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Comprehensive Medical Support in Complex Emergencies (CMSCE): pilot course review

Comprehensive Medical Support in Complex Emergencies (CMSCE): pilot course review Global threats to health and health security are growing. Fragile and failed states, armed groups, ungoverned spaces, outbreaks and potential unknown “Disease X” threats, antimicrobial resistance (AMR), hybrid and gray zone conflict all exacerbate complex medical emergencies. These growing threats increase preventable morbidity and mortality of the most vulnerable populations. In an effort to promote best practices, standardize responses, and prevent excess death and disability in these contexts, The Kofi Annan International Peacekeeping Training Centre (KAIPTC), with support from multiple international partners and a volunteer facilitator faculty, administered the pilot course for military and civilian health officers involved in U.N. peacekeeping missions entitled, “Comprehensive Medical Support in Complex Emergencies (CMSCE 19).” This brief review paper provides a description of the process in designing and delivering an interdisciplinary course for providers and decision makers responding to complex emergencies. We conclude with best practices and next steps for course evolution. Keywords: Complex Emergencies, United Nations, Emergency response, Health Security Introduction adapt best practices that maximize care, especially in impov- Health care professionals responding to complex medical erished environments [1]. State fragility and failure gives rise emergencies and humanitarian crises must be prepared to to armed groups, increases actors committing violence and reduces the capacity of government [2–4]. Political institu- tions and social organizations experience a reduced account- *Correspondence: john.quinn@lf1.cu; dhabalit@student.cuni.cz; Michael. ability with respect to a Responsibility to Protect (R2P) [5, 6]. Reinwald@kaiptc.org; mbourdeaux@partners.org; martin.bricknell@kcl.ac.uk; The combined threats of conflict and disease hinder health alanjlmoore@hotmail.com security, democracy, economic growth, stability, human Prague Center for Global Health Institute of Hygiene and Epidemiology First Faculty of Medicine, Charles University, Prague, Czechia protection and peace. Climate change, environmental deg- First Faculty of Medicine, Institute of Hygiene and Epidemiology Prague radation, economic and financial instability may further Center for Global Health, Dhabalia Global Health Intern Charles University, exacerbate the negative effects of complex emergencies and Prague, Czechia German Armed Forces Course Director Kofi Annan International humanitarian crises and disasters. Peacekeeping Training Centre (KAIPTC), Teshie, Ghana In both long standing and emergency missions, disas- Security and Global Health Project Belfer Center Harvard Kennedy ter, pandemic and outbreak response produce significant School of Government Instructor, Department of Global Health and Social Change, Harvard Medical School, Boston, USA challenges to interoperability by stakeholders and actors Health and Military Medicine, Conflict and Health Research Group and may lead to increases in preventable morbidity and School of Security Studies, King’s College London, K4L.10 Kings Building, mortality. Health providers from the civilian and military WC2R 2LS London, UK FRICS Western Health & Social Care Trust Altnagelvin Hospital domains and actors providing medical support in disas- Londonderr y United, BT47 6SB Londonderry, UK ters, crisis, war, and conflict are increasingly targets of Full list of author information is available at the end of the article © The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/. The Creative Commons Public Domain Dedication waiver (http:// creat iveco mmons. org/ publi cdoma in/ zero/1. 0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Quinn et al. Globalization and Health (2022) 18:39 Page 2 of 6 violence [7, 8]. Cross-agency and cross-health responder Complex Emergency A humanitarian crisis in a country, region orsociety where there is a total communication during and  after emergencies, and or considerable breakdown of author- standing forums to exchange of lessons learned are vital ity resulting from internal or external to maximize success and ensure effective and efficient conflict, and which requires an interna- tional response that goes beyond the crisis response. capacity of any single agency and/or Complex emergencies witness a rise in mortality and the ongoing UN country program. morbidity among the population, either as a result of the Responsibility to Protect (R2P) The responsibility to protect embod- direct effects of war or conflict, or indirectly through the ies a political commitment to end the worst forms of violence and increased prevalence of disease (i.e. malnutrition, trans- persecution; it seeks to narrow the gap mission of communicable diseases); these are often the between Member States’ pre-existing result of deliberate political strategies on the part of the obligations under international humanitarian and human rights law parties to a conflict (military, armed groups, militia etc.) and the reality faced by populations [9, 10]. at risk of genocide, war crimes, ethnic Characteristics of complex emergencies include a large cleansing and crimesagainst humanity [18]. number of civilian victims, populations who are besieged or displaced, human suffering on a major scale; substan - The Kofi Annan International Peacekeeping Training tial international assistance is needed and the response Centre (KAIPTC) is an internationally recognized train- goes beyond the mandate or capacity of any one agency; ing center and a Centre of Excellence (COE) of the Eco- delivery of humanitarian assistance is impeded or pre- nomic Community of West African States (ECOWAS). vented by parties to the conflict; high security risks for The Ghana Ministry of Defence (MoD) established the relief workers providing humanitarian assistance; and Kofi Annan International Peacekeeping Training Centre relief workers targeted by parties to the conflict [11, 12]. (KAIPTC) in 1998 and commissioned it in 2004. The pur - Complex emergencies require coordination between mil- pose was to build upon and share Ghana’s five decades of itary and civilian entities. internationally acclaimed experience and competence in Military and security forces face increasingly complex peace operations with other states in the Economic Com- scenarios requiring crisis management that includes the munity of West African States (ECOWAS) region and the use of medical and health capabilities. The civil-military rest of Africa. interface requires not only evidenced-based practices The Kofi Annan International Peacekeeping Training and policy rooted in precedent, but also immediate infor- Centre (KAIPTC) provides an environment in which the mation exchange. Civilian-military interoperability prove specific challenges to standardize education and universal vital during complex medical emergencies - especially training in promotion of evidence-based practices in inter- in areas of conflict [13]; Korram-Manesh, et  al. 2019; agency coordination and collaboration can be shared with [14]. For example, addressing  the 2014-2015 polio and representatives of multiple institutions with global impact. 