Conflict and Catastrophe Medicine: A Practical Guide Second Edition
Editors
Adriaan P.C.C. Hopperus Buma, David G. Burris, Alan Hawley, James M. Ryan and Peter F. Mahoney Associate Editors
Ravi Chauhan and John-Joe Reilly
Conflict and Catastrophe Medicine A Practical Guide Second Edition Foreword by Norman M. Rich, MD, FACS, DMCC
Editors Adriaan P.C.C. Hopperus Buma, MD, PhD, DMCC Inspector General Military Health Care Ministry of Defence (MOD NL) Hilversum, The Netherlands Alan Hawley, OBE The Army Medical Directorate Former Army Staff College Camberley Surrey, UK Peter F. Mahoney, OBE, TD Defence Professor Anaesthesia and Critical Care DMA&CC Royal Centre for Defence Medicine Birmingham, UK Associate Editors Ravi Chauhan, MBChB, DipIMC, RCSED Department of Anaesthetics Queens Hospital Burton Burton-Upon-Trent, Staffordshire, UK
ISBN 978-1-84800-351-4 2nd edition ISBN 978-1-85233-348-0 1st edition DOI 10.1007/978-1-84800-352-1
David G. Burris, MD, FACS, DMCC, COL, MC, USA Uniformed Services University of the Health Sciences Department of Surgery Bethesda, MD USA James M. Ryan, OStJ, FRCS, MCh, DMCC, Hon FCEM Emeritus Professor, Faculty of Conflict & Catastrophe Medicine St George’s University of London Tooting, London, UK & Uniformed University of the Health Sciences Department of Surgery Bethesda, MD, USA John-Joe Reilly, BSc (Hons), PhD, DIC, GI Biol, BMedSci (Hons), BM, BS, RN Department of Emergency Medicine RCDM, Birmingham City Hospital Birmingham, West Midlands, UK
e-ISBN 978-1-84800-352-1 2nd edition
British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Control Number: 2008941005 © Springer-Verlag London Limited 2002, 2009 Apart from any fair dealing for the purposes of research or private study, or criticism or review, as permitted under the Copyright, Designs and Patents Act 1988, this publication may only be reproduced, stored or transmitted, in any form or by any means, with the prior permission in writing of the publishers, or in the case of reprographic reproduction in accordance with the terms of licences issued by the Copyright Licensing Agency. Enquiries concerning reproduction outside those terms should be sent to the publishers. The use of registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant laws and regulations and therefore free for general use. Product liability: The publisher can give no guarantee for information about drug dosage and application thereof contained in this book. In every individual case the respective user must check its accuracy by consulting other pharmaceutical literature. Printed on acid-free paper Springer Science+Business Media springer.com
Preface to the Second Edition
Six years have passed since the first edition of Conflict and Catastrophe Medicine was published. Those 6 years have not been peaceful: conflict has continued in Iraq, Afghanistan, Africa, and the Middle East. Terrorist attacks have continued around the world and London has had its first experience of suicide bombings. The landscape for humanitarian work is dangerous and challenging. The aim of this second edition is in line with the first edition – to provide an entrylevel resource for people working (or considering work) in a hostile environment. Contributors with real hard one practical experience have been invited to share their views, and they do this with a raw honesty in a variety of writing styles. The second edition of Conflict and Catastrophe Medicine has benefited from these contributions, and we hope our prospective readers will do so as well. The book editors are donating their royalties from this book to the charity “Help for Heroes’. Adriaan Hopperus Buma Alan Hawley David G. Burris James M. Ryan Peter F. Mahoney
v
Preface to the First Edition
This work is intended as an entry-level text aimed at medical, nursing and paramedical staff undertaking work in a hostile environment. It covers aid across a spectrum of hostile environments encompassing natural disasters, man-made disasters and conflict in all its forms, and extending to cover remote areas and austere industrial settings. The common thread in these situations is an increased risk of injury or death, which extends to both the local population and the expatriate workers. Providing care in these environments needs an understanding of the situation, and how this constricts and limits what can be achieved. This understanding bridges the fields of medicine, politics, economics, history and international relations. Many humanitarian and equivalent organisations have long recognised the difficulties which can be experienced, and run a wide variety of courses, workshops and exercises to broaden the skill and knowledge of the worker. We hope this work will help in these endeavours, and provide a link to the more specialist texts and training available. It should give the prospective volunteer a feel for the depth and breath of the subject, and make volunteers realise the importance of external factors which impact upon medical care. It should also heighten their respect and understanding of other professionals in the field, such as engineers and logisticians. Finally, this work should educate and inform those who now, or in the future, volunteer to deploy into an environment of conflict or austerity. Jim Ryan Peter F. Mahoney Ian Greaves Gavin Bowyer
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Foreword
The experienced authors and editors provide us with an expanded and improved valuable resource. The first edition of Conflict and Catastrophe Medicine was of great value, particularly to those studying for the Examination for the Diploma in the Medical Care of Catastrophes under the auspices of the Apothecaries of London. Having worked extensively with all of the Editors, I have learned considerably from all of them based on their vast individual and collective experiences as well as the academic and teaching abilities of all involved. Admiral Hopperus Buma, COL/ Professor Burris, General Hawley, COL (Ret.)/Professor Ryan, and COL/Professor Mahoney representing perspectives from the Netherlands, the UK, and the USA have had broad civilian and military experiences at multiple levels in government and in healthcare delivery throughout the world. These editors/authors have augmented and complimented their own experiences with specific contributions by other authors who have had significant recent experiences. The six sections in the Table of Contents provide a rapid review and help identify specific areas of interest ranging from a broad spectrum of medical responses to both natural and man-made disasters, including military conflicts. The topics range from health planning in action in the Rwanda Crisis and from “Operation Phoenix” with the British Medical Aid Program in Sarajevo in the Balkans to multiple other topics including conflict recovery and ethics involved with those who have the misfortune to be injured or who are deprived of even the basics for human survival. This is a “must read” for anyone working in the broad field of conflict and catastrophe medicine to include those in non-government organizations (NGOs), military medical personnel around the world, and those in government addressing these global challenges. Specifically, this will be the primary source for review for those being examined for the Diploma in the Medical Care of Catastrophes. The material is informative and interesting being well organized. Hopefully, reading this material and teaching from this book will create an exciting incentive in others to contribute to those less fortunate around the world as “globalization” becomes more part of our common existence. Norman M. Rich
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Contents
SECTION ONE: Introduction: Players and Paradigms 1. Baghdad Christmas David R. Steinbruner . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3
2. New Paradigms: The Changed World Since 9/11 James M. Ryan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5
3. The World Seems to be Crumbling Around Us David R. Steinbruner . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
13
4. The Spectrum of Conflict Alan Hawley . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
17
5. The Players: Humanitarians, Militaries, Industry and Private Security Companies A – Humanitarian Organizations and Their Coordination in Humanitarian Assistance M. Kett and A. van Tulleken. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B – Military Medical Assistance to Civilian Health Sectors Martin C.M. Bricknell . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C – Private Security Companies and First-Line Care T. Spicer and K. Morland . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . D – Oil and Gas: Industry in Remote and Volatile Areas Bob Mark . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6. Interfaces A – Medical Ethics Is Never Easy David R. Steinbruner . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B – Village Medical Outreach or MEDCAP: A Policy Perspective Martin C.M. Bricknell, Robin Cordell and David C. Mcloughlin . . . . . . . .
31 49 61 70
75 77
7. Conflict and the Media Daloni A. Carlisle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
89
8. Remote Medicine Steven A. Bland. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
101
xi
xii
Contents A – Medicine at the Ends of the Earth: The Antarctic Iain C. Grant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B – High Altitude Sundeep Dhillon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
107 114
SECTION TWO: Disasters, Public Health, and Populations 9. Disasters: An Overview Tony Redmond . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A – The London Bombings 7th July 2005: Forward Medical Response Steven A. Bland . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
125 143
10. Responding to Acute Humanitarian Crises: Health Needs Assessment and Priorities for Intervention Aroop Mozumder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
151
11. The Military Approach to Medical Planning Martin C.M. Bricknell . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
177
12. Health Risk Management Matrix: A Medical Planning Tool Martin C.M. Bricknell and Gareth Moore . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
189
13. Surveillance and Control of Communicable Disease in Conflicts and Disasters Tim Healing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A – Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B – Health Surveillance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
197 197 199
14. Health Planning in Action: Rwanda Crisis Alan Hawley . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
223
15. Health Planning in Action “Operation Phoenix”: A British Medical Aid Program to Sarajevo Tony Redmond and John F. Navein . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
241
16. Health Care of Prisoners and Detainees Maarten Hoejenbos and Adriaan Hopperus Buma. . . . . . . . . . . . . . . . . . . . . . .
251
17. Populations and People David R. Steinbruner . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
261
SECTION THREE: Introduction: Living and Working 18. Getting There and Being Involved A – Hello Folks David R. Steinbruner . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
267
Contents B – Getting Involved Steve Mannion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C – “R and R”: Moving Between Worlds David R. Steinbruner . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . D – Team Building and Maintenance Kenneth I. Roberts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19. Safety and Security A – Staying Safe and Effective: In a Humanitarian Context (Or as Safe as Is Reasonably Possible When You Know You Should Have Stayed at Home!!!) Garry M. Vardon-Smith . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B – Thinking Ballistic: Aspects of Protection Kenneth I. Roberts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C – Mines and Weapons Awareness Kenneth I. Roberts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . D – The Oil Camp Bob Mark . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20. Voices from the Field A – Just a Word About Toilets David R. Steinbruner . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B – Conflict Medicine: A View from the Ground Luke J. Staveley-Wadham. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21. Applied Communications in Conflict and Catastrophe Medicine John F. Navein and Simon J. O’Neill . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22. Mental Health A – Practical Psychological Aspects of Humanitarian Aid Ian P. Palmer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B – Psychosocial Resilience and Distress in the Face of Adversity, Conflict, Terrorism, or Catastrophe Richard Williams and David Alexander . . . . . . . . . . . . . . . . . . . . . . . . . . . . C – Requiem: Going Home . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . David R. Steinbruner
xiii
268 281 284
287 300 303 306
315 317 323
345
360 374
SECTION FOUR: Introduction: Hospitals and Health Systems 23. Conflict Recovery-Health Systems in Transition James M. Ryan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
379
24. Eating an Elephant: Intervening in Hospitals, Pristina Tony Redmond . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
391
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Contents
25. Conflict Surgery: A Personal View Andrew Bruce . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
393
26. Military Health Services Support in Conflict Martin C.M. Bricknell and Roderick J. Heatlie . . . . . . . . . . . . . . . . . . . . . . . . . .
397
27. Military Medical Assistance to Security Sector Reform Martin C.M. Bricknell and D.F. Thompson . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
405
28. Hospital Blues David R. Steinbruner . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
413
SECTION FIVE: Introduction: Clinical Care 29. Trauma and Surgery A – Introduction: Scene-Setting Walter Henny and Adriaan Hopperus Buma . . . . . . . . . . . . . . . . . . . . . . . . B – Trauma and Triage Walter Henny and Adriaan Hopperus Buma . . . . . . . . . . . . . . . . . . . . . . . . C – Soft Tissues and Skeleton Ralph de Wit and James M. Ryan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . D – Ballistics and Blast Ralph de Wit and David G. Burris . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . E – Abdominal Complaints and Acute Surgical Emergencies Walter Henny and Adam Brooks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . F – Maxillofacial, Eye, and ENT Jan Roodenburg and Peter Dyer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . G – Head Injury Andrew Maas and Walter Henny . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . H – Anaesthesia and Analgesia Chris Bleeker . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
417 418 428 438 446 462 471 478
30. Acute Medical Problems David G. Burris, Manolis Gavalas, Claire Walford and Shautek Nazeer . . . . .
493
31. Women’s Health Charles Cox and Hervinder Kaur . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
527
32. Children’s Health M. Gavalas, S. Nazeer, Claire Walford, and A. Christodoulides . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
541
33. Conflict, Terrorism, and Disasters: The Psychosocial Consequences for Children Richard Williams and David Alexander. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
553
Contents
xv
SECTION SIX: Introduction: Resources 34. Materials and Information James I.D.M. Matheson and Adriaan Hopperus Buma . . . . . . . . . . . . . . . . . . . A – Checklists, Suppliers, and Specialist Advice . . . . . . . . . . . . . . . . . . . . . . . . B – Publications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C – Internet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
571 571 575 579
35. Rehabilitating Diagnostic Laboratories Timothy Healing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
591
36. Enablers and Confounders: Achieving the Mission Ken Millar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
597
37. Ministry Overlaps Within Health Sectors Martin C.M. Bricknell and Donald F. Thompson . . . . . . . . . . . . . . . . . . . . . . . .
611
38. Accreditation in Field Medicine Ken Millar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
613
39. Humanitarian Work in the Era of Modernising Medical Careers James I.D.M. Matheson . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
619
Code of Behaviour . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
625
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
627
Contributors
Daloni A. Carlisle Sevenoaks Kent, UK
David A. Alexander Director Aberdeen Centre for Trauma Research Professor of Mental Health at University of Aberdeen Aberdeen Scotland, UK
A. Christodoulides Senior Specialist in Accident and Emergency Medicine Larnaca General Hospital Cyprus
Steven A. Bland Emergency Department Queen Alexandra Hospital Portsmouth UK Chris Bleeker Institute for Defence and Partnership Hospitals University Hospital Nijmegen The Netherlands Martin C.M. Bricknell HQ Allied Rapid Reaction Corps UK Adam Brooks Academic Department of Military Surgery & Trauma RCDM Edgbaston, Birmingham UK Andrew S.W. Bruce Department of Orthopaedics Doncaster Royal Infirmary Doncaster, South Yorkshire UK David G. Burris Uniformed Services University of the Health Sciences Department of Surgery Bethesda, MD USA
Robin Cordell 1st (UK) Armoured Division Herford, Germany Charles W.F.M. Cox Women’s Unit, New Cross Hospital Wolverhampton West Midlands UK Ralph J. de Wit Department of Surgery Medisch Spectrum Twente Enschede, The Netherlands Sundeep Dhillon Institute of Research and Development, Edgbaston Birmingham, UK Peter V. Dyer Maxillofacial Unit Royal Lancaster Infirmary Lancaster, UK Manolis Gavalas Emergency Department UCH, London UK
xvii
xviii Rowland Gill Society of Apothecaries London, UK Iain C. Grant British Antarctic Survey Medical Unit Derriford Hospital Plymouth, Devon, UK Alan Hawley The Army Medical Directorate Former Army Staff College Camberley, Surrey UK Timothy Healing Independent Consultant in Medical Humanitarian Aid Oxford, Oxfordshire UK
Contributors Maria E. Kett Leonard Cheshire Disability and Inclusive Development Centre University College London London UK Andrew I.R. Maas Department of Neurosurgery University Hospital Antwerp Antwerp, Belgium Peter F. Mahoney Defence Professor Anaesthesia and Critical Care DMA&CC Royal Centre for Defence Medicine Birmingham, UK Steve Mannion Blackpool Orthopaedic Department Blackpool Victoria Hospital Blackpool, UK
Roderick James Heatlie SO1 Joint Medical, Development Concepts and Doctrine Centre MOD Shrivenham Swindon, UK
Bob Mark Frontier Medical Services Vantage Point Business Park Mitcheldean, Gloucestershire UK
Walter Henny Colonel, Royal Netherlands Army reserve formerly University Hospital Rotterdam The Netherlands
James I.D.M. Matheson Faculty of Conflict and Catastrophe Medicine and Health, St George’s University of London Tooting, London UK
Maarten J.J. Hoejenbos Surgeon Captain ret. Royal Netherlands Navy Aerdenhout, The Netherlands
David C. McLoughlin RAF Centre of Aviation Medicine RAF Henlow Bedfordshire, UK
Adriaan P.C.C. Hopperus Buma Inspector General Military Health Care Ministry of Defence (MOD NL) Hilversum, The Netherlands
Kenneth N.A. Millar HQ Land Command Wilton, Salisbury UK
Hervinder Kaur Obstetrics & Gynaecology Royal Wolverhampton NHS Trust Wolverhampton, West Midlands UK
Gareth Moore Combat Service Support Division Headquarters Allied Rapid Reaction Corps Mönchengladbach Germany
Contributors Kenny Morland Aegis Defence Services London, UK Aroop Mozumder COS Health (RAF) RAF High Wycombe High Wycombe Buckinghamshire, UK John F. Navein Modernising Healthcare Partnership Stratford-on-Avon, UK
xix James M. Ryan Emeritus Professor, Faculty of Conflict & Catastrophe Medicine St George’s University of London Tooting, London, UK & Uniformed University of the Health Sciences Department of Surgery Bethesda, MD, USA Tim S. Spicer Aegis Defence Services London, UK
Shauket Nazeer University College Hospital Cecil Flemming Building London, UK
Luke J. Staveley-Wadham Department of Medicine Brighton and Sussex Medical School Brighton, East Sussex UK
Simon J. O’Neill ICS Limited, Great Hampden Buckinghamshire, UK
David R. Steinbruner Emergency Department Memorial Hospital, Colorado Springs CO, USA
Ian P. Palmer Head of the Medical Assessment Programme Ministry of Defence UK Pensions, Compensation and Veterans’ Unit Visiting Professor of Military Psychiatry to the Institute of Psychiatry London UK Anthony D. Redmond Emergency Medicine Manchester Medical School Salford, Manchester UK
Donald F. Thompson Biological Defense OSD/Combating WMD, Washington, DC USA Alexander G. van Tulleken Centre for International Health and Development University College London London, UK Garry Vardon-Smith Department of Security and Risk Consultancy Centreville, VA USA
Kenneth I. Roberts Army Health Unit Army Medical Directorate, Camberley, Surrey UK
Claire S. Walford University College London Hospitals NHS Trust A&E Department London, UK
Jan L.N. Roodenburg Department of Maxillofacial Surgery University Medical Centre Groningen Groningen The Netherlands
Richard Williams Welsh Institute for Health and Social Care University of Glamorgan Glamorgan, Wales UK
xx Chris Bleeker Institute for Defence and Partnership Hospitals University Hospital Nijmegen The Netherlands Walter Henny Colonel, Royal Netherlands Army reserve formely University Hospital Rotterdam The Netherlands
Contributors Maarten J.J. Hoejenbos Surgeon Captain ret. Royal Netherlands Navy Aerdenhout, The Netherlands
SECTION
1
Introduction: Players and Paradigms Peter F. Mahoney and James M. Ryan Associate Editor - Ravi Chauhan 1. 2. 3. 4. 5.
Baghdad Christmas New Paradigms: The Changed World Since 9/11 The World Seems to be Crumbling Around Us The Spectrum of Conflict The Players: Humanitarians, Militaries, Industry and Private Security Companies A – Humanitarian Organizations and Their Coordination in Humanitarian Assistance B – Military Medical Assistance to Civilian Health Sectors C – Private Security Companies and First-Line Care D – Oil and Gas: Industry in Remote and Volatile Areas
6.
Interfaces A – Medical Ethics Is Never Easy B – Village Medical Outreach or MEDCAP: A Policy Perspective
7. 8.
Conflict and the Media Remote Medicine A – Medicine at the Ends of the Earth: The Antarctic B – High Altitude
2
Section One
The aim of this section is to give the reader the context in which conflict medicine is delivered. The deployed environment is a complex blend of: People: those living the conflict or disaster and those arriving to help or hinder the recovery, as either individuals or organizations. Organizations: with a vast array of world views from media to militias, industry to armies. Organizations become involved in conflict and disaster situations with very different agendas. Constraints: either climatic, geographic, or man made. Expectations: of those involved and those watching events in the printed or broadcast media. Politics and cultures: indigenous and imported. The aim of this section is to provide a sampler of these different factors. The intention is that the reader will start to see the issues within the issues when considering how a conflict or disaster is unfolding and what their place should be in the process. The link pieces and personal views show how different individuals came to be in a particular place at a particular time and what they made of the experience.
1. Baghdad Christmas David R. Steinbruner
Baghdad Christmas, December 25, 2005 Hello folks, I will keep these big e-mails to a minimum. Just thought I would take a moment during a lull to reach out and say hello. For those of you who tuned in late, I am now stationed at Ibn Sina Hospital in the IZ or International Zone. I have been here just about a month now and have settled in. It is strange. Though I live in the heart of Baghdad, I see very little of the city. Occasionally I will go up on the roof and can see into the “Red Zone.” That is the area beyond the well-fortified walls of our city within a city. Baghdad looks sleepy, exotic, and peaceful … from a distance. Ibn Sina was the jewel in the crown of Saddam’s medical system, though much of it was flash without substance. The long years of sanctions took a devastating toll on the medical system here. The ER has marble floors, which makes for a bizarre juxtaposition of blood and stone. There is a din of helicopters on most days, bringing in the wounded and sick from all around the region, and airlifting our soldiers out of theater. Tonight is quiet (it is midnight here). We are getting a welcome reprieve from several days of nonstop casualties. I am glad because the nurses had given me the title of “black cloud” after several mass casualty incidents on my shift. Perhaps tonight will lift the mantle and lay it on someone else’s shoulders. The mood in our unit is excellent. We know that we have the best mission in the Army. We are safe, relatively. We see more sick patients than any other medical facility and we get to save lives every day. For an emergency medicine doc, this is what we call a good gig. I get to call Gilda and the kids every day and have plenty of hot showers. There is lot of food (how good it is a matter of dispute) and plenty of gym facilities. I do have the strange feeling of being on a ship at sea, working and living in a very small space. There is wonderful common sense of purpose, which strips away the petty jealousies and insipid disputes that plague so many hospitals at home. The deployment will get very stale with time, but for now, I am doing well. Just miss my family and friends. So Merry Christmas, Happy Hanukah, and Peace on Earth.
A. Hopperus Buma et al. (eds.), Conflict and Catastrophe Medicine, Second ed., DOI 10.1007/978-1-84800-352-1_1, © Springer-Verlag London Limited 2009
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2. New Paradigms: The Changed World Since 9/11 James M. Ryan
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Objectives
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To introduce the subject To examine the world before and after 9/11 To describe the failed state and its significance To introduce the concepts of globalization and disintegration To suggest means of staying safe in these new environments
Introduction Confucius’s phrase “May you live in interesting times” can be interpreted equally as a blessing or a curse. When directed at a prospective humanitarian aid volunteer, eager to embark on an overseas mission in the new millennium, the phrase leans more toward the latter. We do live in interesting times because of the advent of global terrorism and the radical restructuring of the world political scene that came about in the last quarter of the twentieth century. Humanitarian volunteers are already feeling the impact of these changes. To improve our understanding it is useful to look back at a number of historical watersheds. In 1648, the Treaty of Westphalia was signed, ending the Thirty Years War and the secular power of the Papacy. The sovereign, independent state as a discrete entity was born and ushered in a period of relative enlightenment, interspersed with wars. These new states embarked on a series of interactions, often resulting in Treaties, concerning such varied activities as trade, commerce, and the conduct of war. This included the treatment of prisoners of war, wounded soldiers, and noncombatant civilians. These attempts at reducing the appalling consequences of wars culminated in the next watershed in affairs between states – the establishment of the International Committee of the Red Cross. In June 1859, the battle of Solferino took place. It resulted in the usual mass slaughter on both sides and the abandonment of the wounded where they fell. The majority would die alone and untreated. A Swiss national, Henri Dunant, witnessed this battle. He was so moved by the plight of the wounded that he organized care for them, and in 1862 he published A memory of Solferino recounting these events. Dunant then set A. Hopperus Buma et al. (eds.), Conflict and Catastrophe Medicine, Second ed., DOI 10.1007/978-1-84800-352-1_2, © Springer-Verlag London Limited 2009
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in motion initiatives that resulted in the creation of the International Committee for Relief to Wounded Soldiers. As its flag, it adopted the distinctive Red Cross on a white background. The following year, members drawn from 16 States drew up the first Geneva Convention for the Amelioration of the Condition of the Wounded in Armies in the Field. In 1880, the name was changed to the International Committee of the Red Cross. Thus was ushered in a period where the rights of wounded and captured soldiers, civilians, and medical aid personnel were enshrined in a variety of treaties and memoranda of understanding. Humanitarian aid organizations including international governmental organizations (IGOs) and nongovernmental organizations (NGOs) concerned with caring for the victims of war and disasters proliferated, particularly in the latter half of the twentieth century. In 1909, there were 37 IGOs and 176 NGOs. In 1997, these numbers had risen to 260 IGOs and a staggering 5,472 NGOs. Two observations can be made on the increase in IGOs and NGOs – the ever-increasing demand and, until recently, their freedom to work in a climate of relative safety. The reasons for this climate of safety are worth noting. Within most nation states, even when at war, there was recognition of the institutions, of law and order, of the laws of war and, in addition, there were codes of ethics and morality governing the activities of noncombatants and combatants alike. Although there were notable exceptions these understandings pertained in most instances.
The World After 9/11 It is commonplace for writers and commentators to look at the twenty-first century world through the prism of the destruction of World Trade Centre and to see the events that followed as directly arising from the attack. The attack on the World Trade Centre and the Pentagon on 9/11, incidentally the most devastating terrorist attack on continental USA, was not the cause of radical and convulsive changes that were witnessed post 9/11 and which are continuing. The world was already reshaping and events were in train that would lead inexorably to war/conflict and the rise of global terrorism. In truth, while 9/11 is the watershed date in recent global history the events that reshaped the new paradigms began in the latter quarter of the twentieth century and were well under way before 9/11.
Background to the New Paradigms The spectacular failure of Marxist–Leninist communism and the rise in nationalism resulted in a convulsive and often violent disintegration of old alliances and power blocks. The collapse of the Soviet Union is the most obvious example, but there are others. Collapse, disintegration, and armed conflict have occurred in the Balkans, the Caucasus, North and Central Africa, and Asia. The result has been the emergence of dozens of new self-governing entities that have obtained or are still seeking recognition as sovereign independent states. United Nations membership statistics are illuminating. In 1991, the United Nations had 166 member states; in 1997, this number had increased to 185. Predictions for the future suggest a membership of up to 400; many
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of these will lack the means to survive independently without international assistance and will fail. The terms failed state, failing state, and defeated state have now entered the literature of sociology, politics, and journalism. Consensus on definition has yet to be reached. They may be defined in terms of governmental mismanagement resulting in the loss of loyalty of the population and leading to disintegration. Further, they may be defined in terms of economic or political nonviability, following the breakup of a larger state or union of states (parts of the former Yugoslavia are good examples). This definition fits many of the newly emerged states in Africa and Eastern Europe.
Conflict in Failed States Failed, failing, and defeated states are characterized by conflict, which may be internal or external. Conflict from without may be the result of the new state’s cleavage from a larger entity. The larger entity may endeavor to ensure the new state’s failure to survive, by economic means or direct military intervention. New or newly emerging states that have suffered in this way include Slovenia, Croatia, Bosnia, Kosovo, Chechnya, and East Timor. Conflict from within may arise because of ethnic or religious divisions. Examples include Azerbaijan, Armenia, and much of Central and West Africa. Some entities are affected by conflict both from without and within; Bosnia and Kosovo are examples. These conflicts pose novel threats to the humanitarian volunteer. The climate of relative safety for humanitarian volunteers achieved in the late eighteenth and much of the nineteenth centuries is no longer to be taken for granted. The reasons for this are complex; no single factor can be blamed: it is discussed in the closing section of this chapter. We now turn to other factors that have had an impact on the new paradigms – these are globalization and disintegration.
Globalization and Disintegration With the start of the new millennium the world political scene changed – a process that actually had begun in the latter half of the last century. Far from looking to a world full of certainty and an end to conflict, the world in the new millennium seems confused. Two distinctive processes can be identified – globalization and disintegration, resulting in a troubling paradox.
Globalization The nature of sovereign independent states is undergoing radical change. States are drawing together over a range of activities including trade, communications, and defence. National economies are moving toward integration and increasing political integration seems inevitable (witness the extent and speed of change within the European Union over the last 25 years). These moves have resulted in a globalized market, which is changing forever the way the world functions. This is in a word, globalization. In 1977, the United Nations General Secretary, Koffi Annan stated:
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“Globalisation is a source of new challenges for humanity…Only a global organisation is capable of meeting global challenges…When we act together, we are stronger and less vulnerable to individual calamity.” It is not just the desire by individual states for closer integration that is driving the trend. New hierarchies, the IGOs, are wielding power and influence. World affairs are increasingly influenced if not controlled by IGOs such as the United Nations, The World Trade Organization, and the North Atlantic Treaty Organization. Transnational regional organizations also exert influence – notably the European Union and the Organization of African Unity. Although these organizations comprise sovereign national states, the power and influence of the individual states is often subsumed. These networks of international interdependence are concerned with a growing range of global issues. The more important are as follows: ● ● ● ● ● ● ● ●
Defence and disarmament Trade and economic development Communication and information dissemination Humanitarian aid and development Human rights Health and education The environment Refugees and internally displaced people (IDPs)
What is clear is that the power of states to act independently is being progressively eroded as the trend toward globalization develops. While the benefits are enormous, problems lie in the resulting inequality between states and groups of states. Already a backlash is evident.
Disintegration and Backlash In opposition to moves by many major states toward integration and an acceptance of cultural diversity, other states and groups within states are resisting. The result is widespread instability with increasing threats to world and local peace. This backlash is occurring and gathering pace. Destructive and disintegrative trends are appearing in parts of the globe. Globalization and its dependence on communication via the new information highway, the Internet, favor the more developed and wealthier economies, leaving much of the less developed world trailing in its wake. There is an increasing view that territorial conquest by sovereign states is of less importance than economic dominance. This shift is occurring as the primary fault line in international affairs as conflict between communism and capitalism disappears. This change, often described as the end of the bipolar distribution of power, has not resulted in stability or world peace. The rise of nationalism, tribalism, transnational religious movements, and racial/ethnic intolerance seems to defy the trend toward globalization and a toleration of cultural diversity. The backlash against globalization is all the more worrying due to the proliferation of weapons, including weapons of mass destruction. The most powerful and lethal weapons are no longer controlled by Great Powers alone. With the collapse of the Warsaw Pact, vast quantities of small arms, explosives, and a range of other weapons
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appeared on the international market at very low cost. Many of these weapons have fallen into the hands of terrorist, extreme nationalist, and religious fundamentalist groups. Further, many smaller states have now developed nuclear weapons and the means to deliver them globally. Many of these states and groups are unstable and vehemently opposed to globalization and integration.
Natural Disasters Natural disasters are discussed in detail in later sections of this work. Here it is appropriate to consider them in relation to the changed world described earlier. Whereas the move toward globalization has great attraction for the developed world, with greater stability and growing economies, the move toward disintegration of unstable and economically poor states, while undesirable seems inevitable. These disintegrating states face double jeopardy. In the last quarter of the twentieth century natural disasters resulted in over three million deaths, and one billion people have been affected by their aftermath, by intolerable suffering and by the reversal of years of development. The World Bank, one of the key IGOs, estimates annual losses to be in the region of £23 billion, while current annual mortality is in the region of 250,000 and is expected to rise. The escalating world population can only lead to further deterioration of this situation, particularly as many of these people will be concentrated in zones, which are prone to natural hazard. By the year 2100, 17 of the 23 cities estimated to have more than ten million people will be in these areas. The double jeopardy arises from the fact that these are the very centers of population, which face the greatest risk of disintegration and internal conflict.
Humanitarian Volunteers and the Changing World Deployment overseas on humanitarian missions has always been associated with risk, and workers have always accepted this – risk goes with the job. The humanitarian community has long accepted this fact and has coped with sporadic instances of death and serious injury. Historically it has been concerned with accidents or disease, and rarely has the humanitarian volunteer been deliberately targeted. There was a widespread belief that the flags and emblems of the humanitarian organizations provided shields for their volunteers. This is no longer the case. The historical safety of the humanitarian volunteer and the noncombatant civilian was based on concepts developed within sovereign states as already discussed. However, these concepts such as neutrality, impartiality, human rights, and the various duties imposed by various Geneva Conventions assume a functioning state with its instruments of power (police and military forces, for example) intact and obeying the rules of national and international law. Within failed, failing, or defeated states such institutions and codes of behavior may cease to exist. This may also apply to states affected by natural disasters, at least for a time. Power or control may become vested in the hands of illegal bodies such as irregular militias, paramilitary groups, or terrorists, often commanded by local
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warlords. Within failed states there may be a myriad of such groups engaged in conflict between themselves, but often forging short-lived alliances, making the climate even more dangerous and unpredictable for outside agencies. The particular tragedy of such conflicts is the deliberate targeting of civilians, including women, children, and the elderly. In some cases, the aftermath of the fall of Vukovar in Croatia, for example, has extended to the slaughter of the ill and injured in hospitals. In past wars, the majority of the killed and injured have been soldiers. The ratio has historically been 80% soldiers to 20% civilians. In modern war and during conflict in failed states this ratio has reversed as a matter of deliberate policy. It is salutary to note that between 1900 and 1987 about 130 million indigenous people were slaughtered by genocide within their own countries. One of the features of conflicts within these states is an attempt to purify the regions ethnically by enforced movement of populations perceived to be alien and posing a threat – this is the phenomenon of ethnic cleansing. On occasion this may extend to attempts at annihilation. Mass murder of refugees and IDPs has occurred in Darfur, Rwanda, Bosnia, Kosovo, and East Timor. Humanitarian volunteers cannot remain immune. Nonstate groups such as militias, or indeed state-sponsored organizations in the case of external conflict, increasingly find political advantage in targeting volunteers and their organizations. The aim has usually been to cause destabilization. Aid organizations are also targeted because they may be seen to favor one faction over another. In Bosnia, Somalia, Sudan, and Afghanistan this has led to hijacking of food and medical aid convoys, and the kidnapping and beating of volunteers. At the time of writing, articles are appearing in international newspapers describing a climate of cold-blooded terrorism against aid volunteers. Volunteers working with the World Food Programme (WPF) are being targeted as they deliver food in refugee camps. Many have been killed. WPF has the unenviable record of having lost more staff members to violence than any other UN agency. The statistics are grim – The UN has lost 184 civilian employees to violence between 1992 and the end of the century. In 1998, more civilian humanitarian aid workers died than armed and trained UN military peacekeepers. Risk extends to all humanitarian aid organizations. Volunteers working for the International Committee of the Red Cross, an organization long considered immune, have been threatened and beaten in Africa and murdered in their beds in Chechnya.
Staying Safe With the close of twentieth century a paradox may be observed. It was on the one hand the most productive century in terms of social progress, education, and health and wealth creation, and on the other hand, it was the most destructive in the annals of human history. There were 250 wars and conflicts resulting in nearly 110 million deaths. These are grim statistics for humanitarian workers gazing in the crystal ball of the new millennium. One fact is clear – during this millennium, no aid worker should consider that donning a white uniform with an NGO emblem on the sleeve is a guarantee of safety. The opposite may be the case. What then are the implications for the humanitarian aid volunteer in the twenty-first century? To withdraw
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completely and ignore such conflicts is not an option – although many have suggested it. Highly motivated and skilled humanitarian volunteers have never been needed more urgently. The numbers required will also rise during the new millennium. Assuming that people will continue to volunteer, the question must be asked – how may they protect themselves and their colleagues? Should they be armed or work under the protection of armed groups? These are vexing questions and must be addressed. At last, the United Nations Security Council is debating these issues. Under discussion are initiatives to train future aid volunteers in techniques such as anticipating danger, recognition of minefields, extraction from trouble at roadblocks, coping with kidnap imprisonment, and interrogation. Many of these difficult and contentious issues are debated in later chapters and sections of this manual. There are no easy or hard and fast answers; however, preparation and training well in advance of deployment has never been more important. While other sections of this manual discuss personal preparation and training in detail, it is reasonable here to emphasize some of the more important aspects.
Choosing an IGO or NGO The proliferation of organization engaged on humanitarian aid missions in areas of conflict and catastrophe has been noted. Many, if not the majority of these, organizations enjoy well-deserved reputation for their effectiveness. They take great care in the preparation of volunteers and look to their safety. However, there are numerous smaller organizations that arise, often involved in single issues, and then disappear. Volunteers should spend time checking the credentials of any IGO or NGO seeking their services. There are central clearinghouses, which hold extensive information on such organizations – notably the International Health Exchange. As a minimum, a volunteer should insist on the following: ●
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Written details of the organization, including annual reports and financial statements Mission briefings, including clear aims and objectives Political and security briefings Details of local and international logistical support Health checks, including vaccination needs and disease prophylaxis Medical insurance scheme including repatriation Mission-oriented training programs and workshops Provision of details concerning mission’s end point and return home
In summary, volunteers should only work for organizations of good standing, who prepare volunteers before deployment, transport them safely, house them adequately during deployment, give clear and achievable tasks, and then ensure safe return.
Personal Preparation In a climate of increased danger, volunteers should examine their motivation and suitability. Physical and mental fitness are paramount. A history of cardiovascular, gastrointestinal, or psychiatric illness should preclude deployment. This also applies
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to those on any form of long-term medication. If in doubt seek expert advice (most reputable organizations demand rigorous heath checks); exacerbation of a longstanding medical condition during deployment may have catastrophic consequences. A well-known aphorism states, “Do not become a casualty yourself and become a burden on already overburdened comrades.” Personal preparation should extend to home and family. Consider “Will and bills.” Check life assurance policies for validity in conflict settings. Consider too the effects of deployments, particularly long and arduous ones, on family life. It is easy to forget that volunteers have to return home and pick up the pieces of their personal and professional lives.
Professional Preparation Any volunteer must consider the professional task required during the mission and then question his/her ability to perform. This extends beyond the individual’s own ability and skill to include the means to carry out a task. It would be pointless to recruit and deploy a surgeon without an appropriate team and infrastructure in place, yet this has happened. It is usually a requirement for volunteers to be multiskilled and adaptable in austere environments. At very least an individual should be capable of personal survival and should, for example, be able to prepare clean water and food, choose appropriate shelter, drive off the road vehicles, and use a basic radio set. Many organizations would regard the above as a minimum set of skills over and above medical or related qualifications. Further, if the volunteer is taking part in a basic or higher professional training program, assurances must be sought that no time or professional penalty will be accrued because of the deployment.
Conclusion This is the uncertain future facing the volunteer in the 21st century. Yet, taking part in a humanitarian aid deployment is an enriching experience and affords a unique opportunity to understand the plight of most the world’s population and to realize the good fortune of those living in stable and wealthy sections of the world. The prospect for the future humanitarian volunteer is that he will live in interesting times. The author of this chapter wishes you bon voyage.
3. The World Seems to be Crumbling Around Us David R. Steinbruner
Baghdad July 1, 2006 The world seems to be crumbling around us. At least, that is the impression one gets with a quick glance at the news. On any given morning, when I manage to get up on time to pass through the checkpoint and go to the dining facility for breakfast (ammunition, check, weapon, check: okay you are safe to go to breakfast), I can see the BBC news on the large screen in the corner. Each day brings more news of deaths in southern Lebanon and Haifa, Israel. Hezbollah promises more death to Israel and the Israeli army responds in kind to the rocket attacks over the border. The specter of Iran, whose long mountain chain and southern lowlands form Iraq’s eastern boundary, looms vividly in the US soldiers’ collective conscience. The once tragic but comfortably distant “conflict in the Middle East” now takes on a frightening intimacy. History is swirling around us like a gathering dust storm. Our control of its course seems tenuous as events threaten to overwhelm us. So much, however, is perception. The reality of what is happening here will likely take many years to sort out. Life in Ibn Sina continues on without much change. The casualties continue to come in: IED and VBIED blasts, firefights among the various factions and against US forces continue to generate wounded. Caught in the middle are the Iraqi civilians, always in that nebulous area, not insurgents but not really friendly to US forces either. According to the latest issue of “Stars and Stripes” almost 6,000 were killed in May and June alone. July does not seem to be much better. The sides are fluid and the categories shades of gray. We have our friends and we have our enemies, but so much of the population seems to tolerate our presence with a mixture of desperate need and dread. So much is in the eye of the beholder. I realize now that to study history is not always an exercise in learning about a different place or time but can be a search for some perspective on what one experienced but did not fully understand. I imagine that I will spend many years reading about this time and place just to gain a true understanding of my small part in it. Last month I had a rare opportunity to get a little visual perspective on what surrounds me but I do not see. I was called down to the EMT or Emergency Medicine Treatment area to transport a patient to the Air Force hospital in Balad, situated northwest of Baghdad. Since we do not have a neurosurgeon at Ibn Sina, we transport any severe head injury (that we feel will survive) north. Most have a tube down their windpipe to help them breath, are heavily sedated and require close monitoring for the flight. This is a job usually done by our nurses and medics, but that day I went. A. Hopperus Buma et al. (eds.), Conflict and Catastrophe Medicine, Second ed., DOI 10.1007/978-1-84800-352-1_3, © Springer-Verlag London Limited 2009
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The transport of a patient is never an easy task. Medevac teams all over Iraq are risking a great deal every day to pluck casualties from roadside ambushes and remote forward operating bases (FOBs), to bring them to us at the Combat Support Hospital (CSH). If the patient is critically ill, the complexity of the thing increases dramatically, the margin for error becomes smaller and, naturally, the chance of equipment failure or a patient to decompensate approaches 100%. It is the medical version of Murphy’s Law. This patient was fairly stable by CSH standards. He had only one IV drip for sedation, he was intubated purely to protect his airway in case his mental status decompensated in flight. His injury, a piece of shrapnel to the base of his brain, had not penetrated so far as to kill him. It should be an easy transfer. Inevitably, 10 min into the flight, his IV drip failed. I spent the remainder of the flight on my knees on the floor of the Blackhawk pushing the sedation into his veins a little at a time. The roar of the engines made it a completely visual exercise in monitoring, resting my hand on his chest and eyeballing the monitor to make sure that he was breathing. To complete the experience, the monitor chose that moment to stop recording his breathing. Murphy, apparently, was a physics professor who must have studied a great deal of chaos theory. Dressed in full battle gear with my M-16 now clutched in the hands of the air-sick nurse who accompanied me, I could only laugh at the absurd picture I must have made to the flight medic and crew chief behind me. Flying sick patients in a combat zone ain’t that easy is it doc? Yeah, I get it. The patient made it successfully to Balad, despite my best efforts at sabotage. We handed him off to a frenzied crowd of nurses and doctors in the emergency section of their hospital. I had run out of the sedation medication just prior to landing and now dutifully handed over a very awake and quite irritated patient. Another smooth transfer. Back now to the CSH, relieved of any responsibilities, I could gaze out of the open side window of the helicopter and take in the scenery below. We flew low and fast, only a few hundred feet above the ground. Below us skimmed the bristling tops of the tall palms, many planted in neat rows…a manicured oasis. The afternoon sun lit up the square drainage ponds and the endless lattice work of irrigation ditches that stretched off to the south and the west. We came upon each field quickly, giving me a vivid, though brief, view down on the daily life of Iraq. First came the dusty roads around Balad, filled with military vehicles and the concrete maze of blast walls. This softened into the irrigated fields, filled with green and scattered with bright points of orange or dry grasses. Then a field with goats slipped by, the herder standing in the middle, now children playing soccer on a patch of dirt, small pickups bouncing down dirt tracks. As far as the eye could see was hazy green and patches of brown and always the flash of water catching the late afternoon sun. The “fertile crescent” revealing itself at 200 ft. and 100 miles/h. The dirt roads turned to asphalt and the traffic increased, now a small forest of palms spread below, square concrete houses hidden in the shade. A large sheet of glass windows emerged below, absurdly fragile in such a hard country. It appeared to be a large greenhouse with dense green beneath. Now the Tigris churned muddy brown below. The city of Baghdad proper spread out in all directions, each neighborhood denser than the last as we sped toward the heart of the
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city. The mother of all mosques, the largest in the world, loomed in the window, construction cranes standing guard around it. The city seemed a carpet of concrete squares, each a different height, giving the impression of a geometric tapestry of shades of red and brown. We flew lower now as the taller buildings of the center of the city slipped by. Down we came, running quickly along the Tigris, the city slums and mansions alternating with visual dissonance below us. Tense now, each of us in the helicopter aware of the sentiments of those below us, we swung over the oddly familiar ground of the International Zone, IZ, or “green zone,” the fortress in the heart of the city which has been my home these past months. It seems so much smaller from above, it is easily the greenest and cleanest part of the city even cut up by the many concrete walls that protect us from the rest of Iraq. Down we settle on the LZ at the hospital. The entire trip was peaceful, no shots fired at us, no sign of any real interest in us as we flew past. For a moment it seemed a different country: green, peacefully going about its business. So much depends on one’s perspective. Last night I worked the graveyard shift. It was once our quietest time, a chance to catch up on emails or sleep a little. Now, with the steady heat of the mid-summer day, the nights have become filled with the aftermath of violence. Killing has become a nighttime endeavor. A young woman is brought in, wrapped in blood-soaked blankets and sheets, her eyes wide and rolling in fear. The medic tells me that she is 5 weeks pregnant, a victim of a mortar. “Doc, her son was killed in the attack.” The agony of this place. So we went to work upon her: Oxygen, IV lines, the monitor, her clothes, and blankets cut away to expose her injuries. Conscious of the embarrassment she must feel, for she is very alert, we cover her quickly. She is indeed pregnant, the baby looks good, seen as a small collection of head, bones and flickering heart beneath the ultrasound probe. The shrapnel, it seems, glanced across her back near her neck and did not plunge deep into her body. It is the only bit of good news which I can give her. She yells and protests as I explore and pack her wounds; always a good sign. It tells me she is still with me, has not lost that much blood. She breaks into surprisingly good English and when asked by me explains that she studied it in school. I tell her how well she speaks, far better than my Arabic, and she smiles and forgets for just a moment where we are, how we come to be here, and what has happened. Now the laboratory tests come back and she reveals that she has lost some blood. I give her some as the trauma surgeon and ob-gyn doctor mull over the next course of action. Again I walk up to her and say in English how sorry I am for the loss of her son. The pain of it, of the whole war and its aftermath, the sectarian killings and the chaos of this place settles wearily onto her face. Enshalah, it is God’s will, she says and turns away to mourn alone and to spare me the sight of it. And so I withdraw from the table. So much, after all, depends on one’s perspective.
4. The Spectrum of Conflict Alan Hawley
Objectives
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To define conflict To describe the spectrum of conflict To indicate the changing nature of conflict To describe the impact of conflict on humanitarian assistance
Introduction From the beginning of recorded history, organized fighting between human groups has been a frequent occurrence. The genesis of this behavior is a matter of debate; theories range from genetically driven to socially created. Regardless of this uncertainty, the fact of conflict is undeniable while its external manifestations vary. Patterns of conflict, purposes, and end states have all varied through the thousands of years of human existence. There have been as many different organizations for conflict as there have been different human societies. Nor should this be a surprise, since the organization of resources required to deliver violence is a social process which necessarily reflects the prevailing culture of the society from which it springs.
The Changing Nature of Conflict The nature of conflict has continuously evolved and changed, while reflecting some external factors and their interplay on each other. Hence, the available technology is a main driver. This has evolved from simple hand-held weapons (possibly derived from hunting tools) to stand-off precision munitions with satellite control systems. In the process, the actual physical component of conflict has altered. There has been an increasing depersonalization of conflict as technology has allowed methods of killing at a distance to be utilized. Not that direct face-to-face violence has disappeared. There is a continuing tradition, and indeed a military requirement in certain circumstances, to close with the enemy and engage him in the most direct and intimate form of fighting. However, for many armed forces this is not the preferred option since it gives free rein to the play of chance and fortune. Risk aversion has political attractions and requires the control, if not the elimination, of chance from the battlefield.
