The role of the UN Security Council in health emergencies: lessons from the Ebola response in Sierra Leone

ABSTRACT The UN Security Council has increasingly involved itself in health emergencies over the last two decades, but the advantages and potential risk of its role have not been well explored. The experience Security Council intervention in the Ebola outbreak in Sierra Leone can be instructive, in particular because it contributed to the establishment of a first-ever UN emergency health mission. While this mission was not considered effective, Security Council involvement may have helped to mobilise resources, highlight the need for a cross-sectoral response, and maintain international flights. More broadly, however, questions remain about whether the securitisation of health risks diverting funding and policy focus towards the priorities of wealthy countries and away from basic health needs.


KEYWORDS
Ebola virus disease; outbreaks; global health security; Sierra Leone What advantages, if any, does UN Security Council involvement bring to health emergencies, and does it carry any risks? In this contribution, we seek to shed light on a specific instance of Security Council intervention, drawing on Walsh and Johnson's first-hand experience with the Ebola outbreak in Sierra Leone (Walsh and Johnson 2018), as a diplomat and a medical worker respectively, and reflecting on implications of this experience for future responses to health emergencies.

The West African Ebola outbreak
The Ebola outbreak in West Africa began in a remote village in Guinea in December 2013 and within months had spread to neighbouring Liberia and Sierra Leone. The scale of the epidemic was unprecedented in modern times and saw further limited spread to countries such as Nigeria and the US.
In Sierra Leone, the epidemic quickly took over daily life, with clear parallels to COVID-19. In the early months, up to 74% of affected patients died through lack of supportive care (Schieffelin et al. 2014). Fear was everywhere. The health emergency quickly developed to include wider humanitarian issues such as livelihoods, food security, education and the safety of women and girls. Nevertheless, it seemed to those of us on the ground that the world outside was asleep during the early months of what we felt was a catastrophe.
The WHO eventually declared the situation a Public Health Emergency of International Concern in August 2014, only the third time this designation had been made. A major international response was mobilised that included foreign governments, humanitarian organisations and UN agencies-although this took several months to begin in earnest. By the end of the outbreak in June 2016, a total of 28,616 cases of EVD and 11,310 deaths had been reported in the three most-affected countries (US CDC 2019).