2017-present day measles outbreak in Ukraine is compli- The KAIPTC serves in the research and training for con - cated by the outbreak of hostilities. The war in Ukraine flict prevention, conflict management and conflict resolu - poses major challenges for access to the most vulnerable tion and sustainable delivery of enhanced regional capacity populations for vaccine administration and only the Min- building for peace support operations [19]. Courses taught istry of Health with support of Defense forces supported at the KAIPTC include, peace and support operations, con- mitigation of the health crisis [15]. flict management and peace and security studied. Masters and PhD programs are available. The KAIPTC is a magnet Basic Definitions for nonpartisan, nonjudgmental best practices for peace and stability operations for the African Continent and the inter- national community that promote peace. Term Definition Disaster A serious event that causes a systemic breakdown in the relationship The Comprehensive Medical Support in Complex between humans and their environ- ment on a scale that requires extraor- Emergencies (CMSCE) Course dinary efforts to allow the community The aim of this course was to promote an integrated to cope, and often requires outside health response though enhancing interoperability help and international aid [9, 16, 17]. Disasters are divided into two major across civilian and military actors that respond to com- categories: those caused by natural plex emergencies. The central theme was to promote and phenomenon and those caused by humans. Q uinn et al. Globalization and Health (2022) 18:39 Page 3 of 6 develop an understanding among multiple humanitarian, Setting governmental and military actors. Key health challenges The CMSCE course took place in Accra Ghana at the include a lack of access to health care, destroyed health- KAIPTC from 11 to 15 November 2019. The training care infrastructure, medical and disaster logistics and audience and target group for this novel pilot course information sharing, lack of health workers and emerg- included Senior Medical Officers (SMOs) and Force ing epidemiological pressures. The course is focused Medical Officers (FMOs) from the United Nations (UN), on the operational principles that drive the response to the African Union (AU), the Economic Community of disrupted health systems using civilian and military con- West African States (ECOWAS), The North Atlantic tributions to health, access to health and strengthening Treaty Organization (NATO), the European Union (EU), response throughout the disaster cycle. The course is Non-governmental organizations (NGOs). International designed to create discussions between participants that civilian and military personnel preparing to serve on a aim to improve understanding of the controversies and myriad of missions, crisis and disasters in support of best challenges associated with the civilian-military interface practices. across all domains that meet on the humanitarian field of The specific objectives of the course focused on the operations. creation of an understanding of the definition of the complex environment of humanitarian support in con- Course Methodology flict situations. This included the different agendas of the This course was not a didactic instructor to student for - main civilian and military stakeholders in international mat, but rather a facilitator with participant process. Spe- crisis management. Emphasis throughout the curriculum cifically, a Collaborative Problem Based Learning (CPBL) focused on international guidelines, concepts and princi- approach facilitated open discussion and sharing of expe- ples and their application to complex emergencies. Basic rience. Combining this with core skills and guidance, the definitions focused on the complex relations and inter - environment allowed the emergence of a shared view jux- dependence of health and human security. Discussion taposed to current best practices. and debate were encouraged on the analysis of capacity Evidence based decision making and practice is the and capability building programs that strengthen health anticipated outcome from CPBL. In this model that systems in conflict and disaster, especially in affected was deployed for this pilot course, participants’ interac- regions that require joint health and security actors. tions and contributions support success in the learning In addition, the course promoted the International environment. Committee of the Red Cross and Red Crescent (ICRC) ‘Health in Danger’ project that highlight ethics, rights The Pilot Course and responsibilities of healthcare staff. This included dis - The design of this course set out a one-week curriculum cussion on International Humanitarian Law (IHL), inter- conducted at the KAIPTC to expose course participants national human rights of caregivers and patient safety. to relevant and current skills, expertise and best practices Indeed, communities and all actors must address and in the domain of medical support and cooperation. The reduce violence against healthcare workers. Finally, the pilot course had specific emphasis on the African conti - main framework in disaster risk reduction, prevention nent with lessons that can be transferred globally. This and mitigation, including situational awareness, were course was initiated by the German Institute for Defence presented. and Strategic Studies (GIDS) and co-organized with the KAIPTC. The initial funding for this pilot course and Participants the next course in 2020 is provided by the German gov- Participants were selected with attention to a balanced ernment. To ensure sustainability, the goal is to invite geographical, ethnic, gender and professional distribu- multiple sponsoring nations and institutions for future tion. Participants followed the target groups listed above courses. and included special invitation from 15 UN missions, The CMSCE courses’ main aims were to promote an national and international organizations, ministries, integrated health response through enhanced inter- think tanks and centers for global health and profession- operability across civilian and military actors in com- als with an interest to learn about medical coordination plex emergencies. This included value added from and cooperation in key UN mission areas. There were unofficial communication and networking across agen - over 47 applications received online through the KAIPTC cies, domains and countries supporting these best prac- Learning Management System (LMS). Of these 47 appli- tices, especially partners and actors that face the greatest cants, 17 were invited and 23 participants completed the challenges in conflict. course. Seven women participated. Quinn et al. Globalization and Health (2022) 18:39 Page 4 of 6 Highlighted Core Course Content the-box thinking in the approaches to complex emer- To only serve as a superficial review of some of the core gencies. topics addressed