A. Hopperus Buma et al. (eds.), Conflict and Catastrophe Medicine, Second ed., DOI 10.1007/978-1-84800-352-1_4, © Springer-Verlag London Limited 2009
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Section One
The Essence of Conflict Despite all the variations and evolutions witnessed throughout history, the essence of conflict remains the same; it is the defeat of one human group by another using the threat or actual delivery of organized and purposeful violence. By its nature, this involves injury and death. These are inevitable consequences of conflict. Indeed, they are more than this; they are the very currency of conflict. The rational intention of warring sides is to force the other to undertake a certain action. Violence is used to alter perceptions. Fundamentally, war is waged in men’s minds for men’s minds. It is this psychological basis which provides the key to understanding the utility and the limits of conflict.
The Nature of War The essence of conflict is the actual or implied use of violence. This is also the fundamental nature of war, and so the relationship between the two becomes a matter of some significance. Is conflict the same as war? Are the words merely synonyms of each other? If not, what is the difference? Conflict is the process of organized and purposeful violence of one human group against another. In the context of a consideration of war and conflict, violence is taken as actual physical action, although in different settings other forms of action, including verbal and emotional, may be appropriate. It can be seen that war can also be defined in the same terms as conflict. However, war has a forensic dimension with legal implications. Interestingly, there have been few declared wars since the Second World War. However, there have been hundreds of conflicts. Part of the solution to this conundrum is that war implies an act by a sovereign nation state, while many of the conflicts have been intrastate, or states have chosen not to engage in the formal process of a declaration of war. Clearly, there are contingent questions about legitimacy and authority in these deliberations. These can be complex and complicated and require a whole body of law to accommodate them. Nevertheless, there may be ramifications for all parties involved in a conflict or in immediately postconflict operations. As a simple rule, war contains conflict and conflicts; the reverse does not apply.
Massacre, Genocide, and Criminal Behaviour Recent experience has seen the continued play and existence of massacre and genocide on various violent stages throughout the world. Not only are they distinct from each other, but also they are different from conflict and war. While there is a linkage between them (it is difficult to conceive of genocide occurring without conflict), they are patently not of the same concepts. All forms of criminal behavior may become prevalent, especially crimes against the person. Rape has become a distressingly common feature of wars with an ethnic edge to them. Similarly, assault and murder are also more common in these circumstances. Massacre can be thought of as wanton or
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indiscriminate killing in large numbers. It may occur in conflict as a result of temporary loss of control in the heat of battle or as a result of moral and disciplinary laxity. Sadly, there are many examples of this type of behavior and they can be found in the annals of all armies. It seems that the rasp of war may sometimes fray the leash of civilization a little too vigorously. Recognizing this fact, additional moral limits have been applied by outlawing such conduct. Genocide is rather a different matter. This is the deliberate use of violence to kill and eventually eliminate an entire racial, cultural, or ethnic population. It is a perennial fact of human life that such campaigns have been frequent visitations on the species. They have clearly varied in effectiveness, but have not disappeared with the growth of literacy and assumed knowledge. While the experience of the holocaust brought the issue of genocide to an appalled and shocked Europe, recent similar episodes in the Balkans, Rwanda, and Cambodia serve as sad reminders of the tendency to genocide within the human condition. It is a tendency to be guarded against, and to this end, the developing structure of international rights and human rights legislation is welcome. For the purposes of this chapter, the concepts of conflict, war, massacre, and genocide need to be borne in mind since they reflect recent practitioner experience. An insight into how the extent of philosophies of conflict and war has evolved is both a useful and necessary adjunct to understanding conditions in a postconflict context. Without such comprehension, avoidable mistakes and errors will ensue, and in humanitarian operations such failings may cause distress and death.
Traditions of War and Conflict Attempts have been made throughout the history of conflict to make sense of it and to define its purpose. Given the significance and consequences of conflict, it is hardly surprising that effort has been invested in considerations of organized intergroup fighting. The risks are generally high and the results are unpredictable. In addition, there are real moral questions of the legitimacy of killing which require examination and analysis. In general, there are two such generic approaches to these ethical considerations: the absolutist and the pragmatic.
The Absolutist Views of Warfare There are two differing absolutist views of warfare, which can be viewed as polar opposites. The pacifist contention would suggest that no killing and violence can be justified and so it is wrong. Policies which incorporate the acceptance of conflict are ethically unacceptable. Such a view is clear and unambiguous. Conversely, the tradition of a Holy War also bases itself on absolute moral principles and legitimacy, but comes to a different conclusion. In this approach, the sanction, or even the command, of a deity is taken as the driving force behind the conflict. Further, the omnipotent nature of the deity is such that the norms of human intercourse can be overridden. In such a view, all manner of atrocities can be visited upon an opponent because of the support of the Supreme Being. Such support places the action beyond human sanction or consideration. Hence, morally absolute ethical positions, while having the
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advantages of clarity and simplicity, do not sit comfortably with the realities of compromise and negotiation which are the tools and the instruments of international politics. Apart from noting that these two traditions exist and that they are mutually exclusive (pacifism defines an absolute moral duty not to fight), no further consideration of them will be made. Instead, the more general approach of pragmatism and politics will now be addressed.
Moral Basis of Conflict Difficult decisions about the moral basis of conflict have existed throughout history. A justification for shedding blood has been a necessary concomitant to declarations of war as well as other forms of fighting. Such concerns clearly spring from a need in many people to have a clear basis and purpose before committing themselves to the demanding process of fighting. Supplying that justification has been a main preoccupation of leaders before conflict is openly commenced. Throughout history, there have been a myriad of such reasons, ranging from trade, hegemony, security, and principle to sheer covetousness. What such a list also suggests is that conflict can be seen as not an unusual form of human intercourse with both ethical and political dimensions. The emergence of this tradition within the Western world began with the acceptance of Christianity by the Roman Empire. The early Christian movement was a pacifist organization, but the welcome accommodation with the temporal power of the Empire required some rethinking of this issue. The eruption of barbarian threats and invasions gave added point to this development. Accordingly, Saint Augustine and others laid the foundations of the theory of a “Just War.”
Just War Theory This approach attempts to set the context in which conflict and war are acceptable. Inevitably, such a philosophy requires there to be an acceptance of certain limitations. These limitations are applied in two separate but linked areas. The first approach sets down criteria for the war itself. This is the “jus ad bellum,” and lays down a set of conditions to be followed if a war is to be accorded the description of just: 1. There must be a just cause. 2. There must be a right intention; the stated reason for war is the crucial determinant, and ulterior motives are unacceptable. 3. The decision to go to war must be made by a legitimate authority. 4. There must be a formal declaration of war. 5. There must be a reasonable prospect of success; the evils of war must not be lightly entered upon. 6. War must be used only as a last resort. 7. The principle of proportionality must apply. This means that the good coming from the war must be of such significance as to outweigh the evils of the war itself. Once war has been entered upon a different set of conditions apply; “jus in bello.” These are used to codify and define the conduct of the conflict. These are essentially simple and linked concepts.
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1. Noncombatant immunity must be respected. Fighting must be directed against other combatants. 2. Proportionality of means must also be used (as well as that of ends). The means adopted must not be such that the evils and the harm inflicted outweigh any possible good to be achieved. This corpus of philosophy has become ingrained in the norms of state conduct and personal ethos. It has provided the underpinning for much of the current body of international law in this area. It is now uncontentious and widely accepted. However, there are other strands in the philosophical foundations for war, and some of these substantially predate the Christian church. Many of them spring from China.
Sun Tzu and the Art of War The most well known oriental military philosopher is Sun Tzu. He was a Chinese warlord who lived about 600 BC. His life was spent in the hard pragmatic school of field soldiering. He accrued experience and expertise in warfare during a series of campaigns within China itself. Much of this knowledge was then recorded in a book, The Art of War (Gray 1999), that has survived in part to contemporary times. In this book, a series of aphorisms and advice has been recorded. While many of these are of limited relevance to the actual physical conditions of modern conflict, the underlying philosophical approach still has relevance. Indeed, much of it has provided the intellectual foundations for the maneuvrist approach that has become enshrined in much contemporary Western military thinking. An important element of this philosophy is the requirement to match one’s strength against an enemy’s weakness. Sun Tzu enjoins his readers to avoid unnecessary bloodshed by avoiding matching strength against strength; it is the exploitation of weakness which is central to this doctrine. It also implicitly recognizes the central significance of psychology in this process. The creation and the exploitation of uncertainty in the mind of an enemy is the essence of Sun Tzu’s doctrine. This is a lesson in applied psychology.
Von Clausewitz on War While it is invidious to select just a few examples from 3,000 years of military experience, any such collection would always include the musings of Carl Von Clausewitz. He was a Prussian officer who fought throughout the French Revolutionary and Napoleonic wars. His personal experience started at the age of 12 and extended to his death from cholera at the age of 51 in 1832. He never quite achieved the distinction as an operational commander which he craved. However, this frustration was sublimated into a deep consideration of war and its nature. This analysis formed the basis of his great seminal work On War (Howard and Paret 1976), which has been studied and discussed endlessly since its posthumous publication. In this book, the actual form, purpose, and character of war and conflict were examined and analyzed. Von Clausewitz used the examples of conflicts that he had witnessed, and illustrated points by reference to recent historical events. He surmised that the purpose of war lay in seeking political advantage over an opponent. Indeed, he postulated that war was itself part of the process of political intercourse. As such, he recognized and gave
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voice to the realist position in politics and strategy; war was a process of cost–benefit analysis in the endless struggle between states. However, his own experience in battle and campaigns against the French convinced him that conflict has a dynamic of its own. It possesses a tendency to escalate from a limited form into the absolute. Nor should this be a surprise, since the actual physicality of combat means that chance and uncertainty have a major effect on the events of that conflict, and the process of bloodshed serves to harden and change perceptions. Such alterations in commitment and engagement require a dispassionate analysis of the political purpose and goals of the conflict to be continued. Von Clausewitz believed that this ultimate rationality should remain the duty of the government. Further, he felt that the state consisted of three elements (1) the government, (2) the military, and (3) the people. There was a necessary interplay between them in order that the political benefits of the conflict could be achieved, and each component had its own specific part to play. A successful outcome could only be achieved if all elements did their duty within this relationship. Fundamentally, as an experienced practitioner of warfare, Von Clausewitz understood the psychology of conflict. He knew how to use the methods of applied psychology in the realm of uncertainty which was the battlefield. Highlighting this truth by an analogy with a wrestling match in which each opponent seeks to gain an advantage and eventually to secure victory by throwing the other, he explained the central essence of conflict. The exercise of maximum effort, chance, and free will helps to guarantee a probability rather than a certainty. Nothing can be taken for granted, since there is a universal potential for disruption. This he described as friction due to the interplay on the battlefield of chance, fatigue, and fear. Together, this combination ensured that human failure and frailty continued to affect the outcomes of conflict. Furthermore, Von Clausewitz memorably described the requirement for character in a commander by asserting that in strategy all things are simple, but not on that account necessarily easy. It is an admirable description of the reality facing a commander and his troops on the battlefield. Clarity and fortitude are basic requirements to meet the challenges of combat.
Marx, Lenin, and Political Conflict For Prussia and Von Clausewitz, the security problem faced by the state was one of the survivals against stronger neighbors and no natural defensive positions or features. In such a situation, the central organization of the state, so that all of its resources could be most efficiently deployed, was of paramount importance. This set of geostrategic realities led to a communitarian orientation of society, with the rights of the individual being subordinated to the security of the whole. It also coincided with the political instincts of revolutionary movements, especially those of Marx and Lenin (Neumann and von Hagen 1986). The political nature and dimension of conflict dovetailed with their perception of revolutionary struggle. Accordingly, Von Clausewitz was embraced by the new schools of revolutionary thinking and enshrined in their philosophy of action. In particular, his understanding of applied psychology, the political nature of conflict and the relationships between the components of society were adopted. Implicitly accepted in this analysis was the communitarian view of society. This was the antithesis of the libertarian
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view, which placed the individual at the heart of the society, and then placed rights and obligations around him in order to maximize personal liberties. Such a view was the predominant philosophy in the Atlantic maritime states with a global trading viewpoint and the geostrategic security which that geographical position gave.
Mao, Giap, and Revolutionary Warfare The revolutionary warfare concepts developed by Mao (2000) and Giap (1974) bore clear evidence of their genesis from Sun Tzu and Von Clausewitz. The essential political nature of conflict was derived from the latter, while attacking the enemy’s weaknesses and subsequent exploitation of that vulnerability came from the Sun Tzu camp. Both Mao and Giap pioneered the struggle by a movement against a stronger government establishment. The importance of politics and the need to win men’s minds were central to successful revolutionary warfare. The pursuit of these ends was to be ruthlessly maintained. Since the eventual result was to be a revolution, conventional means and methods were not necessarily to be used. Thus, the creed of the end justifies the means became enshrined in this revolutionary doctrine. Reprisals and violent acts against those identified as enemies of the revolution were to be routinely employed. Terror and intimidation were used alongside conciliation and reward. Such a heady mixture of outrage and selflessness bore fruit in a number of different campaigns. The retreat from empire in the postwar period saw many examples of this approach. It also witnessed some successful campaigns against revolutionary war, notably in Malaya and Dhofar. Such examples owed their effectiveness to the early recognition of the political process enshrined in revolutionary action, and the appropriate coordinated politicomilitary response. However, such successes were not easily won, since they required an investment in time and in military, financial, and political resources. The conflict itself was often highly destructive and had many of the unpleasant features of civil war. Frequently, populations were the targets of direct military action, with the recognized effects of migration, disenfranchisement, and poverty, as well as trauma in all its guises. Humanitarian aspects became increasingly significant. Terrorism has been spawned from the ideas of revolutionary warfare and is the antithesis of humanity in conflict. Sadly, it is a commonplace problem in the contemporary world and is always a possible option open to opponents. It can be waged either nationally or internationally, with varying degrees of discrimination and violence. However, it is based on Mao’s advice, “Kill one, frighten 1,000.” Once more, it can be seen that violence is being used to change and manage perceptions. The moral context may differ from that of conventional conflict, but the underlying purpose does not.
Modern Military Philosophy Modern military thinking is inevitably derived from historical, philosophical, cultural, and technological imperatives. Essentially, its basis is the realistic view of international relations in which the pursuit and promotion of the national interest in a competitive world is underpinned by the exercise of power. This approach implicitly
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depends upon an understanding of and commitment to the rationality of force; military power is cast in the Von Clausewitzian role of political action. For most developed nations, the likelihood of conflict is seen in terms of fighting against either comparable powers or less well-developed opponents. This division is usually referred to as symmetric and asymmetric warfare.
Symmetric Warfare Symmetric conflict occurs between two opponents who have similar capabilities. Furthermore, these capabilities are matched by similar commitments to targeting policies, limits of action, and acceptability of risk. In many ways, symmetric conflict can be viewed as traditional warfare between approximately equal nation states. It is a quintessentially Von Clausewizian perspective. There is some degree of commonality in ends, ways, and means between the competing sides. Thus, in modern times the Falklands Campaign and the repeated Indo-Pakistan conflicts are representatives of this genre. There is an understood and usually implicit commitment to the common standards of acceptability. Within this overall commitment, both sides will seek to gain maximum advantage in order to prosecute their case most effectively. As Von Clausewitz emphasised, bloodless battle is a chimera; fighting means the expenditure of money, resources, sweat, and blood. Nevertheless, symmetric warfare presupposes equivalence in capability and commitment.
Asymmetric Warfare On the other hand, asymmetric conflict reflects the divergence in ends, ways, and means between two antagonists. Such a conflict highlights the fundamental asymmetry between both warring parties. Differences in targeting policies are frequently key areas of asymmetry. Thus, one side may adopt a more terrorist-like targeting approach, aiming to hit selected individuals by assassination or frighten whole populations by arbitrary acts of indiscriminate violence. Meanwhile, a whole raft of considerations (political, ethical and military) may restrain the other side to a more traditional engagement of opposing military forces only. Equally, substantial differences in available military power may be reflected in these opposing approaches. Indeed, classic revolutionary warfare enjoins the insurgents not to match strength against strength. For the weaker force, attempting to match an adversary’s strength with one’s own is a recipe for military defeat. Instead, using one’s strength against his weakness, along the lines of Sun Tzu, is a more profitable line of operation. A corollary of this is the concept of protracted struggle.
Protracted Struggle In order to circumvent the greater military strength of an opponent, the weaker party needs to avoid quick solutions and adopt a strategy to prolong the struggle. Such a philosophy would tie up increasing proportions of the enemy’s resources and render it increasingly expensive in all dimensions, including casualties. For this strategy to
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become effective, time is required for the commitment to grow in terms of resources engaged, while the commitment in terms of politics will decline in the face of burgeoning bills for finance, materials, and manpower. This strategy was perfected by Mao and was termed a “protracted struggle.” The strategy recognized the disparities in ways, means, and ends in an asymmetric warfare, and outlined the approach by which the militarily weaker party might eventually prevail. Time was the critical component. As an example of the successful waging of asymmetric warfare by a weaker side, the Vietnam War is a classic. In this conflict, the most powerful nation on the earth failed to subdue an insurgency from a small peasant-based economy. At heart was Giap’s belief that the Vietnamese could maintain being killed for longer than the Americans could maintain killing them. The disproportion in casualties between the two sides underlines this contention (55,000 US troops, 1.3 million Vietnamese) (Lomperis 1996). In the end, the strength of political commitment to the cause was greater on the Communist side.
Maneuvrist Approach The complexities of symmetric and asymmetric warfare may differ from each other in both kind and degree. However, they both share an understanding that it is the human mind that is the real battlespace. Conflict is the process by which perceptions may be changed; it is at heart a political process. The contexts may vary, but this essential truth is recognized by both streams of warfare. Equally, both approaches recognize an underlying doctrinal view known as the maneuvrist approach. Basically, this approach is derived from an amalgam of historical and philosophical antecedents which have produced a military doctrine enshrining the importance of the psychological elements within it. In this philosophy, uncertainty is recognized as being unavoidably intermingled with conflict and the battlespace. The recognition of this central fact then allows the military to exploit it by seeking to reduce their own uncertainty, while accepting that an irreducible minimum exists, and simultaneously increase that of the enemy. Uncertainty can be most debilitating, especially to organizations that require detailed planning and coordination to deliver their capability as military forces. Hence, the central significance of uncertainty to the applied psychology of the battlespace is enshrined in a series of training, organizational, and equipment issues for most armed forces.
Technocentric War Military development is an iterative process of an intensely pragmatic nature tempered by intellectual rigor. Consequently, the future direction of military development in a climate of increasing resource constraint and increasing unit costs for personnel and equipment is a matter of much debate and consideration. This process has been loosely called a revolution in military affairs, and is an attempt to resolve the competing issues of the utility of the military, the contexts in which development and deployment might occur and the structure of future military organizations. Many of these questions are complex and opaque in nature. However, in accordance with Von Clausewitz’s
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direction to use recent history for illumination, the significance of the Gulf War of 1991 has been central to this debate. One school of thought that might accurately be described as technocentric suggests that the Gulf War is the first of the modern wars. In this view, conflict will be characterized by a reluctance to engage the enemy closely. Instead, standoff weaponry will be used to reduce casualties. In addition, modern technology will allow an increasing precision of effect, so that the need to risk a close engagement, with all the uncertainties of casualty generation and loss of materials, will be avoided. Instead, the relatively risk-free, clean option of conflict at arm’s length will be attainable. In order to achieve this, the importance of the air dimension is emphasized. Indeed, the only way in which this option can be maximally developed is by switching resources into the creation of capabilities delivered from air/ space. Target acquisition, reconnaissance, surveillance, and weapons deliveries are all to be effected from the air and aerial platforms. The importance of traditional military structures in armies and navies is then greatly reduced. Instead, the air element is emphasized. Such a view is profoundly challenging to many military orthodoxies.
Van Creveld: An Alternative View Equally challenging is the approach of Van Creveld, the eminent Israeli strategist and military writer. While agreeing that the Gulf War has a central significance, his view is markedly different from the technocentric perspective. Far from being the first of the modern wars, Van Creveld argues that the Gulf War was the last of the old-style conflicts. At heart, his argument rests on the nature of political organizations in the future. The Gulf War model implicitly accepted the existence and the relevance of the nation state with the interplay of the traditional three players (1) the government, (2) the armed forces, and (3) the people. This is the trilogy as described by Von Clausewitz. However, political and economic realities are increasingly undermining the existence of the nation state, with many of them foregoing sovereignty for reasons of economic or security interests. In addition, the nature of conflict is becoming less interstate and increasingly intrastate in nature. Thus, the usual pattern is for a state to suffer separatist tensions that evolve into political and military campaigns with potential overlays from terrorism, organized crime, and interested outsiders, some of whom may be commercial organizations. This is a complicated welter of influences and ideologies to which the technocentric view of warfare has at best only limited applicability. Instead, the military requirement is for close engagement almost in a policing role with the ability to escalate up to full military action for particular objectives. While the advantages of better surveillance and target acquisition capability which are central to the technocentric view would be useful in Van Creveld’s picture of future conflict, technocentrism is irrelevant to the core question of the political problem. On the contrary, the importance and the relevance of the traditional military organizations and structures are confirmed. Thus, these two views of future conflict set the parameters for the debate on the revolution in military affairs. Within these poles there is a range of views and beliefs which are part of a continuing and complex debate.
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Aspects of Conflict The contemporary world is composed of a mixture of states in varying degrees of economic, political, and military development. The passing of the Warsaw Pact and the decline of superpower rivalry have resulted in a patchwork of national tensions and rivalries across all the continents of the world. In many ways, the loss of the certainties associated with the superpower ideological struggle has made the globe a more dangerous place. Instead of the control exercised by the two superpowers over their respective satellite states, there is now no effective, extant, overarching control mechanism for international conflicts other than the United Nations (UN). Recent experiences in the Balkans, sub-Saharan Africa, and Asia illustrate the problems that the UN faces in preventing and then engaging in these sorts of conflicts. As a consequence, a series of bloody conflicts has arisen and these have resulted in thousands of deaths, many of which have been in civilian populations. The spectacle of migrant populations and poorly targeted, if not indiscriminate, military action had become all too familiar a sight on the television screens of the world. Conflict has re-established itself as one of the prime drivers of population movement. Frequently, humanitarian disaster follows forced migration.
The Changing Pattern of Conflict The pattern of conflict has altered over the last 200 years. During this period, warfare has moved from being predominantly an international state affair (largely European and North American in extent), through three major world wars (the Napoleonic, and the First and Second World Wars), to the age of wars of national liberation (the retreat from empire by colonial powers). This process has seen a decreasing likelihood of developed nations waging war against each other. Instead, a pattern has emerged of war being waged between developed and developing nations or between two developing nations. Many of these are legacies of colonial, political, or economic affairs. In these conditions, symmetry and asymmetry apply to both sets of circumstances. In contrast, processes of negotiation, trade sanctions, and compromise resolve disagreements between developed nations. Nevertheless, all nations remain vigilant about their own security and are reluctant to forego the means of guaranteeing it, and so the military option remains available.
Failed States Not infrequently, circumstances may change so that the actual viability, or even the existence, of a state is called into question. Prolonged civil strife, war, or economic failure that is severe enough to threaten the fabric of a society may cause such conditions. In such a situation, the delicate balance between the needs of the individual and the requirements of the community is completely disrupted causing the failure of normal social and economic relationships. Hardship and destitution follow, with the young, the women, and the elderly frequently being the most vulnerable. In such a society, there may be reversion to gun
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law and a complete failure of social norms. Sadly, such examples abound in Africa (notably Rwanda, Somalia and Angola at various times). Regrettably, the problem of the failed state is likely to be a continuing challenge in the future. It presents a particular challenge for humanitarian involvement because of the complex of security, political, logistic, legal, and ethical dilemmas that may ensue. Conflict will almost always be a further complicating factor in the mixture, and its nature may vary from the symmetry of deployed military groups with the concomitant pattern of fighting to the vagaries of gun law and arbitrary violence.
The Spectrum of Conflict Attempts have been made to codify and simplify the pattern and the nature of conflict. One of the best known is the spectrum of conflict depicted in Fig. 4.1. In this model, there exists a gradual gradation of the level of conflict from assistance to the civil power up to full high-intensity warfare. Usually, this top end of the spectrum refers to the type of conflict seen during the 1991 Gulf War, using the full range of conventional weaponry in an integrated strategy within the battlespace. This type of warfare would ideally be waged at high tempo and continuously until the objectives T Military assistance
Humanitarian operations Peace-support operations
Low-intensity operations
Mid-intensity operations
High-intensity operations
Fig. 4.1. Spectrum of conflict.
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Postconflict
Preconflict
Conflict
Fig. 4.2. Cycle of conflict.
had been attained. Such conflict demands the full synchronization of air, land, and maritime elements throughout all weathers and regardless of night or day. Figure 4.1 also usefully illustrates the possibilities of escalation and de-escalation within a particular conflict. Indeed, there might occur simultaneously a range of conflicts within the same theatre of operations. Thus, high-intensity operations could be prosecuted in one sector while low-intensity conflict is being waged, all this being coterminous with humanitarian relief. It is a potentially complicated mixture that the model illustrates with some clarity. An alternative model of conflict portrays the process as a continuous cycle varying between preconflict, conflict, and postconflict stages as shown in Fig. 4.2. This view allows for the different stages of the conflict process to occur simultaneously, and demonstrates how they may meld from one to another. It is a useful construct since it gives some idea of the dynamism which conflict generates. It also indicates the element of confusion that always exists with conflict. The confusion is an aspect of Von Clausewitz’s friction as well as being inseparable from the complexities of simultaneous operations. The concept of a cycle with ease of passage between the different stages of the continuum is extremely useful in conveying the operational and philosophical reality.
Conclusions Conflict has existed throughout recorded history. It has evolved to accommodate cultural, economical, political, and technological aspects. As a result it is a multifaceted process with distinctive differences between peoples and countries. Whether it is the cause of instability or the product of it is a difficult question that would require a detailed case-by-case analysis. Probably, the truth lies somewhere between the extremes, with an acceptance that conflict may exacerbate instability but is more usually the manifestation of it. At any rate, it has become a perennial factor in the process of human relations.
Humanitarian Law and the United Nations There has been a slow change in both the acceptability and the utility of conflict in the world. With the emergence of a body of humanitarian law and the establishment
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of the UN, a vehicle for the analysis and expression of the rationale for conflict has been provided. While in many quarters there is a deep cynicism about the value of the UN in conflict prevention and resolution, there is an undeniable requirement for states to justify a resort to arms in settlement of a dispute. Even the most powerful states feel compelled to invest effort in public defence of their actions and if possible to seek UN support for such action. A significant example of exactly this process was the detailed negotiations and dealing that preceded the arrival of the British Task Force in the Falklands in 1982. Both the British and the Argentineans mobilized their supporters and the UN in support of their particular cause and action. Similarly, the American-led coalition against Saddam Hussein in 1991 expended considerable effort to ensure UN support. These examples may be interpreted as an acceptance by states that there are legal, political, and moral considerations in the choice of conflict to resolve differences between them.
The Role of Law The increased significance of the role of the law on the international stage is a recent development. The gradual evolution of a coherent body of humanitarian law is a major element in this success. However, compliance with the law is still patchy at best. Recent captures and successful prosecutions of war criminals by the War Crimes Tribunals are notable developments. Nevertheless, the process is still in its infancy and has a long way to go. Similarly, the attempts to outlaw war itself seem to be premature given the state of the world political stage and the lack of an enforcing mechanism. The trend is easily identifiable, but a successful imposition of a single international criminal code regulating interstate relationships seems a far distant prospect. In the interim, it is likely that conflict will continue to afflict mankind. This means that all the uncertainties, brutalities, and vicissitudes of the battlespace will continue to be visited upon combatant and noncombatant alike. An understanding of why a particular conflict is being waged and its nature will remain invaluable to a successful humanitarian operation. Only if the essence of conflict is comprehended can maximally effective humanitarian assistance be applied. Shortcomings in this crucial comprehension can only worsen the prospects for humanitarian actions as well as the security of all involved. Knowledge is power in all fields of human endeavor. On the other hand, in the situation of conflict, ignorance may represent failure and even death rather than bliss.
References Giap VN. People’s War People’s Army. Delhi: Natraj, 1974; 41–74. Gray CS. Modern Strategy. Oxford: Oxford University Press, 1999; 124–7. Howard M, Paret P. Carl Von Clausewitz – On War. Princeton, NJ: Princeton University Press, 1976; 3–58. Lomperis TJ. From People’s War to People’s Rule. Chapel Hill, NC: University of North Carolina Press, 1996; 108–10. Mao Tse Tung. On Guerrilla Warfare (Translated by Griffiths S). New York, NY: Doubleday, 2000; 61–101. Neumann S, von Hagen M. Engles and Marx on revolution, war and the army in society. In: Paret P, editor. Makers of Modern Strategy. Oxford: Oxford University Press, 1986; 262–80.
5. The Players: Humanitarians, Militaries, Industry and Private Security Companies Part A – Humanitarian Organizations and Their Coordination in Humanitarian Assistance M. Kett and A. van Tulleken
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Objectives ● ●
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To describe the agencies and organizations that health care providers are likely to encounter in disasters and complex humanitarian emergencies To outline the mandate and expertise of some of these agencies To describe recent humanitarian reforms, including the UN-led Cluster Approach for coordination of humanitarian assistance in disasters and complex emergencies To highlight the potential obstacles to effective communication and cooperation between agencies To direct readers to useful resources for coordination between agencies
Introduction The way humanitarian aid is delivered has changed over the past few decades largely as a consequence of lessons learned, but also in response to the different contexts of contemporary humanitarian emergencies. This has necessitated a process of significant reform. Debates about the number of humanitarian crises continue: while numbers of cross-border conflicts have statistically dropped, intrastate or nonstate conflicts have increased (Cramer 2006; Goodhand 2006). Long-term effects of such crises include an increase in civilian injuries and deaths, as they are often deliberately targeted as part of low-intensity warfare, population displacement, resource scarcity, poverty, inequality, and exclusion of poor and marginalized groups. Questions are raised as to the extent to which some states are able, and willing, to protect their citizens in these circumstances. There are also increasing concerns about climate change and its effect on the environment and availability of resources, which can be a significant factor in precipitating conflict. These events often take place in insecure political contexts, with A. Hopperus Buma et al. (eds.), Conflict and Catastrophe Medicine, Second ed., DOI 10.1007/978-1-84800-352-1_5, © Springer-Verlag London Limited 2009
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limited resources and capacities to respond. All this has led to an increase in the number of complex humanitarian emergencies. This chapter aims to give an overview of who intervenes to assist before, during, and in the immediate aftermath of violent conflict and humanitarian crisis: what are the roles of the many different international and national organizations, agencies, and individuals who intervene? What are their responsibilities? Who coordinates these? This chapter will assist those involved in humanitarian assistance in understanding who is who, their various agendas, and the potential areas of cooperation and conflict that arise in response to complex emergencies.
Humanitarian Organizations and Their Role in Emergencies At the time of writing there are over 20 UN agencies present in Darfur, Western Sudan, as well as peacekeeping forces, African Union Soldiers, and over 70 international NGOs. There are also numerous local NGOs, international oil companies, private security companies, three armed rebel groups, and local and national government departments. This number and variety of different actors is not uncommon in a complex (humanitarian) emergency. The logistical difficulties of communicating and coordinating in circumstances when infrastructure has been destroyed or never existed are vast. In addition many of these parties may have differing and competing agendas. It is impossible for any healthcare provider to function in a vacuum and many of these agencies and organizations will be encountered in the course of providing humanitarian relief. In addition to clinical challenges healthcare workers are often required to take on administrative roles and are required to coordinate their work with other agencies as well as report to UN departments, their own donors, and the host government. Much of this work must be done with very limited resources, in uncomfortable and often dangerous circumstances. There are an enormous number of different agencies in the field at any one time. For the sake of brevity, this chapter will focus primarily on lead agencies (often, though not exclusively, UN agencies) as will as give a brief outline of the mandate of some of the other organizations and agencies likely to be encountered.
The Structure and Purpose of the UN At the time of writing there are 192 UN members, recognizing nearly every independent state. Each UN member is a signatory to the Charter of the United Nations, which outlines the purposes and aims of the United Nations including the following: ● ● ●
“…to maintain international peace and security” “…to promote social progress and better standards of life in larger freedom” “…to employ international machinery for the promotion of the economic and social advancement of all peoples…”
The principles of the Universal Declaration of Human Rights (1948) are integral to the role of the UN and its agencies. A detailed description of the incredibly complex structure of the United Nations that has developed since it was brought into being in 1945 is beyond the scope of this chapter. For readers who wish to understand more of the politics and history surrounding this controversial organization there are some suggestions in the References.
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It is, however, useful to understand some basic concepts about the organization and its agencies as almost everyone working in a humanitarian response will come into contact with one or more of the UN agencies at some point. The UN is administered by five bodies: ● ● ● ● ●
The General Assembly The Security Council The Secretariat The Economic and Social Council The International Court of Justice
The General Assembly The general assembly is composed of all member states and operates under the “one state, one vote” principle. It is the main deliberative organ of the UN and acts as a parliament of nations. When voting on “important” matters, including recommendations on peace and security, a majority of two-thirds is required to pass a resolution. The GA meets in regular yearly sessions from September to December, under a rotating presidency.
The Security Council The Security Council (UNSC) is composed of fifteen members. The five permanent members are The United States, The United Kingdom, France, the Russian Federation, and the People’s Republic of China. All the permanent members have a veto over any resolution under debate. There are also ten elected members who serve 5-year terms and are elected by the general assembly.
The Secretariat This is the administrative department of the UN with offices in New York, Geneva, Vienna, and Nairobi. The Secretary General is the Head of the Secretariat.
Economic and Social Council The Economic and Social Council (ECOSOC) is the coordinating body for planning and implementing policies concerned with all areas of economic and social issues. It is the largest of the main UN bodies. ECOSOC coordinates the overlapping functions of the UN subsidiary bodies, including the International Labour Organization (ILO), World Health Organization (WHO), and United Nations Children’s Fund (UNICEF), as well as the functional commissions (e.g., UN Human Rights Council) and the five regional commissions (e.g., UN Economic Commission for Africa).
International Court of Justice The International Court of Justice (ICJ) is the main judicial organ of the United Nations (UN). It is based in The Hague, Netherlands. Its principal function is to settle
34
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disputes in accordance with international law and advise the UN and its organizations on aspects of international law.
Humanitarian Emergencies and the UN System In most large-scale responses to complex emergencies and disasters the UN leads coordination attempts. In many cases, however, NGOs are responsible for over half the operational capacity of a response, and so their involvement in any process of coordination will determine how useful it is. Coordination of UN responses across the world is through the Office for the Coordination of Humanitarian Affairs (OCHA). OCHA is a department of the secretariat, headed by an Emergency Relief Coordinator (ERC). The ERC is also chair of the Inter-Agency Standing Committee (IASC), which was established in 1992 in response to UN resolution 46.182 on the strengthening of humanitarian assistance, which affirmed its role as the primary mechanism for interagency cooperation. IASC membership is currently composed of all operational UN organizations along with standing invitations to the International Committee of the Red Cross and Red Crescent, the International Federation of Red Cross and Red Crescent Societies, and the International Organization for Migration. It is these UN agencies that are most likely to be encountered in the field, and a brief description of their activities is given later. It is also through the IASC that much of OCHA’s coordination function is carried out. For each disaster or complex emergency OCHA appoints a Humanitarian Coordinator (HC – see later) who is responsible for a coherent relief effort. OCHA coordinates humanitarian efforts in several ways: It is responsible for developing common policies, guidelines, and standards across humanitarian response procedures, and it raises and distributes funds to support humanitarian responses through administration of the Consolidated Appeals Process (CAP), Flash Appeals, and the Central Emergency Relief Fund (CERF). It is not an implementing agency but operates a network of field offices to support the HCs, and a 24-Hour Monitoring and Alert system covering the globe. OCHA also supports surge capacity mechanisms such as the UNDAC (the United Nations Disaster Assessment and Coordination System)1 and information services, including Relief Web and IRIN news (see “Resources section” later).
Humanitarian Reform: The Benefits of Coordination The United Nations is frequently criticized for being inefficient, political, slow to act, and in cases such as Rwanda and Darfur, inexcusably negligent. These criticisms are justified in many instances, and the ongoing process of reform acknowledges its
1
The Surge Capacity is the OCHA response mechanism for rapid deployment of staff to provide timely support to the OCHA field structures and IASC (Inter-Agency Standing Committee) Country Teams in emergency situations.” (http://ochaonline.un.org/AboutOCHA/Organigramme/ EmergencyServicesBranchESB/SurgeCapacity/tabid/1943/Default.aspx).
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recent failures in humanitarianism. However, the ability of the UN to respond to disasters has been severely limited by two major factors. The first is the budget of the UN, which is annually approximately $12 billion. This is a smaller budget than that of New York City Fire Department, to run an organization that operates in every country on earth. While donations either of money or resources are made available separately to fund operations, the real value of contributions to run many departments of the UN has not increased for decades, making it extremely difficult to invest in infrastructure or reform. The second limiting factors on the United Nations are also its greatest assets: the Security Council and the General Assembly. The United Nations organization can only be as good as its member states allow. The delicacy with which UN agencies operate in the field can be infuriating for NGO staff. But the UN’s hesitation in condemning human rights abuses, or in taking decisive action in the face of atrocities stems from the conflicting agendas of its member states. For example, the failure of the United Nations to respond to the crisis in Darfur is in some part due to China’s reluctance to pass resolutions imposing penalties on Sudan, one of its major oil suppliers. Agencies operating independently of the UN in a humanitarian response have right to demand action from the UN in the face of atrocities, but it is rarely apathy or ineptitude on the part of UN field staff that is the underlying problem. One of the key problems has been that of coordinating the vast number of actors in the field and ensuring cooperation in response.
Coordination and Cooperation Every natural disaster and complex emergency produces different challenges and involves different actors. Political and geographical circumstances will to a large extent determine the nature of the responders, and how effectively they coordinate. In addition, the nature of the particular humanitarian crisis, for example, whether of slow or rapid onset, affects the nature of the intervention. The coordination structures described in this chapter are not therefore universally encountered, nor do they always function the way they are intended; nevertheless, the overall structure of the coordination system described is frequently employed in response to a disaster or emergency. Coordination is time consuming and expensive, so it is important to justify the resources spent on it. In 2001, a letter published in The Lancet entitled “Cowboys in Afghanistan” outlined how the humanitarian endeavors in Afghanistan routinely failed to direct aid to where needs were highest. Amongst the criticisms listed were ad hoc, uncoordinated meetings, poor information sharing between NGOs competing for funds, and a lack of good-quality field data available to donors. Problems such as these have been common in the past as humanitarian crises generate massive influx of NGOs and UN agencies with large budgets and disparate agendas to places where infrastructure and government control is often extremely poor. The benefits of agencies coordinating their activities are obvious. The sharing of information between organizations regarding everything from reporting the first observed cases of measles or meningitis in a camp, to the location of displaced persons who are not receiving any assistance, is invaluable. It allows effective prioritization of tasks so that the populations with the greatest needs can be targeted first, and
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Section One
prevents duplication of programs so that resources are usefully divided within the affected population, ensuring that no sector of activity is inadequate to meet the needs of the population and that no part of the population is neglected. The United Nations has come under heavy criticism over the course of repeated disasters where, despite available resources and funds, there have been evident gaps in the humanitarian response. In 2005, under pressure from the General Assembly, the then UN Emergency Relief Coordinator, Jan Egeland, commissioned the Humanitarian Response Review (HRR), an independent report that sought to identify why the humanitarian aid community was falling short of its goals, and to make recommendations for reform.2 The recommendations made in this document have become the basis for Humanitarian Reform, a set of changes designed to improve response capacity, predictability, and accountability; to streamline financing; to improve coordination of agencies in disasters both in the field and globally; and to improve partnerships between the United Nations and NGOs. These reforms focus on three main areas: ● ● ●
The development of the Cluster System Strengthening the role of The Humanitarian Coordinator Improving financing with the Central Emergency Relief Fund (CERF)
These changes are examined later. They will impact fieldwork in many ways, and it is important for healthcare workers to understand the basis of them, whether working for a UN agency, as Head of Mission for an NGO, or as a healthcare provider in the field.
The United Nations Cluster System In September 2005, the Inter Agency Standing Committee (IASC) agreed to implement a new coordination system that would be used in all new emergencies. Known as the cluster system, this system is subject to ongoing review and alterations, but regardless of how effective it turns out to be it is likely that most field workers will encounter it in some form, and an understanding of its structure, and its strengths and weaknesses will be invaluable. The aim of the cluster system is to eliminate gaps in a humanitarian response by allocating an agency of the United Nations to take the lead in each sector. The lead agency is not only responsible and accountable for the quality of work done in the sector, but also is “provider of last resort” – that is, if there is a deficiency that cannot be met by any other implementing partner then it falls to the lead agency to intervene. The clusters approximately correspond to the main sectors, which have been recognized as important in disaster response. There are sectors in which there has historically been clear leadership (e.g., agriculture, led by FAO; food, led by World Food Program; refugees, led by UNHCR; and education, led by UNICEF) of which agriculture
2 Humanitarian Response Review, commissioned by the United Nations Emergency Relief Coordinator and Under Secretary General for Humanitarian Affairs, August 2005. Available in multiple locations online: http://www.reliefweb.int/library/documents/2005/ocha-gen-02sep.pdf.
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Table 5.1. Global cluster leads Sector or area of activity
Global cluster lead
Clusters associated with service provision Emergency Telecommunications Logistics
OCHA/UNICEF/WFP WFP
Cluster dealing with relief and assistance to beneficiaries Emergency Shelter IDPs (from conflict) Disaster situations Education Nutrition Water, Sanitation and Hygiene (WaSH) Health Agriculture
UNHCR IFRC (convener)3 UNICEF Save The Children (UK) UNICEF UNICEF WHO FAO
Clusters dealing with cross-cutting issues Early Recovery Camp Coordination/Management IDPs (from conflict) Disaster situations Protection IDPs (from conflict) Disasters/civilians affected by conflict (other than IDPs)4
UNDP UNHCR IOM UNHCR UNHCR/OHCHR/UNICEF
and education sectors now have designated Global Clusters (see later). In addition, in 2005 the IASC designated lead agencies for nine sectors, which in the past either lacked predictable leadership or needed strengthened cooperation between humanitarian actors. There has been ongoing confusion amongst NGOs regarding the number of clusters that exist. Much of this stems from the fact that while there are 11 clusters at a global level (Table 5.1), the number of clusters and the cluster leads at a field level can vary depending on the circumstances. The differences between global and field level clusters are explained later.
Clusters at a Global Level The global cluster leads are responsible for ensuring system-wide preparedness and technical capacity. It is hoped that this will be achieved by activities in three main areas:
3 IFRC has made a commitment to being a “convener,” not a “cluster lead,” and it is therefore not committed to being “provider of last resort” nor is it accountable to any UN agency. 4 UNHCR is the Global Protection Cluster Lead. At the country level in disaster situations or in complex emergencies without significant displacement, any of the three core protection-mandated agencies (UNHCR, UNICEF, and OHCHR) can assume the role of Lead for Protection.
38 ● ●
●
Section One Standards and policy setting, including identification of best practice Building response capacity, including establishing and maintaining material stockpiles and standby rosters Operational Support, including needs assessments, securing access to technical expertise, and ensuring complementarity of efforts across UN agencies and other humanitarian actors.
Examples of Global Cluster Leads The World Health Organization The World Health Organization (WHO) is the coordination authority on international public health. Its functions include coordination, research, campaigning, and operational activities. The scope of the WHO’s activities is vast and its research and guidelines affect health policy and practice in most countries. Within the cluster system, the WHO is the lead agency for health and as such is training a roster of specialized Health Cluster Field Coordinators. These people will be the cluster lead and will usually have medical qualifications along with postgraduate training in public health. The strategic areas for the health cluster are as follows: ● ● ● ● ●
Coordination and management Information management Rosters and stockpiles (including surge capacity) Capacity building Operational support (including resource mobilization)
Disasters and complex emergencies can have catastrophic effects on public health, and rapid provision of health care is almost always a critical determinant of survival. Information gathering is the cornerstone of effective public health, and the WHO is responsible for gathering epidemiological data from all responders and making it available in a useful form. As such it is an invaluable resource in the field in planning and assessing strategy. The Health Cluster works closely with the Nutrition and Water and Sanitation Clusters and depending on the context may have close links to the Protection cluster regarding psychosocial issues. Cross-cutting issues such as gender and HIV/AIDS are of particular consideration in the health sector where many of the beneficiaries are likely to be women and children.
The World Food Program The World Food Program (WFP) is the largest humanitarian agency in the world with a direct expenditure of $2.9 billion in 2006. Its operations reach over 80 million people per year, more than half of whom are children. Its aim is to eradicate hunger and malnutrition across the world, and its programs are divided into emergency programs, relief and rehabilitation programs, development programs, and special operations.
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Food supply is a concern in almost every emergency. To deliver the quantities of food needed (four million tonnes in 2006) WFP has developed large and sophisticated logistic capabilities as well as being the lead agency for agriculture; it is also the logistics lead and partners with OCHA and UNICEF as the telecommunications lead within the cluster system.5 In 2006, WFP’s Humanitarian Air Service transported over 300,000 passengers form over 100 NGOs to locations all over the world. It has operational capacity for sea and land transport, and has developed its own field communication system, DFMS, which is used by many NGOs in the field. As the lead agency for the Food sector the WFP will perform emergency needs assessments, procure food using its own internal Immediate Response Account, and launch international appeals for contributions in the form of food, as well as deliver and distribute food. The WFP’s programs are intended not merely to meet the nutritional and calorific requirements of the population but also to rebuild local capacity with food for work programs and to target particularly vulnerable groups such as children and those with HIV/AIDS.
United Nations High Commission for Refugees Under the cluster system, the United Nations High Commission for Refugees (UNHCR) is the lead agency for those internally displaced by violent conflict in three areas: camp management, shelter, and protection. There has been much debate about the differences between internally displaced people (IDPs) and refugees. The 1951 Refugee Convention defines a refugee as: “…a person who, owing to well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion, is outside the country of his nationality and is unable or, owing to such fear, is unwilling to avail himself of the protection of that country.”6 The Refugee Convention was expanded in 1967 to the protection of displaced people globally. Some 146 states are signatories to the 1951 Refugee Convention and/or its 1967 Protocol. Those defined as refugees cannot be forced to return to a country deemed as unsafe for them on any of the grounds listed earlier – the principle of nonrefoulement. While states that have not signed the conventions are not bound by them, they are liable under other international humanitarian laws (such as the Genocide Convention; UNHCR 2007). UNHCR is mandated to take the lead in the care and protection of refugees and to resolve refugee problems worldwide, through the right to seek asylum and find safe refuge in another state, return home voluntarily, integrate locally, or to resettle in a third country.
5 As noted earlier, there is no specific food cluster as the WFP has historically had a clear role as the agency responsible for this sector. 6 Article 1: 1951 UN Convention Relating to the Status of Refugees.