Security Council engagement during the Ebola outbreak
The role of the UNSC in health emergencies can be understood through the prism of three features of its evolution since the end of the Cold War. First, the Council has been adaptive and innovative in responding to crises. Non-traditional security threats, particularly socioeconomic issues that interact with security, have become an enduring part of the Council's deliberations since the 1990s, largely through the influence of its non-permanent members (Von Einsiedel, Malone, and Stagno Ugarte 2015). This has included the passing of resolutions on children and armed conflict (Resolution 1261(Resolution in 1999(Resolution ), 1325(Resolution (2000; women, peace and security (Resolution 1325(Resolution in 2000, as well as on HIV/AIDS (Resolutions 1308 and 1983, from 2000 and 2011 respectively). Second, the ability of the five permanent members (P5) to craft consensus around an issue tends to generate greater influence. It is unusual for a decision of the UNSC to be drafted without the involvement of one or more P5 members (Teixeira 2003). Third, situations that have previously been on the UNSC's agenda tend to attract further action and interest, as seen in Haiti and Democratic Republic of the Congo. Sierra Leone is one such situation. It was a flagship country for the Council, serving as the testing ground for ideas such as 'robust peacekeeping', 'integrated peace missions' and 'peace consolidation', which the spread of Ebola in 2014 threatened to reverse.
UNSC engagement on Ebola began slowly. On 9th July 2014, a Security Council press statement on West Africa had mentioned Ebola only briefly, seven months into the crisis when the scale and the spread was already starkly evident to those of us on the ground (United Nations 2014a).
However, the UN, more broadly, was engaged on Ebola in Sierra Leone at an early stage. A number of UN agencies had a significant presence in the country prior to the outbreak, and these became key partners to the national government, although their performance was highly variable. For instance, WHO provided supported clinical management and disease surveillance, UNICEF led on social mobilisation, while UNFPA supported contact tracing.
In September 2014, it seemed to us in Freetown that the world, including the UN in New York, finally woke up. On 2 September, a special Member State briefing on Ebola was organised at the UN, which included a presentation by the president of Médecins Sans Frontières (MSF) calling for massive military intervention to stop Ebola, the first time in its history that the organisation had made such a call (Liu 2014).
On 18 September, the UNSC met for the first time on the Ebola crisis and declared, in Resolution 2177, that 'the unprecedented extent of the Ebola outbreak in Africa constitutes a threat to international peace and security' (United Nations 2014b). This was notable in part because there had been no active conflict in the affected countries for over a decade. However, the Council's history of peace-building after the civil wars in Liberia and Sierra Leone was a significant factor in its consideration. Resolution 2177 'recognized that the peacebuilding and development gains of the most affected countries concerned could be reversed in light of the Ebola outbreak.' The resolution had 130 co-sponsors, the highest number ever. 9 This reflected the widespread nature of the concern felt about the potential spread of Ebola beyond West Africa.
Resolution 2177 laid the ground for the unanimous adoption of UN General Assembly Resolution (69/1) the following day, which welcomed the Secretary General's decision to set up a special UN Mission for Ebola Emergency Response (UNMEER). The Secretary General had spoken to the Council about this Mission during the session preceding the adoption of Resolution 2177 (UN 2020). While the Resolution did not mention UNMEER specifically, many Member States welcomed the announcement of the Mission during the Council session.
Indirectly, Resolution 2177 also reinforced the Secretary General's plan to establish this first-ever UN emergency health mission by raising the profile of the crisis and by helping to mobilise resources for the response more broadly. For instance, the Resolution, welcomed 'the intention of the Secretary-General to convene a high-level meeting on the margins of the sixty-ninth United Nations General Assembly to urge an exceptional and vigorous responses to the Ebola outbreak' and the Council session also included opportunities for countries to pledge resources, which they did (United Nations 2014c).
The Security Council continued to pay attention to the crisis after the adoption of Resolution 2177. It organised another briefing on Ebola on 15th October which urged Member States to provide more support and was followed by a press statement. Finally, a Security Council Presidential Statement on 21st November recognised progress made and called for further strengthening of the response.