in the pilot course, this section high- • On day 5, the TTE scenario continued in the pres- lights the central themes. The course timetable designed entation of a complex humanitarian crisis with over- directed a ‘learning journey’ across one week as opposed lays of food insecurity and conflict that included an to a didactic lecture series. inject of a “Disease X” outbreak. The emphasis of the TTE was on collaboration among the various actors, understanding how to interpret indicator informa- • Day 1 included a review of foundational concepts of tion as a vital component to situational awareness, health security, complex emergencies, and key actors and how to connect that information to preparedness involved in humanitarian assistance. In the opening and response. The TTE reflection and insights from session on ‘what is health’, perspectives on human participants on considerations going forward. The security, national security and global security with participants shared and reflected upon the concepts consideration of the formal and informal actors in applied and knowledge gained over the week course the health economy within a country were presented. and how they would apply core principles into their • Day 2 explored perspectives of organizational actors respective practice. and stakeholders such as emergency humanitarian responders, public health, peacekeeping missions, and health security intelligence. The humanitarian charter, Monitoring and Evaluation Outcomes humanitarian imperative and international law were and next steps presented and reflected upon with respect to specific The CMSCE Pilot course was successfully conducted and situations in military conflicts [20]. This section also participants and facilitators were both vital to the suc- highlighted medical ethics in conflict with discussion cess. Based on feedback from participants and facilita- of the law of armed conflict and international humani - tors, and a facilitator roundtable review, many outcomes tarian law with specific reference to the rights and can be described. Going forward, the CMSCE will be duties of healthcare workers and ‘healthcare in danger.’ offered in two separate courses: basic and advanced. The basic course will be foundational and will focus on prin- ciples and common guidelines and definitions found in • Day 3 introduced challenges in civilian-military response the SPHERE handbook, multiple UN disaster and out- to conflict, medical ethics in conflict, and included an break response guidance and other core definitions used offsite military hospital visit that included an interactive for those who respond to complex emergencies. Owing discussion of how to address mental health in complex to feedback about practical applications and health- emergencies for deployment. Organizational perspec- care under threat, this basic course will also include the tives included the planning cycle in military medical very practical first aid at point of injury found in the UN operations with civilian actors as a mitigation of the out- guidelines and military medicine. These concepts found comes of intentional violence between armed actors. One in the paradigm of tactical emergency / combat casualty module of the course contained basic information about care (TECC / TCCC) which focus on preventable causes the ethical and legal backdrops of humanitarian aid. of death from war related trauma. • Days 4 the SPHERE concept and a scenario-based The advanced course will be run as a workshop and will tabletop exercise (TTE)  were introduced [21]. assume a foundational understanding of basic core con- Principles and minimal standards of humanitar- cepts and will instead address current and emergent topics ian aid in the sections of Water, Sanitation and for subject matter experts and senior leadership responding Hygiene (WASH), food, shelter and medical aid to complex emergencies on a strategic level. The advanced were described in order to prepare the participants workshop will have different topics each iteration and the for the tabletop exercise (TTE) so they could prac- curriculum will be designed and created in 2020. tice referencing humanitarian standards as well as Another outcome to maximize time during the course address a global health complex emergency. The TTE is to introduce a more robust online learning environ- spanned 1.5 days and included a practical approach ment with open-source materials in the form of videos, to SPHERE methodologies and encouraged out-of- articles, chapters, online quizzes and other academic materials. This eLearning component will be introduced through the existing KAIPTC Learning Management System (LMS). This eLearning component aims to pre - The Sphere Project and its Handbook are well known for introducing con - sent core definitions while course participants are still in siderations of quality and accountability to humanitarian response Q uinn et al. Globalization and Health (2022) 18:39 Page 5 of 6 awarded the Companion of the Order of Bath, the Order of St John and the US their home country prior to arriving to KAIPTC and tak- Bronze Star during his military service. ing the live portion of the course. Dr. James M Wilson is a board-certified, practicing pediatrician who specializes in operational health security intelligence, with a focus on the anticipation, detection, and warning of infectious disease crises. Dr. Wilson was the first Conclusions operations chief of the Department of Homeland Security’s National Biosur- veillance Integration Center. Dr. Wilson led the private intelligence teams that In summary, global health threats are increasing, and exac- provided tracking of H5N1 avian influenza as it spread from Asia to Europe erbating factors are making complex medical emergencies and Africa, detection of vaccine drifted H3N2 influenza in 2007, warning of the ever more difficult to approach and apply best practices. 2009 H1N1 influenza pandemic, and discovery of the United Nations as the source of the 2010 cholera disaster in Haiti. Dr. Wilson is a strong advocate for In an effort to promote best practices, to standardize effective and accountable global health security intelligence and the need for response and to mitigate preventable death and morbidity, credible and balanced threat assessments. the Kofi Annan International Peacekeeping Training Centre Timo Ulrichs is professor for global health at Akkon University for Human Sciences (www. akkon- hochs chule. de). He studied medicine and specialized in (KAIPTC) administered the pilot course entitled, “Compre- medical microbiology and infection epidemiology and holds another doctoral hensive Medical Support in Complex Emergencies (CMSCE degree in public health. His research interests are infection control, health 19).” The next courses to be offered will breakdown into a care system strengthening, global health security and the nexus between humanitarian aid, development aid and peacekeeping. He works as a trainer basic and an advanced level for practitioners. for SPHERE standards and interventions and runs several collaborative projects This brief review paper describes the process of design - in health