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Section One
UNHCR’s mandate has gradually been expanded to include those designated internally displaced people (IDPs). According to the 1998 United Nations Guiding Principles on Internal Displacement, they are defined as: “…persons or groups of persons who have been forced or obliged to flee or to leave their homes or places of habitual residence, in particular as a result of or in order to avoid the effects of armed conflict, situations of generalised violence, violations of human rights or natural or human-made disasters, and who have not crossed an internationally recognised State border.”7 These Guiding Principles are not legally binding, though they have been incorporated into national policy in a number of countries, including Angola, Burundi, Colombia, Georgia, and Uganda. According to the Internal Displacement Monitoring Centre, by the end of 2006, the number of people internally displaced by conflict alone was estimated to be around 24.5 million people in 41 countries (IDMC 2006). The vast majority of these are in Africa, including around 5.3 million people in Sudan, but there are IDPs in almost every continent of the world. In Colombia, estimates of the number of IDPs vary between 1.8 and 3.8 million. By their vary nature, accurate numbers of IDPs are hard to obtain as it is very often their own states that are creating the protection problems for people in the first place. Women and children make up the majority of IDP populations (approximately 75–80%), making protection issues even more essential. IDPs are particularly vulnerable to political change, having both insecure political status and a lack of international protection. Opposing factions may use IDPs as political pawns to highlight causes, which may result in their situation being worsened and prolonged. Crucial to the debate is the fact that IDPs are not afforded any protection under the refugee conventions as they have not crossed international borders and therefore remain citizens of their own countries, and subject to sovereign laws. They do, however, have the right to protection under international human rights instruments and customary law. Furthermore, in armed conflict, they enjoy the same rights to the protection provided by international humanitarian law as long as they take no active part in combat. Though there are numerous organizations who take on responsibility for the care and protection of refugees, UNHCR takes the lead as mandated under the 1951 Refugee Convention. However, much of its operations are undertaken through national partner NGOs in the field. As noted earlier, under the cluster system, UNHCR shares responsibility for refugees and IDPs with a number of other organizations including the International Federation of the Red Cross Red Crescent (see later) and the International Organization of Migration (see Box 5.1).
7
Guiding Principles on Internal Displacement (1998 Introduction: Paragraph 2).
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Box 5.1. International Organization of Migration (IOM) IOM is an intergovernmental organization, established in 1951 to ensure humane management of migration, promotion of international cooperation on migration issues, assisting with the search for practical solutions to migration problems and to provide humanitarian assistance to migrants in need, including refugees and internally displaced people. IOM works closely with governmental, intergovernmental, and nongovernmental partners. IOM activities include the promotion of international migration law, policy advice, and protection of migrants’ rights (http://www.iom.int/ jahia/jsp/index.jsp)
International Red Cross and Red Crescent Movement The Federation (IFRC), together with the National Red Cross Red Crescent Societies and the International Committee of the Red Cross (ICRC), makes up the International Red Cross and Red Crescent Movement. The movement is based on seven fundamental principles of humanity, impartiality, neutrality, independence, voluntary service, unity, and universality. Across the world the Movement works with governments, donors, and other aid organizations to provide humanitarian assistance to vulnerable people. The ICRC has the mandate under international law (Geneva Conventions) to carry out humanitarian activities in situations of armed conflict. These include prison visits, monitoring the implementation of international conventions, organizing relief operations, assisting with missing persons, and family reunification. The ICRC is one of the world’s leading humanitarian organizations in terms of size and technical expertise. It has however attracted controversy because of its policy of nondisclosure. It cannot be compelled to give evidence in any court about war crimes it has witnessed. This neutrality gives it access to populations that would be denied to many NGOs, but the ICRC had been criticized for failing to condemn human rights abuses in some situations. The ICRC does considerable amounts of advocacy work with governments in complex emergencies, but does not publicly denounce them. The IFRC coordinates and directs international assistance following natural and man-made disasters in nonconflict situations. The IFRC works with National Societies to respond to catastrophes around the world. The National Societies works with public services in their respective countries to provide a range of services including disaster relief, health, and social programs. The Secretariat, based in Geneva, coordinates the provision of humanitarian assistance to international emergencies, as well as promoting cooperation between National Societies and representing the National Societies in the international arena. Under the UN cluster system, it is the Federation Secretariat, rather than the National Societies, that is the convenor. Although the IFRC has agreed to be shelter cluster convenor for people displaced by natural disasters, it has argued that being
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Section One
accountable to the UN would compromise its principles, especially of neutrality and independence. Therefore, it will not commit to being provider of last resort, nor will it be held accountable to the UN Emergency Response Coordinator.
Clusters at a Field Level The Field Clusters will usually be an in-country team for a given sector of activity, with a lead agency that will, in most instances, correspond to the global cluster lead. There may be cases where particular sector groups are not needed, where clusters may merge at a field level (e.g., Health and Nutrition or Food and Agriculture), or where it is appropriate for a particular NGO to act as a sector lead in parts of the country where they have a strong presence or particular expertise. The field clusters will focus on four main activities:8 ● ● ● ●
Needs and priorities assessments Securing commitments to follow up gaps in the response Assessments of performance of the cluster as a whole and of individual actors Acting as provider of last resort
The concept of provider of last resort is a particularly important feature of the cluster approach. It represents a commitment of the lead agency of each cluster to ensure that a humanitarian response is of a minimum standard for the population it aims to serve. The cluster should function to direct all the actors involved in the response to programs that will maximize their effectiveness. In the case of a shortfall in resources the sector lead is committed to fill the gap. Clearly this is easier said than done, and budgetary insufficiency and security concerns may make this impossible in many instances. Even in these circumstances, however, the provider of last resort is expected to pursue methods such as advocacy to fill the gap. A clear account of the cluster leads and field functions of the various clusters can be found in “Key Things to Know,” a document published by Humanitarian Reform to assist cross-cluster coordination.9
Other Agencies and Organizations in the Field In addition to the many UN bodies, there are also many other international and national nongovernment organizations and civil society organizations that will be encountered in any form of humanitarian response, both in the immediate and longer term. Each has its own mandate, core values and beliefs, and ways of working in the field. There have been attempts to unify and standardize responses in the past, including the drafting of the SPHERE Guidelines on Minimum Standards in Emergencies (see SPHERE 2004), as well as the Global Humanitarian Partnership – an arena for
8
A complete term of reference for Sector/Cluster leads at the country level can be found in Annex 1 of the IASC Guidance note on using the cluster approach to strengthen humanitarian response. 9 http://www.humanitarianreform.org/humanitarianreform/Portals/1/cluster%20approach%20page/ training/CSLT%20oct07/Day3/KTK-ALL.pdf.
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dialogue between the UN and NGOs.10 However, it is still debatable to what extent southern NGO voices have yet been heard within these. One of the main aims of the reform of the UN and the Cluster System is to enable coordination of all the different players. However, not all agencies adhere to the Cluster System: for example, Médecins Sans Frontières (MSF) believes that humanitarian imperatives to save lives and provide for immediate needs should be the primary goal of humanitarian assistance, and should not be subordinated to political goals or solutions (Stobbaerts et al. 2007). MSF have its own mechanisms for coordination and data collection in its responses and as yet has had limited participation in the cluster system (see Box 5.2). Box 5.2. Médecins Sans Frontières (MSF) MSF is an independent humanitarian emergency medical aid organization established in 1971. As an organization, MSF has remained mainly neutral and largely independent of individual governments, including their sources of funding. However, MSF will speak out to renounce violations of basic human rights encountered during its work. Though MSF has not publicly announced its position about the current humanitarian reform process, it has highlighted its increasing politicization, which, it argues, compromises the provision of humanitarian aid. It has clearly stated that it will not be a member of a cluster and that its actions will neither be placed under the responsibility of UN humanitarian coordinators nor be accountable to them11
There are a number of other organizations whose scale and size alone enables them to equal the UN in terms of interventions. In 2006 World Vision, one of the world’s largest NGOs received a total income of $2.6 billion, $540 million of which was spent on disaster relief. In 2004, the world’s seven largest NGOs all had annual incomes of over $100 million.12 In the case of organizations such as MSF over half of this income was from voluntary donations, giving them freedom to operate outside constraints imposed by government donors. Many of these NGOs, funded through large government donations, operate closely with, or within the cluster system. Indeed Save the Children UK (SCUK) is leading the Global Education Cluster. A detailed description of the activities of the huge variety of NGOs, both international and local, is beyond the scope of the chapter; there are NGOs that operate in
10
www.icva.ch/ghp.html. http://www.msf.org/msfinternational/invoke.cfm?component = article&objectid = 95542E25–5056AA77–6C6F0623221C3658&method = full_html. 12 Global Humanitarian Assistance, 2006. Available online at http://www.globalhumanitarianassistance.org/pdfdownloads/GHA%202006.pdf. 11
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Section One
every sector, at every level, and the largest ones have implementing capacities to rival any UN agency. It is worth noting the relationships between NGOs and their donors. Large sums of money are spent by donor governments on humanitarian assistance through NGOs – the largest official donor globally is the European Union (through ECHO), spending $403 million in 2004 – therefore, donors hold considerable influence over NGOs. Many of the large donors effectively contract NGOs to do specific work, for example, provide medical services to a certain number of people, within a given region. The NGOs compete for these contracts, and while this does promote efficiency and accountability it has the intrinsic drawback of disincentivizing some forms of cooperation and coordination. The major government donations are usually distributed through government bodies with a specific aid budget, such as the UK’s Department for International Development (DFID) and the United States’ USAID. These donations are inextricably linked to the donor government’s foreign policy, and it has been argued that the term “humanitarian” should not be used to describe donations that have a political motivation. Large government donations, while often pledged rapidly, can take considerable time to deliver. In an emergency these delays can be critical to relief efforts, and new financing systems are being developed as part of the process of humanitarian reform to streamline access to funds.
The Military Another increasingly important player in the field is the military, which in terms of manpower, technical skill, and resources, often has an advantage over many NGOs or UN agencies. For example, the Pakistan military played a vital role in the search and rescue efforts after the Kashmir earthquake in October 2005. However, they also highlighted the international relations aspects of involving the military – India refused to allow the Pakistan military to search in disputed territories. Other debates about involving the military include expense and duration of involvement. The military usually only have very short-term mandates, especially in disasters. However, the links between civil and military joint missions seem essential in current situations of increasing insecurity and in countries where the boundaries between humanitarian operations and military involvement are blurred, such as Afghanistan. Increasingly, humanitarian aid is being used as a tool to win combat through hearts and minds. An option that is becoming increasingly popular in very insecure areas is the use of private contractors to undertake projects. The advantage is they are contracted to do a particular job, hence will usually do whatever is necessary to ensure that the job is completed. However, such practices as viewed as antithetical to traditional humanitarian interventions as they are seen as profit making, as opposed to most aid and development that does not make a profit per se. It is likely that future decisions on how budgets are allocated by donors to future humanitarian and emergency response may well be affected by the role of these organizations.
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Practical Considerations in the Field The headquarters of the eleven clusters, along with many other UN agencies are likely to be found in the capital city, along with the Humanitarian Coordinator. If the disaster is occurring in another region of the country then there will be subclusters or humanitarian hubs that are near the site of aid delivery. In both locations there will be frequent meetings to facilitate coordination; meetings between NGOs and UN agencies within the clusters and cross-cluster. Not all NGOs are invited or even allowed to attend cluster meetings but it is important to be aware of the clusters as potential resources. The health cluster, for example, is responsible for, amongst other things, providing databases of technical experts, health and nutrition tracking service, global stockpiles of health supplies, and guidance for advocacy and fund raising. The functions of the clusters can be of great value to humanitarian efforts, but may require considerable input from partner organizations. The health cluster for instance will be responsible for gathering considerable quantities of epidemiological data regarding measles and meningitis epidemics, and health NGOs may be expected to devote some resources to gathering and reporting data.
Coordination Problems: Problems with the Cluster System Since its first use in response to the Pakistan earthquake in 2005, the cluster system has been used in Africa, South East Asia, and South America in a wide variety of situations, and the problems encountered with the system have been well described by a number of NGOs [see also Forced Migration Review (2007)]. This is potentially a challenge to UN coordination, since international NGOs are not obliged to operate within the cluster system. In many disasters over 50% of the operational capacity may lie with NGOs and without their cooperation the effectiveness of the cluster system may be severely limited. The main criticism leveled by several NGOs is that the system is extremely UN-centric. In many circumstances NGOs or the ICRC may have a larger operational capacity or more expertise than the lead UN agency within a cluster. NGOs have reported that they are uninvolved at the creative and strategic stages of response planning and are treated only as implementing partners. Numerous other problems have been reported from different locations: ●
●
● ● ● ●
Proliferation of subclusters or Cluster Spread in the field as specialist clusters develop, creating communication problems and making it difficult to ascertain which organizations are responsible for which activities Poorly organized, overly long meetings with no clear agenda and meeting timing changes at short notice. Many field staff have begun to regard meetings as talking shops, which achieve little, and prefer to work outside the clusters Poor staff training and high staff turnover in field clusters Lack of involvement of local NGOs. Lack of understanding of the purpose of the cluster system amongst NGOs. Underfunding of the Cluster Approach infrastructure
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Section One
However, there are solutions to most of these problems, and changes are ongoing to improve the joint training of NGO and UN staff in using the cluster system. Overall, despite some of the problems outlined earlier, there has been widespread support for the approach from NGOs. In 2006, a Global Cluster Building Capacity Appeal was launched to raise nearly $40 million dollars. A similar appeal will be used to fund the cluster approach in 2007– 2008, after which time capacity building costs will be a factor in the individual agency’s budgets.
Other Aspects of Humanitarian Reform As well as the implementation of the Cluster system the Humanitarian Response Review recommended reforms of the UN’s human resources (in the form of Humanitarian Coordinators) and improvements to the system of financing emergency relief.
Strengthening the Role of Humanitarian Coordinator In each country where the UN is operational there will be a Resident Coordinator (RC), a senior UN official (usually the head of UNDP in that country, and funded and managed by UNDP). The RC’s role is to work closely with national government, advocating the interests and mandates of the United Nations. In an emergency or humanitarian crisis the Emergency Relief Coordinator (ERC), in consultation with the IASC may appoint a Humanitarian Coordinator (HC). The HC will be a representative of the ERC and consequently of OCHA. The normal practice is to double-hat the Resident Coordinator, but in cases where the RC is too busy or special expertise is required, then a separate HC is appointed. The cluster heads report to the HC who assumes overall responsibility for ensuring a rapid and effective response to the emergency. The roles of the HC include the following: ● ● ●
●
Consulting cluster leads to develop overall strategy Ensuring that information sharing takes place Ensuring that cross-cutting issues (gender, HIV/AIDs, age, disability) are addressed in all sectors Supporting all sectors to ensure a comprehensive, well-prioritized humanitarian response.
The strategy for strengthening the HC’s role focuses on developing a system to select and train the most effective individuals, in order to maintain a pool of highly qualified HCs who can be deployed in an emergency. These individuals may be drawn from non-UN IASC partners including Oxfam and the Norwegian Refugee Council but the pool will be maintained and assessed by OCHA.
The Financing of Humanitarian Operations: CERF, CHAPs, and CAPs Lack of rapidly available financing for operations has previously severely hampered UN operations, especially those elements of a response that are time dependent. In most
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humanitarian operations prior to 2006 the main funding mechanisms were the Consolidated Appeals Process (CAP) and Flash Appeals. Bother of these are strategic response plan requests for funding from donors, not funds in themselves. A consolidated appeal relies on a Common Humanitarian Action Plan (CHAP), a strategic plan for the overall humanitarian response within a region. The CHAP should provide the following: ● ● ● ● ● ●
An analysis of the context in which the response takes place A needs assessment Best, worst, and most likely scenarios Identification of roles and responsibilities (who, what, where) A statement of long-term objectives and goals A framework for monitoring and revising the strategy
The CHAP, as part of the CAP is an essential part of the coordination of any humanitarian response. It is produced by the close collaboration of donors, UN agencies, NGOs, and the International Red Cross. It assists not only in fund raising, but also in planning, implementation, and monitoring activities. Despite attempts to streamline the process of CAP and flash appeals there have often been considerable delays in getting funding for emergency response. Between 2002 and 2005 only two of the 20 flash appeals achieved over 50% of their funding requirements for the first month of operations. Nine flash appeals during this period received less than 20% of their first month requirements. In response to these problems one of the major UN reforms has been to modernize the previously existing Central Emergency Revolving Fund to the Central Emergency Response Fund by adding a $450 million grant facility to the existing $50 million loan facility. The CERF is administered by the Emergency Relief Coordinator who disburses funds in consultations with Humanitarian Coordinators and other humanitarian agencies. The loan facility exists to cover costs when donors have committed funds but not yet paid, or when commitment is thought highly likely. The grant portion of the fund is divided in two ways: two-thirds are for rapid response to disasters, and one-third is to be used for underfunded crises. CERF is not intended to substitute for regular fundraising but rather to provide rapid and efficient access to funds for implementing agencies. The money is earmarked for core, lifesaving projects and is specifically not to be used for building infrastructure, disarmament, or other medium- to long-term relief strategies. It is important to note that in 2005 $12.8 billion was spent worldwide on humanitarian assistance; the CERF fund makes up less than 5% of this total.
Conclusions The vast number of different organizations with varying agendas, working in response to disasters and complex emergencies creates intrinsic coordination problems. When these are added to problems of inadequate funding, and the difficulties of working in countries where there is little or no infrastructure, coordination becomes a monumental task. However, the diversity of organizations in humanitarian assistance is to be welcomed,
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not lamented, and though this diversity presents enormous challenges there are encouraging signs that these are being met. The UN reforms, though they will not entirely suit the purposes of NGOs wishing to remain independent and apolitical, should create a mechanism through which parties can communicate and share information. The importance of the concept of “a provider of last resort” can not be over estimated; it is to be hoped that many of the gaps that existed in previous humanitarian responses will close, to the benefit of the target populations, and that funding will be more rapidly available for lifesaving projects. The market economy that drives donors and NGOs is not, despite apparently higher motives, different to any other market and brings with it benefits and costs that are easier to understand and work within, than to fundamentally alter. Finally, it is worth noting that while most of what has been discussed in this chapter has focused on immediate responses to an emergency or a disaster, current thinking in the field advocates far better linkages between immediate relief and long-term development. This acknowledges that the repercussions of a disaster or emergency can go on for many years, or in the case of places such as Bangladesh, are recurring; therefore, agencies need to take this into account in planning interventions and activities. Strengthening infrastructure and creating sustainability and capacity are vital to ensure future growth and development. It must also be remembered that the nature of any type of intervention is as political as the initial cause of the crisis.
References Cramer, C. (2006) Civil War is Not a Stupid Thing: Accounting for Violence in Developing Countries. London: Hurst. Forced Migration Review (2007) Humanitarian Reform: Fulfilling Its Promise? Issue 29. http://www.fmreview.org/FMRpdfs/FMR29/FMR29.pdf. Fritscher, G. (2001) “Cowboys in Afghanistan,” The Lancet 358: 2002. Goodhand, J. (2006) Aiding Peace: The Role of NGOs in Armed Conflict. Rugby: ITDG Internal Displacement Monitoring Centre (IDMC) (2006) Global Statistics. Available at http://www.internaldisplacement.org/8025708F004CE90B/(httpPages)/22FB1D4E2B196DAA802570BB005E787C?OpenDoc ument&count=1000, accessed 09 June 2007. Internal Displacement Monitoring Centre (IDMC) (2007) Guiding Principles – Rationale and Genesis. Available at http://www.internaldisplacement.org/8025708F004D404D/(httpPages)/168DF53B7A5D0A8 C802570F800518B64?OpenDocument, accessed 09 June 2007. SPHERE (2004) Minimum Standards in Humanitarian Emergencies. Stobbaerts, S., Martin, S. and Derderian, K. (2007) “Integration and UN humanitarian reforms,” Forced Migration Review (29): 18–20. URL: UNHCR (2006). Refugees by Numbers, 2006 edition. Geneva: UNHCR. Available at http://www.unhcr.org/ basics/BASICS/3b028097c.html. UNHCR (2007). The 1951 Convention Relating to the Status of Refugees. Available at http://www.unhcr.org/ protect/3c0762ea4.html.
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Part B – Military Medical Assistance to Civilian Health Sectors Martin C.M. Bricknell
Introduction Military medical services have a long history of being involved in providing humanitarian medical assistance to local civilian populations. Conventional thinking considers military medical services to be a rapidly deployable capability that can move to the site of a natural or man-made disaster as part of an emergency response. More recent employment of international military forces in complex humanitarian emergencies had led to consideration of the role of military medical services in the transition and development phases of humanitarian emergencies if international military forces remain as part of the international intervention (Gill 2001). This chapter will review some of the historical and recent employment of military medical services in humanitarian emergencies. It will consider some of the unique and complementary capabilities of military medical services compared with International Agencies (IAs) and Non-Government Organizations. The chapter will then examine two specific areas where military medical forces may be engaged with the civilian health sector: direct patient care, and the development of medical facilities. A third area, MEDCAPs or Village Medical Outreach Programmes, will be considered in Part B of Chap. 6.
Background This section will review some humanitarian aid operations involving the UK Defence Medical Services since 1939. During the Second World War the Allies developed a system for restoring local civilian infrastructure including health services that followed immediately behind the combat forces (Spencer 1944). After a town had been captured a Mobile Army Area HQ would move in behind the fighting troops to take control. The Assistant Director Medical Services (ADMS) would be responsible for identifying sites for all area medical units. He would establish contact with the local Mayor, Medical Officer of Health, the Chief Doctor, the Head of Police, and any other local civilians as appropriate. He would ensure that health and sanitary provision for the local population was arranged in conjunction with the civilian authorities and the Allied Military Government of Occupied Territories (AMGOT). Specific military medical humanitarian operations included a response to aid the relief of famine in the western Netherlands in late 1944/early 1945 and the relief of former Nazi concentration camps (Day 1984).
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The Suez operation in 1956 required the UK Defence Medical Services to provide medical aid to the indigenous population in Port Said during the period the port was under British control (Archer 1957). The administration of the port was undertaken by the British Civil Affairs Unit, which included a pair of army health specialists, a RAMC administrative officer, and a chief clerk. The team identified nine actions to be taken to safeguard the health of the local population: restoration of public utilities, removal of street refuse, essential services and supplies for hospitals treating casualties, care of homeless and destitute, disposal of the dead, epidemic prevention measures, provision of medical supplies, importation of fresh food, and restoration of normal hospital and outpatient services. These tasks were achieved through coordinating the activities of the British forces, the local population, the International Red Cross, and the United Nations. In 1970 the Army Medical Services deployed a Field Hospital to Jordan to support the Red Cross and Red Crescent in the provision of medical assistance in the aftermath of civil disturbances. This deployment, called Operation Shoveller, is fully chronicled in the Journal of the Royal Army Medical Corps (Goodall 1971; Kirby 1971). The British Military Hospital in Dharan in East Nepal was actually at the site of a major earthquake in 1988. This Army Medical Services unit, with reinforcements from Hong Kong and UK played a key role in the provision of specialist care for the injured (Guy 1990). The conclusion of the report on the military response highlighted the potential value of air-transportable, rapidly deployable, and self-contained medical units in providing a lifesaving response to populations affected by disasters. In April 1991, the United Kingdom contributed a joint military force to assist the international relief effort providing humanitarian aid to 500,000–700,000 Kurdish refugees driven from Northern Iraq by Saddam Hussein. The USA under the direction of the United Nations coordinated the operation. This operation involved 50 international relief agencies and more than 22,000 military personnel from 13 nations. In August 1994, 23 Parachute Field Ambulance was deployed to Rwanda as part of the British Contingent of the United Nations Assistance Mission in Rwanda (UNAMIR) (Hawley 1997). A 3-month civil war and campaign of genocide had led to huge population movements both within Rwanda and also to neighboring countries, Zaire, Tanzania, and Burundi. It was primarily the media images of terrible conditions in the refugee camps around Goma in Zaire that stimulated Western nations to be seen to do something. Approximately 600 soldiers were deployed, which included medics, signallers, engineers, logistic specialists, and infantry. This deployment of medical personnel was to assist with the provision of humanitarian aid to the displaced populations in Rwanda. Medical activities included providing primary care in several refugee camps, providing a surgical team for emergency cases, and running a meningococcal meningitis vaccination program. The British contribution was widely acknowledged to have been successful, principally because the medical contingent was composed of mobile primary care teams made up of general duty medical officers and medical assistants. This enabled the unit to react speedily to changes in the conditions on the ground. The Rwanda Conflict is considered in more detail in Chap. 14. In December 1995, NATO deployed a multinational peace implementation force (IFOR) to Bosnia-Herzegovina to support the Dayton peace accord. The initial focus
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was toward separating the warring factions and ensuring the smooth handover of territory in accordance with the agreement. This progressed well and so the mission was expanded to include humanitarian aid projects in order to demonstrate the rewards associated with peace. This enabled military medical units to make a positive contribution to the rehabilitation of the local population. For the UK, requests for funding medical projects were submitted by the medical personnel to the in-country representative of the Overseas Development Agency (forerunner to the Department for International Development). If financial authority was given, military medical staff in support of local health facilities managed these projects. Medical training was also found to be an ideal activity for the military medical services to undertake. It is manpower intensive, costs little, and can have a high impact. Furthermore, this offers opportunities for the military medical staff to develop their own skills and may even be incorporated into their own professional training (Davies 1997). When NATO forces entered Kosovo in 1999, international military medical personnel initially treated many civilian casualties from the ethnic conflict. As military activities developed into a peace-support operation, military medical services were then involved in supporting the development of the local health economy and providing some direct primary care services for minority populations (Reade 2002). Immediately after the invasion of Iraq in 2003, military medical services assisted International Agencies and NGOs to survey the status of civilian medical facilities. Military medical personnel supported the re-establishment of the Iraqi civilian public health system and provided some medical training to local healthcare personnel. Since 2003, military medical facilities have provided emergency medical treatment to a large number of injured civilians prior to transfer to local medical facilities.
The Changing Context of Complex Emergencies A complex emergency, as defined by the Inter-Agency Standing Committee of the United Nations (IASC), is “a humanitarian crisis in a country, region or society where there is total or considerable breakdown of authority resulting from internal or external conflict and which requires an international response that goes beyond the mandate or capacity of any single and/or ongoing UN country programme.” In this new operational environment military forces have been used to create security and stability to enable the restoration of civil order and a political process. This has resulted in a new interest in the civil–military interaction and a requirement for direct military involvement with International Agencies (IAs), such as the United Nations, and with Non-Government Organizations (NGOs) such as the International Committee of the Red Cross. Military forces have seen the potential value of “civil-action programs” as means to engender support for their activities by the local civilian population. This has become more than pure “humanitarian assistance” in that the purpose is to achieve support for political and military objectives rather than solely saving lives and alleviate suffering of a crisis-affected population. The military approach to operations in Iraq and Afghanistan has further reinforced the use of military capability in direct support of the local population through the use of civil–military Provincial
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Reconstruction Teams (PRTs) as a channel for the expenditure of national funds on development projects. The language of military operations has also changed to include a new phase of a military campaign “stability operations.” This is defined as “military and civilian activities conducted across the spectrum from peace to conflict to establish or maintain order in States and regions” (Department of Defense Directive 2005). It includes stabilization, security, reconstruction, and transition operations, which lead to sustainable peace’. Campaign objectives in this new environment include developments along diplomatic, information, military, and economic themes (DIME). The military medical services can provide support to civilian communities by restoring or supplementing the existing local health facilities and assisting with the regeneration or development of local health systems coordinated with local authorities, local communities, International Agencies (IAs), and nongovernmental organizations (NGOs). Thus the output of military medical services extends from purely medical support issues to effects that impact on the total force mission (Allied Joint Publication 4–10(A) Allied Joint Medical Support Doctrine NATO). The strengths and weakness of military forces for humanitarian operations are well rehearsed. These include strengths in command and control, deployability, logistics, sustainability, security, discipline, and integration. Weaknesses include political shorttermism, very expensive, political rather than institutionally humanitarian, and tailored for military rather than local needs (e.g., food rations). The increasing casualty toll amongst humanitarian organizations has also led to a demand for an explicit separation between military forces and humanitarians in order to create “humanitarian space” between parties to a conflict in which the needs of civilian noncombatants can be met. UN humanitarian agencies and other humanitarian NGOs rely primarily upon their neutrality for security and use negotiation rather than implied military capability as the principal means of gaining safe access to the affected population. This contrasts with the diplomatic and military view that regards the integration of all themes as the key to creating sufficient support amongst the local population to drive out those who oppose the restoration of security and stability. Furthermore military medical forces also have obligations under the Geneva Convention and other ethical frameworks to also ensure separation between military health services and military objectives. The United Nations has published a number of international guidelines that represented consensus in the reconciliation of these cultural conflicts in humanitarian emergencies. UN General Assembly Resolution 46/182 states that humanitarian assistance must be provided in accordance with the principles of humanity, neutrality, and impartiality. For the first, human suffering must be addressed wherever it is found, with particular attention to the most vulnerable in the population, such as children, women, and the elderly. The dignity and rights of all victims must be respected and protected. Humanitarian assistance must be neutral and provided without engaging in hostilities or taking sides in any political, religious, or ideological conflict. Finally, humanitarian assistance must be provided without discrimination as to ethnic origin, gender, nationality, political opinions, race, or religion. UN guidelines for the use of military and civil defense forces in complex emergencies limit such involvement to situations where there is no comparable civilian alternative and only the use of military
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assets can meet a critical humanitarian need (Guidelines on the Use of Military and Civil Defence Assets to Support United Nations Humanitarian Activities in Complex Emergencies, March 2003 – http://ochaonline.un.org/DocView.asp?DocID = 426 accessed Jul 2006). Humanitarian assistance for the relief of the suffering must be guided solely by needs, and priority must be given to the most urgent cases of distress. The use of military and civil defense resources should under no circumstances undermine the perceived neutrality or impartiality of the humanitarian actors, nor jeopardize current or future access to affected populations. The UN cautions “while motivation for this (involvement in civil affairs by military forces) can be purely humanitarian and needs based, assistance can also be motivated by a desire to legitimize missions, gain intelligence, and/or enhance protection of forces. Unilateral support of this nature can be inappropriate, lack longevity, and can disrupt assistance that forms part of a coherent immediate and long term programme.” Operational experience in Kurdistan, the Balkans, Afghanistan, Iraq, and Somalia have necessitated various forms of civil–military coordination for humanitarian operations and have led to an erosion of the separation between the humanitarian and the military space. This led to the publication of a series of principles by the United Nations to bind both parties in the civil–military relationship in a complex emergency [see Civil–Military Relationship in Complex Emergencies (An IASC Reference Paper – Inter-Agency Standing Committee Working Group (IASCWG) as an IASC Reference Paper at its 57th Meeting of June 16–17, 2004. It complements the “Guidelines on the Use of Military and Civil Defence Assets to Support United Nations Humanitarian Activities in Complex Emergencies” of March 2003; Relationships with Military Forces in Afghanistan – Guidelines for UNAMA Area Coordinators and Other UN Personnel, 2002 – http://ochaonline.un.org/webpage.asp?Page = 999 access Jul 2006]. However, these guidelines are restricted to the civil–military interaction in the “emergency” phase of a complex emergency. Experience in Iraq and Afghanistan has shown that the “humanitarian” community and the “military” community have to remain engaged if a complex emergency transitions into a counter-insurgency campaign (waged on behalf of a legitimate political framework) within national plans for reconstruction and development. After the immediate tasks of provision of security, restoration of essential services, and supporting humanitarian needs are met, the international community must shift the campaign to the development of indigenous capacity to secure essential services, a viable market economy, rule of law, democratic institutions, and a robust civil society. In this respect, military forces will be operating within the framework of national and international legitimacy and thus are an integral element of the multidimensional solution to the complex emergency. Natsios (Natisios 2005) has proposed nine principles for Reconstruction and Development, comprising ownership, capacity building, sustainability, selectivity, assessment, results, partnership, flexibility, and accountability. These are based on the extensive experience of USAID working alongside the US military in a number of complex emergencies. Table 5.2 shows both the UN principles and Natsios’ principles. Both lists promote an ethical framework for military involvement with indigenous civilian communities within the context of a continuum of military operations from combat through stability operations toward restored and functioning nation states.
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Section One Table 5.2. Principles for civil–military relationships in a complex emergency and reconstruction and development IASC (Archer 1957)
Natsios (Kirby 1971)
Humanity, neutrality, and impartiality Humanitarian access to vulnerable populations Perception of humanitarian action Needs-based assistance free of discrimination Civil–military distinction in humanitarian action Operational independence of humanitarian action Security of humanitarian personnel Do no harm Respect for international legal instruments Respect for culture and custom Consent of parties to the conflict Option of last resort Avoid reliance on the military
Ownership Capacity building Sustainability Selectivity Assessment Results Partnership Flexibility Accountability
Principles for the Wider Employment of Military Medical Forces The military element of the international community is unique in that it deploys as a fully integrated package including medical support. Military medical services may be the only medical capability in remote areas and in areas with poor security, and thus military medical services may be the only source of medical care for other IAs and NGOs operating in this environment. This same principle may apply to local security forces, especially if they do not have a well-developed medical service and they are operating alongside international military forces. The Geneva Convention and other international laws mandate minimum standards in the health care of detained individuals, even if they are not classed as prisoners of war. Therefore, detainees may also become a defined dependant population (see Chap. 16). Finally there is the local community; in the event of life- or limb-threatening emergencies this group has access to military medical care under humanitarian grounds. However, any extension of military medical support for the local population beyond this definition requires very careful consideration for the principles described earlier and the details described later. Non-military populations potentially eligible for military medical support during stability operations are summarized in Table 5.3. When considering the employment of military medical forces beyond the provision of medical support to “own” forces, a clear understanding of the philosophy behind such assistance is required in order that the affected civilian population may be best served, both in the short and longer term. Wilensky has recently reviewed the effectiveness of the military medical programs in support of civilian populations during the Vietnam War (Wilensky 2006). He identifies seven principles for these activities that are shown in Table 5.4. In principle the affected population should be encouraged to help themselves, and military medical assistance should only be provided on a subsidiary basis when IAs
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Table 5.3. Potential nonmilitary populations eligible for military medical support International agencies/nongovernmental Organizations Local security forces Detainees The local community
Table 5.4. Principles for military medical engagement in civilian healthcare programs 1. The value must be based on training the indigenous population to care for themselves 2. Civilian care programs are always a secondary mission to providing medical care for military forces 3. Medical intelligence of disease prevalence obtained from caring for the local population is useful 4. Supporting the development of the indigenous healthcare infrastructure must be determined by what the local population needs and is prepared and resourced to support 5. Military medical care programs for local civilians can be effective in advancing campaign objectives 6. The objective must be to engender support for the local government, not foreign forces 7. Military support to civilian aid programs can only be effective if the civilian population has a need and such activities fit wider campaign objectives
or NGOs are unable to meet the overall requirement. This should be carefully defined to avoid competition and also to avoid either duplication of effort or gaps in the overall care provided. Military medical services are structured to provide the best possible care for military forces and may exceed the technology available within the host nation. Any clinical care provided to the indigenous population should take into account aspects such as the availability of medical follow-up capabilities, military means and resources, and the need to have sufficient capabilities and capacities left for support of the military force. Even if there is a clear health need, the military response should be designed to enable sustainment by the local community with the final outcome being the establishment of the local civil medical infrastructure under local political control. Alongside these clinical sensitivities, it is vital that medical services are tailored to local sociocultural and religious customs and rules. This particularly applies to the role of women within health professions and in the care of local women. Finally, military medical services must be employed in a manner consistent with their noncombatant status under the Geneva Convention. Although under military command, tasks given to military medical services must be in accordance with clinical need and should not be dependant on engagement with military operations such as intelligence collection – though it is legitimate to conduct this in parallel but using separate organizations. Military medical forces have the potential for involvement in a wide range of activities in support of nonmilitary populations within stability operations. Examples are summarized in Fig. 5.1. Figure 5.1 also highlights areas beyond pure medical treatment, where military medical services may have an effect. This includes technical assessment and planning, public health interventions such as vaccination and health education to
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Fig. 5.1. Examples of military medical civil action programs.
training and mentoring local health providers. These capabilities extend beyond just doctors to include nurses, paramedics, laboratory technicians, physiotherapists, environmental health specialists, dentists, optometrists, and veterinarians. Many military medical services are able to access particular specialist advice through the deployment of reserve forces.
Provision of Direct Clinical Care by Military Medical Services As stated earlier, military medical services have an ethical duty on humanitarian grounds to provide emergency medical care to any patient, particularly those in vulnerable groups. This does not mean automatic access to the full national military medical evacuation chain but should be limited to treatment within the country of origin, care appropriate to local capability for further management, and early handoff to local medical providers or health-related IAs/NGOs. The definition of emergency may be difficult, and there may be pressure from external agencies to facilitate access to military medical services as a source of influence. Furthermore there have been occasions where opposition groups have used simulated patients as an attempt to bypass security systems. Thus the management of access to military medical treatment facilities by the local population requires a form of access control. This should usually include a security check (balancing cultural norms with security imperatives) and a preliminary medical assessment to determine need. This preliminary medical assessment should also determine whether the military medical facility has the resources to influence the patient’s clinical outcome. As local medical services develop, this assessment process should be based on a formal referral from a local medical
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practitioner – but the military medical services should ensure that this arrangement is not exploited for personal gain. Joint clinical casework can be a further refinement of referral, where military medical personnel visit local medical facilities as part of a mentoring program and agree to jointly manage cases with local practitioners. Joint clinical casework has the potential to increase knowledge and understanding between medical personnel from both settings and can also be used as a mechanism to role model more “Western” styles of clinical care involving multidisciplinary teams including nurses, physiotherapists and other practitioners in the holistic care of patients. All clinical care should be in accordance with local capabilities and cultural norms. This includes ensuring that all medication is prescribed in accordance with local formularies and ensuring that hand-off or discharge arrangements reflect the realities of providing continuing care in the local community. It would normally be inappropriate to initiate medical care for chronic, long-term conditions that require continuing medical supervision and treatment unless this has been very carefully coordinated with local medical providers, possibly including NGOs, and included such issues as care at home and financial support.
Example 1. Military Medical Programs in Vietnam During the Vietnam War US military medical services ran a number of programmes in support of the civilian community through such efforts as PHAP (Provincial Health Assistance Program), MILPHAP (Military Provincial Health Assistance Program), MEDCAP (Medical Civic Action Program), and CWCP (Civilian War Casualty Program). Apart from the humanitarian aspects of the various civilian medical assistance programs, this involvement provided US medical personnel gainful and rewarding activity during lulls between peak military medical support requirements. This, in turn, contributed to the high morale of committed U.S. “medics.”(Spurgeon 1991)
The provision of direct clinical care can be very rewarding to military medical practitioners but introduces a number of practical and ethical challenges that are not normally present in “Western” clinical practice. As the military operation evolves from the immediate postconflict phase, it is vital that any clinical support is fully coordinated and integrated with the prevailing local health economy. There should be no suggestion that the presence of a military medical treatment facility is distorting or undermining the regeneration and development of long-term medical services for the local community. This includes being sensitive to the way in which local medical care is financed (i.e., to not provide free treatment if local providers have to raise charges) and ensuring that all costs are covered by the military medical services. It is vital that military medical staff are aware of these issues before deployment and recognize that their primary duty remains to provide care for the military community.
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Example 2. Managing obstetric emergencies and trauma – MOETs courses. In Basra in Iraq, the military hospital has been used as a base to host a visiting team of non-military specialists in obstetrics and gynecology to teach a short course in the management of obstetric and trauma emergencies to local Iraqi doctors. This provided a secure environment for the hosting of the course for both the visiting specialists and also the visiting local doctors. The course is an internationally recognized course and adds clinical credibility to the local doctors and also provides a tangible way to reintegrate Iraqi medical staff into the international medical community (Dr. J. Ryan Personal Communication, Feb 2006).
Development of Medical Facilities The renovation and construction of infrastructure medical facilities has been a natural extension of military “hearts and minds” projects. Alongside examples of successful medical constructions projects are examples of decaying empty buildings that have no staff, have been ransacked of equipment, and not provided any practical improvement in the healthcare available to the local population. While the opening of medical facilities can be an important milestone in engaging the local population, it is vital that this investment is safeguarded for the long term by ensuring that the project lies within a wider health program and is sustainable in terms of staff, equipment, consumables, and local community commitment. There are very few indications for the use of military field hospitals for humanitarian aid and development (PAHO 2003). The renovation and construction of infrastructure health projects should be planned and coordinated with local and national health officials. Any infrastructure health project should start with a full needs assessment both in terms of the population and the requirements of the individual facility. The project should comply with local and national plans. Ideally the project should be used as a lever to develop local medical planning capacity and therefore should involve local health officials and any IAs/NGOs that may be legitimate stakeholders. The project plan should ensure the integration of all components: money, facilities, people, intellectual process, capital equipment, and consumables. It is vital that all technology and equipment is appropriate to the local circumstances. Specific technological solutions, such as solarpowered refrigerators, may be better than conventional equipment. It should also include a post-completion plan to include follow-up engagement with key stakeholders, review of the use and maintenance of equipment, resolution of unforeseen problems and continued integration with local health plan. The whole process is summarized in Fig. 5.2. A successful medical infrastructure project can be very rewarding for all involved as well as making a substantial difference to the local population served by the facility. However, there are a number of pitfalls to avoid. Examples are listed at Table 5.5.
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Fig. 5.2. Medical infrastructure project process.
Table 5.5. Pitfalls to avoid in medical infrastructure projects Providing field hospitals Planning projects not programs Listening to only one opinion Focusing on infrastructure rather than capability Focusing on physical capital rather than human capital Providing treatment solutions without considering prevention Providing inappropriate technology Providing “one-off” donations of consumables Concentrating on doctors without considering “low-technology” health providers Considering healthcare as only medical care (remember dental care, optometry, environmental health, veterinary programs)
Conclusion Military medical forces can play a role within the “reconstruction and development” phase of complex humanitarian emergencies beyond just caring for military forces involved in the imposition of security and stability. While there are established guidelines
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for the role of military forces and military medical forces in the provision of humanitarian aid, the policy framework for long-term engagement of these forces in reconstruction and development is less well defined. The paper has discussed two specific roles for military medical services: direct clinical care and the development of health facilities. MEDCAPS will be considered separately (Part B of Chap. 6). All of these roles demand additional knowledge and skills beyond those required for medical support to a purely military population. In all respects, military medical services should only work within the civilian health sector when it does not undermine the primary role to support military forces, when there is a clear health need and only in support of and in cooperation with civilian agencies, both national and international, and NGOs. This chapter contains material previously published in the Journal of the Royal Army Medical Corps (www.ramcjournal.com) and is used with permission.
Acknowledgements This article draws on material previously published by the JR Army medical corps and is used with permission.
References Archer TCR. Civil Affairs – Port Said – 1956. J R Army Medical Corps 1957;81–86 Davies K, Bricknell M. After the Battle. Nursing Times 1997;93:35–37 Department of Defense Directive Number 3000.05. Military Support for Stability, Security, Transition, and Reconstruction (SSTR) Operations, November 28, 2005 Gill RMF. The Roles of the Army Medical Services – Shaping the Battlespace? J R Army Med Corps 2001;147:111–112 Goodall TM. Operation Shoveller. The Deployment and Task of 2 Field Hospital RAMC. J R Army Med Corps 1971;117:59–66. Guy PJ, Ineson N, Bailie R, Grimwood A. Operation Nightingale: The role of BMH Dharan Following the 1988 Nepal Earthquake. J R Army Med Corps 1990;136:7–18 Hawley A. Rwanda 1994: A Study of Medical Support in Military Humanitarian Operations. J R Army Med Corps 1997;143:75–82. Kirby NG. Operation Shoveller. Surgery in Cyprus. J R Army Med Corps 1971;117:86–93. Natsios AS. Parameters, Autumn 2005 The Nine Principles of Reconstruction and Development. Reade MC. Medical Support for British Peace-Keeping Operations in Kosovo. ADF Health 2002;3:71–76 Spencer-Cox WL. The Medical Aspects of the Occupation of Captured Enemy Towns and Ports. J R Army Medical Corps 1944;82:109–114 and 152–156. Spurgeon Neel. Medical Support of The U.S. Army in Vietnam 1965–1970. Department of The Army Washington, DC, 1991. VE Day – A Medical Retrospect. British Medical Association, London, 1984 PAHO. WHO-PAHO Guidelines for the Use of Foreign Field Hospitals in the Aftermath of Sudden-Impact Disasters Area on Emergency Preparedness and Disaster Relief Pan American Health Organization Department of Emergency and Humanitarian Action World Health Organization International meeting Hospitals in Disasters – Handle with Care San Salvador, El Salvador, 8–10 July 2003, PAHO, Washington, DC, 2003 Wilensky RJ. Military Medicine to Win Hearts and Minds: Aid to Civilians in the Vietnam War. Texas Tech University Press. 2006.
Further Reading Hodgetts T, Mahoney PF, Mozumder A, McLennan J. Care of Civilians on Military Operations. IJDM, Vol 3, No. 1–4, July 05, pp 3–24.
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Part C – Private Security Companies and First-Line Care T. Spicer and K. Morland
Background The rapid expansion of deployment of Private Security Companies (PSCs) in support of military forces in theatres such as Iraq and Afghanistan has focused attention on the vital aspect of first-line medical treatment for PSC staff. Aegis Defence Services is the largest security provider to the US Department of Defence in Iraq. As such, we have the benefit of close coordination with and support of Coalition Medical Support including CASEVAC and extensive hospital treatment in theatre and in the USA and UK. Nevertheless, we still have to rely on our own team medics for initial response and treatment during the golden hour.
The Need Aegis has approximately 1,500 staff in Iraq. In the last 3 years Aegis’ close protection teams have carried out a total of 26,777 missions – or 24 missions a day. Two-hundred seventy one of these missions have been attacked by small arms, IEDs, or a combination of weapons systems. Aegis has had casualties. There is clearly a need for highly trained advanced trauma medics in each team not only to carry out treatment but also to bolster confidence and morale within the teams. In addition there is a very strong belief held by Aegis management at all levels that there is a duty of care to employees to ensure that they have the best protection, best equipment including medical equipment, and the best training available in order to do their job in a highrisk environment. This involves the provision of highly trained medics in each team.
Medical Training To achieve this requirement Aegis runs a comprehensive training program. This course endeavors to provide a more in-depth knowledge in line with Aegis medical protocols to give the team and the clients we carry a greater survivability rate from the first point of injury to evacuation to a field hospital. This course encompasses the elements required to provide Battlefield Basic Life Support including care under fire, tactical field care, prolonged field care, and casualty procedures as well as the specific medical skills and protocols required for each of these phases of field care. In addition, it does teach how these phases of care affect definitive care.
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The protocol that guides the medical training in places takes into account several factors: ●
● ● ●
Level of risk and probability of injury that Aegis is willing to accept as the course of our activities Time frame for evacuation from point of injury to first-line medical facility Analysis of injury most likely to occur in the environment Limited equipment
The Training Team provides a basic introduction to medical training for all new staff but the Team Medic course is run over 12 days for specific individuals. So far, we have trained 145 individuals since the creation of the Team Medic course 18 months ago. Significantly this is a pass/fail course. Five individuals have failed and this low number is due to the excellent tuition and rigorous preselection. We aim to have two medics qualified to this level on each of our security teams. We have evidence that those individuals who have passed this course have been involved very quickly afterward in a complex incident. The knowledge they gained during this course has saved life.
Medical Equipment Training is supported by the provision of up-to-date and effective equipment. We pride ourselves in equipping our medics with the most up-to-date equipment available to us. Constant research and improvement of skills are paramount to our training team and medic staff.
The Value The value of a proactive, professional, and comprehensive first-line medical program can not be overstated. The confidence level instilled in those who face daily the full spectrum of insurgent attack is immeasurable. The practical value of lifesaving treatment has been proved again and again. None of those wounded in an incident has subsequently died after having been stabilized by an Aegis medic. Time and time again, I have heard doctors and surgical staff say – “if he hadn’t had that treatment at the point of wounding, he’d be dead.” In the wider sphere of our activities in Iraq we are looking at the development of a primary health care capability to reinforce the work of the Aegis Charitable Foundation. Medical outreach has been proven to be one of the major factors assisting operations through the basic principles of Counter Insurgency. All our medical instructors are aware of the benefits from this and teach it accordingly to Aegis personnel with clear appraisal of the legislative constraints attached to this. Primary healthcare skills in this respect are useful to reinforce the work of our Liaison teams in the role of developing “hearts and minds” projects and the project we run in support of the Italian Government PRT.