Reflections on impacts of the Security Council's engagement
In Sierra Leone at the time, the rapid-fire succession of the aforementioned UN activity in September felt like a huge relief; finally, we thought, a cavalry would come in and take charge. Earlier in the same week that the UN meetings took place, the US and UK had announced major contributions: the US announced they would send 3000 troops to Liberia to help with the response and the UK pledged to support 700 beds to treat Ebola patients in Sierra Leone (Cooper et al. 2014;UK Foreign & Commonwealth Office et al. 2014). After the UN meetings, it seemed to us that the new UN mission would coordinate these contributions, along with all other resources pledged by Member States. However, more experienced UN hands in Sierra Leone tempered our optimism. And they were right.
Notwithstanding the consensus that underlined the adoption of Resolution 2177, the reality on the ground in Sierra Leone in the ensuing months did not match the expressions of solidarity and cooperation. UNMEER had the objective of scaling up the response on the ground and establishing a unity of purpose among responders in support of the nationally-led efforts. Unfortunately, UNMEER was handicapped from the beginning by being an unprecedented type of UN mission, established in the middle of a crisis and thus very slow to start given heavy UN bureaucracy. In addition, in Sierra Leone, the UK Ebola mission, although from a P5 country, was initially quite dismissive of UNMEER and UN interventions in general, preferring to go it alone with parts of the Sierra Leonean government and international NGOs (Walsh and Johnson 2018). 1 Nevertheless, the Security Council's involvement in the West African Ebola outbreak likely did bring benefits to the response. The repeated calls for action by the Council, and its work behind the scenes, seemed to have stimulated the mobilisation of funding and resources: for example, the US Government used its position as rotating President of the Security Council in September to actively solicit contributions, with President Barack Obama and Ambassador to the UN Samantha Power individually calling heads of state to ask for pledges. 2 The timing would appear to suggest that the Council, in its strongly worded resolution, was actually responding to (rather than leading) decisions by P5 countries to make major commitments to the Ebola response. Nevertheless, in Freetown it felt like the UN activity had helped raise the profile of the crisis significantly from September onwards.
The Security Council also helped to highlight the need to 'mitigate the wider political, security, socio-economic and humanitarian dimensions' of the crisis, notably the impact on women, with a more holistic response that worked across sectors. Resolution 2177s specific call to Member States to lift general travel and border restrictions to the affected countries likely contributed to the maintenance of some international commercial flights. This was vital to the Ebola response because it enabled international health workers and essential medical supplies to continue to arrive.
More broadly, however, the growing engagement by the Security Council in health emergencies does raise questions about whether framing global health as a security issue is a positive development. While the 'global health security' agenda could be seen as a route to raising the profile of health as a government and public priority, leading to increased investment in health issues, this comes at a cost. It focuses the international community's attention towards infectious diseases that might threaten high-income countries, rather than the main health issues faced by low-income countries, in a way that could be considered neo-colonial (Flahault et al. 2016). It also channels global health funding towards narrow programme areas, such as disease surveillance and vaccine development, while horizontal health systems strengthening remains chronically underfunded. An example of major investment in 'global health security' would be the US Government's $200m Predict programme, to search for previously undiscovered pathogens by collecting animal samples in over 30 countries, including Sierra Leone (USAID 2020). This approach does not contribute meaningfully to the health aims in the Sustainable Development Goals or the WHO's campaign for universal health coverage. While there is clearly a need to strengthen both outbreak control capacity and broader health care, we would argue that the best protection from epidemics is a strong health system with well-trained and motivated health workers at the community level.

Lessons for the future
The Security Council's intervention at a critical stage during the outbreak of Ebola in West Africa in 2014 demonstrates that its value lies in its ability to raise the profile of an issue and give credibility to response activities. We would argue that the Council's intervention in health emergencies is most useful when it occurs early in a crisis, and that it can produce effective concerted action when the three features mentioned earlier are present.
We note two further important lessons for future responses to global health emergencies. Firstly, the UNSC often appears to be a potentially useful instrument of P5 members when unilateral action is not desirable or when the universal reach of the Council might be more beneficial. The UK and US were already mobilising support for Ebola response in Sierra Leone and Council profile: raising influence and further resources from others, particularly for Guinea, was desirable. However, if P5 interests do not coincide-or P5 consensus is not possible-the UNSC might be rendered powerless in the face of a global pandemic. Second, P5 members can sometimes undermine the Council's decisions on the ground if implementation does not suit their purpose, as demonstrated by the UK's initial dismissiveness of UNMEER.

Notes
1. This attitude did eventually change, and the UK worked well with UNMEER later in the crisis in 2015. A strengthening of UNMEER leadership in-country was also a factor here. 2. Walsh met with Samantha Power in Freetown on 28 October 2014 and she outlined these actions.

Disclosure statement
No potential conflict of interest was reported by the author(s).

Note on contributors
Dr Oliver Johnson trained as a medical doctor and is completing a PhD focused on health leadership in Sub-Saharan Africa.
Sinead Walsh completed her PhD at the London School of Economics and has been Ireland's Climate Envoy since 2020.
Professor 'Funmi Olonisakin is Professor of Security, Leadership and Development at King's College London and was appointed an Extra-Ordinary Professor in the Department of Political Sciences by the University of Pretoria in 2016.