and biomedical research with partners in Eastern Europe, Southern ing and delivering this interdisciplinary pilot course and Caucasus and Africa. For these research activities, he founded the Institute for Research in International Assistance at Akkon University. sets forth a roadmap for the future. Funding Acknowledgements The German Government sponsored for accommodation of all course partici- The authors wish to thank the KAIPTC for the opportunity to participate in this pants, flights, food, accommodation and sustenance of the facilitator faculty pilot course. We also wish to thank the German Government for its financial, and the Learning Develop Design Workshop in Accra, Ghana. managerial and organizational support provided by Col. Michael Reinwald. Lastly, we wish to thank all those who respond to disaster and run into a com- Availability of data and materials plex emergency while most are trying to escape out of it. To the anonymous The datasets generated and/or analyzed during the current study are available responders, we thank you all for your service. in the KAIPTC repository. Authors’ contributions JQ, JW, TU and MB provided the first four drafts. MR, PT, TA, MB, AM, SG and CH Declarations provided vital analysis and final draft of the “Highlighted Core Course Content” section. All authors approved of the final manuscript. Ethics approval and consent to participate No ethics or internal review board permission were sought or are required Authors’ information for this paper. The Kofi Annan International Peacekeeping Training Centre John Quinn is lead researcher at the Prague Center for Global Health (www. (KAIPTC) approved the administration of this pilot course under its leadership. pcgh. lf1. cuni. cz), Staff Emergency Medicine Registrar in London and Medical Director and consultant to Tangiers International. He works in conflict, disaster Consent for publication and emergency medicine. He holds his Masters in Public Health (MPH), PhD in Not applicable. Hygiene and Epidemiology and is both a paramedic and emergency medical doctor with over 20 years’ experience globally. His research efforts are found Competing interests here: Researchgate: https:// www. resea rchga te. net/ profi le/ John_ Quinn_V ; Authors disclose no competing interests of any kind. LinkedIn: https:// www. linke din. com/ in/ johnm quinnv and ORCID ID: orcid. org/0000-0001-6877-8298. Author details Dr. Quinn has performed emergency medical assessments in Ukraine, Israel 1 Prague Center for Global Health Institute of Hygiene and Epidemiology and Palestine, Iraq, Kurdistan and Timor-Leste. He has established and oper- 2 First Faculty of Medicine, Charles University, Prague, Czechia. First F acult y ated remote medicine clinics in conflict zones and for remote communities of Medicine, Institute of Hygiene and Epidemiology Prague Center for Global and has consulted for NATO and NATO partner nations in the health and Health, Dhabalia Global Health Intern Charles University, Prague, Czechia. medical stability operations sectors. He worked as an emergency physician 3 German Armed Forces Course Director Kofi Annan International Peace - at a Level One Trauma Center in Ireland and has worked in Ukraine providing 4 keeping Training Centre (KAIPTC), Teshie, Ghana. 37 Military Hospital Accra emergency medical consulting and training in Tactical Combat Casualty Care 5 6 Ghana, Accra, Ghana. M2 Medical Intelligence, Inc, Accra, Ghana. Ghana ( TCCC) and Damage Control. 7 Red Cross Society Ghana, Accra, Ghana. Security and Global Health Project Resuscitation (DCR). Presently, Dr. Quinn completes clinical time in the UK in Belfer Center Harvard Kennedy School of Government Instructor, Department emergency medicine and conducts global health research related to conflict of Global Health and Social Change, Harvard Medical School, Boston, USA. and disaster. He is based in Prague with his family. 8 Institute for Research in International, Assistance Akkon University for Human Professor Bricknell took up his appointment as Professor in Conflict, Health 9 Sciences, Berlin, Germany. Health and Military Medicine, Conflict and Health and Military Medicine at King’s College London in April 2019. Prior to his he Research Group School of Security Studies, King’s College London, K4L.10 served 34 years in the UK Defence Medical Services, culminating his service as 10 Kings Building, WC2R 2LS London, UK. FRICS Western Health & Social Care the Surgeon General of the UK Armed Forces. He undertook operational tours Trust Altnagelvin Hospital Londonderr y United, BT47 6SB Londonderry, UK. in Afghanistan, Iraq, and the Balkans with multiple additional overseas assign- 11 United Nations Division of Healthcare Management And Occupational ments. In 2010 and 2006, he held senior Medical Adviser appointments in the 12 Safety and Health, New York, USA. German Institute for Defence and Stra- NATO ISAF mission. He commanded 22 Field Hospital in 1999-2002. He has tegic Studies (GIDS) Research Coordinator Health Security Interface & CMSCE trained as a general practitioner and is an accredited specialist in both Public Chief Facilitator, Hamburg, Germany. Health and Occupational Medicine. He holds two doctorates and 3 master’s degrees. He has published over 100 academic papers across military medical Received: 30 January 2020 Accepted: 3 September 2021 subjects. He is especially interested in how organizations learn, care pathways in military healthcare, and the political economy of health in conflict. He was Quinn et al. Globalization and Health (2022) 18:39 Page 6 of 6 References 1. DeFraites RF, Hickey P, Sharp TW, Beadling CW. The Health Care Response to Disasters, Complex Emergencies, and Population Displacement. In Hunter’s Tropical Medicine and Emerging Infectious Diseases. 2020 p219-227. 2. Beehner L. Fragile states and the territory conundrum to countering violent nonstate actors. Democracy Security. 2018;14(2):101–27. 3. Lemay-Hébert N. From Saving Failed States to Managing Risks: Reinter- preting Fragility Through Resilience. In: Governance and political adapta- tion in fragile states. Cham: Palgrave Macmillan; 2019. pp. 75–101. 4. Fazal TM, Poast P. War Is Not over. Foreign A. 2019;98:74. ff 5. Bellamy AJ, McLoughlin S. Human Protection and the Politics of Armed Intervention: With Responsibility Comes Accountability. Global Responsi- bility to Protect. 2019;11(3):333–61. 6. Busser M. Ethics, Obligation, and the Responsibility to Protect: Contesting the Global Power Relations of Accountability. Routledge; 2019. 7. Lafta RK, Falah N. Violence against health-care workers in a conflict affected city. Medicine Conflict Survival. 2019;35(1):65–79. 8. Patel P, Gibson-Fall F, Sullivan R, Irwin R. Documenting attacks on health workers and facilities in armed conflicts. Bull World Health Organ. 2017;95(1):79. 9. Spiegel PB. “Differences in World Responses to Natural Disasters and Complex Emergencies, JAMA 2005;293, No. 15. 10. Salama P, Spiegle lP, Talley L, Waldman R. “Lessons learned from complex emergencies over past decade.” Lancet. 2004; 364: 1801-1813. 