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Conclusion I fully expect the involvement of PSCs in support of the military in furtherance of National Security Policy to increase. Therefore, the continuing development of training and implementation of medical support within PSCs is essential. It is also important to cross-fertilize with military medical staff to ensure that there is mutual understanding and sharing of the latest techniques. There will undoubtedly be times when the first medic on the scene of an incident involving military casualties would be from a PSC.
View of an Aegis Medic Introduction My name is Kenny Morland. I am 43 and work for Aegis Defence Services in Iraq as the senior in country medical advisors and trainers. I am currently responsible for the medical welfare and teaching of basic life support skills to almost 1,000 men and women in Iraq. I also teach a 10-day Basic Life Support course, which is primarily applicable to security personnel within the Iraqi theatre of operations for the company that I work for. The protocols and teaching within this course follows closely the UK HSE First Aid protocols and the British Army BATLS protocols. The protocols have been tweaked and adjusted to suit the environment the personnel now find themselves in here in Iraq, and you must remember that what may work in one theatre of war or environment may well have to be adjusted or updated to be applicable in another theatre. Here is a little about myself and my background. I joined the British Army in 1979 as a boy soldier starting life as a “JOCK” in an infantry platoon with the first Battalion the Black Watch, and later I moved to the Parachute Regiment in search of greater excitement, experience, and I suppose greater exposure to the bigger world. My first taste of medical training to any great degree apart from military basic life support came about as a result of becoming a Regimental Medical Assistant (RMA) within the Parachute Regiment. Like many I was “volunteered” for this course and on reflection like many others who were “volunteered” before me I was dreading my first day at the Defence Medical Collage (DMC) at Keogh Barracks in Ashville just outside Aldershot. To my surprise the regimental medical assistant’s course turned out to be the turning point in my life. Not only was it a fantastic stepping stone for me into the world of conflict medicine but it was also a turning point morally as a young soldier from the Mortar platoon of First Battalion of the Parachute Regiment with no real skills in life apart from jumping out of airplanes. I continued with my medical education in the form or self-education through related publications on trauma medicine with related application to the military environment and civilian basic medical course, which were available to me at that time.
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As a result of this dramatic change in direction I transferred from the Parachute Regiment to the Royal Army Medical Corps to continue my medical training with the army. My peers in the RAMC decided that it was best that I started life within the medical corps with 5 Field Ambulance based in Preston, Lancashire, so that I could experience first hand the type of job and role that was performed by a typical field ambulance unit of the time. After my probation period at 5 Field Ambulance I was sent back to the Parachute Brigade in Aldershot to become a part of 23 Parachute Field Ambulance, which at that point in time was the UK Spearhead medical support unit deployable to any conflict location in the world along with, and sometimes separate to 5 Airborne Brigade.
1. While serving with 23 Parachute Field Ambulance I have served in a medical capacity all over the world carrying out primary-care medical roles in most British Armyinvolved incidents gaining a huge amount of experience not only in medicine and its application in a conflict but also I suppose life in general. While serving with the “AIRBORNE MEDICS” I was selected and put forward for the army’s Operating Theatre Technicians course (Civilian Operating Department Practitioner) at the Royal Defence Medical Collage at HMS Dolphin in Gosport Hants and Southampton University Teaching Hospital, which as a civilian environment was a major culture shock working under civilian mentors. For me this was a huge stepping stone in my further education and would certainly secure my future employment once I finally left the armed forces. Once I completed and passed my OTT/ODP training in 1999 I once again returned to 23 Parachute field Ambulance only this time to the Field Surgical Troop. I spent my remaining years with the unit in a surgical capacity serving in conflicts such as Bosnia, Kosovo, and Sierra Leone where we gained invaluable surgical medical experience as a field surgical team led by some fantastic military surgeons and anesthetists. My last job within the army was that of team leader of the counter terrorist surgical support team for the special forces, which as is implied provides first-line surgical support for the UK Special Forces counter terrorist teams and the role which they carry out.
History I left the army in 2002 and as I had foreseen, my education and training as an OTT/ ODP secured employment for me in the civilian medical sector both in the NHS and private hospital operating departments. Working within the civilian surgical sector was both an eye opener and further education in my chosen trade. I worked all over the UK and finally was invited to the world of “Private Security” in 2002. At that time you were invited into the circuit based on those who knew you and your skill levels, ability to do the job, and ability to be trusted, unlike today when there are so many people with dubious backgrounds. My first job within the private security industry was in Nigeria where I was employed as a Security/Medical advisor on an oil rig off the southern coast of Nigeria, near the Niger Delta with very little medical application apart from lotions and potions.
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In 2003 as the war in Iraq was coming to an end I was offered a job in Basra, again with a private security company that was to provide security and safety to a huge electrical company from the USA. Initially there was no risk of terrorist attacks in Iraq, and we and most other security companies enjoyed a short-lived honeymoon period of unmolested movement and continued ability to try to rebuild the Iraqi infrastructure.
2. In 2004, I returned to the UK and back to the world of operating theatres and recovery suites until being asked once again to be a medic in Iraq. Aegis Defence Services had just been awarded a huge contract with the US Government in Iraq as part of the Project Contracting Office (PCO), which was responsible for thousands of reconstruction projects within Iraq to help rebuild the basic infrastructure and was actively recruiting a broad spectrum of various skilled subject matter experts for this contract, i.e., signals, intelligence, linguists, medics, etc. – effectively a battalion of “hearts and minds” personnel. I started my career with Aegis as a PSD (personal security detail) team medic, and within the first few months the most I had to deal with in the way of conflict medicine was to use my skills in a “hearts and minds” role when we had occasion to visit outlaying communities, which were starved of primary healthcare and indeed healthcare in any shape or form. Indeed AEGIS has a dedicated team, and I have visited many of the Iraqi hospitals in the course of reconstruction and was not only shocked by the state of the surgical operating theatres and facilities but horrified at the state of the medical wards in the pre and post op environments. What we take for granted in the UK they just do not have in Iraq for various reasons. The operating departments that I have inspected in Iraq have less than what a military surgical team would ever dream of going to war with, and the standard of hygiene and aseptic techniques or even barrier nursing does not exist. It would appear that the skill level and education is just not present.
Current Within the private security or private military companies in Iraq the need or requirement within the past 2 years for highly skilled medical personnel within these security teams has become very apparent and sometimes only as a result of deadly lessons learned. To that end, people like myself have been actively recruited for our experience in conflict medicine and application of first-line basic and advanced trauma life support giving our men the best chance available to survive prior to evacuation to a surgical facility. At the present time in Iraq the “Golden Hour” rule is pretty fluid from approximately 30 min to no chance at all in which case what remains of the security teams after an incident find themselves having to try to extract as best they can with their casualties to the nearest surgical/medical facility without assistance – a dangerous and delay task for both the team and the casualty (although I have to say that Aegis being a US Government contractor has a greater chance of US intervention with regard to medical assistance and casualty evacuation). This presents with not only a
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higher mortality rate in the casualties but inadvertently adds increased cases of traumatic stress (often overlooked or ignored) to the teammates dealing with their friends and colleagues.
3. Most security operatives in Iraq at the present time come from a varied cultural military background including British, US, German, Polish, and South African armies. The standard of basic life support skills varies from country to country and as a direct result of the standard or nonstandard medical training the instances of deaths are either greater or lesser. I am currently the senior medical advisor and trainer for Aegis Defence services In Iraq, and it has been my experience that as a general rule, the best basic base line standard of basic life support skills comes mainly from ex-British military personnel although not exclusive. The US military personnel usually come second to the British and all the other countries are behind the US. Now this may appear that I am being biased as I am British but believe me when I tell you that my only concern is providing good sound medical support for the teams here in Iraq and as far as I am concerned medics do not have nationality only transferable lifesaving medical skills. Looking at this you will no doubt ask why there is such a variety in medical basic life support medical skills between each nation. I can really only speak of experience with both British and US military personnel. I am afraid, and to be honest, until the Iraqi conflict both countries were very much out of date and inexperienced in BLS techniques and skills that were relevant. As an example of out-of-date teaching and techniques, the old/past British Army protocols with regard to tourniquets were that they must only be used as a last resort, and the type of tourniquets used were the old and very out-of-date “SAMWAY” tourniquets, which although adequate 100 years ago were in great need of replacement with a much better user-friendly and casualty-friendly type tourniquet. It was also taught that if a tourniquet was to be used in the field that it was to be applied and then slowly realized to check for continued bleeding and clotting. This teaching is not only outdated and potentially deadly but unrealistic in an environment where you may have a security team fighting for their very lives while still having to try to deal with any casualties they have sustained in an attack by terrorists. A further example of out-of-date teaching and protocols is that of dealing with casualties who have sustained burns. The former protocol was to apply a “DRY STERILE” dressing to burns. Now in this environment where the temperatures are in excess of 100°C the result will be the dressing adhering directly to the burnt tissue, and the postincident result of unnecessary tissue trauma is unacceptable. Dressings! Dressing in the British army until very recently has not changed in its basic format for the best part of 100 years. The First Field Dressing (FFD) was a huge dressing with wholly inadequate tapes on either side for application of the dressing to the wound, which was an unconforming bandage. As most will be aware this type of
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dressing/bandage is inadequate for application to a wound, which requires direct pressure to insure any form of hemostasis.
4. Further, misguided practices even reach as far as the teaching of first-line fluid resuscitation in casualties here in Iraq. Although former British military personnel understand the requirement for fluid resuscitation in casualties they are very unskilled in this practice with over half of the operatives that I teach never having taught how to gain IV access or the reason behind the need. The former US military operatives, on the other hand, seem to have a bit more hands on but tend to be too intent on IV access and fluid resuscitation to notice that the basics of airway maintenance, respiratory function, and hemorrhage control should be their first priority in casualty management. A classic example of a little knowledge is a very dangerous thing. The long and short of my personal experience of conflict management here in Iraq is that we have had to update very rapidly our teaching, application of medical equipment, and expectations of the individual medical provider. As I said previously I teach a 10-day BLS package aimed primarily not only at the security operatives on the ground but also incorporating the teaching to those key personnel involved in the security of our “secure bases,” which are attacked sometimes on a nightly basis with 120-mm artillery and 81-mm mortar rounds. This BLS package is to offset the lack of professionally trained military background medics and only touches on the basics of life support in a conflict zone. I have to teach BLS, which is applicable in military environment and one that is user friendly in a tactical scenario for my men. To that end as with all conflict medicine, the tactical situation “must” come before the medical situation. Once the tactical situation has been resolved the men can then apply their skills in a safe environment. It must also be remembered that life must come before limb in all frontline conflict medicine and this will always cause internal emotional conflict with the individual providing BLS. As a team medic the BLS providers are first and foremost shooters (Riflemen) and then medics. Their role in this environment is invaluable to the team, and they are very often underestimated in their value. The medic is responsible for up to 12 men in his team and has to cope with both the tactical as well as the medical situation. The medic must be strong enough in mind and knowledge to deal with any form of trauma that presents itself to him on a weekly and sometimes daily basis. He can be expected to deal with traumatic amputations as a result of off-route explosive devices; gunshot wounds, burns of a higher degree than would be expected of any civilian counterpart, and any other form of traumatic injuries you can imagine. He also has to deal with the deaths he will most likely come across as a result of terrorist attacks on his team, and this in its self is no easy task for any individual, and I speak of this with firsthand knowledge having lost a very close friend in 2004 as a result of a suicide car bomb attacking my convoy enroute to Baghdad international airport.
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5.
Effective BLS Techniques For all of us here in Iraq the past 2 years have been a steep learning curve in lifesaving techniques. As a result of this my teaching and equipment have changed to meet those requirements. We currently use the following new equipment: ● ● ●
●
● ●
CAT (Combat Army Tourniquet) Israeli First Field Dressing (conforming elasticized bandage) Quick clot hemostatic granules (used in cases where tourniquets cannot be applied) HEMCON hemostatic dressing (similar to Caltostat dressings used in ENT theatres) McGill’s forceps Handheld suction device (Lardel, Vitalagraph, etc)
Other teachings that have had to be updated based or real-time events are as follows: ●
●
●
●
●
●
Tourniquets must be readily considered at an early stage and often applied before a dressing. In most of the cases we have had with traumatic amputations, the casualties have been saved by immediate application of tourniquets. Quick clot: In windy conditions, it is also advisable to wear goggles and a mask to cover your face as the powder granules from the packet are wiped up and blown everywhere causing injuries that are negligent in the tactical situation. First field dressings: The new Israeli dressings although smaller than the old British FFD are very adequate and are now invaluable dressings used in the tactical environment. McGill’s forceps and handheld suction devices that are part of the team medical bags are invaluable pieces of airway maintenance equipment in the BLS provider’s bag in a situation where blast injuries have been sustained in face and upper airways by the team members. Wound packing! In the past, the British have always been told to apply field dressings to the outer section of any wound. After having experience in operating theatres and indeed here in Iraq, I teach my students to pack all wounds before applying a dressing for obvious reasons. I must admit to receiving strange looks on a section of the military community to whom this concept is alien but once the reason is explained they fully understand and appreciate the logic. On the other hand, this technique has been the norm for ex-US military personnel. Manual handling and extraction of casualties in a tactical situation: This part of medical training was in the past very underestimated by all regardless of nation or organization. It has been my experience that immediate extraction of casualties from vehicles (which we use daily to get around Iraq) is essential and is the first line in BLS here in Iraq. In April 2004, I lost a friend in a VBIED (vehicle born improvised explosive device) on one of the busiest road in Baghdad. My team had left the base 10 min before and the explosion destroyed one armored vehicle and
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disabled another. When I got to the vehicle that had born the brunt of the explosion my friend was still in the vehicle and I was unable to remove him because of a number of various reasons, which have now been rectified and we have learnt from. Unfortunately, I shall live with that sight and memory for the rest of my life. It is essential that all casualties are removed from disabled vehicle ASAP regardless of injuries with the protocol in force that “life must come before limb” – a concept that is alien to most.
9. The alternative to not following this protocol is almost certainly death! The operatives must remove the casualty immediately from the disabled vehicle for both tactical and medical reasons by any means available. Vehicles are a death trap, are very flammable, and make for big targets for the terrorist to lock onto. With the exception of massive hemorrhage arrest and airway maintenance no prolonged treatment must be given to the casualties until both they and the medical providers are in a safe environment, bearing in mind that the first rule of medical treatment states that “you must not become a casualty yourself ” and that in evacuation and treatment in a hostile/conflict zone “life must come before limb.” Again, these protocols may seem alien if not disturburing to some but you have to remember the environment that the medics here in Iraq face. These are just a few examples of lessons that have been learnt by myself while working in Iraq over the past 4 years, and as a result of this I have adjusted and amended training and lifesaving techniques, and I am sure that other security companies have done exactly the same.
Summary In summary the life of a private security company medic is one fraught with constant danger and an unending supply of the worst imaginable injuries that they could have ever imagined they would face. That said each medic has risen to the challenge and excelled in his job as both “shooter” and “medic”. Without these unsung heroes of conflict medicine, the death rate among private security contractors in both Iraq and Afghanistan would be much higher. One thing that you can count on here in Iraq with Aegis is that each medic aggressively pursues continual professional development in his chosen field of conflict medicine and if you ever have reason to come to Iraq these men will almost certainly give you the best possible chance of survival in what is the worst conflict zone since the Vietnam War. Long gone is the stereo typical image of the mercenary medic immortalized by the character of “Arthur Witty medical orderly” to Col Faulkner in the film “Wild Geese.” We are medical professionals now with a proven track record and have proved our worth. Given the correct direction and support we will continue to develop our skills into the future of conflict medicine in preparation for the next theatre of war.
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Part D – Oil and Gas: Industry in Remote and Volatile Areas Bob Mark
The term “remote” is used here to describe situations, which are isolated in terms of distance or time and where any immediately accessible medical facilities fail to meet acceptable standards. The business of searching for oil and gas and extracting them is often conducted in such areas, which are also subject to more than their fair share of conflict and catastrophe. The following review will give an insight into the industry and guidance on how to set up its medical provision, thereby emphasizing principles common to all medical operations conducted in austere environments. Particular attention will be paid to the prevention of illness and injury and involvement with the local community and its health workers. Examples of how these industrial projects have been directly involved in both conflict and catastrophe will be described.
Oil Exploration and Production The process of utilizing oil or gas deposits begins when competing oil companies bid for an exploration and drilling license issued is by the host country. To ensure a close working relationship the division of the potential revenues and other contractual obligations are agreed at the outset by company and state. The initial phase of exploration is conducted by seismic survey. Pressure waves are set off in a grid pattern over the search area. The echo is then analyzed and provides a picture of the underlying geological structures. The company may also conduct other geological and aeromagnetic surveys. If any of these appear to be potentially oil bearing they are subjected to exploratory, or “wild cat”, drilling. Production facilities and pipelines must be constructed once oil is discovered that is both recoverable and marketable. These various steps are often conducted discontinuously depending on factors such as seasonal climatic changes, contractual issues, or funding. The driving force behind the whole process is, of course, financial success for both the oil company and the host country. Success depends on the ability to sell the product of this immensely complex and expensive enterprise. The economic limiting factor is the projected price of a barrel of oil on the international market, bearing in mind the readily available “bath tubs” in the Middle East. The oil exploration company will nearly always bear the initial costs, which can be between £10 million and £50 million, or more, even before oil is found. They will therefore have the controlling decision on whether to abort the project at any of the various milestones.
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Reconnaissance and Planning The military adage of “time spent on reconnaissance is never wasted” is readily applicable to the medical preparations for these projects. The wise operator will research both the area and the proposed activities before leaving home. Talk to colleagues who have recently returned from the area and use the available telecommunications to converse with helpful sources in country. The best use can then be made of the time available for inspection on the ground. Time and effort spent in this way will always be repaid. Diligent enquiry will reveal the hazards to health including extremes of climate, standards of accommodation, hazardous plants and animals, local diseases, food safety standards, potential for dangerous lifestyle habits (e.g., abuse of drugs and alcohol), etc. If you are dependent on reacting to problems, rather than being able to plan for them, the project and its staff will pay a price in morbidity and mortality, lost working time, medical evacuations, and economic success. The risks to be identified and controlled will now be examined in greater detail using the format outlined in the Exploration and Production Forum’s Health Management Guidelines for Remote Land-Based Geophysical Operations.
The Local Community In areas of unemployment, underemployment, and poverty the arrival of the oil industry is a major event. Hiring of locals can give a boost to the local economy. To be usefully employed can be a source of personal satisfaction and dignity. However, community relations can be fragile and must be developed sensitively (Wasserstrom and Reider 1998). Issues of land rights, rights of way, and environmental protection must be addressed. The project’s medical staff must reach agreement with all parties regarding the treatment of local people. The usual arrangement is that the company will take responsibility for the treatment of locally hired personnel and their families. The local definition of “family” may be broader than that with which you are familiar. Remember to take into account the sensibilities of the local medical workers. It will be necessary to perform some medical screening of local workers. For example, check the eyesight of drivers (using an illiterate E chart) and ensure that food handlers are free from tuberculosis, gastrointestinal infection, and parasites. The opportunities provided by the industry can, however, be divisive. Competition for jobs may exacerbate religious or tribal hostilities. The influx of petrodollars may inflate the prices of a range of goods and services to the disadvantage of local consumers and businesses alike. Purchase or rental of land may lead to resentment amongst those landowners who have not profited by providing property for the project. Above all, it is essential to avoid encouraging long-term dependency on company support. The project will eventually close through failure to progress at one of the stages of development, when the deposit runs dry or if overwhelming contractual, economic, and environmental or security problems ensue.
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Security The industry can be subject to security risks for a number of reasons other than conventional war itself. State control tends to be weaker in remote areas. Foreign investment can engender political and xenophobic hostilities against these high-profile projects. Terrorists can attempt to disrupt the industry’s activities as an economic weapon. Both criminals and rebel groups use extortion by threats of violence. Criminals and terrorists may kidnap personnel including expatriates. A ransom demand may be for money, medical supplies, improvements in public services, arms, the cessation of company activity, or the release of members of the group held prisoner by the government. Theft from the opportunistic to the organized will take its toll. Extreme violence may result if you try and stop a thief whom you have disturbed: life is very cheap in some parts of the world. Oil installations are sometimes vandalized in order to cause environmental damage. The perpetrators will then seek compensation for the damage done to their crops and other property. The police and judicial system may not be wholly supportive. They can sometimes be part of the problem. Security risks will make exploration and production more expensive, sometimes prohibitively.
Examples of the Industry in Conflict and Catastrophe Kuwait Oil Fires, February 1991 At the end of the Gulf War in Kuwait Saddam Hussein’s troops detonated explosive charges over 900 oil wells. Some of the wells burnt producing huge clouds of smoke whilst others failed to ignite and produced massive oil lakes. The operations to cap these wells were probably the largest and most expensive peacetime logistical exercise in history. The Emir of Kuwait on November 5 the same year ceremonially extinguished the last fire. Kuwait’s oil fields do not contain significant levels of hydrogen sulpfide, a highly toxic contaminant. If wells were to be blown on a large scale in other fields, with high concentrations of this “sour gas,” the immediate threat to life could be huge.
AIDS Amplification in Africa An oil pipeline is to be built in Chad and Cameroon. Experience has shown that linear construction projects of this nature are associated with migration of the transient working population up and down the line. This leads to a thriving local sex industry and increased HIV infection rates amongst the oil workers, the sex workers, and the
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community at large. Companies involved in this project are required to put in placeapproved measures to prevent the potential AIDS amplification.
Pipeline Fires Ufa, Siberia, June 1988 While the world’s attention was focused on events in Tienanmin Square, Beijing, a large gas pipeline near the town of Ufa in the Former Soviet Union was leaking gas into a railway cutting. As two passenger trains crossed in the cutting the gas ignited. An explosion followed, which felled trees 2 miles away and shattered windows at a distance of 7 miles. Of the 1,200 passengers on the train hundreds died immediately and hundreds were injured as result of the explosion and fireball. The final toll of dead and injured has never been publicized. Casualties were treated as far away as Moscow. Plastic surgeons assisted from countries around the world.
Warri, Nigeria, December 1998 A crude oil pipeline near this village developed a leak. Sabotage, theft, or accidental damage has all been alleged. The villagers turned out in hundreds to collect the free fuel. This ignited, perhaps as the result of a motorbike backfiring. The resulting fire caused more than 1,000 casualties, with hundreds of deaths.
Summary Oil and gas exploration and production may take place in areas affected by conflict or catastrophe. Medical operations in remote areas, for whatever purpose, need to be carefully planned, equipped with suitable supplies, staffed by the right people, and provided with international support. Good relationships must be established with the local community in general and its health workers in particular.
Reference Wasserstrom, R. and Reider, S. Petroleum companies crossing new threshold in community relations. Oil and Gas Journal 1998;96:24–27.
6. Interfaces Part A – Medical Ethics Is Never Easy David R. Steinbruner
Baghdad February 2006 Medical ethics is never easy. So much of us, of our humanity, lies just beneath the surface of every question. Even the most straightforward situation buckles with nuance when the details come out. Throughout my medical school and residency training, awkward questions about the end of life and what constitutes a “good death” were at least partially answered with familiar responses. Deeper minds than mine had scrutinized and argued these issues for some time. Our hospital, like many others, had an ethics committee to give the medical staff some advice about how to proceed and the authority to do so. The burden of making and implementing these decisions was shared, laid on many shoulders. But that was a different place. For here, at Ibn Sina hospital in Baghdad, there is a volatile mix of war, politics, and medicine that makes the stateside burdens seem wonderfully clear in comparison. Those who study ethics and those who teach others find themselves in dark territory. The easy answers are few and the conclusions drawn are unsettling. For the entire history of US military medicine, the answer to treating casualties has been to take all comers, friend and foe alike. All are treated as appropriate given their medical situation. I imagine that this was never entirely the case, but it was and is the goal we strive for. The difficulty stems, perhaps, from our success in rapidly evacuating any casualty to advanced surgical and intensive care. Ibn Sina hospital, the 10th Combat Support Hospital (CSH) in fact, is one of only a handful of medical centers in Iraq, which can provide advanced, intensive care at a standard that we would recognize in the States. All of these are run by the USA. The Iraqi medical system lies scattered and broken after years of sanctions, Saddam’s crushing hand, and the war. Most hospitals have little equipment, no nursing staff, and a diminishing number of doctors, many of whom are poorly trained. Think about putting the Mayo Clinic down in the middle of Tijuana and you get the picture. Where do you think that the Iraqi’s would choose to be seen? Our policy is to see our forces, Iraqi forces, and those caught in the cross fire, either by choice or by mistake. We have made a decided effort to let the Iraqi medical system treat the average Iraqi citizen, whatever the injury. A. Hopperus Buma et al. (eds.), Conflict and Catastrophe Medicine, Second ed., DOI 10.1007/978-1-84800-352-1_6, © Springer-Verlag London Limited 2009
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When you see reports of multiple car bombs exploding around Baghdad, do not think that I am seeing all those victims. Most, if not all, are civilians and never make it to our doors. We are locked within layers of security in the IZ. Even those explosions that happen at the gates of the IZ may not bring the casualties to us, if they do not have the authorization to be here. This policy is rooted in pragmatism. We cannot treat all the sick and injured of this large city and still be a functional combat support hospital. And we will not be here forever. Sooner or later, the newly birthed Iraqi government will need to take on this burden. Now add to this dichotomy of technology and training the collective guilt and frustration of our nation. We have the ability on an individual level but not the means collectively to treat all the wounds of this broken country. There is a constant game being played by the sick and injured. How can I get seen at Ibn Sina? We are daily assaulted with requests from various “family members” of our employees to be seen. If all are to be believed, the entire nation appears to be related by marriage. Men and women clever enough to find their way into the IZ and to our front gate have already learned to claim chest pain or respiratory distress to find their way in. But the really difficult questions revolve around the truly sick and injured. When an American soldier or foreign contractor is critically injured they spend very little time in our hospital. We stabilize them in our emergency department, take them to the operating room, and do what is necessary to preserve life, limb, or eyesight. We then fly them out of the country as soon as they are stable enough for transport. The Iraqis stay with us until we can transport them safely to an Iraqi medical facility in Baghdad. Herein lies the problem. People with devastating head injuries, bilateral amputations and anyone still attached to a ventilator or requiring intensive nursing care will often die once they leave our doors. Women or girls with severe burns or amputations, even if not life threatening, will no longer be fed or cared for most of the time. We have transferred people to Iraqi ambulances on ventilators, only to watch the patient disconnected and left alone in the back to slowly suffocate. So to what end is all of our efforts? Remember, every time I order a patient transferred, either by ground or air, I put a crew of medics, an RN or a flight crew at risk. The IEDs and RPGs are aimed at any target of opportunity, and a medical transport would make for good press. So when do we stop? Dark territory, indeed. Physicians in the USA do not like to think about the cost of even minor tests, much less the cost of intensive interventions. Treat all according to need and ignore the ability to pay. But the cost here is human life, our soldiers at risk, for dubious gain. Unless we are prepared to transfer every critically injured Iraqi to the USA, free of charge, we will have separate standards of care. What makes it difficult is not that we do not know the outcome of our efforts, but rather that we do. We can anticipate the endgame even as we resuscitate them in our trauma room. The Iraqi people understand and accept this fact. We are having more difficulty with it. It is not how we like to perceive the world and our place in it. Perhaps, like much in this country, the reality is very different from what we wish it to be. Several days ago, in the middle of the night, an older Iraqi soldier was brought in by helicopter. Even as he rolled in through the front door, I could tell that he was in bad shape. He was lying on his side, mouth curled in pain, and his eyes oblivious to the world around him. Streaks of vomit spread out on the stretcher beside him and his
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body had begun to twist, his arms curling up indicating severe damage to the brain. There was no sign of trauma on his body – only a brief history of a rapid change in mental status. We placed a tube in his trachea to help him breath. His blood pressure was extremely high, indicating a bad bleed in his head. A CT rapidly confirmed what we already knew. He had suffered a devastating stroke, deep in the brain, in a place where no neurosurgeon would be able to reach. Even in the States his prognosis would have been grim. “Any family or unit commander?” “No. No one to contact.” I talked to the surgeon on call, a man who always gives his honest and often blunt assessment and is not afraid to make a difficult call. We did not really need to say anything to each other. The CT said it all. “Call me if we need to put him on the ward for a while,” he said. “That’s okay, we will handle it ourselves.” We wheeled him to the back room, took him off the ventilator, and pulled the tube out. He pulled hard to breath, snoring loudly and seemingly distressed by what we had done. “Perhaps a little morphine?” The young nurse, who had seen this far too often for someone of her age, looked relieved. “Thank you, captain.” His breathing eased, the snoring quieted. And we watched him slowly lose his battle to breath. Four hours after he arrived, our Iraqi soldier passed away peacefully, without ever waking. Perhaps his family or unit might have wished the same had they been around to say. War makes for difficult choices, but it can sometimes bring great clarity as well. There will be many medical lessons learned from this conflict. The standards for combat surgery and rapid resuscitation will be rewritten undoubtedly. Perhaps the ethics of medicine will undergo an honest reappraisal as well. Peace
Part B – Village Medical Outreach or MEDCAP: A Policy Perspective Martin C.M. Bricknell, Robin Cordell and David C. Mcloughlin
Introduction The authors were deployed on the International Security Assistance Force (ISAF) mission to Afghanistan between April and August 2007 (RC and DM) and earlier in 2007 (MB). RC was employed as the Medical Director and DM as the medical lead for Reconstruction and Development within the ISAF Headquarters Regional Command (South). The overall policy framework for ISAF military medical engagement with civilian health sector reconstruction and development in Afghanistan has been set out in the Provincial Reconstruction Team Handbook (ISAF 2006). Under the
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umbrella of Co-operative Medical Assistance (CMA), this policy is based on four strands: liaison and situational awareness, facilitation of resources, training and mentoring, and direct patient care. In the ISAF mission in Afghanistan, most military medical services are involved in some form of direct patient care to local Afghan civilians. When conducted in a primary care setting, this type of medical care has attracted the label “MEDCAP” or “VMO.” The term MEDCAP derives from Military Civil Assistance Programs initiated during the Vietnam War. The phrase “Village Medical Outreach” covers medical, dental, and veterinary activities that provide direct services to local nationals or their animals in an outpatient or ambulatory care setting. The potential roles of military medical services in supporting the wider reconstruction and development of the civilian and military health sectors are covered in other chapters in this book.
Afghanistan Health Situation The success of the ISAF mission, in creating a safe and secure environment in support of the Government of the Islamic Republic Afghanistan (GoIRA), is fundamentally underpinned by obtaining the consent of the Afghan population. This requires engagement with the population and demonstrating the practical evidence of the benefits of the consent on their lives. Meeting the basic human need for health, and access to healthcare, can be a powerful demonstration of the benefit of this consent. In Afghanistan the healthcare sector had seen little development since the Soviet invasion in 1979. After some 25 years of almost continuous disruption, health indicators are among the poorest in the world. For example, the under-five mortality rate was 257 per 1,000 live births (United Nations Human Development Report 2006) in 2004. The WHO report for 2001 states that the majority of children dying before their fifth birthday succumb to pneumonia, diarrhea, and vaccine preventable disease; access to such basic resources as clean water is assessed at 23%, sanitation at 12%, immunization coverage at 30%, and life expectancy for men as 45.3 years and women 47.2 years (WHO 2002). At a population level the most effective interventions to improve the health of the Afghan population will be led by the Ministry of Public Health (MoPH) and based upon improving the resources and infrastructure of the healthcare system. The MoPH, with the support of the international health community, has developed a comprehensive series of health polices underpinned by policies for the Basic Package of Health Services (BPHS) and the Essential Package of Hospital Services. The BPHS describes the provision of primary healthcare services across Afghanistan and is delivered through a mixture of directly provided services and services contracted out to Non-Government Organisations (Palmer et al. 2006). The structure of the Afghan health system is summarized in Fig. 6.1. Unfortunately, achieving significant improvements in population level health statistics will take time, and at a local level, visible direct patient care to the local population remains a powerful evidence of the effectiveness of the GoIRA and International Community (IC). Where care cannot be provided by local Afghan health workers, there is scope for this to be provided by international military medical forces. However these interventions are targeted at the individual, personal level and are unlikely, by themselves, to have any impact on long-term health indicators at a population level.
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Fig. 6.1. Structure of Afghan health system.
Vietnam War and Onward The term MEDCAP originates from the Vietnam War (Neel 1991). US military assistance had two strands: hospital-based programs and primary healthcare programs or Medical Civil Action Programs. Initially the hospital Provincial Health Assistance Program (PHAP) was delivered by civilians under the auspices of the United States Agency for International Development (USAID), but with the deteriorating security situation and increased US military build-up, this transformed into a joint program between the USAID and the military. The focus of the hospital program was to increase the capacity and capability of the indigenous medical system using US military personnel and US Embassy development funds. The best known of the various programs in Vietnam for medical civil assistance was MEDCAP. It developed from a joint proposal by the American Embassy, Saigon, and US military command made in 1962. MEDCAP began operation under the auspices of the Department of the Army in January 1963. The primary objective of MEDCAP was to provide increased outpatient care for Vietnamese civilians living in rural areas. American and Vietnamese military medical personnel were used in the program, a major goal of which was to increase mutual respect and cooperation between the military forces and the civilian population. MEDCAP teams normally traveled to hamlets and villages with their AVRN (Army of the Republic of Vietnam) counterparts and established temporary health stations to provide medical care for the inhabitants. US personnel were directed, unless it was impractical, to conduct
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their medical civic action effort through a member of the Vietnamese army medical service or the Vietnamese civilian government medical authorities. Medical supplies were provided through the Vietnamese Army medical depot system, but difficulties of distance and coordination made this means of supply increasingly unwieldy. Eventually MEDCAP units were authorized to requisition material directly through the regular US Army supply channels. As well as medical personnel, dental personnel conducted visiting dental clinics under the label “DENTCAP.” In a country as predominantly rural and agricultural as Vietnam, treatment of sick and wounded animals, cattle vaccination, and guidance in the care and feeding of swine, and cattle veterinary activities, under the label ‘VETCAP’ were also very effective means of engagement with the local population. Wilensky identified seven key principles from a review of the effectiveness of US military medical policies and activities toward civilians during the Vietnam War (Wilensky 2006). ● ●
● ●
●
● ●
Value must be based on training of the indigenous population. Civilian medical care programs are always a secondary mission to providing care for own forces. Medical intelligence obtained on local disease prevalence can be useful. Before starting, determine what the indigenous population want and are prepared for/resourced to support. Medical care programs can be effective in advancing overall campaign objective of local consent. Aim must be to get support for local government not foreign forces. Civilian care programs can only be effective where a health need exists and such military activities fit the wider CONOPS for the military campaign.
In addition to the Vietnam War, military medical services have been used to provide community-based health services within other military campaigns including Oman, Kurdistan, Bosnia (Thornton et al. 1997), and Kosovo. In all instances these community health activities have been based on medical need but within a wider military campaign objective of providing security and obtaining consent of the local population by providing health services. The UK developed the military medical training exercise, Exercise SHARPPOINT, in Kenya as a rural health outreach program. This exercise was directed by the UK Embassy under the auspices of the Kenyan government and involved UK military primary healthcare staff (doctors, nurses, and medics) conducting health clinics and immunization programs for rural communities that were underserved by existing health services. Within the civilian medical aid community, the use of mobile medical clinics to provide primary care services is considered to be a short-term, transitional arrangement to provide health services to populations without access to any permanent, fixed medical assistance. Guidance from the International Committee of the Red Cross emphasizes the need for carefully planned and tailored medical services and the fact that mobile medical clinics are expensive and logistically demanding compared with other methods of providing access to health care (ICRC 2006). The activities of a mobile medical clinic can cover combined curative medicine, preventive medicine
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(immunizations), and health promotion but the exact role must be tailored to specific circumstances. The ICRC guidance emphasizes the importance of referral arrangement for patients with medical conditions that are outside the scope of care provided by the mobile medical unit.
Definition and General Guidance In Afghanistan, a Village Medical Outreach activity is defined as a Civil–Military Operation (CMO) designed to support the military campaign using direct provision of community health services in order to shape the battle space through winning the confidence and trust of the Afghan people and promoting the legitimacy and interests of the GoIRA. The spectrum of VMOs is shown in Fig. 6.2. The ultimate endpoint is to facilitate an Afghan healthcare worker providing healthcare to an Afghan within a secure environment. Where this goal cannot be achieved then we should move in a stepwise fashion to the left until we reach an achievable method of delivery. Paradoxically, foreign uniformed medical personnel providing aid to the civilian population may reinforce the view that the Government is unable to provide these services or the security on which development of such services depends (Wilensky 2001). Health activities within VMOs should be consistent with the national health strategy and contribute toward the end state of the national government meeting the needs of the local population within its own resources. These activities should combine assessments and surveys (such as disease detection, child health), public health interventions (immunization, vitamin supplementation, and health education), and direct medical treatments so as to achieve the maximum impact on the health of the village.
Fig. 6.2. Spectrum of VMOs.
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Section One Table 6.1. Examples of health activities undertaken within Village Medical Outreach Public Health Assessments General resources: Food, water, shelter, sanitation, security, and employment General health: mortality, burden of disease, and specific disease surveillance Child health: height, weight, body fat, and immunization uptake Public Health Interventions Lower the high maternal mortality rate Review women of child-bearing age in order to identify maternal risks Provide assistance to midwife training programs Provide multivitamin, iron, and folate therapy for women of child-bearing age Provide health education on the importance of pre- and postnatal care, breast feeding, nutrition, basic hygiene and sanitation, maternal/child health, malaria, and family planning Lower the infant mortality and under-five child mortality rates Assess height/weight/skin fold thickness Provide assistance to Ministry of Public Health Expanded Program of Immunizations (EPI) Provide deworming treatment for children Promote use of oral rehydration therapy, iodized salt, chlorine Promote use of insecticide-treated bed nets Treatment Interventions Diagnosis and treatment of short-term conditions Facilitated referral to indigenous hospital care
Specific examples of such activities are shown in Table 6.1. VMOs can be used as a means to assist local health officials and providers to access rural populations and ideally much of the actual health activities should be delivered by local staff. They can also be used as a means of education and mentoring for local health staff. Health professionals conduct VMOs, and therefore these are subject to the ethical provisions of the Geneva Convention (ICRC 1907) and their professional bodies. The actual clinical component of a VMO must be absolutely separate from any offensive military activity (e.g., intelligence collection). Access to clinical care must be unhindered without coercion or any implication that there is an obligation to support military activities. However, it may be legitimate to use the environment of the VMO to communicate information relevant to the military campaign. Military VMOs have been criticized by the international health sector as an inappropriate use of military forces and for “contamination” of humanitarian space by the association of health services with security forces (McHugh and Gostelow 2004). It is claimed that this jeopardizes the impartiality of civilian healthcare workers and potentially makes them a “legitimate” target of opposition forces. It is absolutely correct that military VMOs should not substitute or replicate civilian health services. They should only be conducted where there is a clear unmet health need and with the explicit approval of the local community and local health workers. In Afghanistan, military VMOs are being conducted on behalf of the GoIRA and are an instrument of the international community in support of the people of Afghanistan. This is absolutely aligned to the Provincial Reconstruction Team (PRT) concept in which military and civilians work jointly toward overall campaign objectives.
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Tactic Techniques and Procedures A VMO must be considered as a formal military operation because the only reason that ISAF forces are undertaking the operation is because the Afghan security forces and the Afghan medical services are unable to provide access to health services themselves. Thus, it is implicit that there is a potential security threat to the VMO. A formal VMO is appropriate for a village size of between 1,000 and 2,000 people. Smaller VMOs, “tailgate” or “de minimis” can be conducted informally by medical staff in association with other military tasks such as patrols but still should conform to the general guidance contained in this chapter. Prior to a formal VMO, the site should be visited and all elements should be fully coordinated with local dignitaries such as village elders. Externally, the local Provincial Health Director should approve the activity and it should be planned so as to conform to wider military information operations. It is vital that there are “hand-off ” or referral arrangements for patients with clinical conditions beyond the capabilities of the VMO staff. Such arrangements could be to local fixed medical facilities, NGO medical facilities, or ISAF medical facilities. It may be appropriate to provide transport, cash, or other means to enable the patient to access this care. The ISAF Medical Adviser and CJ9/CIMIC cell should endorse the final plan. VMOs are not without risk; in June 2007, a US soldier was killed in southern Afghanistan while undertaking a MEDCAP in an apparently permissive area. There may also be risk to those people receiving aid; if enemy forces perceive that in return for medical aid local people have provided information on their activities, reprisals could follow. In July 2007, a suicide bomber struck in a small town as a MEDCAP was taking place; subsequent assessment was that the MEDCAP was the target, but that the attack was switched to another target due to the effectiveness of security arrangements in place for the MEDCAP. At the tactical level, normal military practice of predeployment preparation including mission analysis, formal planning, briefings, rehearsals, and contingency plans for possible enemy action should be thoroughly addressed. Particular consideration should be given to ensuring effective engagement of female Afghans through provision of a separate female area, female search staff, female medical staff, and female health workers. It may also be necessary to brief medical staff on clinical issues such as prevalent medical conditions and the necessity to adjust Western healthcare practice to be locally appropriate and culturally sensitive to the environment of Afghanistan. The funding and procurement of medical materiel for VMOs varies between nations with some allowing use of military equipment and others requiring a formal separation between medical material used in support of military forces and that used for “humanitarian purposes.” It may even be possible to establish a collective “stockpile” for use by all international medical forces. In all cases the medical material used must be appropriate to the local clinical conditions and should conform to the MoPH national formulary in order to ensure patient access for further treatment if necessary. It is also necessary to consider how to dispense medical material such that it is used by the patient and not sold in the local bazaar. This might include individual patient packs and unique marking of dispensed medication. Key points are summarized in Table 6.2.
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A VMO should be undertaken under the direction of the ground commander
Reconnaissance
May be done by CJ9/CIMIC personnel
Notification
Plan approval by RC MEDAD/CJ9/CIMIC
Coordination
ISAF, other agencies, locals, hand-off/referral arrangements
Resources
Security team, medical team, females, interpreters, Afghan National Security Forces, Afghan medical staff, shelter and heaters, humanitarian aid supplies, medical material, desks, chairs, couches, information operations, patient records, survey sheets
Rehearsals and briefing
Vital if the VMO group has not previously worked together
Conduct of the Village Medical Outreach The site layout is the most critical component of the tactical execution of the VMO. The design must ensure the security of the VMO personnel and local participants but this must be balanced by the need to enable effective engagement between healthcare personnel and patients. The whole event should be carefully managed to ensure that the VMO is not overwhelmed especially at the beginning before everything has been set up and also at the closedown, particularly if not everyone has been seen. It may be appropriate to use “humanitarian” donations (e.g., blankets, clothing, boots, food) as a distraction during these periods. It should be noted that the giving of gifts is an important part of the Afghan culture, and appropriate donations can alleviate humanitarian needs within this social context. A generic layout for a VMO site is shown in Fig. 6.3. An indication of potential “throughput” is shown in Table 6.3. Culturally, males and females must be treated by same sex providers in a location that does not allow males and females to view one another. This includes separate entrances for males and females as well. The clinical areas must be indoors with adequate light and space for each healthcare provider. The following description of a VMO outlines procedures for “crowd control.” Patients will line up outside the entrance control point (ECP, which typically which should be at least 50 meters from the clinic building) males at one point and females at another. The VMO clinical supervisor will request patients in small groups as required (typically 5–10 at a time, male or female). Once security checked, the patients will be directed to the clinical area. Along this route there will be a deworming station set up for all children 14 and younger. At the clinic building the patients will be directed to a waiting area and held there by security personnel (preferably ANA or ANP) until called in to the clinic by the provider. Normally, females will be called in as family groups, however if the family is large the provider may ask for it to be split. Males will generally be divided between older men and youth (age 0–20) and seen by separate providers. Once treated, the
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Fig. 6.3. VMO generic site layout.
Table 6.3. VMO patient throughput Adult males: 15 per clinic hour (120 per 8-h day) Adolescent males: 25 per clinic hour (200 per 8-h day) Females: 25 per clinic hour (200 per 8-h day) Children deworming: 50 per clinic hour (400 per 8-h day) Animal care: 125 per clinic hour (1,000 per 8-h day) Dental care: 10 per clinic hour (80 per 8-h day) Hygiene teaching and distribution for females: 50 per clinic hour (400 per 8-h day)
patient will be requested to leave the clinical area either via the ECP or another route as directed by your security set up. It has been found to be best (but rarely practical) if there is a separate departure point from the ECP. Patients only go through the line one time. While in the clinic the patients’ hand will be marked with a “W” deworming and/or an “X” Treatment completed. Security personnel should look for and deny re-entry to anyone who has been marked. If any questions arise here, consult our clinical supervisor.
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The veterinary site should be on generally flat ground, without excessive rocks, with a wall or similar barrier along one side, and some shade (such as a tree, tarpaulin, or tent) throughout the day. There should be no razor wire set up or planned within 25 m of the vet site. It must be well separated from human patient gathering areas and from the exits. The vet site also requires a separate animal gathering area, which is easily accessed by animals (does not have to be flat) and a “fly out” exit route that is free of human patients. The veterinary site should be near enough to the medical site to provide access and security, but far enough away to avoid injuring patients if animals bolt from the area. The best veterinary setup provides a clear entrance through which animals can come, a treatment area that is cordoned off to prevent onlookers from getting too close (preferably with some shade), and a free exit through which animals can bolt without injuring themselves or others: i.e., no cliffs, barbed wire, or patients waiting. This can usually be achieved with pickets and engineers’ tape. Some units give out “humanitarian” supplies to the villagers during CMA missions. However, the distribution of humanitarian supplies should not take place in the inner perimeter of the clinical area. This creates confusion and makes patient care and flow difficult. It is best to distribute these supplies just outside the clinical compound on exit from the ECP and use it as a means of flowing patients away from the clinic following their treatment. Obtaining medical treatment should not be a requirement in order to receive humanitarian supplies. These functions should be kept separate. Table 6.4 provides a snapshot of the type of VMOs undertaken in the South of Afghanistan in early 2007.
Table 6.4. MEDCAP/VMO within RC(S) 19 May – 8 Aug 2007 Date
Province
District
Organizing units
Remarks
No.
19–25 May
Zabul
Shinkay
Helmand
SBK
Including ANA male physician; only a few women attended First ANA VMO
200
23–29 June 27 June
Zabul
Qalat
Kandahar Kandahar Helmand
Arghestan Kandahar Sangin
25–27 July
Zabul
Daychupan
2–5 Aug
Helmand
Sangin
Qalat (US) Provincial Reconstruction Team US medical troops
6–9 Aug 7–8 Aug
Helmand Heimand
USV Nahr-e Saraj
ANA mentored by US medical troops ANA mentored by US medical troops
7–8 Aug
Helmand
Sangin
ANA mentored by US medical troops
Male and female US doctors supported clinic US, Romanian, and Polish doctors 48 patients in Aliza Kalay US medical teams including female medics Undertaken in a Forward Operating Base US medical, dental, veterinary teams including female staff US sponsored In support of UK troops (Task Force Helmand) village development plan In support of UK troops (Task Force Helmand) village development plan
300
7 July 13 July 20–27 July
Qalat (US) Provincial Reconstruction Team Afghan National Army (ANA) mentored by US medical troops Qalat (US) Provincial Reconstruction Team with ANA staff US and Polish troops UK Force Protection US medical troops
100
605 48 800 160 857 400 150 200 3,820
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Postmission Activities All VMOs are different. As with any other military activity, there should always be a post-VMO debrief of personnel, and a formal postmission report should be submitted through the chain of command to Regional CJ3, CJ9/CIMIC, and MEDADs. Medical and other stocks should be replenished. Any hand-off or referral arrangements for individual patients should be completed.
