The Blurring Line Between Militaries and Health Workers

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This August, only weeks after South Africa hosted the World Cup to show off itself and its remarkable post-apartheid progress, the country was brought to a state of national emergency by a three-week long strike by 1.3 million public sector workers. Though the labor dispute behind the strikes amounted to a relatively minor 1.1 percent pay increase and R200 ($18) monthly housing allowance, it brought much of the country to a halt, including the all-important health sector. With everything from research hospitals to rural clinics crippled or closed entirely, and with South Africa still struggling against one of the world's worst HIV epidemics, the human cost of the strike could have been far worse.

Thankfully, the South African military stepped in, providing health services nationwide and allowing me to observe something I have long studied: what it means when the military plays doctor. Whether a military intervenes to provide necessary humanitarian aid, or whether it incorporates health services in pursuit of a larger security goal, this intersection of soldier and doctor was on full display in South Africa.

My first encounter with the labor dispute strike was outside Durban's Addington Hospital. The hospital is within sight of the former location of the FIFA World Cup Fan Zone, where thousands of spectators, including myself, watched the games. Weeks before, thousands of World Cup visitors had ambled past the hospital along Durban's waterfront. This time, a crowd of workers clustered outside the hospital's entrance.

These striking health workers, represented by the trade union federation, were the forerunner of the countrywide strike that started less than a week later. Unlike American protests, South African demonstrations look more like a cross between a tailgate party and a street festival. Instead of marching in circles, protesters dance and sing to show their grievances. Less than two weeks later, the strikes spread nationwide and brought the entire country, including hospitals like Addington, to its knees.

The strike devastated the government-run health system, which provides health services to all but the small minority able to afford private insurance. Nurses and orderlies abandoned patients into the care of non-striking doctors and hospital security guards. Hundreds of newborns were left in intensive care units. Strikers wielding whips stalked the halls in one Durban hospital, chasing health workers from their posts. Nurses refusing to strike were subject to threats, kidnappings, and violence. By the second week, government hospitals were almost completely abandoned and patients left to fend for themselves. Patients with HIV/AIDS avoided coming to hospitals to collect their medication out of fear for their safety. Outside Addington Hospital, police fired rubber bullets at protesters blocking patients and non-striking workers from entering the building.

Facing a collapsed health system, the South African government turned to its military. During the first week, over one thousand military doctors, nurses, and other health workers deployed to hospitals throughout the country. By the end of the strike, 4700 military health professionals were serving in 73 hospitals across eight of South Africa's nine provinces. Additional soldiers provided security and even stood in for striking hospital janitors. While it replaced only a fraction of the civilian health system the military was able to keep at least some hospital doors open. This mission is not a new one for the South African military. Twice in the last four years, South African Military Health Service personnel deployed to maintain essential health services during health worker strikes.

South Africa is not alone in using the military as a stopgap health system during labor crises. Sierra Leone, Zimbabwe, Guatemala, and Nigeria have all relied on their militaries to provide medical care when health workers went on strike. The military is an appealing health provider of last resort for two reasons. First, military health services are uniquely equipped to provide health care during crises. Military medical personnel have access to their own pool of supporting services including security, transportation, and maintenance. This capacity can be critical during general strikes, when the civilian sector is crippled and many of the services regularly provided by private businesses and civil service workers are shuttered. Second, it is almost universally illegal for military personnel to go on strike. The simple fact is that in major strikes like the one last month in South Africa, the military becomes the only fully staffed health care service available to governments.

Worldwide, in times of crisis, countries are increasingly turning to their militaries to be health workers and emergency services of last resort. During Pakistan's devastating floods, the Pakistani military and not the civilian government had the most prominent role in the disaster relief effort. The Pakistani Army, the only group that could safely access many affected areas, delivered thousands of tons of supplies and rescued over 100,000 stranded people . After Katrina, U.S. Army, Air Force, Navy, Marine Corps, and Coast Guard personnel played a critical role in the government's response. Coast Guard helicopters lifted tens of thousands of Americans to safety, Air Force teams set up numerous field hospitals, and the navy stationed a hospital ship off the Gulf Coast. This 'softer' military role is becoming particularly common in international disaster relief.

The U.S. military has provided medical care and humanitarian assistance after almost every major natural disaster of this decade, including the 2004 tsunami and the earthquake in Haiti. It's not just the United States using its military for international disaster relief: Canada, Israel, Mexico, and the Netherlands all sent military units to assist after Hurricane Katrina.

The growing role of militaries in health provision and disaster relief is not without opponents. Humanitarians worry the trend will lead to the politicization of aid, while defense establishments fear it will turn militaries into little more than armed Peace Corps. But these concerns misunderstand what's causing the shifting military role. The spread of globalization, democracy, and human rights over the last century has changed how states treat armed conflicts and health crises, which have become more intertwined. In the age of terrorism and insurgencies, humanitarian disasters are more likely to turn violent; and military campaigns, such as the U.S. missions in Iraq and Afghanistan, tend to focus less on killing the enemy and more on winning over the local population, as militaries find that healing people is cheaper, more likely to win over locals, and less likely to inspire backlash.

Even non-state military actors such as Hezbollah and Lashkar-e-Taiba have taken to providing health services to achieve their military goals. Whether by providing basic care during a labor strike or building a clinic in Afghanistan, the military use in administering health services is likely to become only more common.

Image: Members of the South African Military, filling in for the doctors and nurses who had abandoned their posts for the labor strikes, assist a patient and her newborn at the Labour Ward of the King Edward VIII Hospital in Durban. By Rajesh Jantilal/AFP/Getty.

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Christopher R. Albon is a political science Ph.D candidate at U.C. Davis specializing in the relationship between armed conflict and public health. He writes at Conflict Health, Current Intelligence, and the U.S. Naval Institute blog.

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