by others as unnecessarily politicizing humanitarian aid.3 In 2010, a camp of the UN Stabilization Mission in Haiti (MINUSTAH) was found to be using highly dangerous sanitation practices in a fragile health environment, leading to the first outbreak of cholera in Haiti in over 150 years and killing at least nine thousand Haitians, according to official figures.4 The case raised significant, open questions about the effects peace operations can have on humanitarian settings and the roles and responsibilities of such operations vis-à-vis humanitarian actors.

At the time, the 2018 Ebola outbreak in the DRC was the only major epidemiological crisis to have taken place in an active conflict setting in recent history. This is no longer the case. The COVID-19 pandemic has brought the questions faced by MONUSCO and the humanitarian health community to the front steps of all peace operations in the world. As new vaccines and treatments roll out, many of the phenomena encountered in the DRC are likely to be reproduced in other places. Relatedly, the Ebola crisis in the DRC formed part of an ongoing global trend of increased politicization of humanitarian assistance and access and a correlated surge in attacks on health care facilities and personnel in these places.5 A WHO compilation of open sources found that, in 2014 and 2015, almost six hundred attacks on health care facilities in emergency settings were reported in nineteen countries, resulting in the deaths of 959 people and injuries to 1,561.6

To improve both mandate effectiveness and the safety of health, humanitarian, and peace and security actors, we must better understand the tensions that can arise when health emergencies develop in conflict settings and identify strategies to address them. This paper asks how peace operations should interact with international humanitarian responses during health emergencies in contexts of violent conflict. The answers should inform not only how these missions provide support to international humanitarian and health responses but also how they adapt their operations to execute their own mandates under these conditions, including the ways in which the responses to an emergency can impact the effectiveness and legitimacy of the mission. The answers also hold important implications for humanitarian policy as international health systems continue to adapt their programs to the evolving COVID-19 pandemic.

The paper proceeds in four parts, bringing together several bodies of literature. The first section draws on the history of the public health system in the Congo to analyze the roots of the intersection between health and conflict in the east of the country and to help explain the responses by the population and armed actors to the health crisis in 2018–2020. The second section dissects the role played by the UN Mission in Liberia (UNMIL) during the 2014–2016 West African Ebola crisis, highlighting the ways in which the mission interacted with other parts of the national and international response and describing how the lessons learned by the international community in that crisis informed the subsequent policies and practices adopted in the DRC. The third section briefly examines the conflict dynamics in the eastern DRC at the time of the outbreak in 2018, the characteristics of the national and international health responses—known collectively as the Riposte—and where MONUSCO fit into the picture.7 To isolate and analyze the role of MONUSCO, the analysis is complemented with data from interviews conducted with current and former UN and humanitarian officials. The final section distills a series of conceptual, operational, and policy challenges for health, humanitarian, and peace and security communities as they continue to implement COVID-19 interventions around the world and look ahead to future health emergencies.