Donations: Medical Supplies and Infrastructure Development Many VMOs are conducted in association with donations of medical supplies or development of community healthcare infrastructure such as medical clinics. It is important to recognize that these are separate but complimentary activities that must also be coordinated. In Afghanistan there is little free provision of pharmaceuticals through the public health system. Furthermore, salaries for public healthcare professionals are meager and so many doctors supplement their income by ownership of pharmacies. The unstructured donation of pharmaceutical supplies may, inadvertently, act solely to increase the income of local doctors, and so all donations must be done in association with the local representatives of the MoPH and should also be clearly labeled as donations.
Conclusion In conclusion, VMOs can be a valuable and legitimate use of military medical resources in support of the wider counterinsurgency campaign by increasing access to health services for local communities. This chapter describes the policy framework and practical guidance for undertaking VMOs within the ISAF mission in Afghanistan. This chapter contains material previously published in the Journal of the Royal Army Medical Corps (www.ramcjournal.com) and is used with permission.
Acknowledgements Elements of the work have appeared in the journal of the Royal army medical corps and are used with permission.
References ICRC. The First Geneva Convention. Convention for the Amelioration of the Condition of the Wounded and Sick in Armed Forces in the Field. ICRC, 1907. ICRC. Mobile Health Units: Methodological Approach. ICRC, Geneva, 2006. International Security Assistance Force (ISAF). Provincial Reconstruction Team Handbook. International Security Assistance Force, Kabul, 2006.
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McHugh G, Gostelow L. Provincial Reconstruction Teams and Humanitarian-Military Relations in Afghanistan. Save the Children, London, 2004. Neel S. Medical Support of the U.S. Army in Vietnam 1965–1970. Department of the Army, Washington, DC, 1991. Palmer N, et al. Contracting out health services in fragile states. Brit Med J 2006;332:718–22. Thornton R, Cordell RF, Edmonds KE. Humanitarian aid operations in Republica Srpska during Operation Resolute 2. J R Army Med Corps 1997;143:141–5. United Nations Human Development Report 2006: Afghanistan. Accessed at http://hdr.undp.org/hdr2006/ statistics/countries/data_sheets/cty_ds_AFG.html on 19 June 2007. WHO-EM/EHA/003/E/G 2002. Reconstruction of the Afghanistan Health Sector: A Preliminary Assessment of Needs and Opportunities, WHO, 2002. Wilensky RJ. The medical civic action program in Vietnam: success or failure? Military Med 2001;166(9):815–19. Wilensky RJ. Military Medicine to Win Hearts and Minds: Aid to Civilians in the Vietnam War. Texas Tech University Press, Lubbock, TX, 2006.
7. Conflict and the Media Daloni A. Carlisle
Journalists and humanitarians have always had close links. They work in the same places and, although this may be hard for some readers to stomach, they often work with the same motives. Take Florence Nightingale. In 1854, The Times’ correspondent William Russell described the terrible suffering of the sick and wounded in the English camps compared with that of the French, provoking outrage in England. In September that year he asked, “Are there no devoted women among us, able and willing to go forth to minister to the sick and suffering soldiers of the East in the hospitals of Scutari? Are none of the daughters of England, at this extreme hour of need, ready for such a work of mercy? Must we fall so far below the French in self-sacrifice and devotedness?” Apparently not. The rest, literally, is history. Fast forward to Ethiopia in 1984 and Michael Buerk’s reporting of the catastrophic famine, or in media shorthand, “biblical famine.” During his reports from the region – the first mainstream international reporting of the increasingly serious situation – Buerk interviewed ICRC nurse Claire Bertschinger about her dilemma as she chose the few who would survive from the tens of thousands of people seeking help. Cameraman Mohammed Amin filmed her surrounded by starving children, and the pictures went round the world, mobilizing a massive response and inspiring Live Aid. Singer Bob Geldof said Bertschinger was his inspiration for the original Band Aid single. “In her was vested the power of life and death,” he said. “She had become God-like and that is unbearable for anyone.” More than 20 years later and the footage is still cited. In August 2007, Ronan Scully, an aid worker with Ireland Goal, wrote about his recent trip to Ethiopia in the Galway Independent newspaper: “Ever since I saw the BBC’s Michael Buerk’s report on the famine and heard Bob Geldolf and GOAL’s John O’Shea shouting at the tops of their voices for the international community to wake up to the catastrophe there, I have wanted to work in Africa, especially in Ethiopia.” For nearly all of us, the media are also our first and often only source of information from around the world, from the World Service at 3’o clock in the morning on Boxing Day 2004 reporting the first news of an earthquake in the middle of the Indian Ocean to The Times’ legendary story (and winner of the Most Boring Headline competition run by the subeditors) “Small earthquake in Chile, not many dead.”
1 Daloni Carlisle is a freelance journalist. She worked for the International Federation of Red Cross and Red Crescent Societies and the ICRC in Serbia and Albania in 1998/1999. The views here are entirely personal.
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Fig.7.1. Watching them, watching you: Red Cross workers come under scrutiny in Lebanon in 2006. Media exposure is part of daily life for humanitarians in high-profile conflicts (courtesy of British Red Cross).
Curious, is it not that we say we do not trust the media, yet much of what most of us know about the wider world comes from the media. It is important for those who work in conflicts and catastrophes to understand how the media work, why you might need to work with them, and how to get the best out of them (see Fig. 7.1).
What Media Are You Likely to Meet? From a UK perspective it is easy to think only of our own international media: the BBC, foreign pages of the Telegraph, Sky News, ITV, and Channel Four. On the ground in an international crisis, you will find these big domestic players along with international media from other countries: CNN and ABC from the USA as well as the Washington Post or Boston Globe, Canal Plus from France, and so on. Within this group are the serious journalists, broadcast and print, as well as the less serious such as the UK’s Red Tops. There will be journalists on daily deadlines, weekly deadlines, and perhaps even monthly for some magazines. There will be people filing hourly to websites, multitasking with cameras and a microphone, as well as those working in large teams. A major TV news broadcasting team may consist of a presenter, sound recordist, cameraman, translator/fixer, and driver. Then there are the news agencies – Reuters, AFP, and Associated Press. Often these organizations have a local or regional office staffed locally and will bring in international reporters as things hot up. They do not broadcast or print in their own right but provide news stories and pictures to other media outlets around the globe.
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In Pristina in 1999, in the weeks after the NATO bombing of Serbia had ended and KFOR troops arrived, 2,000 international journalists descended like a cloud of locusts. Everyone wanted an exclusive; each had to report faithfully the same details of the same story as colleagues or face questions about why their details differed. Each faced requests from home for stories that had nothing to do with the reality on the ground but were informed by domestic political dimensions. Alternatively, there may be no one at all to bear witness: places where the press has been excluded, say the frontline in the Eritrea/Ethiopian border dispute or Kashmir, places th at are deemed too dangerous, such as Baghdad in 2006/2007, or places that have little or no external political significance, such the Democratic Republic of Congo for most of the last decade. The size and intensity of the international media presence has very little bearing on the size of the catastrophe. There is also the local media. Depending on the context they will be more or less independent, and more or less well developed. However, their reporters and the agendas that drive them have a potential to make a real impact on your work and your security. When the international media have long gone, they will still be there, but more of this later.
Who Are These People? I hesitate to use this particular cliché, but it is wise to know your enemy. Here is a story told by Jonathan Freedland, the Guardian’s veteran foreign correspondent. “I once spoke to a journalist who had covered the war in Bosnia in the early 1990s. He said that he and his colleagues kept heading into harm’s way because they believed that once the world knew of the horrors they had witnessed, the world would be stirred to act. They filed their reports and waited. Soon enough, they understood. The world knew what was going on and yet it did nothing. For some of those reporters, this experience broke their faith in the power of journalism. For others, it broke their faith in their fellow human beings.” How similar, he goes on to say, was the experience of aid workers and UN staff who signed a collective statement on the plight of Darfur in January 2007. “Fourteen different UN humanitarian bodies…issued an unprecedented cry of despair,” he wrote, going on to detail the dire situation faced by the civilian population. “I’m sure that when they drafted that message they believed the world would stir and come to their rescue. Surely it would not ignore such a stark, desperate plea from those whose motives is to save lives?” Well, the world did ignore it and the suffering goes on. The point in retelling his story is not to highlight the uncaring nature of the world but the similarities between journalists covering humanitarian crises and humanitarians. We are not so different. Having said that, reporters are not a homogenous group. Some are household names; many are freelancers who work independently. Some are vastly experienced and sit down to competitions with colleagues about who was on the spot in Timor/ Mali/Rwanda on which day. Others are new to the game and just learning. Like humanitarian workers they usually choose to work in areas of conflict and catastrophe for a mixed bag of reasons that includes altruism, adventure seeking, and
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inability to fit in at home. Many are hugely idealistic about the role of the free press. Lots of them are great fun to hang out with and many are extremely well informed. Take the Crimes of War Project. This was set up in 1999 by a group of journalists, academics, and lawyers to broaden journalists’ and the public’s awareness of the Geneva Conventions and International humanitarian Law. One of the founders was the journalist Roy Gutman who won a Pulitzer Prize for his work at Newsday during the Bosnian war in the early 1990s. He realized that the atrocities he was documenting were violations of IHL and therefore could be challenged internationally. At the launch (admittedly in front of a bunch of journalist and journalism students at City University in London) he talked passionately about how IHL was a force for good and a reference point against which reporters could measure the scale of what they were reporting on. Many reporters and cameramen risk their lives for their journalism. A survey by the International News Safety Institute found that between January 1996 and June 2006 more than 1,000 media workers died while reporting the news – one in four in war situations. The INSI said at the time that 2006 was the worst year on record with 138 deaths. Sadly, 2007 was shaping up to be even worse with 137 deaths already recorded by mid-September.
What Are the Media For? Now here is a thought. “No substantial famine has ever occurred in any independent and democratic country with a relatively free press.” Nobel-prize winning economist Amartya Sen has made this assertion many times and yet, as he also points out, the quiet presence of endemic hunger does not usually make the headlines. The media have several roles. One is undoubtedly selling newspapers/raising viewing figures. Another is providing information and analysis. A third is holding governments or bureaucracies to account, either for their actions or the way they spend public money. A fourth is increasing awareness of the wider world around us. But there is evidence that the media are less and less good at this. Newspaper circulation is in long-term decline; broadcast media and its audiences are increasingly fragmented as channels multiply. Coverage of developing world issues has been in decline for years, as documented by 3WE (now part of the International Broadcasting Trust), a coalition of humanitarian agencies that includes ActionAid, Amnesty International, CAFOD, CIIR, Comic Relief, Oxfam, Sightsavers International, Skillshare International, VSO, UNICEF UK, and others. Its research since 1989 has charted the change. Where once we had World at War and other documentaries about international affairs, we now have Love Island and I’m a Celebrity Get Me Out of Here. In its 2005 report Bringing the World to the UK, 3WE said, “Television coverage of the world outside Britain is vital in exposing UK viewers to cultures, landscapes and ethnic groups which are not available to the vast majority of viewers in their everyday lives. Television’s potential power as providing a ‘window on the world’ which can offer a deeper understanding of the world beyond the UK has long been recognised, and has been an integral part of the UK’s public service broadcasting.” Despite the long-term decline, 3WE was at that point hopeful. The 2003 Communications Act laid down specific obligations on public service broadcasters, including
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airing programs, which deal with “matters of international significance or interest.” The regulator Ofcom is obliged to monitor and report on whether this is being achieved. Meanwhile, the 2006 White Paper on the future of the BBC defined, for the first time, six “public purposes,” which the BBC will be expected to fulfill over the next 10-year Charter. The fifth of these is a specifically international aim of “Bringing the UK to the world and the world to the UK” aiming to make “UK audiences aware of international issues and of the different cultures and viewpoints of people living outside the UK.” It covers all forms of output beyond news and current affairs, including drama and documentaries. What does this mean? Here is one example. In 2006, Guardian Films (the film unit of Guardian News and Media) funded Iraqi doctor, Omer Salih, to film life inside alYarmourk Hospital, one of Baghdad’s busiest hospital. It was shown on BBC2 later that year and in 2007 was up for an Emmy award. Dr. Salih said of the film: “Before this film they never knew what the situation was like in Baghdad’s emergency rooms. They always see the explosions and the site of an attack and that’s it. When I started to speak to doctors, the main reaction I got was that they very scared. I really hope it will make people understand what’s going on in Iraq.” At the other end of the spectrum we have Millionaire’s Mission, a reality TV program aired by the BBC in autumn 2007 involving several entrepreneurs splashing out their own cash in Uganda. Not very lofty but does it fulfill the “public purpose” outlined in the Charter? You decide (see Fig. 7.2). There are some crucial differences between individual reporters and the media they represent. Reporters may act on the most admirable of motives. The media they represent are a different matter. They are not impartial and are not guided by principles of neutrality. Their priorities are not those of humanitarians; their coverage is not proportional to the amount of suffering but guided by western interests.
Fig.7.2. The shape of things to come? World Vision Uganda director Rudo Kwaramba prepares for filming in her role as mentor to the British entrepreneurs in Channel 4 reality-TV series Millionaire’s Mission (courtesy of World Vision).
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This has been quantified repeatedly. In 2005, Reuters AlertNet published a survey of media coverage in 200 English language papers for the 12 months to February 2005. The most covered items were the 2004 South Asia tsunami with 34,992 citations, the conflict in the Sudan (two million people affected) with 7,661 citations, and the conflict in DRC (estimated four million dead) with 3,119 citations. Since this report, AlertNet has refined its methodology and now produces a day-by-day world media watch, tracking the number of citations of 88 emergencies in 107 English language print publications. So (to quote AlertNet’s somewhat breathless introduction to its tool) “Which emergencies grab the media limelight? Which are ‘forgotten’ by the press?” Can you guess? Top of the list comes Iraq, not so closely followed by Afghanistan and the Israeli–Palestine conflict. The AIDS pandemic received one-tenth as many mentions as Iraq – and it was fifth on the list.
Does This Matter? Yes. International media coverage is intimately linked to funding. The more column inches or prime time TV minutes, the more money floods in. In 2002, the International Federation of Red Cross and Red Crescent Societies compared the donor response to the 2000 floods in Mozambique. The South African Airforce had called in the cameras, and spectacular images were relayed live around the world – most memorably the woman who gave birth in a tree. Result: $470 million of financial and material aid pledged. In 2001, there were more floods, this time higher up the Zambeze valley. The fields were flooded but the farmhouses, higher up, were not and the farmers elected to stay put. The TV cameras came and, with no dramatic rescues to film, they left. Over subsequent months the situation deteriorated as the river did not subside and by May 220,000 people had sought refuge in 65 displaced person centers. But with no media coverage there was almost no donor response. The Federation did not comment on the nature of the coverage. In fact, the news in 2000 centered on how the aid agencies had failed to respond to this crisis. Look at all these poor, poor people and not a good-looking blonde nurse in sight! This did not affect the donors’ generosity one jot. It was the images on the TV screens that they responded to. This phenomenon has given rise to the idea of “forgotten” or “neglected” crises. In 2006, the Federation devoted its entire annual World Disasters Report to the subject. Media coverage is obviously not the only factor at play and the report offers a lengthy analysis. But it is a crucial component as Markku Niskala, the Federation’s secretary general, pointed out in her introduction. “Whether we like it or not, the media continue to exert a strong influence over where resources flow for humanitarian crises – and not just for the tsunami or [hurricane] Katrina. The South Asia Earthquake attracted 86 minutes of TV coverage on US networks in 2005 and raised over US$300 per targeted beneficiary. Meanwhile, Somalia and Cote d’Ivoire attracted no TV coverage at all and raised respectively just US$53 and US$27 per beneficiary.” Broadly speaking, the media go to places that their readers/viewers/listeners are interested in. The tsunami in 2004 received so much coverage because large numbers of Westerners had visited the affected regions on holiday and indeed knew people caught up in the events. The UK was militarily involved in Kosovo; ditto Iraq and
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Afghanistan and actually it is quite right and proper that a county’s media should provide coverage of its own armed forces. Then there are historical influences. The UK has colonial links with Sierra Leone but not with Cote d’Ivoire. As for Sudan, well that is been going since forever, has it not?
Where Does This Leave Humanitarians? Often in a scramble for publicity. Alongside AlertNet’s world press tracker is another tool tracking, which aid agencies get the most media coverage. As the website’s methodology section puts it: “Aid workers are also keen to know how their organisations are faring in the struggle to “drum up global press attention.” Top of the list is Red Cross/Red Crescent (and by a large margin), with Oxfam and Médecins Sans Frontières at numbers 2 and 3. Aid agencies do have different policies on press coverage. The ICRC is notoriously tight-lipped and argues that its neutrality and impartiality will be threatened by talking to the press. It argues that continued access to victims of war outweighs a wider duty to speak out. Bernard Kouchner, a one-time ICRC doctor, and in 2008 appointed French foreign minister by President Sarkozy famously fell out with his employer on just this issue in the Biafra War in Nigeria in the late 1960s and early 1970s. He felt that he should speak out about the atrocities he witnessed; the ICRC felt otherwise. So, he left ICRC and founded MSF in 1971 on the principle of bearing witness and public campaigning. Is speaking out always the right thing to do? It is an ongoing debate. In 2004 Gerald Martone, then director of emergency response at the International Rescue Committee, took part in a debate at the Carnegie Council on the theme of Humanitarianism Under Fire. He urged caution, saying, “Certainly in the founding of MSF in 1971, it was the implacable neutrality and silence of doctors working for the ICRC that rose up to create MSF. Oxfam was created the same way, when Oxford academics who were providing relief to Greece in 1942 during the Nazi blockade recognized that this wasn’t a question of not enough food, but rather of a lack of political engagement. It’s a cruel irony that now, at the tenth anniversary of the Rwandan genocide, we find ourselves once again in ethnocide in Darfur, western Sudan. We operate in an environment where we must interact with the government of Sudan and the rebel forces at work. We are forced to be careful about our public statements, to choose our words carefully, and to watch what we say. For example, some of you might be aware that the other day the country representatives of Oxfam and Save the Children UK were both expelled from Sudan because of public statements they made that were critical of the government of Sudan.” It does not always pay to speak to the media.
When Is It a Good Idea to Talk to the Media? At the risk of stating the bleedin’ obvious, when you have something to say. This might be something of immediate interest, for example, aid agencies warning of the deteriorating situation in Dafur.
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You may be the people on the ground in a situation where the media are not present or simply able to provide the eye-witness accounts, known as “color” by the media. Reporters often want to talk to someone from their own country. They like to hear from nurses and doctors in particular. This is because nurses and doctors are trustworthy; they are also familiar to the folks back home. We all know a nurse and it is easier for most of us to empathize with the nurse than with someone whose language and way of life is completely foreign to us. This does of course reinforce some of the arguments earlier in this chapter about awareness and the partiality of coverage; it is also the real world. You may have new information. For example, some months after the South Asian tsunami when all the international media had gone home, Oxfam released a report saying women had been disproportionately harmed by the disaster. They had been left widowed, jobless, and homeless. The report received widespread international coverage. The trouble sometimes is that the media do not want to listen to you.
The Humanitarian Window Stories have an existence that is outside the humanitarian framework. Generally, reporters are not present solely because of the humanitarian situation but because the humanitarian situation has a political dimension. This affects the way a story is covered and creates “windows” for getting a humanitarian message across. Here are a couple of examples. In the summer of 1999, NATO was bombing Serbia. Some several hundred thousand Kosovo Albanians had made their way to Albania and to Macedonia. The media had been kicked out of Kosovo in the days before the bombing started and were camped out in Skopje and Tirana. At the height of the bombing, the British foreign secretary Robin Cooke announced in the House of Commons that there were organized rape camps in Kosovo. It was not in fact true but the London news desks sent their on-the-spot reporters to find and interview rape victims. Now you could regard this as tasteless and send the reporters packing and I would be hard pushed to argue with you on that. However, there is another response: use this as an opportunity to talk about work you or your local partners might be doing with women. Tirana in particular was awash with international news organizations because the United States air force had stationed 29 Apache helicopters at the airport, indicating to war watchers that a ground offensive was in the making. ABC had a studio at the airport; CNN was operating from a large hotel in town. The BBC, Reuters, and others were there in force. But nothing happened, leaving expensive news crews justifying their position and trying to remain occupied. This proved a very good window for humanitarian stories as TV crews and reporters were persuaded to cover food distributions, family tracing services, and even the plight of elderly refugees abandoned by relatives. It is a very good idea to keep up with the news and political developments that affect the arena in which you work.
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Local Media In 1993, in Rwanda a new radio station called Radio Television Libre des Mille Collines started broadcasting. It opposed peace talks between the government of President Juvenal Habyarimana and the Tutsi-led rebels of the Rwandan Patriotic Front. It broadcast “hate messages,” referring obliquely to the Tutsi population as cockroaches in need of extermination. In 1994, President Habyarimana’s plane was shot down. The radio called for a “final war” to exterminate the cockroaches. During the genocide that followed it broadcast lists of people to be killed and instructed killers on where to find them. In a country where 60% of the population was illiterate, it was a powerful influence. The media played a major role in inciting the violence, and in 2003, the key players were given lengthy prison sentences by the International Criminal Tribunal for their role. Not all media are as seriously implicated in war crimes as RTLM. Nevertheless, the media in developing countries and in particular in countries affected by war are usually deeply compromised and are little more than agents of government propaganda. Given that most aid agencies will be governed by principles of impartiality and will seek to help both sides in a conflict, it can be uncomfortable to be in a country where the newspapers and radios portray you as helping the enemy. Actually, it can be more than uncomfortable; it can be downright dangerous. On the reverse side, there is a multitude of examples of positive work with local media, usually based around health education. UNICEF and the ICRC have repeatedly used local radio stations to broadcast details of ceasefires negotiated for immunization days. Johns Hopkins University in the USA has been running health education soap operas on the radio in developing countries since the 1960s. In 1994, the BBC’s Afghan service launched a radio soap opera based on the Archers called Naway Kor, Naway Jwand, or New Home, New Life. It has 35 million listeners. In my experience, working with the local media is far and away the most complex media challenge. It is essential for any humanitarian in any context to have an understanding of how your beneficiaries get their information and what value they place on it. The local media can make or break your mission and seriously impact on your security. Sometimes you can influence this, other times not. Get to know your local media. Meet them; take reporters out to visit your work; line up beneficiaries to talk to them. They are usually very stretched for resources and will welcome the chance. If they do not publish the sorts of stories you want then buy some space. The back page of a local newspaper can make a pretty useful poster advertising changes in food distribution points or information about basic hygiene.
What Stories Do the International Media Like? ● ● ● ●
Children, especially orphans Stories about donations of out-of-date drugs Landmine/cluster bomb stories, especially involving children “Unless we get some more aid in quickly people are going to start dying” stories
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Section One A nurse/doctor/other health worker from their country, preferably someone who is a hero and is prepared to say “I cried when.. …” Atrocities and human rights violations, especially rape A good slanging match, for example, between the aid community and governments or between aid agencies and the UN system.
The British and French media often want a negative story; the Swiss often play it very straight and are fairly uncritical. The Spanish want someone who speaks Spanish to the point of not covering a good story without a Spaniard – for the Americans, the more sentimental the better. This is especially true of American television. The Germans report in depth and their reporters often ask very searching questions. In general, though, they do not stitch you up.
What Do Not They Like? ● ● ●
Anything too complicated Anything that goes against the current accepted version of events Old or ugly people.
This may seem unnecessarily provocative but think about it for a minute. One of the most common problems in a mass movement of people is that the old people are left behind. How often do you here that story told?
What Stories Do Local Media Like? Local media are often very poorly resourced and they will often respond well to invitations that help them fill space easily. For example, many will simply publish your press releases in full or join aid distributions using your transport and report very favorably. Often the journalists are not trained to ask questions but to accept whatever they are told. This is not universal. Many are part of their government’s propaganda machine and it is important to understand this. In a conflict, articles appearing on one side may be misused by the other. For example, “Aid agency gives food to starving people” on one side becomes “Europe supports the enemy” on the other. For field staff, misrepresentations (whether by accident or on purpose) in local media can be much more damaging and dangerous than in international media.
Why Do They Always Go for the Negative Story? There is an old newsman’s adage: Dog bites man – no story. Man bites dog – it is a story. The same principle applies. Aid agency gives food to the starving – well, that is what they do. Aid agency fails to give out food – that is a story. Another definition: news is something that someone, somewhere does not want to be told. All the rest is PR.
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It can also be true of the local media where there are cross-border issues in conflicts (making the enemy look bad for propaganda purposes with the local population); also, local partners/organizations who are dissatisfied use the media to grind their axe or make statements to their own communities. This emphasizes the need to understand the local context and to recognize that the presence of foreign aid workers is not necessarily regarded as a good thing.
Dealing with the Media: A Checklist 1. Check the organization’s policy on talking to the media. In some places, and for very good reasons, all contact is restricted to the head of mission and/or press officer. If this is the case, politely refer questions to the appropriate people. 2. Keep to the facts. Make sure you are well briefed (if there is a press officer they should have packs and they should be able to give you the wider situation of the organization’s press lines. They should be able to accompany you if you are nervous about talking to the media.). 3. Keep to the point. What do you want to say? Avoid waffling and try to be concise. Try not to be flippant as this is often what leads to complaints that you were “quoted out of context.” 4. Try not to treat questions as stupid. Reporters do ask naïve questions but that is because their audience is probably very badly informed about the situation. “How do you feel?”.……not “How do you think I feel?” but “It is very difficult to see the desperate situation of the people here but in the last week when we have been able to deliver 5,000 tons of food it is a relief to know that at least for now, people are out of danger.” 5. If you do not know the answer to a question say so, but offer to find out. 6. Remember you are talking to the reporter’s readers/viewers/listeners and not to the individual in front of you. Therefore, do not resort to jargon. Talk about food and blankets, not relief supplies. Other meaningless words include mission, logistics, food security situation, affected population.… 7. Have some anecdotes ready about your beneficiaries. If reporters want to meet beneficiaries seek their consent first. 8. Keep a record of whom you have spoken to and about what and report it to your managers and/or the press officer. 9. Wear a tee shirt or badge with your organization’s logo prominently displayed. 10. Try not to say “no comment” unless this is the organization’s policy; it sounds defensive and a bit pompous. You can use political questions to underline principles: “Does the Red Cross favour NATO intervention?” respond: “The Red Cross is an impartial and neutral organisation. Our concern is for the safety of the civilian population.”.…“Should the hostages be released?”……“The role of the International Committee of the Red Cross is to ensure that the detainees are treated according to international humanitarian standards.” 11. Do not be afraid to ask questions: Why are you doing this story now? What is your story line? What are you going to ask me? What other information do you have?
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12. Check deadlines, as a missed deadline may be a missed opportunity. 13. Television and radio are actually easier to deal with than print media. Usually, radio and TV journalists need you on tape so you can have a chat before the cameras or tape recorder goes on. Print can be trickier as whatever you say can go down into a reporter’s notebook. 14. Be wary of going “off the record.”. Nonattributable briefings, where the reporter will use the information but not attribute it to you or your organization can be a useful tool but can backfire.
Dealing with Negative Stories: A Checklist 1. Listen to the criticisms; ask reporters to substantiate what they are talking about (often they have nothing but an impression or are following a story set out by other reporters – the news desk back home will have seen a story in another media outlet and wants the same). 2. Be ready with the facts – how many, where, how much. Take them to your model projects; be realistic about the difficulties you have but ready to talk about your achievements. 3. Try not to be defensive. Beware of criticizing other organizations and never do it unless this is the press policy of the organization. UN agencies are a very easy target for the media and this is often politically motivated, especially from US news agencies.
8. Remote Medicine Steven A. Bland
Introduction Remote medicine is about managing risk and anticipating medical emergencies. There are many lessons that crosslink between remote area care and planning medical support in conflict and disasters. As humans continue to explore the planet and beyond, locations become increasingly remote and require extra medical planning. Two-thirds of the planet is under water and remains unexplored. Only a few vessels have the capability to remain under water for any significant length of time. There is also a permanent human presence in space with the construction of the International Space Station (ISS) continuing, plans for a return to the Moon, and a more ambitious goal of sending a human mission to Mars with a likely return journey time of 2 years. When reviewing missions to remote locations, it would be remiss to ignore the similarities and contrasts that space and submarine missions have with those in Antarctica, or indeed with an isolated conflict situation. When considering the challenges of medical support to remote locations such as submarine, space, and Antarctic medicine, it is necessary to understand the constraints to exploration that contribute to the remoteness of a specific manned mission. The remote nature of these missions may be due to a number of factors: ●
●
●
●
Physical – This is most likely to be geographical distances although distances “as the crow flies” may not be numerically great, considering low earth orbit is only 100–300 miles. However, there are other physical constraints such as the energy required to reach these altitudes as well as the g-forces encountered. At sea, distances have significant impact on the availability and cause delay in the arrival of any rescue assets. Operational – Mission objectives may require communication silence (submarine patrol). This adds a self-imposed constraint to the medical support at the remote location and limits medical advice available, if deployed without a medical professional. Time – As well as distance affecting time for rescue, operations in different time zones with respect to the parent nation may affect decision making, including the availability of senior advice “out of hours.” Environmental – The location of the remote operation may have its own obvious impact on the ability to evacuate casualties or facilitate rescue. Constraints may
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vary with seasons (Antarctica) as well as areas with less predictable weather patterns (shuttle landing site in Florida).
Current Mission and Medical Profiles UK Submarine Missions The UK deploys submarines on strategic nuclear deterrent patrols. Crews may range from 130 to 160, and mission duration is likely to be up to 3 months. To maintain mission security, a strict radio silence is maintained. This has a significant implication for medical support and advice. For this reason, each submarine deploys with a doctor with additional training in atmosphere control and radiation medicine. The submarine has a one-bed sickbay and a limited surgical capability.
International Space Station (ISS) In low earth orbit, a multinational crew inhabits and supervises the construction of the ISS. The US Space Shuttle provides mission support and acts as a ferry, although the Russian Soyuz can and has been used. The current crew has six crew members, and average mission duration is approximately 6 months. The ISS does not have a regular physician but provides additional medical training for one or two members of the crew. The ISS remains in continuous communication contact with Mission Control and has significant radio bandwidth to provide medical video conferencing and telemedicine. Medical equipment onboard includes a Crew Health Care System (CHeCS), which provides mission control with physiological data as well as basic diagnostic equipment with telemedicine links to the ground-based flight surgeon.
Antarctic Base Stations Many of the base stations are well established with missions running over the Antarctic winter and lasting more than 6 months. There is a base doctor and surgical facilities with X-ray. A full description of Antarctic medicine has its own chapter. A summary of the hazard and mission profiles is given in Table 8.1.
Types of Medical Challenges Like many risk assessments, medical events can be classified based upon probability and consequence. These may range from self-limiting upper respiratory infections to catastrophic injuries. Some incidents may affect an individual or several personnel, while some infectious diseases may spread throughout the crew. A survey comparing health risk perception by NASA and observed medical incidence during submarine patrols provides an interesting contrast with one key difference being crew size. A smaller crew size may put greater behavioral stress on the crew with less significant
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Table 8.1. Summary of environmental considerations and mission profiles
Factors General
Environmental
Intrinsic
Extrinsic Mission profile
Mission length Activity risks
Personnel Medical staff Onsite medical facilities Radiation medicine Communications
Catastrophe
Catastrophic failure scenarios
UK SSBN Submarine
International Space Station
ANARE Antarctic Station
Conventional injuries Conventional medical conditions Isolation Air purification Radiation Noise Nutritional deficiencies Hyperbaric Hypothermia
Conventional injuries
Conventional injuries
Conventional medical conditions Isolation Microgravity Air purification Noise Nutritional deficiencies Vacuum Radiation Hypothermia 6 months (Low risk, but in microgravity) Extravehicular activities (EVA), minor injuries due to microgravity environment 6 Two crew medical officers (nonphysician) CHeCS
Conventional medical conditions Isolation Nutritional deficiencies
2–3 months (Low risk) Ladders, electrical hazards, hydraulic systems 150 One doctor and two medical assistants Sickbay and limited surgical facility Yes Constant one way (surface to submarine), none from submarine Collision Hull breech – flooding Fire – atmospheric contamination Epidemic Radiation accident
Casevac (individual) options
Crew evacuation options
(if operationally acceptable) Helicopter, subject to range Surface vessel Controlled escape with recovery support in Mk10 submarine escape suit (SEIS) Rush escape in SEIS Rescue submersible (DSRV)
Yes Constant with video c onferencing and telemedicine
Hypothermia 6–9 months (May be arduous) Construction, trekking into polar region, heavy machinery 450 (summer), 100 (winter) One doctor per station plus “assistants” Sickbay, operation theater, laboratory, and X-ray No Constant, ANARESAT with telemedicine
Collision
Fire
Hull breech – decompression Fire – atmospheric contamination Epidemic Solar flare, increase in cosmic radiation Space shuttle
Epidemic
Crew return vehicle (Soyuz/other) Space shuttle crew return vehicle (Soyuz/other)
Transportation accident
(Not during winter)
Fixed wing aircraft (+/− ship) (Not during winter) Weather-dependent (air)
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Disease category
NASA perception of risk survey
US Navy SM Officers 1997–2000
US Navy SM Enlisted Crew 1997–2000
Polaris SM patrols 1968–1973
Mental disorders Sensory Circulatory Respiratory Gastrointestinal Genitourinary Skin Musculoskeletal Injury/poisoning
2 6 9 4 8 7 1 5 3
9 5 7 1 6 8 4 3 2
7 5–6 9 2 5–6 8 3–4 3–4 1
7 6 2 3 5 4 1
Table 8.3. Risk assessments of elements for autonomous medical care (NASA).
19 20 21 22 26
Risk/event
ISS
MOON
MARS
Major illness or trauma Pharmacology of space medicine delivery Ambulatory care Return to gravity/rehabilitation Palliative, mortem, and postmortem care
Y Y G G Y
R Y G Y R
R R Y R R
Red(R) - High risk, Yellow(Y) - Med risk, Green(G) - Acceptable
respiratory conditions and minor injuries (Table 8.2). When planning for future space operations, NASA reviewed 50 aspects of health provision for the ISS, lunar missions, and Mars. Each aspect is classified using the traffic light system of red, yellow, or green. The aspects include elements of primary health care, autonomous medical care (Table 8.3), radiation medicine, medical countermeasures, and behavioral science. When addressing issues such as autonomous medical care, there are five factors: prevention, monitoring, diagnosis, treatment, and informatics. These factors can also be applied to all types of remote medicine. In some cases, prevention may include countermeasures against environmental exposures and hazards such as radiation, malnourishment, and microgravity. Some medical events, although relatively insignificant at home, may be catastrophic in a remote location. This may be due to the incapacity of a key member of crew and subsequent loss of mission capability. In particular, if the healthcare provider is affected then a return to full health may be compromised. Some medical conditions may be beyond the capabilities of the medical facility or experience of the provider. In some locations this may require a casualty evacuation. For some missions, the risk of these events is still prohibitive, e.g., major trauma during a Mars mission. The casualty evacuation itself may be too stressful for an unwell patient, and these factors need to be planned into future missions and may require further research and new technologies.
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Choice of Medical Personnel The responsibility of providing onsite medical care does not always fall to a health professional. Basic medical training is given to all members of the ISS crew while UK submarine crews have a 10% proportion of designated first aiders as well as a medical team. The ISS has nominated and trained Crew Medical Officers (CMOs) trained in advanced techniques but have a non-medical primary mission role. A UK deterrent submarine will deploy with a doctor (Medical Officer). The decision to deploy with a doctor on any mission or to a location depends on the mission, communications (telemedicine), and the ability to evacuate casualties in the event of a condition beyond the capability of a CMO to treat. It is unlikely that any doctor deploying on a remote mission will be used only for medical treatments. Secondary roles are likely but may remain within a bioscience field. Non-medical secondary roles should not interfere with the primary medical role.
Casualty Evacuation Despite preventative measures, injuries and illnesses will occur. Early diagnosis, possibly through monitoring and health surveillance, may prevent deterioration and allow early evacuation preparations, thereby limiting the risks of casualty evacuation. In some cases, conventional treatment may be modified or changed. Cases of possible appendicitis may be treated conservatively with antibiotics rather than embark on surgical management. The decision to evacuate a patient depends on a number of factors: ● ● ● ● ● ●
Operational situation, especially if a military mission Underlying condition and risk of deterioration Supplies/medical experience available on site Facilities to action an evacuation (using own resources) Facilities to action a rescue (using other resources) Risks to other personnel during evacuation/rescue
In the event of a catastrophic failure (see Table 8.1), the evacuation of the entire crew may be required. Recent examples include the Space Shuttle Challenger (explosion during take off, 1986), Russian submarine Kursk (torpedo explosion, 2000), and Space Shuttle Columbia (loss of hull integrity during reentry, 2003). Not all failures result in complete loss of life and many occur during the early or late stages of the mission – take-off and landing phenomenon. This means that evacuation or rescue may still be feasible. Such events may include fire, loss of structural integrity leading to flooding or decompression, or epidemic. In these circumstances, there are still options for the type of crew evacuation. The extraction method depends on the following: ● ● ● ● ●
Timescale and current situation Presence of lifeboat or escape apparatus Availability of recovery services, e.g., on surface of sea or at landing site Availability of rescue services Number and severity of casualties, including ability of crew to facilitate own escape
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In the UK, individual submariners are issued Mk10 Submarine Escape Immersion Suit (SEIS). This allows an individual within a certain depth of water to escape a crippled submarine and survive the elements on the surface before the arrival of recovery services. An individual escape suit has also been researched by NASA for emergency escape into space, in the event of a catastrophic failure onboard the ISS. Where individual submarine escape is restricted by depth of water, rescue submersibles remain the optimal mode of escape. These vessels include the UK LR5 and the US Deep Submergence Rescue Vehicles (DSRVs). The submersibles may require another submarine to act as a mother sub (MOSUB). When the ISS went online, it was originally intended to have a permanently docked lifeboat as the space shuttle is not always docked. Currently the Russian Soyuz capsule can be used although the reentry profile may have g-forces that could be detrimental to an injured or critically ill patient. Until recently the capsule was to be replaced by the X-38 Crew Return Vehicle (CRV). This experimental vehicle used a paraglide mechanism to descend to the Earth rather than parachute.
Research One of the ISS’s primary missions is the preparation for manned missions to the Moon and Mars. This not only includes a physical presence of an Earth orbiting station, but research into the long-term effects of space including microgravity. Countering the effects of space travel includes the effects of low gravity on calcium metabolism and bone, real-time monitoring of the effects of radiation exposures, and countering these effects. Much of the research from the space industry has spin-offs that may have other medical applications. Miniaturization and medical telemetry means that some ground-based treatment may be more accessible worldwide.
Summary Despite very different environments, there are key principles for medical support to any remote location. Medical risk is a function of probability and consequence, and this can be used to plan any mission and the medical resources to mitigate a significant event. The choice of medical staffing depends on the medical risks as well as the size of crew and logistics. A serious or catastrophic event may require either evacuation or rescue depending on whether transition is made using intrinsic or extrinsic resources. Any remote mission will generally encounter hazard in order to reach the location. The journey may be dangerous and despite all safety mechanisms, failures may occur. It is important that any lessons are learnt and applied not only to the same environment or industry but also to any remote mission that involves similar risks.
Further Reading Stuster J. Bold endeavours – Lessons from polar and space exploration. Naval Institute Press: Annapolis, MD. 1996.
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Part A – Medicine at the Ends of the Earth: The Antarctic Iain C. Grant
Medicine at very high latitudes is probably the most remote setting in which a doctor can practice. The setting is so unique that it has been described as “Fourth World” medicine. Organizations that routinely deploy personnel to the Polar Regions, however, demand a service that is as close to “first world” as practicable, and patients’ expectations are continually rising. Polar medicine derives its identity from the geographical location and nature of the environment in which it is practiced. There is no physiological process that makes polar medicine different from other branches of medicine as there is, for example, in hyperbaric work. It is simply the remoteness, the hostility, and the unforgiving nature of the environment in which man struggles to survive let alone work, which makes polar medicine so challenging. Even to define “polar” regions is far from easy. The Arctic and Antarctic circles lie at latitudes 66°33′ North and South respectively, and at these latitudes on at least 1 day a year the sun does not rise nor set. The 10°C isotherm (where maximum temperature does not exceed this) correlates quite well with this defined area, but it is at greater latitudes and considerably more extreme temperatures that The British Antarctic Survey (BAS) and other organizations undertake the majority of polar science and exploration in the southern polar regions. While both poles of the earth share common attributes of cold, dark, and severe weather, the two ends of the earth are very different. The Arctic is a sea surrounded by land, and influenced by the Gulf Stream, while the Antarctic is a land mass surrounded by ocean from which cold currents drag heat. As a result, Antarctica is colder and considerably drier. The average winter temperature at the South Pole is almost 40°C colder than at the North. The Antarctic plateau is more similar in climate to Mars, than to the rest of the earth. It is a frozen desert, much above 10,000 ft, where little in the way of natural life forms can exist. Perhaps, above all else, it is the isolation that makes Polar and particularly Antarctic Medicine unique. Anywhere else in the world it is usually possible to arrange a medical evacuation within at most a few days. At Halley Bay, one of the British Research Stations, in winter, such arrangement may not be possible for several months. Indeed, it is more likely that a patient could be evacuated from the International Space Station, than from Halley in winter (Lugg 2006). The doctor practicing polar medicine must be self-reliant. The welfare of the doctor, the patients, and other base members depends upon it. There are indigenous people in the Arctic. Throughout Northern America, Europe, and Asia, native people carve out an existence, living all year round in the area. Medicine among these peoples is like that in any other aboriginal population, and there are well-developed systems of healthcare that follow models of primary, secondary, and tertiary services. In the Antarctic, however, the population is transient. There
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are scientists, explorers and tourists, fishermen, and commercial surveyors. Most of those who visit, and certainly all who stay for the long harsh winter, are young, fit, and carefully medically screened before they are permitted to journey South, although there remains debate about the utility of much of the screening undertaken (Grant 2002; Catalano 2002). Nevertheless, injury and illness do occur. In recent years tourism has steadily increased, with some questions being raised about medical standards of some parts of this industry (Levinson and Ger 1998). The geopolitical importance of the polar region is increasingly recognized, and more and more research takes place. NASA and ESA have recognized the analogues with space travel, which Antarctic isolation provides at a fraction of the cost of actual space flight. Polar medicine grows in importance with the “development” of the continent. Evidence on which to base medical decision making in polar regions is extremely sparse. The principles of trauma care, environmental and occupational medicine, and of the management of emergencies undoubtedly apply to polar medicine as they do in temperate zones, but the detail of Western medicine does not necessarily translate well to the polar environment. The doctor needs to become more self-reliant, to develop clinical judgment and at the same time learn to depend less on investigations (which are simply not available). Prevention and preparation are both of increased significance in polar isolation where treatment may be more difficult. Where lives are at stake, it is possible to argue that planning should be for the worst case scenario rather than likely events. This philosophy has to be some extent tempered by realism as far as costs and benefits are concerned. This results in Antarctic bases that are equipped to an adequate, but necessarily lesser level in terms of therapeutic equipment than can be expected in hospital (Catalano 2002; Mao 2002; Figueroa 2002; Council of or Managers of National Antarctic Programs, http://www. comnap.aq). The doctor cannot be too specialized in approach; a broad knowledge and wide range of practical skills are necessary to provide good polar medical care. In small bases, where less than 25 personnel overwinter, there is no room for the luxury of anesthetists and surgeons, dermatologists, and psychiatrists. These roles all reside with the same person. Modern developments in communication and information technology help make the polar physician less isolated from advice and counsel (Grant 2004; Pillon 2004; Pillon et al. 2004a, b; Scientific Committee on Antarctic Research. Expert Group on Human Biology and Medicine, http://www.medicalantarctica.org), but it remains impossible to physically evacuate patients, or provide specialist skills “in person” to a substantial proportion of the polar population for the majority of the year. The doctor is an important member of the polar team and must strive to maintain the highest practicable standards. The “generalist” is a very rare medical animal nowadays. Increasingly, doctors become more specialized at an earlier stage in their careers. Recruiting Antarctic doctors therefore is based more on the person than on his or her curriculum vitae. Training can help to provide necessary knowledge and skills but cannot produce the type of person who can survive an Antarctic base winter. Doctors come from a wide range of backgrounds. In recent years anesthetists, general practitioners, and emergency physicians have formed the majority of appointees. These doctors spend between 3 and 9 months preparing for deployment during which time they acquire practical skills and specialized knowledge. Most BAS doctors undertake a diploma or
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masters degree in Remote Healthcare at the University of Plymouth during their preparation and deployment, undertaking research while deployed, which can form the basis for a master’s dissertation on return (Grant 2002b).
Antarctic Medical Problems Physical Health Problems In British Antarctic bases, the vast majority of the work for the doctor is of a routine, relatively minor, nature (Fig. 8.1). Many of the somatic health problems in Antarctica have to do with cold, altitude, and trauma. In a midwinter setting, where a cup of tea thrown in the air freezes before it hits the ground, the dangers of cold injury are obvious. It has been estimated that an inactive person in full “polar” clothing can in winter have a drop in core temperature to life-threatening levels in under 30 min. Cold injury is also frequent (if usually minor), and particular care is needed when handling liquids at low ambient temperatures where even a small accidental splash can mean instant frostbite (Ohno and Takahiro 2002; Mahar 2002; Cattermole 2001). Not only patients suffer from the effects of cold. Medical equipment is often not designed to function at these extremes of temperature: plastics become brittle, metal untouchable, fluids are impossible to keep liquid, and necessary clothing simply gets in the way. Weather unpredictability makes rescue difficult and sometimes dangerous; rescuers and medical staff must be constantly wary that they do not themselves become victims. Much of the fieldwork in Antarctica is carried out a relatively high altitude. Most bases are at or close to sea level, and ascents tend to be rapid due to airlifting of field parties straight onto the plateau. At the South Pole weight loss of 5 kg in the first week, attributable to resting tachypnea and tachycardia has been reported, emphasizing the physiological stress applied by such rapid ascent (Mahar 2002).
Sprains / strains
Dental
Environmental Trauma Dental Non Trauma Psychological Trauma Environmental Sprains /Strains
Psychological Non Trauma
Fig. 8.1. Workload analysis (2004–2006).
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In summer, the combined effects of an ozone hole and reflection from snow with a ground albedo of 80–90% can rapidly become painfully evident to the unwary. Nutrition has always been important in polar expeditions. Fresh food is at most available for the short summer season in limited amounts. For most of the year there is reliance on dried, frozen, and tinned foodstuff. On expeditions away from base, the amount and type of food that can be carried is limited. There is, therefore, much reliance on dehydrated meals, which are lightweight and easy to prepare with limited equipment. Energy requirements are high, with allowance on field trips being about 3,500 keal per person per day, but meeting this simple nutritional goal can be very difficult in the ill patient. Field rations and hard work can lead to considerable drops in body fat, increased HDL cholesterol, increased overall strength, and paradoxical drop in aerobic power. Vegetables are relatively scarce, but other sources of fibre and vitamins are available. Personnel need to be encouraged to take supplements, and medical officers should be alert for vitamin deficiencies. Shackleton, one among many of the greatest Antarctic explorers, was himself sent home from an early expedition suffering from scurvy (Guly 2002; Shackleton). While theoretically this should not be possible today subclinical vitamin deficiencies remain as possibility especially in those who have undertaken two consecutive winter stays. Conversely of course, with relative inactivity and free availability of high-calorie diets, those who overwinter have a temptation to eat too much and a tendency to gain weight. The doctor needs to be active in promoting healthy eating at all times. There has been much speculation about the immunosuppressive effects of Antarctic life. There is evidence of leucopenia and depression of cell-mediated immunity during winter isolation, but the clinical effects of this are not fully understood. Many current studies are attempting to explore apparent viral reactivation, and the longer term effects of possible immune suppression (Muller 1995; Pitson et al. 1996; Francis 2002). A number of studies have investigated the effects of constant darkness on circadian rhythms, melatonin, and other hormonal mechanisms. Significant biochemical disturbances have been reported (for example, the “polar T3 syndrome” where marked drops in free thyroxine were demonstrated in overwintering US personnel) but the clinical significance of these findings remains uncertain (Palinkas et al. 2004).