11. Archer SE. Civilian and military cooperation in complex humanitarian operations. Kansas: Army Combined Arms Center Fort Leavenworth; 12. The United Nations High Commissioner for Refugees (UNHCR). (2001) “Coordination in Complex Emergencies,” 01 September 2001 (viewed 11 December 2019 and available at: https:// www. unhcr. org/ partn ers/ partn ers/ 3ba88 e7c6/ coord inati on- compl ex- emerg encies. html). 13. Yuste P, Campbell J, Canyon D, Childers M, Ryan BJ. Synchronized Humanitarian, Military and Commercial Logistics: An Evolving Synergistic Partnership. Safety. 2019;5(4):67. 14. Grundy J, Biggs BA. The impact of conflict on immunisation coverage in 16 countries. Int J Health Policy Manag. 2019;8(4):211. 15. Debate V. Measles, war, and health-care reforms in Ukraine. Lancet. 2018;390:347–48. 16. Lechat MF. “The epidemiology of health effects of disasters.” Epidemiol Rev.1990; 12:192-198. 17. Noji EK. “The Public Health Consequences of Disasters.” New York: Oxford University Press; 1997. 18. Genser J, Irwin Cotler H. MP. The responsibility to protect. Oxford Univer- sity Press; 2011. 19. Bischoff PH, Aning K, Acharya A, editors. Africa in Global International Relations: Emerging approaches to theory and practice. Routledge; 2015. 20. Khorram-Manesh A, Lönroth H, Rotter P, Wilhelmsson M, Aremyr J, Berner A, Carlström E. Non-medical aspects of civilian–military collaboration in management of major incidents. Eur J Trauma Emergency Surg. 2017;43(5):595–603. 21. The SPHERE. Project, sphere handbook, https:// www. spher estan dards. org/ ( Viewed: Nov 29, 2019). Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in pub- lished maps and institutional affiliations. Re Read ady y to to submit y submit your our re researc search h ? Choose BMC and benefit fr ? 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Abstract

Global threats to health and health security are growing. Fragile and failed states, armed groups, ungoverned spaces, outbreaks and potential unknown “Disease X” threats, antimicrobial resistance (AMR), hybrid and gray zone conflict all exacerbate complex medical emergencies. These growing threats increase preventable morbidity and mortality of the most vulnerable populations. In an effort to promote best practices, standardize responses, and prevent excess death and disability in these contexts, The Kofi Annan International Peacekeeping Training Centre (KAIPTC), with support from multiple international partners and a volunteer facilitator faculty, administered the pilot course for military and civilian health officers involved in U.N. peacekeeping missions entitled, “Comprehensive Medical Support in Complex Emergencies (CMSCE 19).” This brief review paper provides a description of the process in designing and delivering an interdisciplinary course for providers and decision makers responding to complex emergencies. We conclude with best practices and next steps for course evolution. Keywords: Complex Emergencies, United Nations, Emergency response, Health Security Introduction adapt best practices that maximize care, especially in impov- Health care professionals responding to complex medical erished environments [1]. State fragility and failure gives rise emergencies and humanitarian crises must be prepared to to armed groups, increases actors committing violence and reduces the capacity of government [2–4]. Political institu- tions and social organizations experience a reduced account- *Correspondence: john.quinn@lf1.cu; dhabalit@student.cuni.cz; Michael. ability with respect to a Responsibility to Protect (R2P) [5, 6]. Reinwald@kaiptc.org; mbourdeaux@partners.org; martin.bricknell@kcl.ac.uk; The combined threats of conflict and disease hinder health alanjlmoore@hotmail.com security, democracy, economic growth, stability, human Prague Center for Global Health Institute of Hygiene and Epidemiology First Faculty of Medicine, Charles University, Prague, Czechia protection and peace. Climate change, environmental deg- First Faculty of Medicine, Institute of Hygiene and Epidemiology Prague radation, economic and financial instability may further Center for Global Health, Dhabalia Global Health Intern Charles University, exacerbate the negative effects of complex emergencies and Prague, Czechia German Armed Forces Course Director Kofi Annan International humanitarian crises and disasters. Peacekeeping Training Centre (KAIPTC), Teshie, Ghana In both long standing and emergency missions, disas- Security and Global Health Project Belfer Center Harvard Kennedy ter, pandemic and outbreak response produce significant School of Government Instructor, Department of Global Health and Social Change, Harvard Medical School, Boston, USA challenges to interoperability by stakeholders and actors Health and Military Medicine, Conflict and Health Research Group and may lead to increases in preventable morbidity and School of Security Studies, King’s College London, K4L.10 Kings Building, mortality. Health providers from the civilian and military WC2R 2LS London, UK FRICS Western Health & Social Care Trust Altnagelvin Hospital domains and actors providing medical support in disas- Londonderr y United, BT47 6SB Londonderry, UK ters, crisis, war, and conflict are increasingly targets of Full list of author information is available at the end of the article © The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/. The Creative Commons Public Domain Dedication waiver (http:// creat iveco mmons. org/ publi cdoma in/ zero/1. 0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Quinn et al. Globalization and Health (2022) 18:39 Page 2 of 6 violence [7, 8]. Cross-agency and cross-health responder Complex Emergency A humanitarian crisis in a country, region orsociety where there is a total communication during and  after emergencies, and or considerable breakdown of author- standing forums to exchange of lessons learned are vital ity resulting from internal or external to maximize success and ensure effective and efficient conflict, and which requires an interna- tional response that goes beyond the crisis response. capacity of any single agency and/or Complex emergencies witness a rise in mortality and the ongoing UN country program. morbidity among the population, either as a result of the Responsibility to Protect (R2P) The responsibility to protect embod- direct effects of war or conflict, or indirectly through the ies a political commitment to end the worst forms of violence and increased prevalence of disease (i.e. malnutrition, trans- persecution; it seeks to narrow the gap mission of communicable diseases); these are often the between Member States’ pre-existing result of deliberate political strategies on the part of the obligations under international humanitarian and human rights law parties to a conflict (military, armed groups, militia etc.) and the reality faced by populations [9, 10]. at risk of genocide, war crimes, ethnic Characteristics of complex emergencies include a large cleansing and crimesagainst humanity [18]. number of civilian victims, populations who are besieged or displaced, human suffering on a major scale; substan - The Kofi Annan International Peacekeeping Training tial international assistance is needed and the response Centre (KAIPTC) is