Conflict and Catastrophe Medicine: A Practical Guide
Authors: Douglas M Bowley
Journal: Journal of the Royal Society of Medicine (2002)

In 1918 the British Prime Minister, David Lloyd George, believed that with the signing of the armistice between the allied powers and Germany ‘came to an end all wars’. Sadly, mankind seems to have an inexhaustible appetite for conflict. UNICEF has characterized the past fifty years as an ‘age of neglect’—a time when governments sacrificed the basic needs of women and children to build military arsenals and finance projects that did little to help the poorest. Between 25 and 40 wars were active at any one time in the 1980s and 1990s, almost all ‘internal’ and principally targeting civilians and their ways of life. While established democracies move towards globalization in trade, defence, communication and the espousing of ‘human rights’, many unstable and economically poor states move towards disintegration and further internal conflict. In what has been described as double jeopardy, population growth and increasing urbanization in the developing world mean that more and more people are exposed to conflict in the areas most at risk for natural disasters. These trends have been met by a burgeoning in the global humanitarian industry. By 1997, there were 260 international governmental organizations and more than 5400 non-governmental organizations on the world stage, with spending on emergencies running at over US$7 billion per year by the mid-1990s. Massive expansion in the capability of global newsgathering means that the victims of conflict and natural disasters can be viewed halfway around the world in ‘almost real-time’. Often there is a generous public reaction, but in the recent past too much of the assistance from donor countries has been misdirected. A hasty response can make matters worse: it is better to wait until the needs have been assessed. Assistance must take into account local conditions and complement the internal efforts.

Conflict and Catastrophe Medicine: A Practical Guide takes a welcome step towards collating essential knowledge, both theoretical and practical, for healthcare workers contemplating such humanitarian work. The chief editor James Ryan, who heads the Leonard Cheshire Centre of Conflict Recovery based at the Royal Free and University College Medical School, has assembled 43 contributors, mostly from the UK, who deliver a strong thread of personal experience throughout the text. Their collective aim is to provide an entry-level text for medical, nursing and paramedical staff working in hostile environments.

The first of six sections discusses the risks faced by humanitarian volunteers and how they can stay safe. It introduces the concept of ‘the failed state’ and explores the nature of conflict in some detail. Natural and man-made disasters and the problems of refugees and internally displaced people are discussed. Experts on remote medicine offer valuable advice about providing medical care in austere circumstances. The final part of this section discusses the issues around the decision to commit to a humanitarian intervention and introduces the various ‘players’.

The second section details the process of working in international humanitarian aid. In addition to hints on how to combine aid work with career progression back home, it provides specific instructions and check-lists on practical topics such as personal medical preparation, insurance, passports and other documents, clothing and equipment. It advises on safety and cultural issues while working abroad, and a particularly strong chapter, relevant to the aid worker, is the one on the psychological aspects of humanitarian aid, reminding us that vulnerability is not confined to the ‘victims’.

Section three contains information on prehospital planning and on relevant aspects of aviation medicine. Communications technology gets close attention: though the rapidly growing capabilities are revolutionizing humanitarian missions, wrongly used equipment can be a confusing and expensive liability. The last part of this section deals with acute medical troubles such as infectious diseases, surgical illness, trauma, bites and stings, and dental emergencies as well as pain relief and anaesthetic options in an environment outside the usual ‘zone of comfort’. It is recognized that women and children in conflict or refugee settings face special difficulties in gaining access to health services, in obtaining food and commodities, and in securing protection from sexual violence; two chapters focus on these and other issues.

The fourth section introduces the concept of conflict recovery, describing phases of transition from first response to long-term recovery, with examples from the Falkland Islands, Kosovo and Azerbaijan. Particularly enjoyable is the section entitled ‘hard knocks and hard lessons’, with stories that should help well-meaning workers avoid difficulties in the future. The penultimate section includes a guide to publications, Internet sites and specialist suppliers; and in the short final section the editors offer a code of behaviour for humanitarian workers.

Professor Ryan helped to establish the RSM's Conflict and Catastrophe Forum, which aims ‘to create an international forum for humanitarian aid workers of all skills and specialities, to facilitate teaching, training and education in the humanitarian field and to raise the awareness and profile of humanitarian aid and medicine’. The Practical Guide is a valuable resource for all those contemplating involvement in this arena.