Environmental, Occupational, and Public Health Under the terms of the Antarctic Treaty, environmental pollution is strictly regulated with responsible waste management being undertaken by most nations. The environment in Antarctica is, however, extremely sensitive, and personnel must be ever vigilant to prevent personal inadvertent pollution by even minor spillage of toxins. At one stage there was a nuclear reactor at the American station McMurdo. Early problems prompted the removal of this particular potential disaster, but fuel remains a requirement and the potential for dramatic oil spillage exists and requires careful monitoring. The mere disposal of clinical waste, so easy to get rid of in hospitals, needs careful thought in terms of how and where it can be stored, and how it can safely be removed from the continent for safe permanent disposal.
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Trauma is probably the single most important medical problem in Antarctica. Although many injuries are minor, the potential for severe trauma exists, and it is incumbent on the Medical Officer to help as far as possible in accident prevention. Interestingly, in several reports, the incidence of trauma has been higher during leisure than during work activities (Cattermole 1999, 2001; Taylor and Gormley 1997). Adherence to strict occupational health guidelines may be more difficult at remote work sites. The availability of mechanical handling devices may be limited, and where these are present there may be practical difficulties in their use in certain circumstances. The potential for manual handling injuries is high and the doctor must be vigilant in observing lifting practices and individual’s technique. Noise pollution, overuse, and repetitive work syndromes have all been reported (Mahar 2002). Fire is a major hazard in Antarctica where wooden buildings become very dry, while the availability of water for firefighting can be very limited. At least four major fires have occurred, thankfully with few deaths or serious injuries. However, the base members of the Russian Vostock station had to spend 8 months without a power plant to supply heat after a fire. When one considers that Vostock is the place on earth where the coldest temperatures have been recorded, the feat of endurance involved is almost incredible. Air safety is also a serious concern. The majority of the deaths in the US Antarctic program have been aircraft related. The doctor must be vigilant for signs of stress and physical illness among aircrew, and may have to be quite forceful resisting operational pressures to allow a sick pilot to continue flying. Pilot hours are limited by law. In a busy Antarctic summer it is easy for a pilot to “run out” of hours, and the doctor will be involved in application to Civil Authorities for extensions. The increase in Tourism in the area poses considerable potential medical problems. Tourists are often elderly, have no medical screening before departure, and may themselves have little idea of the rigors of even a short trip on land in Antarctica (Levinson 1998). There is much debate about the responsibility of government-sponsored organizations to provide medical care for tourists, which poses interesting medicolegal questions. Essentially, British Antarctic Survey policy, and that of most nations, is that emergency aid will be given to tourists, with a view to safe evacuation to secondary medical care as soon as practicable, at the expense of the tour operator or the tourist.
Psychological Health Problems Psychological “problems” have been reported since the earliest polar expeditions. The lifestyle in Antarctica does put personnel under extreme pressure and minor adjustment problems are not infrequent, although more serious are thankfully rare. On most bases alcohol is freely available, and irrespective of advice from doctors and policies imposed by management, some base members will use alcohol as a coping strategy, sometimes to excess. This can lead to problems of competence at work as well as antisocial behavior, aggression, and personal ill health (Palinkas 2002; Ursin et al. 1991). The effects of psychological stresses on the immune system are recognized but poorly understood, but it seems likely that further work will prove this to be an important factor.
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The effects of social isolation, disillusion with the reality of Antarctic life when compared with expectation, the severity of the environment, and the closed nature of communities are all potential stressors encountered more frequently in polar regions. The doctor needs to have a basic understanding of small group dynamics and should be aware of described “syndromes” such as Seasonal Affective Disorder (although this may be no more prevalent in Antarctica than at lower latitudes) and the so called “Winter-Over syndrome.” Mood swings are common among personnel and do not necessarily imply maladjustment. The working group in human biology and medicine of the Scientific Committee on Antarctic Research (SCAR) has for many years been trying to identify and quantify “abnormal” adaptation to Antarctic life, with only limited success. Most of the “symptoms” of maladjustment can be “normal,” and it is a difficult task for the doctor to weigh often multiple factors in assessing the individual and deciding who actually needs help (Palinkas 2002; Ursin et al. 1991). Many countries use formal psychological screening tests in the selection of personnel especially for overwintering posts, but there is no agreement as to which of the many available tests are valid in the Antarctic environment. There is currently little evidence as to whether these screening tests improve outcome, although research now underway may help to clarify this contentious issue. Some national programs also undertake formal debriefing of Antarctic winterers, but again the benefits are unclear.
Arctic Medical Problems Healthcare in the arctic has lagged behind that in other parts of the same countries, with higher infant mortality, shorter life expectancy, and higher incidence of diseases such as tuberculosis. There remain problems with parasitic diseases, which reflect the lifestyle of the indigenous peoples, and at the same time increased contact with “civilization” increases exposure to other infective diseases, and industrialization poses concerns over environmental health (Nayha and Jarvelin 1998; Curtis et al. 2005; Butler et al. 1999). Alcohol abuse is reportedly very prevalent; the problems of isolation cannot be ignored, and the incidence of seasonal affective disorder may be as high as 20% (Paschane 1998). Polar medicine poses great challenges to the doctor. The workload is often low, and remaining motivated, continuing education, and maintaining skill levels can be difficult. The doctor is subjected to the same stresses as the rest of the population, yet is expected by peers to rise above this and be unaffected. A special type of person is required to succeed. My best wishes go with all who read this chapter who are about to embark on a polar expedition.
References Burns R & Sullivan P. Perceptions of danger, risk taking and outcomes in a remote community. Environ Behav 2000;32(1):32–72. Butler JC, Parkinson AJ & Funk E et al. Emerging Infectious Diseases in Alaska and the Arctic: A Review and a Strategy for the 21st Century. Alaska Med 1999;41(2):35–43
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Catalano F. Antarctic Medical Support and Standards. Proceedings of the Tenth Symposium in Antarctic Logistics and Operations, Shanghai, 2002, pp 22–24 Cattermole TJ. The Epidemiology of Cold Injury in Antarctica. Aviat Space Environ Med 1999 Feb;70(2):135–140 Cattermole TJ. The Incidence of Injury with the British Antarctic Survey, 1986–1995. Int J Circumpolar Health. 2001 Jan;60(1):72–81. Curtis T, Kvernmo S & Bjerregaard P. Changing Living Conditions, Life Style and Health. Int J Circumpolar Health 2005;64(5):442–450 Figueroa M. Medical Capacities of the Chilean Antarctic Program. Proceedings of the Tenth Symposium in Antarctic Logistics and Operations, Shanghai, 2002, p 177 Francis JL, Gleeson M & Lugg DJ et al. Trends in Mucosal Immunity in Antarctica During Six Australian Winter Expeditions. Immunol Cell Biol 2002;80:382–390 Grant I. Telemedicine in the British Antarctic Survey. J Circumpolar Health 2004, 63(4):356–364 Grant IC. Medical Screening in the British Antarctic Survey. Proceedings of the Tenth Symposium in Antarctic Logistics and Operations, Shanghai, 2002a, pp 51–55 Grant IC. Training of Medical Officers for Antarctic Service. Proceedings of the Tenth Symposium in Antarctic Logistics and Operations, Shanghai, 2002b, pp 57–61 Guly HR. Medicine in the Heart of the Antarctic 1908–2001. Emerg Med J. 2002;19:314–317. Levinson J & Ger E. Safe Passage Questioned. Cornell Maritime Press, Maryland, 1998 Lugg DJ. Head of Environmental Medicine. NASA, 2006, Personal communication Mao Y. The medical support for China Antarctic Scientific Expedition. Proceedings of the Tenth Symposium in Antarctic Logistics and Operations, Shanghai, 2002, pp 1–4 Mahar H. A 5 Year Summary of USAP Medical Care Activities in the Antarctic. Proceedings of the Tenth Symposium in Antarctic Logistics and Operations, Shanghai, 2002, p 178 Muller HK, Lugg DJ & Ursin H et al. Immune Responses During an Antarctic Summer. Pathology 1995;2792:186–190 Nayha S & Jarvelin MR. Health Trends in Northern Finland. Int J Circumpolar Health 1998;57(2–3):94–103 Ohno G & Takahiro M. Morbidity of Wintering-Over Participants in 1st to 41st Japanese Antarctic Research Expeditions: Analysis of 4760 cases. Proceedings of the Tenth Symposium in Antarctic Logistics and Operations, Shanghai, 2002, pp 36–45 Palinkas L, Reedy K & Smith M et al. Influence of Latitude on the Physiological and Psychological Correlates of Polar T3 Syndrome. Terra Nostra. Proc SCAR Open Science Conference, Bremen, Germany, 2004, p 196 Palinkas L. Psychology of Isolated and Confined Environments. Proceedings of the Tenth Symposium in Antarctic Logistics and Operations, Shanghai, 2002 Paschane D. Variability of Substance Abuse. Global Variability: Is Latitude a Unique Etiological Factor? Int J Circumpolar Health 1998;57(4): 228–238 Pillon S, Peri A & Bachelard C. Website for Medical Information Sharing in Antarctica. Terra Nostra. Proc SCAR Open Science Conference, Bremen, Germany, 2004a, p 348 Pillon S, Todini AR & Vanni PB. Telespirometry Testing in Antarctica. Terra Nostra. Proc SCAR Open Science Conference, Bremen, Germany, 2004b, p 195 Pillon S. eHealth in Antarctica. J Circumpolar Health 2004;63(4):436–442 Pitson GA, Lugg D & Muller HK. Seasonal Cutaneous Immune Responses in an Antarctic Wintering Group. Arctic Med Res 1996;55:118–122 Shackleton EM, diary, 16 January 1903 (ScottPolar Research Institute) Taylor DM & Gormley PJ. Emergency Medicine in Antarctica. Emerg Med 1997;9:237–245 Ursin H, Bergan T & Collet J et al. Psychobiological Studies of Individuals in Small, Isolated Groups in the Antarctic and in Space Analogues. Environ Behav 1991;23(6):766–781
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Part B – High Altitude Sundeep Dhillon
Objectives
●
●
●
To describe the physiological effects of high altitude and acclimatisation To outline the prevention, recognition, and treatment of high-altitude illnesses To discuss the provision of medical care during conflicts or catastrophes at high altitude
N.B. Drug dosages are given as a guide only and should be checked. Medicines should only be used under supervision of an appropriate and competent medical authority.
Introduction Humans probably evolved at sea level and with the exception of the high-altitude populations of Central Asia and South America (who have adapted over many generations to the rarefied air) are poorly suited to high altitude. The most significant problem is hypobaric hypoxia (low oxygen levels as a result of a reduced barometric pressure), but cold, wind, reduced humidity, increased ultraviolet radiation, and a paucity of flora, fauna, and readily available drinking water make this a challenging environment. Mountains are formed under conditions of great pressure and are often located in proximity to tectonic plate margins. As a consequence these regions are often involved in natural disasters, mainly earthquakes and mudslides. On October 8, 2005 an earthquake registering 7.6 on the Richter scale occurred in Pakistan. At least 86,000 people were killed and more than 69,000 injured with extensive damage to property and infrastructure in northern Pakistan. The heaviest damage occurred in the Muzaffarabad area in Kashmir, where entire villages were destroyed and at Uri where 80% of the town was destroyed. Most of the affected people lived in mountainous regions with access impeded by landslides that blocked the roads, leaving an estimated 3.3 million homeless in Pakistan. The UN reported that four million people were directly affected, prior to the commencement of winter snowfall in the Himalayan region. It is estimated that damages incurred are well over US$5 billion (300 billion Pakistani rupees). The subsequent relief effort was hampered by the high-altitude terrain, remote villages with single access roads blocked by landslides, and the onset of the Himalayan winter (snow started falling in some areas on October 13). Mountains form a natural barrier, often used as the border between countries. When disputes arise, increasingly over the origin of water courses originating in the mountains, soldiers are exposed to the hazards of the high-altitude environment. The highest conflict in the world is the dispute between India and Pakistan over parts of Kashmir. Troops have been stationed and have fought at altitudes over 5,000 m on the Siachen Glacier.
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Nearly 140 million people live at altitudes above 2,500 m. The two regions of the world with the largest high-altitude populations are the South American Andes and the Tibetan plateau (Himalaya and Karakorum). It is estimated that between 10 and 17 million people live at over 2,500 m in the Andes, and that over 50,000 people in Peru reside above 4,000 m. Lhasa (3,658 m) in Tibet has over 130,000 inhabitants. Other areas of the world with significant high-altitude populations include Central and North America (Rockies), Europe (Alps), Russia (Caucuses), Africa (Tanzania, Kenya, Uganda, Somalia, and South Africa) and Indonesia.
Definition There is no universally accepted definition of high altitude (Table 8.4), but in medical terms the following definitions reflect the underlying physiology. There is much individual variation with some individuals suffering with acute exposure to 2,000 m. Most people will suffer to a greater or lesser degree with rapid ascent above 2,500 m (the height to which a commercial airplane is pressurised). The majority of altitude illness occurs between 2,500 and 3,500 m due to the large number of people ascending rapidly to these altitudes, mainly for recreational purposes. Table 8.4. High-altitude definitions Description
Altitude (m)1
Comments
Low altitude Intermediate altitude High Altitude Very high altitude
<1,500 1,500–2,500 2,500–3,500 3,500–5,800
Extreme altitude
>5,800
No effect on healthy individuals Arterial oxygen saturation remains above 90%. Altitude illness possible2 Altitude illness common with rapid ascent above 2,500 m Arterial oxygen saturation falls below 90%, especially with exertion/exercise. Altitude illness is common even with gradual ascent Limit of permanent human habitation, progressive deterioration with increased length of stay eventually outstrips acclimatisation, marked difficulty at rest
Adapted from The High Altitude Medicine Handbook, 3rd Ed 1 1 m = 3.281 ft. 1 ft = 0.305 m 2 At sea level in healthy individuals, arterial oxygen saturation is 97-100%. Lower values are seen in smokers and those with lung disease. Below 92% supplemental oxygen is usually administered.
The High-Altitude Environment The high-altitude environment is uniquely challenging for humans. A basic understanding of the factors involved is essential in planning sensible strategies for missions into high-altitude regions.
Barometric Pressure Barometric pressure decreases exponentially with increasing altitude. The proportion of oxygen in the atmosphere remains constant at 21% (at altitudes that support life), and therefore the available oxygen is directly related to the barometric pressure.
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At Everest Base Camp (around 5,300 m) the barometric pressure (and therefore the amount of oxygen available to the body) is approximately half that at sea level, reducing to one-third of sea-level values at the summit (8,850 m). Barometric pressure is generally lower in winter than in summer and decreases with increasing latitude (mountains in the subarctic “feel” as if they are equivalent to Himalayan mountains a few hundred meters higher). The available oxygen for any given altitude is, therefore, lowest on subarctic mountains in winter (e.g. Denali) and highest on equatorial mountains in the summer (e.g. Kilimanjaro).
Temperature Ambient temperature falls linearly with increasing altitude (1°C drop for every 150 m of ascent). In a snow and ice environment very little heat is stored by the ground, and radiant heat from the sun provides most warmth. Ultraviolet radiation increases by approximately 4% for every 300 m gain in altitude, increasing the risk of sunburn, snow blindness and skin cancer. When this solar radiation is reflected off white snow and ice, temperatures can reach over 40°C on Everest. Conversely, when the sun sets (or goes behind a mountain feature or cloud) the temperature can drop dramatically by as much as 40°C. Frostbite may easily occur, especially if flesh is exposed to the wind.
Wind Chill The effect of wind on exposed flesh is far more important than the actual temperature. Wind chill is the apparent temperature felt on exposed skin, which is a function of the air temperature and wind speed. The wind chill temperature is always lower than the air temperature, except at higher temperatures (Fig. 8.2).
Wind speed (km/hr)
Air Temperature (Celsius) 6 8 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100 105 110
0 −1 −3 −2 −4 −3 −5 −3 −6 −4 −7 −5 −7 −6 −6 −8 −7 −8 −9 −7 −9 −8 −10 −8 −10 −8 −10 −9 −10 −9 −9 −11 −10 −11 −11 −10 −11 −10 −10 −12 −10 −12 −11 −12 −11 −12 −11 −12 0 to −10 Low
−2 −4 −5 −6 −7 −8 −8 −9 −10 −10 −10 −11 −11 −12 −12 −12 −12 −13 −13 −13 −13 −14 −14 −14
−3 −4 −5 −10 −15 −7 −5 −14 −19 −8 −7 −6 −14 −20 −9 −8 −7 −15 −21 −9 −9 −8 −17 −23 −11 −10 −9 −18 −24 −12 −10 −11 −19 −25 −12 −10 −12 −20 −26 −13 −11 −12 −20 −27 −14 −11 −13 −21 −27 −14 −12 −13 −15 −21 −28 −12 −14 −15 −22 −29 −13 −14 −15 −22 −29 −13 −14 −16 −23 −30 −13 −15 −16 −23 −30 −14 −15 −30 −16 −23 −14 −15 −31 −17 −24 −14 −15 −31 −17 −24 −14 −16 −31 −17 −24 −15 −16 −32 −17 −25 −15 −16 −32 −18 −25 −15 −16 −32 −18 −25 −15 −17 −33 −18 −25 −15 −17 −33 −18 −26 −10 to −25 Moderate −25 to −45 Cold
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Fig. 8.2. Windchill Index (copyright from Wikipedia: http://upload.wikimedia.org/ wikipedia/en/0/02/Windchill_chart.GIF).
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Humidity The amount of water vapor in the air (absolute humidity) decreases with temperature. This can lead to dehydration in cold, high environments since exhaled breath is fully saturated with water. When this is combined with the increased respiratory rates required at altitude (magnified when working) the water losses through breathing alone can be significant, 3–4 l of water per day may be required to avoid dehydration. When this has to be obtained by melting snow, sufficient fuel must be taken.
Acclimatisation Acute exposure to the summit of Mt. Everest would result in loss of consciousness within a few minutes, followed rapidly by death. This is equivalent to sudden aircraft cabin depressurisation. Yet, some people have managed to climb Mt. Everest without the use of supplemental oxygen. This is only possible due to a number of changes in human physiology, which are collectively known as acclimatisation. The main effects noticed by the individual are an increase in resting heart and respiratory rates accompanied by a decrease in exercise capacity (maximum heart rate). The proportion of red blood cells, which carry oxygen, increases along with a raft of other biochemical adjustments, which aim to improve oxygen delivery and utilisation. Unlike adaptation, where favorable characteristics are genetically selected over many generations, the effects of acclimatisation are rapidly lost on descent to low altitudes.
High-Altitude Illnesses Ascending to high altitude too rapidly can result in a range of disorders that may be life threatening. They are best prevented using a gentle ascent profile allowing plenty of time to acclimatise. There is great individual variation, and some people will be susceptible to the effects of high altitude even with an extremely conservative ascent profile. Awareness, early recognition, and prompt treatment of high-altitude illnesses are thus paramount.
Acute Mountain Sickness (AMS) Four teenage members of a youth expedition were attempting Kilimanjaro in Tanzania (5895 m). Setting off late from the park entrance (1600 m), the group reached Mandara Hut (2740 m) in just under 3 hours. After a poor nights sleep, all four complained of a headache, loss of appetite and tiredness the following morning. All were assumed to have AMS and treated with a combination of paracetamol (1 g every six hours) and acetazolamide (125 mg every twelve hours). Following two days rest the group was able to continue and all successfully reached the summit.
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The rate of ascent is probably the most important modifiable factor in preventing high-altitude illness. In Nepal 50% of trekkers getting to 4,000 m in five days suffered from AMS compared with 84% of those who flew directly to 3,860 m. Above 3,000 m one should ascend no more than 300 m per day with a rest day every three days. This may be irritatingly slow for some members of the team, but provides an opportunity for everyone to acclimatise. There will be occasions when it is not possible to camp within a 300 m altitude gain of the previous night’s camp. In these situations an extra night prior to the extra height gain is advised. It is the sleeping altitude that matters, so it is perfectly acceptable to carry supplies higher (say 500 m), provided one descends to a camp at a lower altitude (300 m or less above the previous night’s camp) – “climb high, sleep low.” The symptoms of AMS are headache, nausea, vomiting, lethargy, fatigue, loss of appetite and poor sleep. None are specific and other conditions such as dehydration, hypothermia, exhaustion and viral infections are also common, but AMS must be excluded in the mountains, particularly if there has been a recent height gain. The mechanism is unknown, but thought to involve increased permeability of blood vessels leading to swelling (oedema) of the brain. Swelling of the limbs and face are risk factors for altitude illness. Treatment involves avoiding any further ascent until symptoms have resolved, simple painkillers (paracetamol or ibuprofen) for headache and acetazolamide (125– 250 mg twice a day). With severe AMS (or if the symptoms do not improve with the aforementioned medicines) dexamethasone (4 mg every 6 hours) may be used along with supplemental oxygen. Descending to a lower altitude is the most effective and definitive treatment for all forms of altitude illness. Acetazolamide 125–250 mg at night (or morning and night) is also effective as a prophylaxis to reduce the incidence of AMS in susceptible individuals or when a large height gain is unavoidable (e.g. crossing a high mountain pass). It is most effective if taken a few days before going to altitude.
High-Altitude Cerebral Oedema (HACE) From the summit oft Cho Oyu in Tibet (8201 m) a team of British mountaineers spotted a lone figure moving slowly and unsteadily towards them. Realising he was in difficulty they descended quickly and found him lying face down in the snow. On closer inspection they found that he had lost his gloves and sunglasses and was so confused that he was unable to answer simple questions. A diagnosis of HACE was made and an injection of dexamethasone 8 mg administered. Eventually he was helped down to Camp 3 (7400 m) where he was met by team mates. On returning to Advanced Base Camp (5650 m) three days later he was found to have no memory of the incident. Despite making a full recovery from HACE, he eventually lost four fingers from frostbite. HACE is a life-threatening form of altitude illness. Fortunately it is rare affecting around1-2% of people ascending to 4,500 m. It is usually preceded by AMS, but can occur without warning. The cardinal feature is ataxia (unsteadiness – best tested by
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heel–toe walking with the eyes closed). HACE is often accompanied by strange and inappropriate behavior (such as removing gloves). Almost any neurological sign and symptom may be seen including strokes, but the most common are confusion, disorientation, hallucinations and an inability to pass urine. Untreated it can rapidly lead to unconsciousness, coma and death. The main treatment is immediate descent. Dexamethasone 8 mg is given immediately (oral or iv) followed by 4 mg every 6 hours. Supplemental oxygen should be given if available. A portable hyperbaric chamber may also be beneficial and should be considered by all teams ascending to very high/extreme altitudes. Other altitude illnesses commonly occur along with HACE and both acetazolamide and nifedipine may be considered. Descending to a lower altitude is the most effective and definitive treatment for all forms of altitude illness.
High-Altitude Pulmonary Oedema (HAPE) On descending from the summit of Aconcagua in Argentina (6962 m), a young female climber became increasingly tired and breathless. On arriving back at Camp 2 (5700 m) she began to cough up blood stained sputum and complained of pain in her chest. On examination at rest she was found to have a respiratory rate of 44, a heart rate of 142 and an arterial oxygen saturation of 65%. A diagnosis of HAPE was made and 20 mg of Nifedipine SR given. With her friends carrying her equipment, she was able to descend to Base Camp (4200 m). The following morning she was evacuated by helicopter to the local hospital. After two days of treatment she was given the “all clear” and discharged home. Unlike AMS and HACE that appear to be at opposite ends of the same spectrum of disease, HAPE is probably an independent altitude illness. It also involves increased permeability of blood vessels, but this time in the lung, where fluid leaks into the lung, reducing the space available for gas exchange and causing extreme respiratory distress (drowning from inside). The incidence may be 10% with rapid ascents to 4,500 m, but 1-2% is more likely with a sensible ascent profile. HAPE typically occurs on the second night after ascending to high altitude and is more common following a viral upper respiratory tract infection. It may be preceded by AMS and is manifested by shortness of breath, initially on exertion (out of proportion to the activity) and then as the disease progresses to acute shortness of breadth at rest. They may be so severe that the individual can not lie down (hence symptoms worse at night) and may be accompanied by a wet, bubbly, productive cough with blood in the sputum (pinkor red-stained). A dry cough is common at altitude due to the dry air and if not symptomatic is not related to HAPE. An increased heart and respiratory rate is usually found even at rest. Treatment is immediate descent and nifedipine 20 mg four times a day. Supplemental oxygen and a portable hyperbaric chamber may be used if available. Descending to a lower altitude is the most effective and definitive treatment for all forms of altitude illness.
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People who have suffered an episode of HAPE remain susceptible to HAPE (usually around the same altitude as the original episode). Further ascent is inadvisable, but if unavoidable nifedipine may be used prophylactically. There is some evidence that inhaled salmeterol (125 μg twice daily) may also be effective. Prophylaxis against HAPE should not be a substitute for graded ascent.
Other Problems of High Altitude Retinal hemorrhages are common at high altitude [up to 50% of trekkers at Everest Base Camp (5,400 m)] but are usually peripheral and asymptomatic. If central, there may be a sudden, painless loss of vision. The individual must be evacuated to definitive medical care. Gastrointestinal diseases may result from assuming that glacial water is clean or not boiled for long enough. The temperature at which water boils decreases with barometric pressure, and therefore water must be boiled for longer. Fresh snow may hide the site of a previous camp toilet and care must be taken to select appropriate water sources and ensure that the water is clean. Alluvial deposits in glacial water may lead to gastrointestinal discomfort and mild upset. Sleep is often disturbed. Respiratory drive comes from a build up of carbon dioxide from active tissues rather than from low oxygen. At night the respiratory center is depressed and periodic breathing may occur. Respirations become shallow and irregular and may stop altogether for up to 30 seconds. During this time carbon dioxide levels build up until breathing resumes. This pattern may occur throughout the night resulting in a fitful, restless sleep. Acetazolamide 125 mg at night may be used to treat periodic breathing.
Strategies for Optimizing Emergency Deployment to High Altitude Personnel may need to ascend rapidly to high altitude during disaster relief and military operations. Previous performance at altitude is the most reliable, but not infallible guide to future performance, provided the individual is healthy and not suffering from any illness (especially a viral upper respiratory tract infection). Such missions are hazardous and are ideally undertaken by experienced high-altitude residents or adequately acclimatised small teams familiar with the type of terrain. A doctor experienced in high-altitude disorders should be consulted at an early stage. Medicines such as acetazolamide, dexamethasone, and nifedipine may be used prophylactically. Physical performance (payload carried, speed across terrain, and endurance) will be significantly reduced. Helicopter resupply or evacuation may not be possible unless the airframe has been stripped of excess weight and modified for high-altitude work and is rarely possible above 5,000 m. A detailed risk assessment is mandatory before committing personnel to such a mission.
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Further Reading Medex. Travel at High Altitude. Medex, 2007. Free download from www.medex.org.uk Forgey WW. Wilderness Medical Society Practice Guidelines for Wilderness Emergency Care, 5th ed, The Globe Pequot Press, 2006 Pollard AJ and Murdoch DR. The High Altitude Medicine Handbook, 3rd ed, Radcliffe Medical Press, 2003 Warrell D, Anderson S, Johnson C and Dallimore. Oxford Handbook of Expedition & Wilderness Medicine, 1st ed, Oxford University Press, 2008 West JB, Schoene RB and Milledge JS. High Altitude Medicine and Physiology, 4th ed, Hodder Arnold, 2007
SECTION
2
Disasters, Public Health, and Populations Adriaan Hopperus Buma and Peter F. Mahoney 9.
Disasters: an overview Annex A. Hope Hospital Major Incident Plan extract Annex B. 7th july Bombing-prehospital response
10. 11. 12. 13. 14. 15. 16. 17.
Responding To Acute Humanitarian Crise The Military Approach To Medical Planning Health Risk Management Matrix-A Medical Planning Tool Surveillance and control of communicable disease in conflicts and disasters Health Planning in action Health Planning in action Op Phoenix Health Care Of Prisoners And Detainees Populations and people
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The aim of this section is to give the reader a framework within which to consider disasters and how they affect people. There are different ways of planning a response to bring help to a stricken population, and a number of ways are described here. A population is not a homogeneous grouping – within a population there will be groups with particular vulnerabilities such as prisoners and an introduction is given to the special considerations they require.
9. Disasters: An Overview
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Tony Redmond
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Objectives ● ●
To explain the terminology used in disaster and complex emergencies To describe the features of natural disasters To discuss the purposes of emergency medical aid
Introduction There have been numerous attempts to provide a universally accepted definition of a disaster. Any new definition is almost always accompanied by a challenge to its accuracy and widespread applicability. However, whatever definition is chosen it always reveals a small number of key elements. Something happens, usually quite suddenly, but sometimes over time, that overwhelms the capacity of local agencies to cope. This failure to cope may be relatively short lived, for example when several multiply injured patients present to an Emergency Department or prolonged, for example during continuing civil war in an impoverished society. With this in mind, the response to a disaster will involve the best use of existing resources and the appropriate use of additional resources. How much a system is overwhelmed and how little the system can cope determine the impact of the disaster. Measuring impact clearly involves the number of people affected; and they can be affected in many ways including death, injury, and displacement. The impact may continue for many years if subsequent morbidity is not addressed. Disasters impact upon the environment that may or may not have a further impact upon populations. An impact upon the economy will quickly impact upon people. We therefore have a number of issues to consider when planning a response to a disaster: ● ● ●
Vulnerability Capacity to cope Impact
Sometimes the nature of an event will always lead to it being described as a disaster. This may take no account of the ability of emergency services to cope, the vulnerability of the system, or the impact of the incident upon a population. An air crash is 1
Including material from Ken Roberts and Rowland Gill.
A. Hopperus Buma et al. (eds.), Conflict and Catastrophe Medicine, Second ed., DOI 10.1007/978-1-84800-352-1_9, © Springer-Verlag London Limited 2009
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invariably described as a disaster even when emergency services have responded without difficulty and well within their capacity and the invariably high mortality of the incident has meant that the capacity of local medical services was not breached. Many developed countries now refer to a major incident rather than a disaster. This recognises the special nature of the incident but also recognises that with planning and preparation, a disaster, which is an overwhelming of available resources, can be avoided. The development of major incident plans and planning has been a great step forward in recent years with the recognition of generic roles, a clear command and control structure, and the distribution of casualties more widely in order to increase the capacity of health services in particular to cope. The principles of planning for major incidents in urban areas can be extended to disasters. One must plan, practice and prepare, and recognise and reinforce the need for a clear command and control structure. In fact, it is often the absence of a previously prepared plan and the recognition of the need for the implementation of a clear command and control structure that increases the host vulnerability to an incident, thereby contributing to it becoming a disaster. Once command and control has been established, capacity can increase and the impact be controlled; the disaster moving from uncompensated to compensated. Because the term disaster is applied quite loosely and widely, it can encompass events that involve a sudden large number of casualties in a developed country, usually in an urban area, as well as evolving catastrophes in developing countries that continue for weeks, months, and sometimes years. If the purpose of studying disasters is to improve the response to them then it is probably best to recognise common themes that characterize any “disaster,” but refer specifically to certain types of events and describe in more detail their specific requirements.
Mass Casualty Incident in Developed Countries There are well-established disaster plans/major incident plans that will have or should have been practiced. People will understand the roles that need to be filled and their place in the overall scheme of the response. The response involves the emergency services that will have their gold, silver, and bronze command levels and the local hospital network. Within the hospital, there will be a senior triage officer, an overall medical controller, and senior specialists carrying out further triage to ensure “the most for the most.” As a system, either potentially or actually being overwhelmed is a key element to any disaster, then triage, whereby the bottle neck is relieved, is the key to any response. The principles of triage will be described in the clinical section of this book (p 418). An important element in planning for and responding to a disaster is recognition of the need for a multidisciplinary approach. Fire and rescue, police, military, and ambulance services have essential roles, as also do administrators and managers, and all those who make up the work force of a hospital. Learning to work as part of a team, and a team of which you may not be the leader, is essential if as a doctor you are to maximize the contribution that you can make to the overall response. When planning for disasters and creating a disaster plan, it is important to understand that planning for the next disaster purely on the experience of the last disaster
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is a recipe for – disaster. Each incident has its own characteristics, although all share common themes. A plan should therefore be simple, easily understood, and readily applied. It should maximize the use of existing personnel and systems. It should recognise and emphasise generic roles rather than individual people. A named person on a disaster plan may not be available on the day or take time to arrive at the institution or scene. However, if a generic role is identified this will be adopted by those immediately to hand, although of course replaced by more senior and appropriate personnel if/when they arrive. An extract from a hospital major incident plan is included in Annex A. A prehospital example of major incident management in practice is given at Annex B. An important element in the response to disasters and the planning for disasters is the recognition that illness and injury will continue to occur in the host population and if not catered for alongside the victims of the incident will contribute to the overall mortality and morbidity from the disaster as a whole. The distribution of patients from the scene of an incident is crucial to the overall success. There is a tendency for individuals in hospitals to adopt the “we will cope” approach even when patently they can not. Casualties can be distributed across a range of hospitals rather than overwhelming a single and often the nearest institution. Moving patients on from a hospital once they have been admitted to the Emergency Department is slow and difficult and requires a further use of ambulance personnel. It involves staff appearing to acknowledge that they cannot cope where somebody else might cope better. These problems are best avoided by a more even and appropriate distribution of patients from the scene.
Mass Casualty Incidents in Developing Countries The role of the media is important. They often determine how and if governments respond to certain events by focusing publicity on it albeit for a very limited period of time. The increasing availability of television news in particular at the sites of disasters leads to an impression that they are more frequent. Although this may very well be the case, it is important to remember that the largest famine in human history took place in China between 1959 and 1961 when 30 million Chinese starved to death and largely went unnoticed by the rest of the world. Individual disasters of themselves do not appear to contribute greatly to overall mortality and morbidity. The eight leading causes of death worldwide (15–59 years): 1. 2. 3. 4. 5. 6. 7. 8.
HIV/AIDS Ischaemic heart disease Tuberculosis Road traffic accident Cerobrovascular disease Self-inflicted injuries Violence Cirrhosis of the liver
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The eight leading causes of global disease burden (15–59 years): 1. 2. 3. 4. 5. 6. 7. 8.
HIV/AIDS Unipolar depressive disorders Tuberculosis Road traffic accident Ischaemic heart disease Alcohol use disorders Adult onset hearing loss Violence
However, it again comes down to definitions. The toll from road traffic accidents in developed and developing countries is itself a continuing disaster as in fact is the impact of HIV, AIDS and childhood disease in developing countries. By appearing to focus too much on the rare special and even exotic, we are missing, and therefore not responding, to the greatest disaster of all – poverty. Once accepting that the capacity to cope influences the vulnerability to disaster, then it is not surprising to know that 96% of deaths from natural disasters occur in the developing world. At least 130 million people are affected by disasters. They might be referred to as “natural” disasters but earthquakes, floods, and other phenomena only cause human disaster when human beings lay themselves open to its effects and are unprepared to deal with its consequences. The vulnerability to disasters is likely to increase exponentially as the world population rises inexorably, and this population becomes increasingly concentrated in urban areas. Global warming appears to be creating an increase in the risk of certain natural hazards, and this is compounded by deforestation, urbanization, and poverty. Human beings are forced to live in very vulnerable areas creating large urban settlements within these vulnerable areas. Another billion people have populated the world in the last ten years alone, and most of these are in the developing world adding to urbanization and poverty. The intergovernmental panel on climate change forecasts an increase in the average world temperature of 1–3.5°C over the next 100 years. This will cause global sea levels to rise perhaps by 50 cm during this period of time, although in some places this may be greater. This will increase coastal flooding and we are already seeing its effects. Climate change will also be associated with changes in wind and weather patterns; effects that we also appear to be noticing already. The impact of a disaster is proportionate to the vulnerability of those affected. The poor are always the most vulnerable. The very poorest are the most vulnerable of all. One talks about “sudden onset” disasters such as hurricanes/tropical cyclones, earthquakes, and volcanic eruptions. The event itself may appear sudden but the vulnerability to its effects has usually been there for a long time.
Complex Emergencies When civil conflict meets humanitarian crisis a complex emergency ensues. The inherent difficulty in meeting large scale health needs is compounded by communal violence. This is further explored in the following chapters on the intervention in Rwanda (Page 223) and Operation Phoenix (Page 241).
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Natural Disasters Introduction This phrase is commonly used but is often not helpful. We have now taken to removing the word “accident” from the medical lexicon, as it implies that the condition that resulted was not preventable. I would recommend that the prefix “natural” be removed from disasters for the same reasons. All disasters are fundamentally human made and a function of where and how people choose or are forced to live by economic and political forces and those of conflict. Superimposed on this may be a natural phenomenon but the disaster is the result of human forces. Moreover the impact of the disaster, natural or otherwise, is proportional to the prior vulnerability of the affected population. As in all disasters, a population’s vulnerability relates to political and economic factors. These are compounded exponentially by war and those most vulnerable are usually women, children, and the elderly. The main threat to health does not always come from the disaster itself but the mass movement of people that follows.
Case Study: The Kurdish Refugee Crisis After the first Gulf war, many thousands of people attempted to leave Iraq for neighboring countries. Many attempted to gain access to Turkey. Many also attempted to cross the Iran/Iraq border. These two countries had not long been at war for many years, and now recent enemies were being asked to provide shelter. The area between Iran and Iraq had been the scene of a prolonged and bitter fight and was heavily mined. Therefore, aid workers had to deal with a range of problems including land mine injuries. The mass migration of people led to a typhoid outbreak. People walking across mountains suffered snake bites and tented cities produced epidemics of meningitis. The most important skill for those working in small medical tents was the exercise of triage.
Earthquakes Earthquakes occur below ground and that is where their center lies. The “epicentre” is the point nearest to this on the surface and marks the site where the quake has its strongest impact. The force of an earthquake is measured on the Richter scale. This is a logarithmic scale with each point ten times greater than the one before. The greatest risk from earthquakes and the greatest potential for survival lies in the work of architects and engineers. Earthquake resistant buildings can prevent much loss of life but as ever this is a function of politics and economics. It is no surprise that earthquakes of similar magnitude in the developing world create death tolls and numbers of injured very much greater than those in the developed world and sometimes by a factor of tens of thousands.
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The structure of the building when of poor quality, such as adobe huts and mud brick buildings, has a significant influence on mortality. Such buildings crumble and suffocate those beneath. Sturdier structures that collapse in layers leaving a lean-to structure will allow pockets in which there may be survivors. Medium and low rise buildings of brick or poor local materials collapse into rubble with little or no room for survivors. Not surprisingly, earthquakes are more deadly at night when buildings are more fully occupied. Although the perceived fear of epidemics following earthquakes is repeated by the media after each one occurs, there is no such published evidence. Mass movement of people into tented cities, which may subsequently follow, is associated with epidemics but not the earthquake itself. The commonest immediate consequence of an earthquake is likely to be electrocution and fires. The number of people injured may be up to three times more than those killed, overwhelming local medical facilities for a significant period of time. However, the severity of injury and associated entrapment tends to reduce the number of very severely injured patients presenting to medical services, and the surgical help most required is usually that needed for the treatment of peripheral limb injuries, both orthopaedic and reconstructive. However, the supply of emergency medical aid will usually take second place to the supply of the restoration of communications, transport, and power. Water supplies may be disrupted and occasionally contaminated. As ever local fears of the unburied dead will be augmented by the claims of the local media; but the dead pose little or no threat to the living. Whatever diseases they had at the time they died, will remain with them. It is the mobile living that present a threat of contamination. Great publicity is given to international search and rescue teams but the published evidence from their activity would indicate that they save relatively few lives, although set against this is the cost of their deployment, which is relatively small.
Case Study: the Bam Earthquake (by Ken Roberts) Introduction On Friday 26th December 2003, at 0527 hours, an earthquake with the magnitude of 6.7 on the Richter scale hit the city of Bam in South-eastern Iran. The aim of this case study is to document the disaster and its impacts, and to critically review the acute response to it.
Background The city of Bam is located in the east of Kerman Province, approximately 220 km from the provincial capital (Kerman city), and 1.283 km from Tehran. Bam is the only significantly sized city of its district, and is located on a vast plain between the mountain ranges of Barez and Kabudi. At the time of the earthquake, the population of the Bam District was assessed to be 240,000. Of these, 97,000 lived in urban areas, with an additional rural population of 143,000. The climate is extremely changeable, and the district
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experiences very warm summers (especially on the plains) and very cold winters (especially in the mountains). In addition to being a significant population and administrative center, it is also the site of the 2,000-year old citadel (the Arg-e-Bam), which is the largest sun-dried mud brick construction in the world. As such, this structure represents a highly significant cultural icon for Iran. Most of the 200,000 houses in Bam District were also constructed of mud or brick, and ranged in age from 30 to 50 years. Many were located in narrow alleys. Bam had an extensive and well-developed healthcare system, ranging from “Health Pots” to provide primary care up to District and Maternity Hospitals. Facilities for the training of paramedics and nurses were present in the city. This part of Iran is a known earthquake-prone area: the incident under study was the third to occur in Kerman Province over the previous 25 years.
Disaster and Response Impact Given the magnitude of the earthquake, and the nature of local construction (sundried mud brick, largely) the initial impact was massive. Thirty-one thousand people were killed, 22,000 injured (approximately 12,000 requiring hospital treatment) and 75,000 made homeless. In addition to important public health infrastructure such as water and sewage systems being badly damaged, the majority of the health care facilities were destroyed, and approximately 50% of the local health care workers were killed. Survivors were exposed to near-freezing night temperatures, with no immediate access to accommodation. No significant health care facilities were available. The Arg-e-Bam was reduced to rubble. Response The Iranian government put an existing disaster relief plan into swift execution. The overall response can be summarized as follows: ●
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Patients requiring hospitalization would not be treated in Bam (using field hospitals) but rather evacuated (by air) to the neighboring provinces. A coordinated effort by the Ministry of Health, the Ministry of the Interior, the Red Crescent Society of Iran and the Army airlifted over 12,000 casualties in the first 48 h. An innovative aspect of the plan was to divide Bam, and its neighboring villages, into 12 medical zones. Each of these was allocated to a hospital from a neighboring province. They sent medical teams forward to Bam to provide triage, some immediate life-saving treatment and to prepare casualties for air evacuation. In addition to spreading the impact of the immediate influx of casualties across a number of medical treatment facilities, this strategy facilitated the tracking of the injured through the treatment system. This enabled displaced persons to be reunited with their families relatively rapidly after the disaster. The Iranian government recognized the need for additional external assistance (both financial and physical) and appealed to the international community. This
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effort was coordinated by the UN (with a WHO lead), based on the requirements identified by the Iranian government and by WHO and Iranian assessment teams who deployed to the region. This resulted in assistance being provided by over 40 countries and organizations, ranging from the provision of search and rescue teams who arrived on the scene extremely rapidly, to the deployment of 10 field hospitals. The latter were designed to provide primary care to those remaining in Bam, and to treat minor injuries. They arrived within 3–5 days of the earthquake, and most left within a few weeks, having treated relatively few patients. Indeed, many of these hospitals (despite the need being to provide primary care) deployed with the “traditional” mix of surgeons and trauma treatment staff. National stocks of medicines and surgical supplies, water testing and chlorination kits, generators and pumps were mobilised, and these were rapidly supplemented by significant medical support and materiel from Herat (Afghanistan). Iranian Civil Defence/Red Crescent stocks largely provided tents and heating systems. By 30 December 2003, WHO reported that water supplies were in place, with over 60% of the drinking water network being restored, food supplies were adequate, and being distributed. Electricity supplies had been largely restored. Ten mobile shower units had been deployed. The following problems were identified: waste collection/ sanitation had yet to be established, insufficient shelter was available, and communications were only working with difficulty. The Iranian Ministry of Health established 10 health care centers, with five mobile teams to provide primary health care and carry out surveillance. These personnel visited families in their tents or improvised shelters, assessed health need, collected epidemiological data, and even provided medication for those who had lost drugs for chronic illness such as diabetes. In addition, 33 curative centers (18 of them mobile teams) delivered initial treatment to the population. By 30 December 2003, over 22,000 of the dead had been recovered and buried (many albeit on temporary sites). There were no significant outbreaks of infectious diseases amongst survivors of the earthquake, even though these had been predicted.
Lessons Identified It is considered that the response to this disaster was exemplary, in terms of its speed and appropriateness. It demonstrates the potential effectiveness of national and/or regional resilience strategies, but also highlights the need for planning and stockpiling of appropriate materiel. In this instance, the necessary level of resilience was a result of experience of previous natural disasters (including earthquakes) and an effective Civil Defence organisation formed in response to historical regional tensions.
Tsunami When earthquakes occur at sea they stimulate a seismic wave, which as it approaches land and into shallower waters transfers its energy into building a wall of water which on reaching land destroys buildings and produces flooding. The retreat of the water
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compounds the impact damage with drag forces that erode foundations. Although most deaths are due to drowning, severe injuries can be incurred from floating debris. Tsunamis are more immediately lethal than earthquakes with the dead outnumbering the injured.
Case Study: Tsunami on Sri Lanka (Red Cross worker 2005) “Our team arrived in Northern Sri Lanka in mid January, several weeks after the Tsunami had hit. The team included hospital specialists, water and sanitation engineers and electricians. People and equipment had to arrive in Southern Sri Lanka then travel up country and cross the various lines held by the Army and the LTTE. Although there was a cease fire in place both sides had understandable concerns about the movement of vehicles, personnel and communications equipment between the zones of control. It soon became apparent that our role was not medical disaster relief. That was over and done with. We set up in a local hospital and provided a level of care previously provided by the neighbouring town. The hospital there no longer existed. Patients cared for included women needing caesarean sections, people with new wounds from accidents and others needing ongoing for historic injury. The care given had to be a balance between clinical need and not disrupting or undermining structures that had evolved locally.”
Landslides Deforestation, a purely manmade phenomenon, allows rock and soil to destabilize most commonly after heavy rain producing catastrophic falls onto human habitation below. Snow will dislodge similarly to produce avalanches, becoming more common with global warming. Flows of mud can behave similarly after flooding and tsunami. When extricating victims who have been compressed in mud, snow, or rubble for some period of time, consideration must be given to compensating for the redistribution of circulation that follows prolonged compression. Intravenous fluid loading before, during, and after extrication may protect against a catastrophic fall in blood pressure that can follow sudden release.
Floods Global warming is increasing the frequency and severity of flooding. Increases in human population are leading to building on flood plains. Greater damage to human health and welfare may come from damage to crops, housing, and infrastructure than injury or drowning. Of particular concern is the contamination of water supplies with sewage.
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Volcanoes Injury is a more common consequence of volcano than burning. When the eruption occurs people are injured in the escape, either from falling rocks or simple falls. It is possible for pyroclastic flows to suddenly overwhelm a village and for clouds of toxic gas to threaten populations. However, the mass movement of people into tented villages as ever often produces the greatest risk to health. In the mid 1990s, a volcano eruption occurred in one of the islands of Cape Verde off the west coast of Africa. Volcanic soil can be highly fertile, and although volcanic eruption was a recurring threat to the population, the lure of volcanic soil was always too much to stop a return to farm the crater and sides of the volcano. Early warning measures were in place but not applied due to lack of funding. Again the element of disaster was provided by humans not nature. When eruption did occur most people escaped but to be housed on a neighboring island in tented accommodation. A cholera epidemic ensued. Outside Medical help was required for the treatment of cholera, not the volcano itself. There can be direct effects of volcano particularly from the ash that will produce inhalation burns but only the most superficial of these are likely to lead to survival. Acute respiratory distress with excessive mucus production can occur as can acute respiratory distress syndrome, asphyxia, exacerbation of asthma and in the longer-term potentially silicosis.
