Examining the militarised hierarchy of Sierra Leone's Ebola response and implications for decision making during public health emergencies.

Background: In September, 2014, Médecins Sans Frontières (MSF) called for militarised assistance in response to the rapidly escalating West Africa Ebola Epidemic. Soon after, the United Kingdom deployed its military to Sierra Leone, which (among other contributions) helped to support the establishment of novel and military-led Ebola Virus Disease (Ebola) response centres throughout the country. To examine these civil-military structures and their effects, 110 semi-structured interviews with civilian and military Ebola Response Workers (ERWs) were conducted and analysed using neo-Durkheimian theory.

Results: The hierarchical Ebola response centres were found to be spaces of 'conflict attenuation' for their use of 'rule-bound niches', 'neutral zones', 'co-dependence', and 'hybridity', thereby not only easing civil-military relationships (CMRel), but also increasing the efficiency of their application to Ebola response interventions. Furthermore, the hierarchical response centres were also found to be inclusive spaces that further increased efficiency through the decentralisation and localisation of these interventions and daily decision making, albeit for mostly privileged groups and in limited ways.

Conclusions: This demonstrates how hierarchy and localisation can (and perhaps should) go hand-in-hand during future public health emergency responses as a strategy for more robustly including typically marginalised local actors, while also improving necessary efficiency-in other words, an 'inclusive hierarchical coordination' that is both operationally viable and an ethical imperative.