an internationally recognized train- goes beyond the mandate or capacity of any one agency; ing center and a Centre of Excellence (COE) of the Eco- delivery of humanitarian assistance is impeded or pre- nomic Community of West African States (ECOWAS). vented by parties to the conflict; high security risks for The Ghana Ministry of Defence (MoD) established the relief workers providing humanitarian assistance; and Kofi Annan International Peacekeeping Training Centre relief workers targeted by parties to the conflict [11, 12]. (KAIPTC) in 1998 and commissioned it in 2004. The pur - Complex emergencies require coordination between mil- pose was to build upon and share Ghana’s five decades of itary and civilian entities. internationally acclaimed experience and competence in Military and security forces face increasingly complex peace operations with other states in the Economic Com- scenarios requiring crisis management that includes the munity of West African States (ECOWAS) region and the use of medical and health capabilities. The civil-military rest of Africa. interface requires not only evidenced-based practices The Kofi Annan International Peacekeeping Training and policy rooted in precedent, but also immediate infor- Centre (KAIPTC) provides an environment in which the mation exchange. Civilian-military interoperability prove specific challenges to standardize education and universal vital during complex medical emergencies - especially training in promotion of evidence-based practices in inter- in areas of conflict [13]; Korram-Manesh, et  al. 2019; agency coordination and collaboration can be shared with [14]. For example, addressing  the 2014-2015 polio and representatives of multiple institutions with global impact. 2017-present day measles outbreak in Ukraine is compli- The KAIPTC serves in the research and training for con - cated by the outbreak of hostilities. The war in Ukraine flict prevention, conflict management and conflict resolu - poses major challenges for access to the most vulnerable tion and sustainable delivery of enhanced regional capacity populations for vaccine administration and only the Min- building for peace support operations [19]. Courses taught istry of Health with support of Defense forces supported at the KAIPTC include, peace and support operations, con- mitigation of the health crisis [15]. flict management and peace and security studied. Masters and PhD programs are available. The KAIPTC is a magnet Basic Definitions for nonpartisan, nonjudgmental best practices for peace and stability operations for the African Continent and the inter- national community that promote peace. Term Definition Disaster A serious event that causes a systemic breakdown in the relationship The Comprehensive Medical Support in Complex between humans and their environ- ment on a scale that requires extraor- Emergencies (CMSCE) Course dinary efforts to allow the community The aim of this course was to promote an integrated to cope, and often requires outside health response though enhancing interoperability help and international aid [9, 16, 17]. Disasters are divided into two major across civilian and military actors that respond to com- categories: those caused by natural plex emergencies. The central theme was to promote and phenomenon and those caused by humans. Q uinn et al. Globalization and Health (2022) 18:39 Page 3 of 6 develop an understanding among multiple humanitarian, Setting governmental and military actors. Key health challenges The CMSCE course took place in Accra Ghana at the include a lack of access to health care, destroyed health- KAIPTC from 11 to 15 November 2019. The training care infrastructure, medical and disaster logistics and audience and target group for this novel pilot course information sharing, lack of health workers and emerg- included Senior Medical Officers (SMOs) and Force ing epidemiological pressures. The course is focused Medical Officers (FMOs) from the United Nations (UN), on the operational principles that drive the response to the African Union (AU), the Economic Community of disrupted health systems using civilian and military con- West African States (ECOWAS), The North Atlantic tributions to health, access to health and strengthening Treaty Organization (NATO), the European Union (EU), response throughout the disaster cycle. The course is Non-governmental organizations (NGOs). International designed to create discussions between participants that civilian and military personnel preparing to serve on a aim to improve understanding of the controversies and myriad of missions, crisis and disasters in support of best challenges associated with the civilian-military interface practices. across all domains that meet on the humanitarian field of The specific objectives of the course focused on the operations. creation of an understanding of the definition of the complex environment of humanitarian support in con- Course Methodology flict situations. This included the different agendas of the This course was not a didactic instructor to student for - main civilian and military stakeholders in international mat, but rather a facilitator with participant process. Spe- crisis management. Emphasis throughout the curriculum cifically, a Collaborative Problem Based Learning (CPBL) focused on international guidelines, concepts and princi- approach facilitated open discussion and sharing of expe- ples and their application to complex emergencies. Basic rience. Combining this with core skills and guidance, the definitions focused on the complex relations and inter - environment allowed the emergence of a shared view jux- dependence of health and human security. Discussion taposed to current best practices. and debate were encouraged on the analysis of capacity Evidence based decision making and practice is the and capability building programs that strengthen health anticipated outcome from CPBL. In this model that systems in conflict and disaster, especially in affected was deployed for this pilot course, participants’ interac- regions that require joint health and security actors. tions and contributions support success in the learning In addition, the course promoted the International environment. Committee of the Red Cross and Red Crescent (ICRC) ‘Health in Danger’ project that highlight ethics, rights The Pilot Course and responsibilities of healthcare staff. This included dis - The design of this course set out a one-week curriculum cussion on International Humanitarian Law (IHL), inter- conducted at the KAIPTC to expose course participants national human rights of caregivers and patient safety. to relevant and current skills, expertise and best practices Indeed, communities and all actors must address and in the domain of medical support and cooperation. The reduce violence against healthcare workers. Finally, the pilot course had specific emphasis on the African conti - main framework in disaster risk reduction, prevention nent with lessons that can be transferred globally. This and mitigation, including situational awareness, were course was initiated by the German Institute for Defence presented. and Strategic Studies (GIDS) and co-organized with the KAIPTC. The initial funding for this pilot course and Participants the next course in 2020 is provided by the German gov- Participants were selected with attention to a balanced ernment. To ensure sustainability, the goal is to invite geographical, ethnic, gender and professional distribu- multiple sponsoring nations and institutions for future tion. Participants followed the target groups listed above courses. and included special invitation from 15 UN missions, The CMSCE courses’ main aims were to promote an national and international organizations, ministries, integrated health response through enhanced inter- think tanks and centers for global health and profession- operability across civilian and military actors in com- als with an interest to learn about medical coordination plex emergencies. This included value added from and cooperation in key UN mission areas. There were unofficial communication and networking across agen - over 47 applications received online through the KAIPTC cies, domains and countries supporting these best prac- Learning Management System (LMS). Of these 47 appli- tices, especially partners and actors that face the greatest cants, 17 were invited and 23 participants completed the challenges in conflict. course. Seven women participated. Quinn et al. Globalization and Health (2022) 18:39 Page 4 of 6 Highlighted Core Course Content the-box thinking in the approaches to complex emer- To only serve as a superficial review of some of the core gencies. topics addressed in the pilot course, this section high- • On day 5, the TTE scenario continued in the pres- lights the central themes. The course timetable designed entation of a complex humanitarian crisis with over- directed a ‘learning journey’ across one week as opposed lays of food insecurity and conflict that included an to a didactic lecture series. inject of a “Disease X” outbreak. The emphasis of the TTE was on collaboration among the various actors, understanding how to interpret indicator informa- • Day 1 included a review of foundational concepts of tion as a vital component to situational awareness, health security, complex emergencies, and key actors and how to connect that information to preparedness involved in humanitarian assistance. In the opening and response. The TTE reflection and insights from session on ‘what is health’, perspectives on human participants on considerations going forward. The security, national security and global security with participants shared and reflected upon the concepts consideration of the formal and informal actors in applied and knowledge gained over the week course the health economy within a country were presented. and how they would apply core principles into their • Day 2 explored perspectives of organizational actors respective practice. and stakeholders such as emergency humanitarian responders, public health, peacekeeping missions, and health security intelligence. The humanitarian charter, Monitoring and Evaluation Outcomes humanitarian imperative and international law were and next steps presented and reflected upon with respect to specific The CMSCE Pilot course was successfully conducted and situations in military conflicts [20]. This section also participants and facilitators were both vital to the suc- highlighted medical ethics in conflict with discussion cess. Based on feedback from participants and facilita- of the law of armed conflict and international humani - tors, and a facilitator roundtable review, many outcomes tarian law with specific reference to the rights and can be described. Going forward, the CMSCE will be duties of healthcare workers and ‘healthcare in danger.’ offered in two separate courses: basic and advanced. The basic course will be foundational and will focus on prin- ciples and common guidelines and definitions found in • Day 3 introduced challenges in civilian-military response the SPHERE handbook, multiple UN disaster and out- to conflict, medical ethics in conflict, and included an break response guidance and other core definitions used offsite military hospital visit that included an interactive for those who respond to complex emergencies. Owing discussion of how to address mental health in complex to feedback about practical applications and health- emergencies for deployment. Organizational perspec- care under threat, this basic course will also include the tives included the planning cycle in military medical very practical first aid at point of injury found in the UN operations with civilian actors as a mitigation of the out- guidelines and military medicine. These concepts found comes of intentional violence between armed actors. One in the paradigm of tactical emergency / combat casualty module of the course contained basic information about care (TECC / TCCC) which focus on preventable causes the ethical and legal backdrops of humanitarian aid. of death from war related trauma. • Days 4 the SPHERE concept and a scenario-based The advanced course will be run as a workshop and will tabletop exercise (TTE)  were introduced [21]. assume a foundational understanding of basic core con- Principles and minimal standards of humanitar- cepts and will instead address current and emergent topics ian aid in the sections of Water, Sanitation and for subject matter experts and senior leadership responding Hygiene (WASH), food, shelter and medical aid to complex emergencies on a strategic level. The advanced were described in order to prepare the participants workshop will have different topics each iteration and the for the tabletop exercise (TTE) so they could prac- curriculum will be designed and created in 2020. tice referencing humanitarian standards as well as Another outcome to maximize time during the course address a global health complex emergency. The TTE is to introduce a more robust online learning environ- spanned 1.5 days and included a practical approach ment with open-source materials in the form of videos, to SPHERE methodologies and encouraged out-of- articles, chapters, online quizzes and other academic materials. This eLearning component will be introduced through the existing KAIPTC Learning Management System (LMS). This eLearning component aims to pre - The Sphere Project and its Handbook are well known for introducing con - sent core definitions while course participants are still in siderations of quality and accountability to humanitarian response Q uinn et al. Globalization and Health (2022) 18:39 Page 5 of 6 awarded the Companion of the Order of Bath, the Order of St John and the US their home country prior to arriving to KAIPTC and tak- Bronze Star during his military service. ing the live portion of the course. Dr. James M Wilson is a board-certified, practicing pediatrician who specializes in operational health security intelligence, with a focus on the anticipation, detection, and warning of infectious disease crises. Dr. Wilson was the first Conclusions operations chief of the Department of Homeland Security’s National Biosur- veillance Integration Center. Dr. Wilson led the private intelligence teams that In summary, global health threats are increasing, and exac- provided tracking of H5N1 avian influenza as it spread from Asia to Europe erbating factors are making complex medical emergencies and Africa, detection of vaccine drifted H3N2 influenza in 2007, warning of the ever more difficult to approach and apply best practices. 