Definitions Lava flow – destroys everything in its path. It moves slowly and predictably. It produces secondary fires. There is limited direct risk to life. Pyroclastic flow – is a horizontal blast of gas containing ash and larger fragments in suspension. It moves at several hundred kilometres per hour. The material can be at temperatures of 1,000°C. Its speed is unpredictable as is its movement and poses considerable risk to life. Mud flows – occur when heavy rain emulsifies ash and loose volcanic ash after a volcanic eruption. Mud can have a consistency of wet concrete and might reach speeds of more than 100 km/h when flowing down hill.
Tropical Storms They are called cyclones in the Indian Ocean, hurricanes in the North Atlantic, Caribbean, and South Pacific, and typhoons in the North West Pacific. With global warming these too appear to be increasing in frequency and severity and over sea the winds may reach speeds of more than 300 km/h.
Case Study: Hurricane Andrew and Health Coordination (by Eric Noji) When Hurricane Andrew struck south Florida in August 1992, epidemiologists demonstrated the use of a modified cluster-sampling method to perform a rapid needs assessment. In the first survey, three days after the hurricane, clusters were systematically
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selected from a heavily damaged area by using a grid overlaid on aerial photographs. Survey teams interviewed seven occupied households in consecutive order in each selected cluster. Results were available within 24 h of beginning the survey. Surveys of the same heavily damaged area and of a less severely affected area were conducted seven and ten days later, respectively. The initial survey found few households with injured residents, but many without telephones or electricity. These findings convinced disaster relief workers to focus on providing primary care and preventive services rather than to divert resources toward unnecessary mass-casualty trauma services. The cluster-survey method used was modified from methods developed by the WHO’s Expanded Programme on Immunization (EPI) to assess vaccine coverage. Although cluster surveys have been used in refugee settings to assess nutritional and health status, this represented the first use of the EPI survey method to obtain population-based data after a suddenimpact natural disaster. In the hurricane, medical systems suffered severe damage. Acute-care facilities and community health centers were closed and doctors’ offices destroyed. State and federal public health officials, the American Red Cross, and the military established temporary medical facilities. In the four weeks after the hurricane, officials established disease surveillance at 15 civilian and 28 military free care centers, and at eight emergency departments in and around the impact area. Public health workers reviewed medical logbooks and patient records daily, and tabulated the number of visits using simple diagnostic categories (e.g., diarrhoea, cough, rash). The surveillance was able to characterize the health status of the hurricane-affected population and to evaluate the effectiveness of emergency public health measures. Data from the system indicated that injuries were an important cause of morbidity among civilians and military personnel but that most injuries were minor. Surveillance information was particularly useful in responding to rumours about epidemics, so avoiding widespread use of typhoid vaccine, and in showing that large numbers of volunteer healthcare providers were not needed. Although the surveillance achieved its objectives, there were several problems. First, relief agencies needed to coordinate their efforts. Data from the civilian and military systems had to be analysed separately because different case definitions and datacollection methods were used. Second, there was no baseline information available to determine whether health events were occurring more frequently than expected. Third, rates of illness and injury could not be determined for civilians because the size of the population at risk was unknown. Although proportional morbidity (number of visits for each cause divided by the total number of visits) can be easily obtained, it is often difficult to interpret. An increase in one category (e.g., respiratory illness) may result from a decline in another category (e.g., injuries), rather than from a true increase in the incidence of respiratory illness. (From: Redmond AD, Mahoney PF, Ryan JM, MacNab C. ABC of Conflict and Disaster. Blackwell Publishing & BMJ Books. 2006. with permission).
Famine There is nothing “natural” about the disaster of starving to death. It usually requires the combined maladies of politics, economics, and conflict to produce its greatest
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effects. Socioeconomic and political issues lie at the roots of famine and point the way to its prevention. It is useful to know the language of communication with international aid agencies and that for example a crude mortality rate of 1 in 10,000 a day or more is recognised as a significant trigger point for urgent humanitarian intervention. If such things can be measured then a loss of more than 15% of normal body weight and/or food energy supplies of less than 1,500 Kcal per person per day are also recognized international triggers. The constant threat of mass migration following famine further compounds the effects of the famine itself. Details on food requirements will be given in chapter xx.
Emergency Medical Aid When considering whether or not to respond to a natural disaster, one should first ask a number of questions. ●
●
●
●
How long will it take me to get there? It is well established that the majority of assistance, medical or otherwise, is given to the victims by their fellow survivors. This is closely followed by local medical and emergency services, then by regional and finally national services. It is sometime later before international services can assume any role, even if they are required. If I might be needed am I needed now? International medical aid can help national and local authorities to restore their medical services both for the affected but also the non affected communities. What sort of medical help might they require? The answer to this question lies with the authorities who are running the disaster response in country. Therefore make contact and ask. Do they need medical supplies, medical personnel or both? This is important to establish as it will not be very long before the media, sometimes prompted by some local medical personnel, will be demanding expensive equipment such as dialysis machines for the victims of crush injury. This is very expensive equipment with an obvious part to play but as part of a coordinated longer term programme and complimentary to but not a substitute for good basic resuscitative/medical care. Again seek guidance from agencies such as the International Society of Nephrologists.
There can appear to be a conflict between emergency medical aid, development medical aid, and public health. These are not mutually exclusive. Obviously there are limitations to the effectiveness of emergency medical aid. However, it can be provided alongside longer-term measures and must clearly never be considered a replacement for preparation, planning, and preparedness. These latter activities are likely to produce the greatest health intervention of all that is prevention. One must also not underestimate the impact of simple resuscitative/first aid measures and the philosophical and practical difference between doing something and doing nothing. One must also understand that although a disaster may appear to be sudden onset, the vulnerability to its consequences is likely to have been present for a long time, and once the initial event appears to have passed, the consequences of the incident may last a considerable time longer and paradoxically serve to increase further the vulnerability to later similar or other large scale incidents. Emergency assistance shortly after the
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incident may very well be of value but of equal value and sometimes of longer-term value is to provide assistance to the survivors who may have a medium to longer term requirement for further surgery, rehabilitation, prostheses, etc. When considering medical aid to disasters, one must not lose sight of the value and impact of basic life support. A study has shown that in patients who died before reaching hospital and indeed before arrival of the ambulance service, 39% at autopsy had injuries compatible with life and 85% of these showed signs of airways obstruction. The application of simple airway management and cervical spine control, none of which require technology, is greater than might be initially considered. This must be a part of disaster preparedness training. An often overlooked aspect of “emergency” medical need after a disaster is the rehabilitation of the disabled. This help and it is often some of the most effective help can be provided in a planned and measured way and may be required for years. The commonest risk to aid workers is death by violence. Until recently, this was death from a road traffic accident but increasingly it is death by personal violence. Aid workers may now be targeted, either because they are considered to be siding with one or other faction or for hostage taking and therefore financial purposes. Road traffic accidents still provide a considerable threat. Many aid workers are not trained in the techniques required to drive large four wheel drive vehicles over unfamiliar and rough terrain. Aid workers also ignore safety procedures they would automatically carry out at home but not when in an unfamiliar, exotic, or even dangerous environment. Four wheel drive vehicles can turn over very easily, particularly in the hands of the inexperienced and subsequent injuries magnified by the absence of or refusal to wear seat belts. Furthermore, limited local facilities for the treatment of severe injuries compounds the mortality from such accidents.
Immediate Response and Needs Assessment in Humanitarian Crises If we accept that a disaster by its very nature involves an overwhelming of medical services and a corresponding inability of these services to cope, then what service remains functioning will only achieve its maximum impact if it is targeted on those in most need and most likely to benefit. The application of triage is as relevant and important on a national and regional scale as it is in the emergency department. If aid is to do the most good for the most people it must be targeted. This is best achieved by a rapid needs assessment. This equates to the primary survey of a severely injured patient in the emergency room. From this flows everything else. Further details will be provided in the following chapters. The recognition of the importance and need for immediate assessment is now well established. The United Nations has UNDAC (United Nations Disaster Assessment and Coordination) Teams that will be on site within hours and certainly days of any major international incident. Other major agencies such as the International Committee for the Red Cross and large NGOs such as MSF will also dispatch their own assessment teams. One of the recurring frustrations of international aid remains the lack of coordination of aid effort at high level, with individual governments and organisations continuing to send out their own assessment teams rather than pool
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their resources and/or refer to a single assessment. Local officials can be overwhelmed and disheartened by a procession of assessment teams, each of which is delaying the deployment of aid for the duration of their assessment mission, rather than responding to the findings of those who have gone before. It is imperative that assessment teams be experienced and recognized as having knowledge and authority by other agencies. Assessment reports are often, and certainly always by the UN, posted on their relevant Websites. Aid should be given in response to what has been identified as needed and not in response to what you have to hand or wish to give. This applies as much to personnel as it does to materials. The assessment of need and the response to such findings must take into account the need to not increase dependency by the provision of inappropriate materials. Supplies of food from outside can destroy the local market and donated equipment when unfamiliar or unable to be maintained locally will have a very limited lifespan. Although specific types of incidents such as earthquakes and landslides will predictably cause injury and volcanoes predictably cause respiratory problems, all large scale incidents of whatever cause will produce the mass migration of people, if only over short distances. This phenomenon is the single greatest threat to human life in these circumstances. It will be compounded by geography, climate, and weather and most often and most significantly by political instability and conflict. Assessment teams must arrive early and be self sufficient in food, water, shelter, medical supplies, transport and communications. The team need not be big: a number of pairs of assessors is often adequate but assessment is likely to be more effective if one assessor does the talking with local authorities and the other listens, observes, and takes notes. In this way, little will be missed or misinterpreted. One of the greatest immediate needs after a disaster is information both to those affected and to those wishing to contribute to relief efforts. The gathering and distribution of information is a core part of assessment. It is also important to impart health information to the affected population. If this is to be effective there must be close collaboration with local medical authorities. Health needs almost invariably come second to other needs. When assessing the need for emergency medical aid distinguished between medical and nonmedical needs, the requirement for people versus things, the need to support primary and/or secondary care.
Water You will die of thirst long before you will starve. Potable water must be assessed immediately as it is the greatest human need. Quantity is of more importance than quality but ideally both will be preferred. However, the choice must always be quantity over quality. Water requirements will be high. The minimum maintenance requirement for water, including hygiene needs (potable) is 15–20 L per person per day. However, certain facilities such as a feeding center might require to give a person 20–30 L a day and a health center to give the sick 40–60 L per day.
Sanitation The swift provision of a basic system will save more lives than the delayed provision of a perfect system. There are recognized guidelines that include one latrine seat for
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every 20 people and each dwelling being no more than one minute’s walk from a toilet. If this is not available there either is or very soon will be a serious medical problem.
Food The minimum amount of foot energy for health is recognized internationally as 2,100 kcal (8.8 MJ) per person per day. Once this falls below 1,500 kcal (6.3 MJ) a day, serious health consequences and mortality will follow. When assessing and advising upon food aid, look to local supplies first. This may require the use of aid funding. Failing this provide imported dry food for local preparation. Communicating with aid agencies is important. A population may be considered malnourished when more than 10% of its children are moderately malnourished.
Shelter Establish permanent shelter as soon as possible mindful of the fact that temporary accommodation is rarely replaced and quickly becomes permanent. Sending clothing to stricken areas is a popular international response. However, its transport and storage can be very costly and its distribution to the most needy not always easy. Benefits can be maximized by it being provided by large agencies with long experience, large facilities and good penetration into the affected area. Individuals and smaller agencies are more likely to see their money best spent by donating it directly to such agencies.
Security The uncertainty and frank chaos that follows disaster of any kind can quickly lead to a breakdown of law and order. Many disaster prone areas have little and sometimes no effective security to start with. If aid is to be effective it must be secure. As ever the most vulnerable are women and children, and violence against women in particular is a threat that pervades many refugee camps particularly during and after complex emergencies.
Medical Needs When populations move in large groups into temporary, usually tented, accommodation with poor sanitation, disease follows. Acute respiratory infections are common. Measles is a particular threat to young children. Malaria is an ever present threat and groups of people amassed together are vulnerable to meningitis. Contaminated water will lead to cholera and other diarrhoeal diseases. When making an assessment of health needs, it is particularly useful to find a familiar point of reference. Go to a health facility that you recognize as being similar to your own place of work. Even allowing for differences of culture and economy, there is often enough to establish points of similarity and comparison allowing you to get a flavor of what things were like before the incident occurred and how they have been affected now. Hospitals can often provide a reasonable reflection of the wider
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Fig. 9.1. Major Incident Doctrinal Framework.
community and economy and will also reflect political attitudes to health. They can be readily accessible to those with a medical background and experience. Support local administrative structures, as outside organisational structures are likely to be ineffective as cooperation will be limited and if they are effective then inappropriate recommendations may be ultimately disruptive. Do take account of local practicalities. Whatever you identify might be needed will only arrive it if can be procured, dispatched, and delivered on time. Do get an understanding of the status and capacity of airports, seaports, and roads and the availability of trucks and drivers. Ensure your recommendations are in line with and approved by local coordinating bodies. Clarify which of the issues you have identified are immediate, medium term, or longer term. A recommendation to do nothing either at all or at the present moment might be valid and entirely justified. It might even be helpful. If the local community is coping the inappropriate or untimely dispatch of aid can add to rather than relieve the burden of the affected country. Remember that an intimate part of recovery is restoration of the economy. Although all of us sometimes shun the desire to simply give money to aid agencies, this can in fact be the most useful element in international aid, allowing goods and services to be procured locally and thereby not only providing immediate aid, but also contributing to and restoring the local economy.
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On Site Operations Coordination Center (OSOCC) In the early phases when international aid is arriving, it is important that a coordination center be established. This will usually be established by UNDAC and to avoid competition and duplication, do work through its offices
Three Important Topics Dealing with the Dead A large number of dead bodies can potentially overwhelm mortuary services but in fact in most developed countries capacity can be rapidly increased and a disaster as such avoided. However, this is not the same everywhere. At times a large number of dead bodies can, however, provoke a disaster of another sort. This is not because of the threat from epidemics and infectious disease but because of the fears of such conditions and the overwhelming of mortuary facilities. It appears counterintuitive, for example, to not believe that dead bodies pose risk of infection, promote epidemics, and might contaminate the water supply if buried. However, this is not borne out by the evidence. However, the belief that dead bodies are harmful and pose a significant threat to health is ingrained in all of us, including doctors, nurses, and other health professionals. If information of this type is to be successfully transmitted to the population and the unnecessary and catastrophic rush to mass burial avoided, careful and diplomatic discussions must take place with the relevant local health authorities. The World Health Organisation in particular has an important authoritative role in this area. Locating and identifying human remains is a distressing task and requires medical input and support.
Prevention A declaration by the UN made the 1990s the International Decade for Natural Disaster Reduction (IDNDR) and although much was talked significant change has yet to emerge. It did, however, bring together the wide range of people and organizations and formally recognized the need for disaster mitigation. There has been a review and the UK government for example has now expressed a determination to include up to 10% of its emergency relief budget as earmarked for preparedness and planning. IDNDR has reemerged as an international strategy for disaster reduction.
Medical Evacuation There is an inevitable conflict between the dangers of home and the risks of separation. It is extremely difficult to define who might qualify. Should a doctor say who goes first or who goes at all? Is the problem that the patient is being evacuated for a result of the war or a result of longstanding issues?
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Closing Remarks The issues covered in this chapter will be explored further. Some final thoughts are given in the following bullet points: ●
● ● ● ●
●
● ●
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In addition to food, water, shelter, and sanitation, safety is an essential aid requirement. Primary and secondary care need not be mutually exclusive. Public health medicine and emergency medicine need not be mutually exclusive. Health care reform and emergency medical aid need not be mutually exclusive. High tech medical aid is often thought to be inappropriate but it depends on what the other priorities are at the time, what skills are available locally and if the kit can be maintained. If primary care alone meets the needs, wishes, and aspirations of a local community and is not an expression of unrecognised prejudice or double standards by those from other countries, then high tech or secondary medical aid may not be appropriate. The hidden casualties of war include the old, the already ill and the mentally ill. Remember that doing something is better than doing nothing and that a drop of medicine in a sea of need goes a surprisingly long way. One must be wise cautious but never cynical. One must never underestimate the power of showing that someone cares. Disaster prevention requires economic, environmental, and political initiatives. Doing nothing is never neutral.
Acknowledgments The author wishes to express his gratitude to Ken Roberts, Rowland Gill, and Eric Noji for use of their case studies and other material.
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Part A – The London Bombings 7th July 2005: Forward Medical Response Surgeon Commander Steven A. BLAND Royal Navy
Introduction At approximately 0850, three improvised explosive devices (IEDs) were detonated on the London Underground between Liverpool Street – Aldgate (Circle line), Kings Cross – Russell Square (Piccadilly line) and at Edgware Road station (Circle line). Nearly one hour later (approx 0947), a fourth device was detonated on a doubledecker bus in Tavistock Square outside British Medical Association (BMA) House, close to Russell Square. In total, there were 56 deaths including the four bombers. This is an account of the forward medical (bronze doctor) role during the incident. It includes a narrative of the response from a personal perspective as a prehospital doctor deployed in the first air ambulance team to Kings Cross and highlights lessons identified for future contingency planning and emergency response.
The Response Following reports of power surges on the London Underground, the Fire and Rescue Service was requested at 0859. The initial incident was thought to be a train trapped in the tunnel and as a result ambulance attendance is also usually provided. Within minutes it became apparent that this was a complex incident with multiple scenes and significant casualty numbers. A major Incident was therefore declared after the initial assessments had been made, initially by the Fire Service but followed soon after by the other two emergency services. Although each emergency service has its own Emergency Operations Centre (EOC)/Gold Command responsible for the strategic management of an incident, a joint Strategic Co-ordination Centre (SCC) was set up in Hendon for the coordination of all responders including the Health Sector (Strategic Health Authority and Health Protection Agency). At the Royal London Hospital, it was the monthly prehospital clinical governance day, and once the London Ambulance Service had declared a major incident, additional prehospital resources were deployed by ground and air to the three initial scenes. In total, 18 doctors and 10 paramedics were deployed with a total of 26 air sorties. An air ambulance paramedic is routinely present in the Ambulance Control/ Dispatch Room and is responsible for the tasking of air ambulance teams, either by air or ground. The first air ambulance team deployed by air was sent to Kings Cross, landing two blocks from Euston Road and the main line station entrance. After the initial assessment,
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a team of two doctors and two paramedics was split into a Bronze and Silver Team. As a Forward Medical Incident Officer (Bronze Doctor), the main responsibilities are to assess the medical requirements of the scene within the inner cordon. The geographical inner cordon was beyond the lower ground ticketing hall and down the escalators. At this point, the Fire Service controls the cordon, although on the day initial resources were understandably depleted with multiple entrances and resource requirements. Casualties assessed on the surface showed signs and symptoms consistent with blast injuries with no signs suggestive of nerve agent exposure such as increased secretions and pinpoint pupils. A medical team had been requested to go to the platform and then proceed into the tunnel, as there were more seriously injured casualties. Before deploying further into an incident scene, it is necessary to consider the potential hazards and risks. This was done with the paramedic and escorting fire fighter. The decision was made to proceed, although the down escalator was turned off while the up escalator was left running to assist casualty rescue. This process is called a dynamic risk assessment (DRA). The fireman also pointed out that his newly issued radiation dosimeter had not gone off; therefore, there was no high dose radiation consistent with a radiological dispersal device. It should be noted that low dose radiation could not be excluded. A summary of the hazards, present and potential, is given in Table 9.1. On the platform, there were London Underground staff, who were able to advise that the 600V traction current was switched off. The traction current was probably the most significant hazard throughout the whole incident response. There was still some residual smoke, and passengers were walking out of the tunnel. There was no suggestion of a chemical release although some agents, such as mustard gas, do have a latent period. The train was about 200 m into the tunnel heading to Russell Square. Walking down the tunnel allowed us with some time to discuss the situation and collect thoughts. The most difficult part of responding to a major incident for a clinician is to be not clinical; the main priority is to assess the scene and identify the medical needs. The walking wounded persons were directed back to the platform. The bomb had been detonated in the first carriage and so reaching the scene of greatest need took time. It is understandable that without adequate information, the role of incident (silver) commander on the surface, whether police, fire, ambulance or medical, can be Table 9.1. Present and potential hazards during the London bombings Type of hazard
Present
Potential
Environmental
Confined space Heat Electrical (traction) current Sharps/debris Combustion products Particulate (dust) debris Biological debris, including needlestick risks (bone fragments)
Active combustion/fire
Chemical Biological Radiological Other
Secondary devices (bus bomb)
Specific chemical agents Low dose debris/dust High dose fragments/debris/dust Armed perpetrators
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difficult, and the next priority of the forward team should be to relay the information to the silver commander by any means available. During the incident, there was no direct communication with the surface. After the initial assessment, the main interventions by the forward team, now joined by the second HEMS paramedic, were the following: ● ●
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Liaising with and supporting ambulance and other agencies’ staff Redirecting casualties from heading to Russell Square to the closer Kings Cross station, as additional medical staff were arriving on scene Providing or supervising analgesia administration Assisting extrication of casualties on the train and trapped in the tunnel.
In any major incident, medical staff will present themselves and offer assistance. It is important to ensure they are who they say they are and also are adequately protected and resourced. If they are, they should be directed to the Medical Incident Commander. Many of the casualties exited via Russell Square, although the station was further away than Kings Cross. On discussion, it has been suggested that passengers will instinctively move toward the destination that the train was heading to. After the train had been cleared of live casualties, there was a second sweep of the carriage to ensure there were no more casualties and to estimate the number of fatalities. This was repeated by the Medical Incident Commander.
Lessons Identified After any major incident, it is important to reflect on events and identify lessons to be learnt. Major Incident Medical Management and Support teaching uses the CSCATTT2 principle for prioritising major incident response. This is also a useful guide for post incident debriefing.
Command and Control Major incident scenes generally are modeled on a concentric command structure with the bronze inner zone surrounded by silver command zone with its resources including a survivor reception center and casualty clearing station. The incident is supported at the strategic level by gold command. The concentric model was seen at Aldgate and Edgware Road. Kings Cross/Russell Square was complicated by the fact that casualties left the train from both ends of the tunnel requiring two silver commands at each location. River incidents may also have this requirement for multiple silvers as well as bronze zones on each riverbank. Tavistock Square was also divided into two silver commands (North/South) due to security and safety concerns. A summary of the incident command structures is shown in Fig. 9.2.
2
Command, Safety, Communications, Assessment, Triage, Treatment and Transport
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Civil Contingencies Act (CCA) 2004 LAS NHS Emergency Planning Guidance 2005
Local / Regional Multi-agency Contingency Plans
Police Fire Service Local Other
Major Incident Medical Provider courses Medical Incident Commander Training SOPs
STRATEGIC
Local Ambulance Service Major Incident & other Contingencies Plan
OPERATIONAL Operational PRE-HOSPITAL COMPETENCY FRAMEWORK
SOPs
PRE-HOSPITAL MAJOR INCIDENT RESPONSE
Major Incident Plan: Action Cards
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INCIDENT
CORPORATE MEMORY TRAINING
Clinical SOPs
PATIENT
S A BLAND
Fig. 9.2. London Bombings command infrastructures.
In the early stages of an incident, first responders will be drawn into the incident and may not immediately identify the requirement to assume command roles. Nevertheless, these roles are essential to achieve multiagency liaison and identify initial priorities. The command infrastructure should also be the framework for communications using the chain of command. Silver command is likely to be the most challenging of the three command tiers for all emergency services. At gold level, commanders will often recognise and have exercised with their counterparts from other agencies. At bronze level, the role is often an extension o f current operational roles on scene, although less hands-on. Silver level is difficult because during the initial stages, frontline staff may be assuming the command roles and may not immediately have their counterparts present or identified. Command vehicles and communication equipment will not arrive until later, and so there is reliance on an austere or improvised Joint Services Emergency Control (JSEC) point, until their arrival.
Safety Safety must remain paramount at all times. For any incident where there is a deliberate element to the incident, it is important to consider additional hazards targeted at emergency services (secondary devices) in the initial assessment. At Kings Cross, the clearance of the scene of CBRN agents and secondary devices did not occur until after emergency responders had entered the scene. Although scene clearance is often focused within the inner cordon, secondary devices are just as likely outside the cordon and at potential rendezvous points and marshalling areas.
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Additional equipment required during the response included dust masks and were not immediately available. Electronic personal dosimeters (EPDs) now issued to ambulance staff will detect high levels of radiation; however, low-level particulate material may not be detected. This risk will be mitigated by wearing a dusk mask (FFP3 standard). Latent periods for some chemical agents and toxins mean that responders, both pre-hospital and hospital, should be vigilant for signs of intoxication. A number of individuals were critical of first responders entering the inner cordon before the scenes were cleared. In the absence of any other orders, the decision to enter a scene is a personal one based on a dynamic risk assessment. The assumption that all responders will blindly enter a scene ignorant of the risks is naïve.
Communications Following the post incident debriefs and reports, it was identified that there were shortfalls in communications at all levels. This is not surprising as communication is the Achilles heel of emergency response and operational deployments. As well as the over saturation of VHF channels and mobile phone communication networks, there are operational limitations on the initial use of communication equipment until there has been secondary device clearance. During the London Bombings, the presence of multiple scenes placed added pressure on the communications network. For complex incidents, it may be necessary to assign individual channels to each scene. There are two schools of thought on the role of communications during a major incident. The first is reliance on a fully resilient multiagency system based on digital communications with underground capability. The second school of thought is that all planning and training should be based upon the assumption that there is no communication and the response is predetermined with on scene command flexibility. Whichever method is used, communications should be brief and along established lines of communication. Although communications is considered separately to the establishment of a command structure, the two should be in parallel as the chain of command should be the chain of communications. This reinforces information governance and appropriate integrity and flow of data.
Triage The aim of triage is to manage the incident so that the best can be done for the most. In an ideal situation, the most severely injured casualties will arrive at hospital first. Evidence from several incidents suggests that reverse triage occurs for a number of reasons. The first is that before emergency services arrive, the walking wounded persons will extricate themselves from the scene. Once away from the inner cordon, the differentiation of walking wounded (T3) casualties and uninjured survivors is sometimes difficult especially if exposure to smoke is considered an injury. Understandably, the first responders will be directed to the more seriously injured casualties (T1/T2), who may be trapped or will require assistance in order to leave the scene. The more seriously injured will therefore take longer to be extricated and receive medical
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interventions on scene. One report on the 7th July was critical of emergency services for not attending to the walking wounded and uninjured survivors quickly enough and establishing a survivor reception centre on scene. Many of these casualties/survivors may leave the scene and self-refer not only to local hospitals but also to primary care and medical facilities remote from the incident. The presentation of casualties to any medical facility following a major incident should be recorded and reported to any health register likely to be established, usually by the Health Protection Agency. During the early stages of an incident, limited ambulance and medical resources will be distributed between the initial major incident infrastructure (command and logistic roles) and the treatment of the seriously injured.
Treatment Prehospital medical interventions were limited on the 7th July with emphasis on triage, casualty flow, analgesia, and the management of amputations (total and partial). Some patients did receive advanced procedures including rapid sequence induction and fluid resuscitation. This was dependent on clinical need, number and type of casualties, and medical resources available. Some lifesaving interventions were provided initially by bystanders and included the application of improvised tourniquets. Analgesia was particularly important for casualties entrapped, particularly in the tunnel. Difficulties in establishing intravenous access in casualties were compounded by multiple limb injuries and poor lighting. The drug of choice used at Kings Cross was intramuscular ketamine using the 100 mg/ml concentration. This provided adequate analgesia to allow extrication with less respiratory depression. Care should be taken due to the sympathomimetic effects of ketamine and the chance of rebleeding due to a raised blood pressure.
Summary Since the 7th July, the Civil Contingencies Act 2004 has now come into force. Emergency services are required to have plans in place to respond to a range of major incidents. The role of prehospital physicians has been recognised for sometime and was highlighted during the inquiry by Hidden QC into the 1988 Clapham rail disaster. The response from all of the emergency and voluntary services was extraordinary on the day. The three post 7/7 reports have made several recommendations, the main recommendations focusing on communications and the management of uninjured survivors and relatives. Previous experience of “one-under” incidents has shown that a single casualty trapped under a train can take up to 90 min to be safety extricated. The management of over 700 casualties with a 50% conveyance rate to hospital at four complex incident sites within the documented timeframe was a significant achievement, but it is important not to be complacent. The doctrinal framework that can be applied to a major incident response is complex from Governmental Department and multiagency guidance down to individual training, operating procedures, and contingency plans, this is summarised in Fig. 9.3.
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KINGS CROSS EDGWARE RD
TAVISTOCK SQUARE NORTH (incl. BMA House)
TAVISTOCK SQUARE SOUTH
Kings Cross Tube (Piccadilly Line) Bomb Kings Cross Underground / BR Station Complex 1 Russell Square Underground Station 2 Aldgate Tube (Circle Line) Bomb Aldgate Underground Station 1 Edgware Road Tube (Hammersmith and City Line) Bomb Edgware Road area 1 Tavistock Square Bus Bomb Tavistock Square North (incl. BMA House) 1 Tavistock Square South 2
RUSSELL SQUARE
ALDGATE Not to scale
Fig. 9.3. Tsunami disaster on Sri Lanka, 2005.
Further Reading Home Office. The Report of the Official Account of the Bombings in London on 7th July 2005. London: The Stationary Office. (Accessed November 6 2006 at http://www.londonprepared.gov.uk/downloads/ lookingbackmovingforward.pdf) LESLP. Major incident procedure manual [monograph on the Internet]. 6th ed. London: LESLP; Jul 2004. Available from: http://www.leslp.gov.uk/. Lockey DJ, MacKenzie R, Redhead J, Wise D, Harris T, Weaver A, et al., London bombing July 2005: The immediate pre-hospital medical response. Resuscitation. 66(2):ix-xii,2005 Aug. London Assembly. Report of the 7 July Review Committee. London: Greater London Authority. (Accessed November 6 2006, at http://www.london.gov.uk/assembly/reports/7july/report.pdf) London Regional Resilience Forum. Looking Back Moving Forward. London: Government Office for London. (Accessed November 6 2006 at http://www.londonprepared.gov.uk/downloads/lookingbackmovingforward. pdf)
10. Responding to Acute Humanitarian Crises: Health Needs Assessment and Priorities for Intervention Aroop Mozumder
Since the end of the Cold War, we live in an era when barely controllable armed conflict has become endemic in large parts of Asia, Africa, Europe, and parts of the Pacific. Massacres amounting to genocide and the mass expulsions of populations are once again taking place on a scale not seen since the Second World War. EJ Hobsbawm, 2007. Globalisation, Democracy and Terrorism At the end of the 1990s, 30 million people were estimated to be internally displaced and 23 million were refugees, the vast majority of whom were fleeing conflict zones (Medicins Sans Frontiers. Refugee Health. An Approach to Emergency Situations 1997).
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To understand how health interventions in humanitarian emergencies have evolved in the past three decades To understand how minimum standards in performance and their linkage to human rights and humanitarian principles have arisen To understand how to undertake a health needs assessment of an acute humanitarian emergency To understand the priorities for intervention
Introduction Mass population migration, whether due to conflict, natural causes, or complex humanitarian emergencies, are becoming increasingly common. Large displaced populations present acute and urgent problems that need systematic needs assessment and early intervention, in order to prevent a rapid rise in mortality and morbidity. Whatever the initial cause there are a number of common key factors that need close examination, with a rapid needs assessment which may need completion within a few days. A. Hopperus Buma et al. (eds.), Conflict and Catastrophe Medicine, Second ed., DOI 10.1007/978-1-84800-352-1_10, © Springer-Verlag London Limited 2009
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Over the past three decades there have been significant developments, with the emergence of evidence-based interventions, and wide acceptance of the principles of both needs assessment and priorities, often referred to as the “Top Ten” priorities. This chapter will give an overview of the evolution of health interventions for large displaced populations and describe the priorities for intervention.
Evolution of Humanitarian Interventions in the Last 30 Years During the 1980s and 1990s, most developments in the health arena were based on lessons learned during Cold War conflicts. These were normally curative, lacking norms and guidelines, with agencies working in isolation. However, this period did include the development of some significant advances, such as the management of severe malnutrition in therapeutic feeding centers (TFCs), pioneered by Oxfam, SCF-UK, and MSF-France, with protocols used in a number of major emergencies during the period. From the early 1990s, there was more systematic use of data collection and surveillance and the growing awareness of the need for evidence-based interventions and epidemiological concepts. Humanitarian assistance became a more specialist field with its own reference materials, policies, and indicators (Refugee Health. An Approach to Emergency Situations 1997; Noji and Toole 1997). Quality and program evaluation have been increasingly important themes since the mid-1990s, particularly since the evaluation of the relief operation to Rwanda in 1994 by the UK-based Overseas Development Institute (ODI) (ODI 1995). Until then there was a widespread view, both among aid workers and the general public that “humanitarian workers were always doing good.” The increase in media exposure and scrutiny, in particular to the prolonged Rwanda emergency changed this view. The ODI report stated that 100,000 avoidable deaths could be attributed to the poor performance of the relief agencies. Lack of standards, weak accountability, and poor coordination were principle factors Greikspoor and Sondorp 2001). The joint evaluation of emergency assistance to Rwanda also noted failures in a number of key areas: lack of policy coherence, lack of coordination between UN and humanitarian agencies as well as government teams and military contingents, poor quality healthcare from many NGOs, and inadequate accountability of agencies and their inability to assess their impact. Widespread consideration of such evaluations, not least by donors, led to an increased interest in quality, impact, and accountability. Evidence base for interventions and value for money was demanded by donors, with performance measures and increasing recognition of the requirement for standardization and regulation being key themes in the late 1990s. The first voluntary Code of Conduct was developed by the Red Cross movement and NGOs (Code of Conduct for the International Red Cross and Red Crescent Movement and NGOs in Disaster Relief 1994). It sought to safeguard high standards of behavior, maintain independence and effectiveness of disaster relief. In its ten principles, the Code promoted respect for local culture, involvement of beneficiaries, building on local capacities, and the impartial nature of aid. The Code also described relationships that NGOs should seek with the UN system and with host and donor governments. In 1999, nearly 150 agencies and 144 countries had signed up to the Code of Conduct, committing agencies to defined standards of behavior.
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Evaluation of program performance became an important part of NGO and other agency activity, with donor funding often being reliant on effective evaluation tools by provider agencies. One such method is the use of the logical framework planning method which uses measurable indicators to quantify results. Another major advance was following the publication of the joint Rwanda evaluation, the first good practice review for evaluating humanitarian assistance was published in 1998 (Hallam 1998). This used the following evaluation criteria: coverage, connectedness, coherence, and appropriateness. To these criteria were later added relevance, effectiveness, efficiency, impact, and sustainability, which were originally used in development rather than emergency assistance. This model was adopted by the OECD, after which it became the dominant model used. Another part of the humanitarian “industry” working to increasing performance standards and accountability is The Active Learning Network on Accountability and Performance in Humanitarian Assistance (ALNAP) project, coordinated by the ODI in London. This provides a forum to discuss issues relating to performance and accountability in humanitarian operations, to gather, to analyze, and to disseminate information, research, and examples of best practice.
The SPHERE Project The SPHERE Project of 1998 was brought about by the coordinated activity of a number of established NGOs and the Red Cross Movement, much influenced by the lessons identified from recent humanitarian crises. This brought considerations of accountability to beneficiaries, and improved effectiveness in humanitarian aid delivery. It included the first statement of minimum standards of humanitarian relief in key areas such as water supply and health care, while linking these to fundamental human rights. These principles are now widely taught and adopted. In 2004, the revised SPHERE handbook developed and updated the themes of the first edition.
SPHERE PROJECT 1998 Meeting essential human needs and restoring life with dignity are core principles that should inform all humanitarian action. Through the Humanitarian Charter and Minimum Standards in Disaster Response, defined levels of service in water supply, sanitation, nutrition, food aid, shelter and site planning and health care are linked explicitly to fundamental human rights and humanitarian principles. However, SPHERE, in its first iteration, was considered by some to have limitations, it covered one of the key elements of humanitarian performance, that of competence. Other key elements were timing, coordination, and adequate resourcing. Another view was that although it provided standards, it gave no instructions as to how agencies and other actors could meet the standards. The second edition, however (SPHERE Project 2004) has addressed some of these issues, with more technical advice and detail; becoming more of an instructional manual than the first
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edition. Over 400 organizations in 80 countries contributed to the development of Minimum Standards and Key Indicators. Overall, SPHERE is seen as a major advance in the development of standards in accountability and service delivery, and is widely used.
Evidence Base for Interventions in Humanitarian Aid Bantvala and Zwi (2000) noted that data on the public health effects of war and on delivery of public health in settings affected by conflict were increasingly being assembled, but that the effectiveness of many humanitarian initiatives had not been adequately evaluated. They also noted that generating knowledge and promoting an evidence-based culture would require collaborative initiatives between implementing agencies, academics, and donors. In the past few years, agencies are increasingly using program evaluations, using tools such as the logical framework analysis method for individual project analysis. Donors are increasingly relying on such formalized evaluations to fund agencies. The increasing use of the Code of Conduct, with more widespread adoption of SPHERE standards and protocols by agencies are key advances in operational delivery. The availability of training courses on evaluation, such as those at the London School of Hygiene and Tropical Medicine, increasing research and increased operational activity of UN agencies, together with moves toward improved coordination are also significant improvements. Some of these will be discussed further. There have been attempts to formally share evidence from relief situations, to improve education and disseminate best practice. One of these is the Relief Web database (http://www.reliefweb.int), established in 1996 by the UN. However, some authorities consider that it has been hindered by a lack of submissions from agencies and academic institutions. Some larger agencies have publicly accessible databases at times, but overall comprehensive data is lacking. Another advance has been the Cochrane Collaboration’s work, following the Asian Tsunami, which has led to Evidence Aid (http://www.cochrane.org/evidenceaid/project.htm), a summary of best practice in health care in disaster relief.
Priorities for Intervention in Disasters: The Top Ten Priorities The priorities for intervention have been developed for the seminal MSF Handbook, “Refugee Health: An Approach to Emergency Situations,” which is now often adopted as the manual for those involved in humanitarian emergencies. The top ten priorities remain one of the most useful frameworks for those involved in emergency work. To these, a eleventh may be added, which is becoming of greater importance as conflict and complex emergencies are increasingly prevalent, that of provision of security. Security is increasingly a basic parameter, providing “humanitarian space” for other agencies, both governmental and NGO, to carry out their mandated functions in safety for both their own ex-patriate and local employees, as well as providing a secure environment for the beneficiaries.
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Initial Needs Assessment in Displaced Populations The importance of a rapid, comprehensive, concise needs assessment for displaced populations cannot be overemphasized. It is the first priority before any intervention is provided. The data from such a needs assessment may inform substantial operational planning in various NGO, UN, military, and other organizations, particularly if there is little up to date information available about the scale of a disaster. Health needs assessment needs to be conducted within a few days, it will be constrained by the urgency to minimize mortality and morbidity, as well as the requirements of the tasking organization. The principle is to gather key facts on a range of important criteria, backed by evidence or reference, which can easily be provided to the HQ organization, upon which the principle planning for the relief effort is planned. There are five main areas which a needs assessment needs to cover: demography, resources and logistics, food and nutrition, health status, and environmental risks. These can be further subdivided into key questions.
Demography What is the population at risk (PAR)? What is your mandate, or what part of the population (in a massive disaster such as the Asian Tsunami 2004) do you have responsibility for? This data may be available from the UN or local national relief coordinator if there is one, or from NGOs already on the ground. It is right to consider the accuracy of all such information carefully. Occasionally these figures may be inflated; information that may increase the amount and speed of arrival of relief supplies and relief personnel. However, data from reputable organizations can be considered accurate enough for initial assessment purposes. If this data is not available, such as in the very initial stages of a disaster, there are techniques for estimating the PAR. Maps should be available, from either NGO or military sources, or downloaded from Google Earth. The boundaries of the camp can be plotted by a basic survey of the perimeter. This can then give a camp area which can be subdivided into grid-squares. Cluster sampling of grid squares using random number tables, with detailed shelter to shelter recording of all persons and ages living in each sample area, is extrapolated to give the PAR of the whole camp. It is a tried and tested method, proven over many emergencies to be reasonably accurate. The population makeup of the camp is also important. Tribal divisions, ethnic differences, a high proportion of young mothers with children, and a high number of orphans need serious consideration in the way shelters will be allocated; proximity to water supplies and latrines being key considerations. Tribal division, particularly if there has been recent violence along ethnic or tribal lines, is an important issue. An example is that young women of a particular tribe may be exposed to increased gender violence or intimidation if housed close to men of an opposing tribe. Orphans may have temporary carers but may also have to forage for themselves, they are a particularly vulnerable group, which needs to be sought out and brought together for special care when planning a camp.
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Demographic concerns thus include the increasingly recognized issues of security, the requirement for which underpins much aid effort and the development of relative stability in a camp. Fear of violence and its random nature is one of the most debilitating factors in a camp or displaced population situation. Assessment of the security state of a camp is therefore a key component in any needs assessment.
Environmental Issues The camp environment is clearly intimately related to the health outcomes of the resident population. Shelter availability, population density per shelter, diurnal variation in temperature, water availability and quality, and sanitation facilities are fundamental factors, which need to be assessed and recorded in a needs assessment. These are all factors that contribute to the most common lethal diseases of refugee populations: malaria, lower respiratory infection (lobar pneumonia), and diarrheal diseases, particularly when linked with malnutrition. Availability of water, in terms of walking distance and its continuous availability, as opposed to sporadic availability, its approximate quality, means of storage for families and whether there is enough for washing as well as drinking, are core requirements that determine health status. WHO recommends 3 L per day as the absolute minimum, per person, but 15–20 L per day is their accepted norm. Sanitation facilities, provision of and availability of latrines, their building quality, distance to walk, general quality, and cleanliness and safety are key issues. Whether solid waste is properly dealt with, so that vectors cannot obtain access, or remains in poor quality sanitation facilities is also a key factor (Fig. 10.1).
Fig. 10.1. Water collection – Sudan.
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Shelter quality compared to the current environment, spacing, and level of overcrowding and availability of basics such as blankets also have an important bearing on health status. Vector control is often a problem, more so with large camps, where population behavior or poor camp management has allowed food waste or stagnant water to accumulate. A view on insect and rodent vectors is important. Health promotion, particularly hand washing and basic hygiene, for food and water are key health determinants. Cultural behaviors may often determine this.
Resources Access by main road, availability of river or spring water, quality of the road network, for example if it is passable in the rainy season, requirement for all-wheel drive vehicles, size of truck that can gain access, and proximity to ports and airports, are also health determinants, albeit indirectly. Personnel resources and logistic considerations, such as presence or not of specialist logistic NGOs or UN agencies need to be known. Communications, by telephone or even Internet access, can also make a vital difference in the organization of supplies and personnel to support an emergency situation.
Food and Nutrition Malnutrition prevalence can be assessed very crudely by observation, particularly of vulnerable groups such as children and the elderly. There are a number of means of formal evaluation of the nutritional status of a population, such as the mid upper arm circumference measurement (MUAC) (children aged 1–5 years) and weight for height measures of children. Existing NGOs may have valuable data from these techniques. These will be discussed in more detail later. Food supply, its distribution, family storage capability, cultural appropriateness, availability of cooking implements and fuel are all key factors, that can relatively easily be assessed by observation of the camp area. Cooking fuel and its scarcity may become a key issue if refugees have to forage locally for this resource (Fig. 10.2). The fairness, regularity, quality, quantity, and appropriateness of the ration system must be assessed. Many NGOs have significant experience in managing food distribution, such as CARE, CRS, and CAFOD. These NGOs in turn may be supplied by the World Food Programme (WFP), or have a coordinated mechanism outside of the UN to procure food in bulk. If malnutrition is a major issue, NGOs may have started to establish supplementary feeding clinics (SFCs) and inpatient TFCs. If this is the case, the NGOs will have considerable useful data on the prevalence of malnutrition (Fig. 10.3).
Top Ten Priorities 1. Initial needs assessment 2. Measles vaccination and Vitamin A supplementation in malnourished populations 3. Water and sanitation
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Fig. 10.2. Food distribution – Ethiopia.
Fig. 10.3. Outpatients’ clinic – Sudan.
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Food and nutrition Shelter and site planning Health care in the emergency phase Communicable disease control Public health surveillance Human resources and training Coordination
To the top ten an additional priority is often added: 11. Provision of security
Health Status and Medical Care The assessment of mortality rates, in particular the crude mortality rate (CMR) is fundamental to assessing the health of a population and in measuring the effectiveness of interventions. It is often the most common single figure reported to higher authority. The urgency of aid delivery and resource allocation may partly depend on this figure. The CMR is relatively easy to assess, it is the number of deaths per day per 10,000 PAR. Most cultures will have a burial/body disposal ceremony, which may need additional resources such a burial shrouds or simple blankets. These will most likely occur in a designated area that can be monitored and counted. The CMR is relatively easy to assess if the PAR is known, but if it is not, it can be estimated using cluster sampling techniques. A map of the camp area can be divided into equal-sized grid squares, which are numbered. A sample of these squares is chosen at random, with each chosen square scrupulously examined for the resident population, often using local health workers. This can then be extrapolated to estimate the total PAR. This method is necessarily crude, and assumes a relatively constant population density per square, but remains effective, and may be the only way of estimation in the early stages of a disaster situation. A CMR above 1/10,000 per day is regarded as a serious situation. In the early acute stages of an emergency, this can rise to 10/10,000 per day in extreme situations. Morbidity rates for key diseases, such as malaria, acute respiratory infection (ARI), or epidemic diseases such as dysentery and cholera may be recorded by medical NGOs. An understanding of prevalent diseases in populations is a core part of the needs assessment. The existing healthcare facilities, in particular the type, quality, available resources, appropriateness, diagnostic, laboratory, and pharmaceutical support are the required information, if an NGO or similar agency is providing these. Additionally, if provided by the host nation, knowledge of payment methods, referral systems and agreements in place with the Ministry of Health are useful. Facilities for mental health and reproductive health were often considered less important in a rapidly developing emergency situation, but the importance of these is increasingly recognized, with some specialist NGOs increasingly involved in the area, such as Marie Stopes International, for reproductive health issues. Finally, brevity, accuracy, and timeliness are key attributes of a good initial report. The urgency may allow only three working days or less to conduct the assessment.
