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New Values for Military Medical Personnel? Medical Ethics in Military Context

It was the outbreak of Ebola which led to the German armed forces, German Red Cross (Deutsches Rotes Kreuz, DRK), International Red Cross (ICRC) and Doctors Without Borders (Médecins Sans Frontières, MSF) working together for the first time in Germany’s history. They established synergies in their Ebola prep courses, and benefited greatly from each other’s capabilities during this humanitarian mission. Andreas-Christian Tübler was the first German military chaplain in Liberia. He was there in the field for the helpers and victims.

Vaske: Luckily, few people contracted the disease when you were in the field during the Ebola mission, but there was still a constant fear of infection. What exactly was the purpose of these missions and what was your role as military chaplain?

Tübler: The task and objective of these missions both for the German armed forces (Bundeswehr) and the Red Cross was to break the infection chain. The goal was to break the Ebola infection chain from its outbreak to its end, to provide first aid for people who were infected, and to establish security for the populace. The military chaplain’s task is to offer stability to Bundeswehr soldiers – we didn’t know exactly how big the threat would be. We were certainly prepared to expect many Ebola deaths during the training stage in Hamburg. As it turned out, this fear was groundless, but nevertheless, every patient in our facility during the first two days was treated as if they could have Ebola until there was a conclusive blood test, and this meant being on standby 24/7.

What exactly were you able to do in Monrovia, the capital city of Liberia? What was your daily work routine?

The daily routine began at 6 a.m. and ended at 9 p.m. Among other things, we needed to be present at the adjacent camp (a 200 x 200 m tent city for the wounded and injured) to talk with people, including Bundeswehr personnel, the Red Cross, and finally local people. At the end of the day, we returned to our hotel, talked about our experiences with the soldiers, and organized our free time together (religious services etc.).

What exactly were you able to give the soldiers and volunteer helpers? How were you able to help them?

I don’t know if you can pinpoint it specifically; I was there to hold talks in the back-office area, i.e. behind the scenes of what was going on in the camp, and to give the soldiers reassurance that they were doing a good job. I talked with the people involved about the problems that they had in particular situations. For example, we did not have any Ebola patients, but we had a series of HIV patients who needed our special attention and that was not always so easy. You saw serious injuries or necrotic limbs; and the psychological situation of patients and carers was ambivalent. That’s why things needed to be talked through with everyone. Ultimately, my job is to offer a sympathetic ear to the people in the field.

What do you say to the people on the ground to relieve their specific concerns?

It is about making sense of experiences and particular situations in the form of conversations (question and answer). I experienced the situation firsthand and I visited patients myself, including HIV patients. Although I wasn’t in the suspected Ebola area, I was in the area where there were people who were seriously ill with other infectious diseases. You can try to devise a joint strategy or vision for the future, e.g. in thinking about how to improve the situation in the country, strengthen the healthcare system, or by providing external funding – but of course that alone is not enough. There is corruption, high levels of poverty, and people tend to act out of self-interest. There needs to be “external supervision”, for example people who manage hospitals on behalf of others. We jointly developed these considerations.

The pharma industry found a drug to fight Ebola. Why is it still necessary to continue the work?

Ebola could break out again any day. You can’t assume that this disease is beaten if there are no new cases after four weeks. As a disease, Ebola has been known about for more than 30 years. It wasn’t until there was a specific threat from people traveling into Europe that government and industry took action – this should change. A white helmet force should be specially trained for infectious diseases to enable faster intervention. Also, there are many villages and areas that we have not been to yet, as they are inaccessible due to poor infrastructure. Of course it may be that there are still Ebola patients in these places, but we simply don’t know it. Liberia, Sierra Leone, and Guinea are a gray zone, since no one can say for sure whether Ebola is beaten. That’s why there is still a need for caution.

How afraid were you of catching Ebola?

People were not afraid, but there were always overtones of apprehension. In November last year, we were told to expect many deaths. Fortunately it didn’t come to that. I was less afraid because I knew that if we protected ourselves properly, washed our hands and took all precautions, we could actually live with the risk quite easily. 

Ebola provoked fear, sympathy, and a desire to help. For the first time, the German armed forces, Red Cross, and Doctors Without Borders worked together in preparatory courses and in the field. How well did you work together?

All things considered, it went very well. The level of cooperation was excellent; we saw that after the mission as well. After the mission, we had a joint mission follow up, in which we discussed our experiences and even made new friends.

Things went very well at management level too. The trouble is that the task situation – but that could be partly me – was not so very clear. It was a question of the allocation of tasks. As the Bundeswehr, we were only supposed to have a supporting role, but we did far more than that, including providing medical assistance. The Red Cross was head of mission, but in future there could be a clearer definition of who has to perform what task profile. Otherwise it was good: Transparency creates trust and for subsequent missions it should be determined what the task is and when the mission is to be considered complete. I don’t think there were any major points of criticism about the mission – quite the opposite, in fact. The fact is that both sides learned from each other and prejudices were put aside.

Do you think that such joint efforts in civil missions should be encouraged in the future? What synergies could result from that, especially for the military chaplaincy?

Quite possibly. Especially if we’re talking about aid missions and not combat missions, I can definitely envisage pooling resources. Provided that the task situation (who does what?) is clear for the individual areas and institutions, such partnerships can be implemented with Doctors Without Borders, the German Society for International Cooperation (Deutsche Gesellschaft für internationale Zusammenarbeit, GIZ), or other partners.

Military doctors are doctors and soldiers. As a military chaplain, did you find that military doctors or helpers were in a situation where this dual role was very much perceived as a conflict?

Not during the last mission. There are situations in combat missions in which this conflict of roles can come up. Personally I have not experienced this conflict.

The case here was that the doctors were completely professional, both in the Red Cross and in the Bundeswehr. All doctors had experience being deployed overseas and they all knew what they were getting into; they were real professionals. But professionals with a soft heart who had a keen awareness of the concerns and needs of people affected locally. I found that very positive. So they saw no conflict in their role. On the contrary, they felt really comfortable in their role.

You have worked overseas as a military chaplain several times, not only in the Ebola mission. Which missions were especially precarious and where did the life-threatening dangers lurk?

The fact is that the situation is never totally relaxed. Even in noncombat missions such as the education missions in Mali, danger is always implicit and there is always a residual risk. There could be an attack on the way to visit the embassy (fortunately that has never happened, since the Bundeswehr takes all the necessary steps) or of course you could get an infectious disease. It doesn’t have to be Ebola – it’s bad enough if you get malaria or other diseases. The German armed forces do everything to reduce this risk, but nothing in the world is entirely safe or risk-free.

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Andreas-Christian Tübler is an Evangelical Lutheran military chaplain and has been head of the military chaplain’s office for Appen/Heide/Seeth since 2010. He is part-time lecturer at the German Federal Armed Forces Command and Staff College and has taken part in various overseas missions. In 2014, he spent two months with the German federal armed forces’ training contingent in Mali (west Africa). In 2015, he volunteered for the ebola humanitarian aid mission in Liberia, where he assisted soldiers as well as the German Red Cross.

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