2009 H1N1 influenza pandemic, and discovery of the United Nations as the source of the 2010 cholera disaster in Haiti. Dr. Wilson is a strong advocate for In an effort to promote best practices, to standardize effective and accountable global health security intelligence and the need for response and to mitigate preventable death and morbidity, credible and balanced threat assessments. the Kofi Annan International Peacekeeping Training Centre Timo Ulrichs is professor for global health at Akkon University for Human Sciences (www. akkon- hochs chule. de). He studied medicine and specialized in (KAIPTC) administered the pilot course entitled, “Compre- medical microbiology and infection epidemiology and holds another doctoral hensive Medical Support in Complex Emergencies (CMSCE degree in public health. His research interests are infection control, health 19).” The next courses to be offered will breakdown into a care system strengthening, global health security and the nexus between humanitarian aid, development aid and peacekeeping. He works as a trainer basic and an advanced level for practitioners. for SPHERE standards and interventions and runs several collaborative projects This brief review paper describes the process of design - in health and biomedical research with partners in Eastern Europe, Southern ing and delivering this interdisciplinary pilot course and Caucasus and Africa. For these research activities, he founded the Institute for Research in International Assistance at Akkon University. sets forth a roadmap for the future. Funding Acknowledgements The German Government sponsored for accommodation of all course partici- The authors wish to thank the KAIPTC for the opportunity to participate in this pants, flights, food, accommodation and sustenance of the facilitator faculty pilot course. We also wish to thank the German Government for its financial, and the Learning Develop Design Workshop in Accra, Ghana. managerial and organizational support provided by Col. Michael Reinwald. Lastly, we wish to thank all those who respond to disaster and run into a com- Availability of data and materials plex emergency while most are trying to escape out of it. To the anonymous The datasets generated and/or analyzed during the current study are available responders, we thank you all for your service. in the KAIPTC repository. Authors’ contributions JQ, JW, TU and MB provided the first four drafts. MR, PT, TA, MB, AM, SG and CH Declarations provided vital analysis and final draft of the “Highlighted Core Course Content” section. All authors approved of the final manuscript. Ethics approval and consent to participate No ethics or internal review board permission were sought or are required Authors’ information for this paper. The Kofi Annan International Peacekeeping Training Centre John Quinn is lead researcher at the Prague Center for Global Health (www. (KAIPTC) approved the administration of this pilot course under its leadership. pcgh. lf1. cuni. cz), Staff Emergency Medicine Registrar in London and Medical Director and consultant to Tangiers International. He works in conflict, disaster Consent for publication and emergency medicine. He holds his Masters in Public Health (MPH), PhD in Not applicable. Hygiene and Epidemiology and is both a paramedic and emergency medical doctor with over 20 years’ experience globally. His research efforts are found Competing interests here: Researchgate: https:// www. resea rchga te. net/ profi le/ John_ Quinn_V ; Authors disclose no competing interests of any kind. LinkedIn: https:// www. linke din. com/ in/ johnm quinnv and ORCID ID: orcid. org/0000-0001-6877-8298. Author details Dr. Quinn has performed emergency medical assessments in Ukraine, Israel 1 Prague Center for Global Health Institute of Hygiene and Epidemiology and Palestine, Iraq, Kurdistan and Timor-Leste. He has established and oper- 2 First Faculty of Medicine, Charles University, Prague, Czechia. First F acult y ated remote medicine clinics in conflict zones and for remote communities of Medicine, Institute of Hygiene and Epidemiology Prague Center for Global and has consulted for NATO and NATO partner nations in the health and Health, Dhabalia Global Health Intern Charles University, Prague, Czechia. medical stability operations sectors. He worked as an emergency physician 3 German Armed Forces Course Director Kofi Annan International Peace - at a Level One Trauma Center in Ireland and has worked in Ukraine providing 4 keeping Training Centre (KAIPTC), Teshie, Ghana. 37 Military Hospital Accra emergency medical consulting and training in Tactical Combat Casualty Care 5 6 Ghana, Accra, Ghana. M2 Medical Intelligence, Inc, Accra, Ghana. Ghana ( TCCC) and Damage Control. 7 Red Cross Society Ghana, Accra, Ghana. Security and Global Health Project Resuscitation (DCR). Presently, Dr. Quinn completes clinical time in the UK in Belfer Center Harvard Kennedy School of Government Instructor, Department emergency medicine and conducts global health research related to conflict of Global Health and Social Change, Harvard Medical School, Boston, USA. and disaster. He is based in Prague with his family. 8 Institute for Research in International, Assistance Akkon University for Human Professor Bricknell took up his appointment as Professor in Conflict, Health 9 Sciences, Berlin, Germany. Health and Military Medicine, Conflict and Health and Military Medicine at King’s College London in April 2019. Prior to his he Research Group School of Security Studies, King’s College London, K4L.10 served 34 years in the UK Defence Medical Services, culminating his service as 10 Kings Building, WC2R 2LS London, UK. FRICS Western Health & Social Care the Surgeon General of the UK Armed Forces. He undertook operational tours Trust Altnagelvin Hospital Londonderr y United, BT47 6SB Londonderry, UK. in Afghanistan, Iraq, and the Balkans with multiple additional overseas assign- 11 United Nations Division of Healthcare Management And Occupational ments. In 2010 and 2006, he held senior Medical Adviser appointments in the 12 Safety and Health, New York, USA. German Institute for Defence and Stra- NATO ISAF mission. He commanded 22 Field Hospital in 1999-2002. He has tegic Studies (GIDS) Research Coordinator Health Security Interface & CMSCE trained as a general practitioner and is an accredited specialist in both Public Chief Facilitator, Hamburg, Germany. Health and Occupational Medicine. He holds two doctorates and 3 master’s degrees. He has published over 100 academic papers across military medical Received: 30 January 2020 Accepted: 3 September 2021 subjects. 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Journal

Globalization and HealthSpringer Journals

Published: Apr 12, 2022

Keywords: Complex Emergencies; United Nations; Emergency response; Health Security

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