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It should always be aimed at those who can act on the data: senior UN officials, the military chain of command, the host nation relief coordinator, senior NGO officials, and increasingly UNOCHA cluster leads. The SPHERE handbook (http://www. sphereproject.org) gives additional guidelines and an alternative checklist for conducting such an initial assessment:
SPHERE Health Services Assessment Checklist Preparation: ●
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Obtain available information on the disaster affected population and resources from host country and international sources Obtain available maps and aerial photographs Obtain demographic and health data form host country and international sources
Security and access: ● ●
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Determine the existence of ongoing natural or human-generated hazards Determine the overall security situation, including the presence of armed forces or militias Determine the access that humanitarian agencies have to the affected population
Demographics and social structure: ●
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Determine the total disaster affected population and proportion of children under 5 years old Determine the age and sex breakdown of the population Identify groups at increased risk, e.g., women, children, older people, disabled people, people living with HIV/AIDS, and members of certain ethnic or social groups Determine the average household size and estimates of female and child-headed households Determine the existing social structure, including positions of authority/influence and the role of women
Background health information: ●
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Identify pre-existing health problems and priorities in the disaster-affected area prior to the disaster. Ascertain local disease epidemiology Identify pre-existing health problems and priorities in the country of origin if refugees are involved. Ascertain disease epidemiology in the country of origin Identify existing risks to health, e.g., potential epidemic diseases Identify previous sources of health care Determine the strengths and coverage of local public health programs in refugees’ country of origin
Mortality rates: ● ●
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Calculate the CMR Calculate the under-5 mortality rate (U5MR: age-specific mortality rate for children under 5 years of age) Calculate cause-specific mortality rates
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Morbidity rates: ● ●
Determine incidence rates of major diseases that have public health importance Determine age and sex-specific incidence rates of major diseases where possible
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Determine the capacity of and response by the Ministry of Health of the country affected by the disaster Determine the status of national health facilities, including total number, classification and levels of care provided, physical status, functional status and access Determine the numbers and skills of available health staff Determine the capacity and functional status of existing public health programs, e.g., Extended Programme of Immunization (EPI) and Maternal and Child Health services Determine the availability of standardized protocols, essential drugs, supplies, and equipment Determine the status of existing referral systems Determine the status of the existing health information system Determine the capacity of existing logistic systems, especially as they relate to vaccines and essential drugs
Consider data from other relevant sectors: ●
Nutritional status, environmental conditions, food and food security
Measles Immunization High population density, particularly from existing rural populations who are displaced into camp settings, when linked with high levels of malnutrition, are extremely susceptible to measles, one of the most contagious diseases. Mass measles vaccination for children aged between 9 months and 15 years is the highest priority health intervention and cannot be delayed until other vaccines, or a more structured health service provision is available. Ideally it needs to be initiated within the first 10 days of a camp being established. Logistic considerations, including the crucial importance of an effective cold chain, trained personnel and basics such as needles and syringes must be considered as a priority. The mortality rate from measles can exceed 2–21%, following complications such as lobar pneumonia, diarrhea, meningoencephalitis, and croup. Even higher rates have been reported. Although levels of measles immunity are slowly rising in the less developed nations, due to EPI initiatives, any displaced population where malnutrition is prevalent should be assumed to have imperfect coverage and a vaccination program is essential. Measles in refugee situations is highly preventable, with mass immunization, given together with Vitamin A capsules, giving around an 85% protection in children aged 9 months. Vitamin A has been shown to be particularly effective in reducing morbidity and mortality from the disease. Although high at 85%, this still leaves a significant proportion of children vulnerable to the disease due to its infectivity. Vaccination programs close to 100% coverage are therefore essential, which means accurate census of the population at risk that may have to be estimated using mapping of the entire camp and cluster sampling techniques. For those already exposed, vaccination may reduce the severity of the disease.
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The aim of a measles vaccination program is therefore a mass early campaign, targeting 100% of children, given with Vitamin A supplementation, with a more routine vaccination given with other vaccines once the camp is more established and health services are being provided. Measles, however, is a live vaccine and thus particularly susceptible to cold-chain failures. Management of the measles cold-chain, particularly in the early stages of a refugee migrations and humanitarian crisis, presents one of the most difficult logistic challenges. More recently it has become clear that some populations may have at least partial immunity to measles, through the more widespread reach of the EPI program worldwide. However, this cannot be assumed and the consequences of a measles outbreak are so serious that it must remain as the highest priority health intervention.
Water and Sanitation Lack of safe water, together with poor hygiene practices are a major cause of mortality and morbidity in displaced populations, particularly in the initial phases of a humanitarian emergency. Epidemics of shigella dysentery and cholera have been recorded causing over 75% of deaths in the initial emergency phase. During the initial phase of the crisis the aim should be to provide 5 L of water per person per day, as the bare minimum recommended by WHO for survival. However, this bare minimum provides only enough for food and drinking, hygiene is inevitably reduced, causing significant risk of transmissible disease. The aim as the crisis develops must be to increase this to 15–20 L of water per person per day, as soon as possible. This will allow enough for washing, clothes washing, and better food preparation (Fig. 10.4).
Fig. 10.4. Water collection – Ethiopia.
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For a large population, protecting the source of water is a high priority, particularly if it is surface water, which is easily contaminated by people, livestock, and poor hygiene measures. Controlling access is a method of doing so. Often in the initial phase, water has to be transported in by water tankers or bowsers. These need to be maintained and kept clean, but is usually a very short-term measure. Proper water distribution points need to be built as a high priority, enabling good access, normally by a bank of taps, with a concreted run-off area and good drainage for waste water. These access points can be supplied ideally by bore holes, which almost guarantee water safety, as long as they are deep enough and properly constructed, to collecting spring water or using wells. Temporary tanks, such as “bladder tanks” made out of rubber, or similar material are effective as a short-term measure. The recommended planning guidelines are that there should be one hand-pump for every 500–750 persons, with a bank of six taps of high yield (>5 L/min) in a properly constructed area for at least every 1,200 persons. The population must have access to clean water containers of a suitable size, 20 L containers being the standard, with two per family unit being the target. Lack of reliability and consistency of clean water is a major source of stress for displaced families and its importance in contributing to health in its widest sense should not be underestimated. Water quality should be enough such that the health risks are minimized, with the accepted norm being less than 10 fecal coliforms/100 ml. Surface water must always be regarded as contaminated, with chlorination, normally using calcium hypochlorite, being the standard method of disinfection, for relatively clear water. A level of chlorination needs to be maintained in water that is drunk. Some populations may be unused to this smell and may have to be persuaded that it is safe. Highly turbid water will need prior filtration before chlorination. Environmental Health workers or specialist NGOs are well versed in managing water for displaced populations. Sanitation, including safe disposal of human excreta, is fundamental to the health of a displaced population. It is sobering to know that a camp of 100,000 persons can produce up to 5 tons of excreta per day. Attention to this issue is therefore an early and vital public health measure, which must take into account the expectations and cultural habits of the populations. These will include separation of male from female latrines, knowing the distances people are prepared to walk to a latrine, hand-washing and privacy. Lack of respect for local culture may mean that the facilities will not be properly used and excreta and waste may be left in the open, an obvious source of ill-health. Initially, designated areas may have to be roped off, or otherwise marked. Note that in the tropics, sunlight can destroy pathogens in stools within a short period. However, latrines need to be dug as soon as possible, dependent on the soil conditions and the water table. There are tried and tested designs for latrines, pioneered by many agencies. Oxfam UK is an internationally recognized leader in this field. In the more settled phase of an emergency, one latrine per 20 persons, or ideally one per family unit is the aim. Large banks of latrines are often badly looked after and it is worth employing guards and cleaners if possible or seeking cooperation with the displaced community to maintain the facilities. Well-designed hand-washing facilities, with soap, are vital for this purpose. Waste water must be planned for, with adequate drainage into soak-away pits being mandatory. Stagnant contaminated waste water can easily attract insect vectors, with mosquitoes (vector for malaria,
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dengue and yellow fever) being one of the main insect disease vectors being able to breed in stagnant pools. Bodies are sometimes over-rated as being dangerous disease carriers. However, the transmission of cholera, typhus, viral hemorrhagic fevers, and plague in particular may be associated with bodies. Burial ceremonies must be respected, and bodies protected from animals. Where there are a large number of bodies needing more rapid disposal, quick-lime as a disinfectant may be required. Solid waste is an important problem, with litter and food waste rapidly attracting rodent and insect vectors, and eventually snakes and other undesirables. The availability of land-fill sites and the cooperation of the refugee community is important to keep this under control. Vector control is effective when the first principles of hygiene are adhered to. Effective waste disposal, hand-washing, water storage, and rubbish disposal are key factors, with the cooperation of the refugee community being paramount. However, one specific measure, the use of insecticide impregnated bed nets has been shown to be particularly effective and is evidence based.
Food and Nutrition Protein-energy malnutrition is linked to vulnerability to disease, with measles being particularly important in causing mortality in the emergency phase. Nutritional assistance programs are therefore an important priority to reduce mortality in any displaced population. WHO recommends the minimum food ration of 2,100 kcal per person per day, and this has remained the basic aim of nutritional programs for some decades, with appropriate nutrient balance. Health staffs are usually involved in nutritional assessment, management and selective feeding of those with more serious malnutrition, and advising other agencies on the suitability of the rations delivered. The general ration may be made up of purchased rations in the local markets, if available, or the introduction of substantial amounts of food aid from major donors. In either case, care needs to be taken that the local economy is not disrupted, either by flooding the market with cheap donated grain or by driving up prices such that the locals cannot afford the markets. Either case can lead to major friction with the host community (Fig. 10.5). Nutritional status of a population is usually extrapolated from the nutritional status of children under 5 years. Weight for height (WHF) as a percentage against internationally agreed child growth norms (NHCS/CDC data) is widely accepted as the most sensitive and accurate measure of an individual child’s nutritional status. Standard deviation from the mean, using “Z scores” is commonly used to assess population malnutrition rates. Another quicker method, normally used for screening is the mid-upper arm circumference (MUAC) for children aged 1–5 years. A population’s nutritional survey can be carried out by random sampling of children from 6 months to 5 years, which is compared against a reference population. In many parts of the developing world a global malnutrition rate of below 5% is considered normal, but above 5% is more significant, above 10% is a major problem, requiring intervention. In very severe cases the global malnutrition rate may be artificially low, because those with most severe disease (<70% median WFH, and/or nutritional edema) may have already died; this should be borne in mind when conducting a survey. It is worth noting that children
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Fig. 10.5. Malnourished child – Sudan.
under 5 are not always the most vulnerable. Studies have shown that adolescents or even adult males may suffer disproportionate mortality. Interventions are based on an adequate and culturally appropriate general ration giving 2,100 kcal per person per day, selective feeding programs for those moderately malnourished, and therapeutic feeding programs for those severely malnourished. An increased level of nutritional support may be required if other population indicators are poor, such as a high CMR (greater than 1/10,000 per day) or severe environmental pressures, such as cold or monsoon rain. The general ration needs to contain at least 10% of energy as fat and 10% as protein and should be culturally acceptable. The main components are cereals, pulses, oils, sugar, and salt. The past reliance on dried milk powders has diminished; this is now normally only used in TFCs on the advice of WHO and UNHCR. A number of agencies may be involved in food coordination. The World Food Programme (WFP) is the primary UN agency, while a number of NGOs, such as CAFOD, CARE, and the ICRC have considerable expertise in local distribution and ration programs. NGOs such as SCF, Oxfam, and MSF have expertise in delivering TFC and SFC. Effective and equitable distribution of food to families is a specialist skill; it involves close cooperation with the refugee community, logistical expertise, security of storage, reliability, and attention to detail. Most systems are based on ration cards
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and collection by heads of households on a regular basis. Every system must be prepared for a certain amount of loss, whether by damage, theft, corrupt practices, or by food diversion. Here families exchange food items for those more attractive, but not necessarily useful. An example is trading food for coffee or spices. Selective feeding programs are normally required for the proportion of children who suffer from acute malnutrition, before or even despite a reasonable overall ration for the population. TFCs are heavily resource intensive. They are inpatient facilities during the first phase, where children are admitted, normally with mother or elder sibling, to correct dehydration, treat severe malnutrition, and infections. Such children are seriously ill, with a high mortality. They are often apathetic and need to be encouraged to take food, and may suffer other complications, such as hypothermia, even in tropical climates. They need feeding at regular intervals, often through the night in the most acute cases. High energy milk is often supplemented by Vitamin A supplementation, measles vaccination, antibiotics, and treatment of intestinal parasites. In younger infants, breast feeding should continue, if the mother is present. In the later stages, high energy milk may be replaced by more sold meals less often, porridges or local food may be more acceptable. TFCs need a large number of trained and appropriately experienced health workers to manage them successfully. More recently there has been a move toward more home-based intensive feeding, but TFCs remain important in many crisis situations. Supplementary feeding is for those children with a less acute, although still serious malnutrition measure, in terms of % WFH. Normally children attend as “outpatients” for a few hours of additional feeding. They are also given a supplementary ration, wet or dry, to take home, so that other members of the family may benefit. Finally, there needs to be an awareness of micronutrient deficiencies in acute emergency situations. Xerophthalmia (Vitamin A deficiency), pellagra (Vitamin B3 deficiency), scurvy (Vitamin C deficiency), anemia (iron deficiency), and goiter (iodine deficiency) are particularly common, although a number of other conditions may be seen (Fig. 10.6). The treatment of vitamin A deficiency, previously mentioned in the context of measles immunization, is a particularly effective intervention in acute emergencies, and is often associated with acute malnutrition, particularly in children. Clinically night blindness is followed by dry ocular lesions (Bitot’s spots), leading to corneal softening and permanent blindness if not treated. Vitamin A supplementation, using an oral capsule is effective and cheap, it also has significant immunosupportive effects. It is normally given to all children with any signs of malnutrition. Finally, a good nutritional support program must comprise an effective general ration distribution, an effective selective feeding program, and assessment of health and nutritional status.
Shelter and Site Planning The importance of effective shelter is of obvious health benefit. Overcrowding, when combined with poor hygiene are conducive to the transmission of major outbreaks of disease such as Shigella dysentery and cholera. The principles are that a camp must have a limited population density, should be in family groups per shelter, that traditional village structures should be replicated as far as possible, and that access to
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Fig. 10.6. Therapeutic feeding – Ethiopia.
essential facilities, such as water and latrines must be reasonable. Access for food in trucks, security, and minimizing environmental health risks are also key factors. Clearly in emergency situations, not all these can be addressed, but changes should be made as soon as possible. There are SPHERE guidelines for type of shelter, spacing, and numbers per shelter, which should be followed. For example 2 m is the minimum distance between shelters and each person should have 3.5 m2 of living space. Site planning is also clearly defined in UNHCR and SPHERE publications. Criteria for roads, water supply, medical facilities, storage sites, latrines, and reception areas are considered. These specialist references should always be considered in camp design. Site planning is one of the early priorities; much effective public health can result from a good early design. Temporary shelter material is vital if a large influx of refugees is foreseen, ideally made from toughened plastic sheeting, and with each family able to erect their own shelter (Fig. 10.7).
Health Care in the Emergency Phase It is important to realize that in the vast majority of refugee emergencies, the main causes of mortality are due to four main diseases groups: diarrheal diseases, respiratory infections, malaria, and measles, normally complicated by underlying malnutrition
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Fig. 10.7. Improvised shelters – Sudan.
(Mears and Chowdhury 1994). The mainstay of medical care is therefore to be able to diagnose and treat, using simple diagnostic and treatment protocols (SPHERE based), that can be taught to local and other health workers. The key features of a healthcare system in an emergency situation are: Locally accessible simple protocol-based diagnosis and treatment facilities Provide staged levels of health care from simple health posts to a referral hospital Provide curative and preventive services Treat common diseases effectively Have an understanding of local endemic disease Surveillance, recording, and health information ability, matched to local Ministry of Health protocols and those of UNHCR or equivalent organization Participate in Health cluster meetings wherever organized (with UNOCHA or similar) and use appropriate protocols Be able to cope with high demand Be sensitive to the host population’s needs Flexibility to cope with sudden disease outbreaks or environmental changes Be able to adapt from emergency to postemergency care, such as the setting up of reproductive health services, EPI, HIV/AIDs protocols, TB treatment Have appropriately trained health workers, including doctors who are familiar with tropical diseases and the effects of malnutrition The unique features of an acute emergency, of high morbidity, high levels of mental stressors, and comparatively easy access to health care often leads to unexpectedly
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large demand, where many may have self-limiting disease. The importance of adequate triage, such as the ability to screen rapidly and to assess and treat the more serious cases, is an important requirement for any health system. The accepted form of healthcare facilities is based on four levels: 1. Basic care and screening from a local home visitor from the refugee population, for every 500 people. 2. A small health post with a trained health worker, with a limited dispensary, working to agreed protocols for common diseases, for up to 5,000 people. 3. A more central health center, with a doctor and nurses, with limited inpatient facility, for every 30,000 people. This facility is capable of seeing referrals from health posts, treating more complex cases, providing simple surgical procedures and uncomplicated obstetric and midwifery care. This will have a simple laboratory services, such as malaria blood film screening and microscopy for parasites. 4. A referral hospital facility, which can carry out emergency surgery, treatment of wounds, complex obstetric care, and with a referral laboratory. A balance must be kept on where scarce healthcare resources should be provided. Although large referral hospitals are important, they tend to treat those smaller numbers who are seriously ill; the converse is that attention to clean water may prevent serious outbreaks and prevent a larger morbidity and mortality in the longer term. Clearly such difficult planning questions need to be approached sensitively, with the focus on effective public health measures. The aim, however, is that each of the four levels of health service should be set up at the same time. Different agencies may be mandated to different areas, and this is where the coordinating organization, such as the UNOCHA health cluster lead can advise and if necessary direct where the priority areas are. Often the solution is to set up a central health center and recruit local home, visitors from the refugee population, while at the same time organizing small health posts in further areas of the camp. It is vital to be coordinated with the existing health services of the host country. They may require particular forms of diseases reporting, which should be adhered to, and if necessary the local health facility should be supported and improved. Good relations with the local community and the Ministry of Health are vital to success. SPHERE guidance is useful in defining field definitions for the common diseases, these are valuable for use by health workers who will see the majority of morbidity, noting that the single doctor may only have time to provide guidance on preventive medicine policy, to undertake training and to see complex cases, as well as attending coordination meetings. WHO have developed emergency health kits, suitable for a displaced population emergency situation, to treat a population of 10,000 for 3 months with protocol-based medications and dressings. These have been in use worldwide for many years. The importance of providing reproductive health services and mental health services is increasingly recognized as being valuable, early in an emergency. In terms of reproductive care UNHCR has developed a minimum initial service package (MISP), which comprises managing gender-based violence, HIV/AIDS precautions, simple obstetric care, availability of condoms, postcoital emergency contraception, and the organization of an obstetric referral service.
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Communicable Disease Control The major causes of death in many mass displaced persons following a natural disaster or complex humanitarian emergency are made up of malaria, measles, ARI (lobar pneumonia), and diarrheal diseases, particularly when there is a background of malnutrition. Some studies attribute 60–90% of all deaths due to these illnesses. In addition, typhoid, meningococcal meningitis, yellow fever, typhus, plague, dengue, leishmaniasis, polio, and viral hepatitis often cause major outbreaks. In terms of more chronic disease, TB, particularly when multidrug resistant, and HIV/AIDS can cause much morbidity and mortality. Diseases may be caused by the new environment, illnesses endemic in the indigenous or newly arriving population, or may present due to overcrowding and hygiene failures. The principle is that many diseases tend to be more severe and more easily spread in a refugee population. In order to combat this, any communicable disease control system must include proper case finding and surveillance using home visitors, accessible health services that can treat the main four diseases, and an underlying effective hygiene system that minimizes disease risks and transmission. Preparing and planning for epidemics, which will almost invariably occur, requires good background health intelligence of the area before arrival. It also requires the use of standard protocols for case finding, diagnosis, and treatment that can be easily taught to more junior health workers, simple laboratory facilities and access, identifying sources and the logistic implications of mass vaccination campaigns, and identifying sites for health facilities within the camp. Communicable disease control requires thought, planning, training, and situational awareness. It may be one of the most difficult areas of refugee health, and ready access to trained epidemiologists and public health physicians is very helpful. When an outbreak arises, the cases must initially be confirmed. This requires proper history taking and examination, followed by laboratory conformation if at all possible, of initial cases of a suspect disease. If confirmed, successive cases may be diagnosed based on standardized field definitions, such as those from SPHERE. For example, the case definition for measles is generalized erythematous rash lasting 3 or more days, fever and one of the following symptoms: red eyes, cough, or runny nose. Systematic outbreak investigation and control measures need to be adopted. These include case registration, plotting an epidemic curve with geographic locations, targeting case finding, and treatment to high risk groups and assessing likely sources of the epidemic. Control of any outbreak will include finding and minimizing the sources, such as robustly maintaining water purity in a cholera epidemic, interrupting transmission of disease, such as vector control measures in malaria, and the protection of susceptible groups; the classic example being measles vaccination of all children. Cooperation with the local Ministry of Health protocols and WHO reporting systems is important. Diarrheal diseases are a principle cause of morbidity and mortality in refugee situations. Shigella, rotavirus, cholera, and E. coli are significant pathogens. Bloody diarrhea with fever is a strong indication that Shigella is present, which needs laboratory confirmation. Adequate oral rehydration therapy (ORT) networks and trained workers, attention to camp and personal hygiene, clean water supply, adequate food
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rations, and the promotion of breast-feeding for infants are key control measures. ORT needs significant effort, not all refugee populations or health workers are convinced of its efficacy. Acute watery diarrhea, particularly when arising in patients above 5 years, resulting in severe dehydration, must be presumed to be cholera. The WHO case definition includes these features. Cholera in epidemic form requires significant additional resources: an inpatient area, “cholera cots,” buckets to collect diarrheal fluid, stocks of ORT (or ability to make this up), trained nursing care, and large amounts of clean water and strict hygiene measures, as well as an adequate reporting and case finding system. A cholera outbreak in any camp consumes significant resources and must be planned for. Cholera can have a case fatality rate of up to 50% without treatment; with an adequate control system, the CFR can be well under 2%. The attack rate of cholera in a population may be around 5%, with outbreaks commonly lasting around 4 weeks. It is important to note that bodies of those who have died from cholera are one of the few examples of bodies being particularly dangerous to public health (others being some viral hemorrhagic fevers and plague). Kits to treat cholera outbreaks are available from some major NGOs. ARIs may be defined as any case of fever, cough, and rapid respiratory rate (over 50 bpm). It is relatively easy to diagnose by trained health workers by finding the abnormal breath sounds of lobar pneumonia. Many ARIs are upper respiratory and more mild, but serious disease is common in conditions of overcrowding, particularly when associated with poor shelter, wet climatic conditions, and malnutrition. The cause is normally streptococcus pneumoniae and Haemophilus influenza, both of which can be treated with oral antibiotics in most cases. Case finding, use of field definitions, and adequate training for health workers are important in controlling ARIs. Malaria can be a major problem, particularly with refugees who have migrated to an area of higher endemicity. For example in the Ethiopian famine (1984–1985) many highland communities, who were protected by reason of living at high altitude, moved to Sudan or other low-land areas and suffered from significant P. falciparum disease. Malaria protection is based on controlling the vector by minimizing standing water areas, larvicide spraying, use of permethrin impregnated mosquito nets (where resources permit), and periodic spraying of shelters. Chemoprophylaxis is a subject of debate, but in some emergencies, administration to malnourished children and pregnant women has been considered. The case definition of malaria may be any case of unexpected fever, but is normally confirmed wherever possible by a simple laboratory test. At the most basic level microscopic examination of thick and thin blood smears can be performed. Simple treatment protocols, based on chloroquine, or alternatives where chloroquine resistance is present, are required.
Public Health Surveillance Information is vital in measuring effectiveness of a response. This must be systematically collected, standardized enough to be collated, appropriate to the local situation and acceptable to the Ministry of Health, acceptable to those affected, and regular and timely enough to be useful (Healing et al. 1996). It is important to be consistent, rapid, repeatable, rather than always absolutely exact. Many NGOs, donor organizations, and other international organizations may base their response on the available health
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data; it is therefore a core and important part of any response. Field definitions of common diseases, such as those from SPHERE case definitions are useful for consistency and repeatability. The following data is typically required: Demographic data. Cluster sampling to assess denominator for PAR, work out rates not numbers. CMR. This is the key mortality indicator, upon which many resources and audit of program performance is often based. U5 MR. Morbidity. Key reportable diseases. Nutritional surveillance data. Use secondary data as far as possible from UN, Government, MoH, and NGOs. Integrate with local surveillance systems where possible. Use local reporting chains as well as NGO systems, UN cluster coordination. In order to perform consistent data collection, local health workers should be employed if available. Population estimates are politically sensitive, as numbers lead to resources. Both providers and host nations may have interests in maximizing or minimizing figures, so they cannot always be regarded as accurate. In the early stages of a disaster situations with mass population migration, rough estimates of the population, using cluster sampling and extrapolating data to estimate the total PAR may be required. This can then be refined over time. It is important that within the entry screening facility for new arrivals, that numbers are also counted. In the later stages of a refugee camp, in the postemergency phase, increasing health data can be considered, such as: Extended Programme of Immunization data Maternal and Child Health Clinic (MCH) data, including reproductive health data Consultation rates Treatments against core diseases Reproductive health consultations Mental health activity TB clinic activity Access and barriers to access Health promotion activity The features of health surveillance in conflicts and disasters will be discussed later in Chap. 13.
Human Resources and Training Most NGOs responding to a relief program will tend to send a small group of expatriates who will support their own locally recruited resident personnel who may have worked in the country for some years. An intervention program will often mean a rapid recruitment of a significant number of local staff, with a variety of logistic, medical engineering, or administrative skills. Western military forces may be one of the few groups that are relatively self-sufficient in terms of manpower; however, even
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they are increasingly recruiting interpreters and other key staff to support the relief component of their military mission. Recruiting local staff may be fraught with administrative procedures, costs, negotiations with local government officials, and the need to determine pay rates such that it does not destabilize the local economy. For this reason many organizations try to minimize the numbers they recruit, which may compromise the effectiveness of the program itself. Some NGOs have estimated numbers required to support particular types of programs. For example a qualified health worker can manage about 50 consultations per day, and that a home visitor should have between 500 and 1,000 people to look after. A single doctor may be able to oversee a small team of health workers in an outpatient setting, while also medically supervising a TFC of about 200 children. Qualified health staff in a local country may be contracted to the local MoH, and some negotiation may be required in order for them to be released to look after a displaced community. UNHCR will often provide advice to NGOs and others into the best means of recruiting and screening staff, together with advice on pay rates and local employment law. It is important to be sensitive to local issues such as employment of women and tribal quotas. Expatriate staff, in order to perform to SPHERE guidelines, are increasingly required to have appropriate training and supervision when they deploy to an emergency. This effectively means that elements of “Clinical Governance” and increased accountability are of greater importance and are welcome features of relief programs. Finally, recruiting local and expatriate staff must fall within the principles that most NGOs work within. These are enshrined within the Code of Conduct: Principles of Conduct for the International Red Cross and Red Crescent Movement and NGOs in Disaster Response Programmes.
Coordination Coordination by the various agencies responding to a common humanitarian goal does in theory sound a simple proposition. However, in past decades this has been problematic and has resulted in major system failings; the performance of the international community following the genocide in Rwanda being one example. There have, however, been some recent improvements in interagency cooperation. A wellcoordinated relief effort has a number of features: leadership, normally from a UN agency such as UNHCR or UNOCHA, working closely with the host government, an effective coordinating body with some lower level executive authority, agreed interagency priorities and rationalization of activity such that “economies of scale” can be achieved. Where donor organizations, international military forces, and other IOs are present, it is useful for them to have a seat at the coordinating meeting; this of course may create tensions in some areas, but has also been seen to work effectively. Recent years have seen significant efforts to improve humanitarian response at both field level and in higher policy circles. The interagency standing committee (IASC) of the UN endorsed the cluster leadership approach to deal with emergencies. It also endorsed improved funding mechanisms and the introduction of humanitarian coordinators (HC) responsible to the overall Emergency Relief Coordinator (ERC).
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The cluster approach was introduced in 2005 by Jan Egeland, the UN ERC, following studies of the response in Darfur (Sudan). Cluster leads for various sectors, health, sanitation, and others were used in the response to the Pakistan Earthquake in late 2005, overseen by senior UNOCHA representatives. Cluster leads were responsible for standards and policy setting, building response capacity, operational support, and establishing surge capacity. Although this is a recent development, there are early signs that the cluster approach is a major advance in the coordination of all agencies, from NGOs, IOs, UN agencies, donors, and military forces.
Provision of Security Although not always considered core to the “top ten” priorities for assistance to large displaced populations, the provision of adequate security is fundamental to all other public health and welfare interventions. The control of violence between tribes or ethnic groups, gender violence and fear within a displaced community, are immensely harmful to population health and well-being. Population movements are often as a result of complex humanitarian emergencies, with war and lower level violence being a causative part. The imposition of security can occur from a range of actors: the host population Police or Army, a NATO, UN, or other Western Peace keeping force, a more local military force, such as one from the African Union, or militia within the refugee population themselves. The effectiveness of these forces may be variable, with political influences often present. Behavior and interaction with the refugee community, for example trading sought after goods for donated food rations or labor, may give rise to a number of ethical and moral questions. However, if the overall effect is that a population can exist in relative peace, with access to the main health interventions above, and being able to live without fear, this may be a price worth paying. If western or UN military forces are present, they will normally have a seat at senior planning meetings, alongside senior UNHCR or UNOCHA officials. Their military contribution to logistics, intelligence, provision of security, engineering and medical skills have contributed significantly to many humanitarian crises in the past decades. For example the NATO effort in Pakistan following the 2005 earthquake and support to Macedonia and Kosovo following the Balkans wars in 1999. Humanitarian workers need to accept that military peacekeeping forces are an increasing presence in many complex humanitarian emergencies as well as to pure humanitarian assistance following natural disasters.
Conclusion There has been considerable progress in the evidence base for the health management of a major humanitarian disaster, whether naturally caused or due to conflict. Initial assessment and priorities for intervention are well established with increasing cooperation and integration of the relief effort becoming evident, although much progress is still required. The need for health workers in this area to be adequately trained, with an understanding of both the requirements at field level and a higher strategic appreciation of how an aid effort is coordinated and delivered are key skills, which when
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effective can significantly improve health care of displaced persons and therefore reduce their morbidity and mortality.
References Banatvala N, Zwi A. Public health and humanitarian interventions: developing the evidence base. BMJ 2000, 321, 101–105 Code of Conduct for the International Red Cross and Red Crescent Movement and NGOs in Disaster Relief. Geneva, 1994. http:/www.ifrc.org/publicat/conduct/ Greikspoor A, Sondorp E. Enhancing the Quality of Humanitarian Assistance: Taking Stock and Future Initiatives. Prehospital and Disaster Medicine 2001, 16(4), 209–215 Hallam A. Good Practice Review 7, Evaluating Humanitarian Assistance Programmes in Complex Emergencies. Relief and Rehabilitation Network, ODI, London, 1998 Healing TD, Drysdale SF, Black ME, et al. Monitoring health in the war affected areas of the former Yugoslavia 1992–93. Eur J Pub Health 1996, 6, 245–251 Mears C, Chowdhury S. Health Care for Refugees and Displaced People. Oxfam Practical Health Guide No. 9, Oxford, 1994 Medicins Sans Frontiers. Refugee Health. An Approach to Emergency Situations. Medecins Sans Frontieres, Macmillan, London, 1997 Noji EK, Toole MJ. The historical development of public health response to disasters. Disasters 1997, 21(4), 366–376 ODI. Joint Evaluation of Emergency Assistance to Rwanda, Study III, Humanitarian Aid and Effects. ODI, London, 1995 SPHERE Project 2004. http://www.sphereproject.org The Active Learning Network on Accountability and Performance in Humanitarian Assistance. http://www. alnap.org
11. The Military Approach to Medical Planning Martin C.M. Bricknell
Introduction This chapter will discuss the military approach to medical planning within the context of supporting both military and nonmilitary populations. In addition to providing support for military operations, military medical services have a long history in providing assistance in complex humanitarian emergencies. Military medical forces may be the only medical services available in the immediate aftermath of conflict and are often required to coordinate the reestablishment of civilian services. Military medical personnel were an integral element of the Allied Military Government of Occupied Territories that followed behind combat forces in the Second World War to reestablish the civilian infrastructure. UK medical personnel provided essential services in the immediate aftermath of the invasion in Suez in 1956. UK military medical services have also been directly tasked to provide humanitarian support as demonstrated in following an earthquake in Nepal in 1988, genocide in Rwanda in 1994 (see Chap. 14), and forced population migration in Macedonia in 1999. Since 2001, in Afghanistan NATO military medical forces have been supporting the development of the civilian health system under the guidance of the Afghan Ministry of Public Health and International Agencies such as the World Health Organization. More recently, UK medical personnel provided emergency medical services to civilians and undertook the first health needs assessment in Basra and southern Iraq in 2003.
The Estimate Military medical planners are taught to apply a structured approach to determine the requirements for medical support to military operations called the Estimate. This same structure can also be applied to planning for the mitigation and response to public health emergencies. This chapter will describe the Estimate process. There are two discrete outputs from this process. The first output develops the health promotion and preventive medicine advice, and actions to assist in the maintenance of the physical, psychological and social health of the force. The second output develops the plan to provide missions and tasks for the medical elements of the force.
A. Hopperus Buma et al. (eds.), Conflict and Catastrophe Medicine, Second ed., DOI 10.1007/978-1-84800-352-1_11, © Springer-Verlag London Limited 2009
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Date
Attack on the World Trade Center Dissemination of anthrax in the US postal system Severe acute respiratory syndrome Hurricane Katrina Indian Ocean Tsunami Regional conflict in Darfur Terrorist attacks – Bali, Spain, London, Mumbai, etc. Pandemic influenza
11 Sept. 2001 Autumn/winter 2001 2003 29 Aug. 2005 26 Dec. 2005 Since 2003 Enduring threat Enduring threat
The profile of medical planning within the wider context of civilian emergency planning has been raised as a result of a number of substantial public health emergencies. Examples are shown in Table 11.1. The response to many of these events has involved a wide number of organizations both civilian and military at local, national, regional, and global levels. There is widespread acknowledgement of the importance of effective interagency working, and this can be enhanced through the development of a common approach to planning.
Estimate Format The Estimate can be compared to the formal diagnostic process. In medicine a patient presents to the doctor a cluster of symptoms and signs. The doctor follows a structured approach to data collection based upon a history, examination, and special tests to reach a diagnosis. Once the diagnosis has been reached, the doctor chooses a treatment based upon the collective experience of the medical profession. Thus the critical problem-solving task is the interpretation of the illness in order to attribute a diagnostic label that fulfils the doctor’s concept of disease. In military planning, a commander is given a mission by his superior headquarters. The commander is required to assess this mission in order to establish missions for his subordinates. If these subordinate missions are not clear then the commander may seek further information from his staff, intelligence reports, or reconnaissance. Thus the critical problemsolving task is the interpretation of the mission in order to issue subordinates their missions that fulfil the commander’s interpretation of the capabilities of his subordinates. This intellectual activity has been formalized into mission analysis and the Estimate process. Military medical planners are taught the full range of factors and issues to be considered. Initially they may apply a “blunderbuss” approach, but as they become more experienced, they refine this into a more “hypothetical-deductive” approach. This is directly analogous to the difference in competency between a medical student and the experienced diagnostician. The Estimate follows 5 steps shown in Fig. 11.1.
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Step 1 – Mission Analysis. Step 2 – Evaluation of Factors. Step 3 – Consideration of Courses of Action (COA). Step 4 – Commander’s Decision. Step 5 – Implementing the Plan.
Fig. 11.1. Five steps in the medical Estimate.
Background Information At the start of the Estimate process it is important to assemble the background information needed. This might include maps, situation reports from the local area, news reports, and information about prevalent diseases, the current political and health environment, and organizations already involved in the emergency. The Internet is often an excellent source of information. Sites hosted by international aid organizations such as the United Nations, World Health Organization, US Center for Disease Control Atlanta, and UK Health Protection Agency may contain useful information. Less formal sites such as ReliefWeb and Well Diggers Workstation contain copious quantities of practical information for medical planning.
Step 1: Mission Analysis Mission Analysis. The Estimate process begins with mission analysis based on the mission statement provided by a higher headquarters or organization. Ideally this mission statement should be a unifying task with a purpose similar to a “vision statement” in management theory. Examples of mission statements given to military medical forces in postconflict operations are in Fig. 11.2. Mission analysis involves the interpretation of the mission in order to deduce the tasks specified in the mission and those that are implied by the higher headquarters. This enables the medical planner to determine “what he has to do”.
Step 2: The Evaluation of Factors Generic Structure The Evaluation of Factors stage of the Estimate is designed as a series of tools and checklists to enable the medical planner to determine “how to do it.” The following are considered in all military plans: Environment, Hostile Forces, Friendly Forces, Surprise,
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Kurdistan 1991 - To assist in the provision of security and humanitarian assistance in order to expedite the movement of Kurdish displaced persons from refugee camps directly to their homes. Rwanda 1994 - To provide humanitarian assistance in the Southwest of Rwanda in order to encourage the refugee population to stay in that part of the country. Iraq 2003 - To assess and regenerate the Iraq medical system as smoothly as possible, in order to create the conditions for a stable and secure medical environment in Iraq.
Fig. 11.2. Examples of mission statements given to military medical forces in humanitarian operations.
and Security and Time. In addition, the following factors are used by military medical planners: Casualty Estimate; Medical Force Protection; Medical Capabilities; Medical Logistics; Medical, Nuclear, Biological, and Chemical Defence; and Medical C4 (Command and Control, Communications and Computers). The generic structure is designed to enable the Estimate to be performed by a single individual or divided among several planners working together.
Environment This step involves a review of the geography of the area of operation and determining whether issues such as distance, temperature, roads, airfields, and other geographic features are relevant to the medical plan. It is important to note the locations of indigenous medical facilities and structures relevant to medical planning such as water treatment facilities, power stations, food storage sites, etc. In a conflict environment this might also include an assessment of sites of potential toxic industrial hazards that might be released if they are damaged.
Hostile Forces Many public health crises are the result of conflict. Medical planners should review the weapons (e.g., small arms, artillery or aircraft, mines, booby traps) available to hostile forces to generate a list of the types of injuries that might need medical care. The threat from release of chemicals (either deliberately or from collateral damage of industrial facilities) should also be identified at this stage. Indigenous diseases may also be considered as “hostile forces.” These may be identified from local knowledge or from information sources such as the WHO, UK Health Protection Agency, or the US Center for Disease Control.
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Friendly Forces Population at Risk It is vital to know how many people are dependant on the health service plan – the population at risk (PAR). In military operations this will include both friendly military forces and also the opposition as there is a duty under the Geneva Convention to provide impartial medical care to parties of the conflict. In complex emergencies involving a wide number of agencies the PAR might extend to international agencies, civilian contractors, and in certain circumstances, local civilians. In humanitarian operations the PAR can be considered as two groups: those providing the humanitarian response and those who will be recipients of this response. It is vital that the medical planner considers the health needs of those providing the humanitarian response in order that they are suitably screened for preexisting illness prior to deployment and that there is a “safety net” in case of severe injury or illness. The health needs of the recipient population should be estimated prior to deployment and then confirmed by a formal assessment.
The Overall Plan The medical plan must be aligned to the overall plan both involving the military and also within the plans of other organizations involved in the health sector. This will frequently consider wider humanitarian issues such as security; law and order; food, water, and fuel distribution; establishment of representative government; education, and other developmental issues.
Security Parties to conflict in complex humanitarian emergencies increasingly regard the humanitarian community, including medical personnel, as targets. It is vital that the security of the humanitarian community is given a high priority even if this has the potential to constrain the ability to meet needs of the dependent population. Many international agencies employ security coordinators to monitor the threat to their staff, develop emergency evacuation plans and undertake assessments for the employment of their staff in high-risk environments.
Time Time is a vital factor in health care. Ideally the organization of ambulance services and the location of medical facilities should be chosen to minimize delay in the pro-
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vision of the health-care needs for the dependent population. This may need to be balanced against the resources available and the need to maintain the security of medical staff.
Casualty Estimate The Casualty Estimate is an integration of the Hostile Forces factor with the PAR to produce an estimate of the numbers and types of casualties that will require treatment and evacuation. In the military environment casualty estimation is often based upon an analysis of data from historical sources supplemented by computer simulation of the predicted military engagements. This approach may also be useful in the planning of the health sector response to outbreaks of infectious disease. In the humanitarian situation, a casualty estimate may be made using sampling techniques in the affected population – details of such an approach are available from the WHO Health Action in Crisis and Médicins Sans Frontières Web sites.
Medical Force Protection Medical Force Protection describes the preventive medical actions that need to be undertaken to protect both the intervention forces and the dependant population arising from the threats identified in the Hostile Forces section. Examples might include predeployment immunization; direction on sources of food and water to prevent gastrointestinal illness; use of body armor to protect against fragmentation weapons; and antibiting measures and chemoprophylaxis for the prevention of malaria (see next chapter).
Medical Capabilities The sum total of the preceding factors will determine the types of medical facility required (surgical, pediatric, environmental health, etc.) and the capacity of each facility. These should be listed – e.g., 5 primary health care clinics, 1 mobile hospital with 2 surgical teams and 2 intensive care beds, 1 fixed hospital with 4 surgical teams and 6 intensive care and 30 general care beds, 20 ambulances, etc.
Medical Logistics Medical Logistics merits a separate heading because of the technical complexity of the subject. Detailed planning for supply of individual line items, oxygen, blood and blood products (e.g. fresh frozen plasma), and clinical waste needs to be considered in addition to medical modules. Special attention must be paid to the storage and distribution chain to ensure that medical material is kept within specified temperatures.
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Medical CBRN (Chemical, Biological, Radiological, Nuclear) The proliferation of NBC weapons may mean that the health consequences of their use become a significant planning factor in conflict and public health emergencies in the future. Many Western public health systems have undertaken detailed planning and preparation to mitigate the consequences of a deliberate release of CBRN agents as a result of a terrorist attack. Such planning includes organizational issues, equipment issues (protective equipment and treatment kits), and training for health-care staff.
Medical C4 (Command and Control, Communications and Computers) The efficiency of the medical system is dependent on the effectiveness of the C4 of the various medical elements in area. The treatment and movement of a single casualty may involve coordination across a number of medical facilities and organizations. It may be necessary to establish liaison officers, communication links, and other means to enable information to be passed efficiently between medical agencies involved in the public health emergency. Post-event inquiries almost invariably identify issues relating to C4 that hampered the effective implementation of the emergency plan. It is vital to consider the training requirements for the decision-makers in the plan under this factor.
Humanitarian Factors The Sphere project recommend 10 priorities for intervention, as listed in Fig. 11.3. These were discussed in detail in a previous chapter and form the humanitarian factors that should be considered in the medical Estimate. The relative importance of the “10 priorities” will depend on the exact humanitarian emergency. A forced population displacement in the winter in the Balkans of previously well-fed and healthy civilians will create very different challenges than will severe flooding affecting a malnourished, resident population in Mozambique. The principal task is assessment. There are a number of information-gathering tools for use in humanitarian emergencies. Ideally, the humanitarian community should rapidly establish a common system so that all agencies can contribute to the data collection for the initial assessment and that this information can be collated into a shared information system. The Internet is increasingly being used as the basis for the common information architecture. The United Nations Office for the Co-ordination of Humanitarian Affairs (OCHA) set up an Internet site for this purpose for the crisis in Iraq in 2003. The UK military medical services set up rapid assessment teams to visit medical facilities in the Southeast of Iraq immediately after each town had been secured, to determine the health-care needs of the population and provide information for the humanitarian agencies.
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1.
Initial Assessment
2.
Measles Immunisation
3.
Water and Sanitation
4.
Food and Nutrition
5.
Shelter and Site planning
6.
Health care in the emergency phase
7.
Control of Communicable Disease and Epidemics
8.
Public Health Surveillance
9.
Human resources and training
10.
Co-ordination
Fig. 11.3. Ten priorities for medical intervention in humanitarian emergencies.
The detailed information required to enable planning to meet the needs of a displaced or refugee population in regard to water, food, shelter, and sanitation, and the other priorities has been discussed in other chapters of this book. Even during the emergency phase, it is vital that the humanitarian community establishes a pragmatic balance between needs of the affected community and creating expectations and dependencies that are unsustainable as the crisis moves from the emergency phase into long-term development. The central, long-term task for all members of the humanitarian community is coordination. Each agency, including military medical forces, will have specific rules regarding its involvement with both the dependant community and each other. It is vital that each agency accepts the moral responsibility to coordinate its work through a central authority, often the local offices of the United Nations or World Health Organization, in order to ensure that the distribution of humanitarian aid is humane, equitable, and sustainable and not in competition between agencies.
Assessment of Tasks The evaluation of factors will generate a list of tasks. These should be listed and matched to resources. An example of the list of tasks that were derived from the UK medical Estimate to support humanitarian operations in Iraq in 2003 is shown in Fig. 11.4.
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Regeneration of Medical Services in Iraq. The regeneration of medical services requires: (1) The locating and recruitment of medical personnel from the occupied population. Medical personnel include professionally qualified individuals from all specialties, managers and ancillary staff. (2) The locating and assessment of medical facilities. Information may be available on medical installations in Iraq, their previous capacities and capabilities. However, medical assessment teams will be required to provide up top date assessments of those facilities. (3) The locating and assessment of medical materiel and equipment (including such items as ward equipment, pharmaceuticals and ambulances. (4) During the regeneration of medical infrastructure, the occupying force has the right to redistribute medical assets from one point to another. This may be required in order to generate as much capability and capacity as possible from within existing resources and lowering the overall burden of UK forces to replicate lost facilities. (5) Also of importance is an understanding of the medical funding pre-conflict. UK medical care is free at the point of consumption. It may not be so in Iraq. It may be inappropriate to provide free medical care as this might upset the local medical economy and hinder the return of civilian medical staff to their posts. (6) NGO Arrival. It has been stated that NGO’s will not be in a position to offer assistance for at least 30 days. However, their arrival could be eased by a free exchange of information now, in order for the NGO’s to queue their assets according to need. (7) Possible Resource Requirements. The following capabilities might be required during the regeneration phase of the occupation of urban areas: Generators Water filtration equipment. Hospital eqpt of all natures. Obs/Gyn staff Paediatricians Geriatricians.
Fig. 11.4. List of tasks from postconflict medical estimate in Iraq.
Step 3: Consideration of Courses of Action This is often the most difficult but most important part of the Estimate process. The medical tasks generated in the Assessment of Tasks need to be converted into a series of Mission Statements or Task Lists for the medical elements of the Force. Ideally the Estimate process will lead to a number of key decisions, some of which may have a series of options. These should be examined under Consideration of Courses of Action. It is important to remain focussed on the level of decision-making at which the Estimate is being undertaken.
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Step 4: Commander’s Decision In military circumstances the Commanding Officer will have the final accountability for the plan. It may be necessary to invest a considerable amount of energy to generate consensus for a plan in a complex humanitarian emergency involving a number of agencies. While military medical staff may have well-developed planning and decision-making skills, it may be more appropriate for other organizations to take the lead in planning and coordinating the health-care response.
Step 5: Development of the Plan A plan has no value unless it can be communicated and coordinated to all parties involved. This may require written instructions and verbal briefings – even orders. Military organizations have a well-developed structure and procedures for the writing and communication of orders so that all members of the team are aware of their role in the plan. Each humanitarian agency might have its own similar procedures. It is incumbent on the medical planner to carefully craft the “mission statements” for each of the components of his organization so that the subordinate leaders are clear how their missions contribute to overall output of the humanitarian response. Graphical tools such as marked maps or project-planning timetables may help to convey specific details. Planning conferences and workshops, such as tabletop exercises used in emergency planning, may also help to aid mutual understanding between organizations. Military medical staff are taught to communicate their plan as a formal set of “orders” to a defined structure. This ensures that those personnel receiving the orders know when to expect to receive key pieces of information and provides a checklist to ensure that all aspects of the problem are covered.
Summary The military medical Estimate is a formal decision-making tool like medical diagnosis. This provides a structure to enable considered analysis of the factors involved in a complex humanitarian emergency. The output of this work is a plan for the military medical response to an emergency situation. This decision-making tool may provide a suitable structure for use by other organizations working in this environment.
Web Sites WHO Tools and references for Health Action in Crisis. http://www.who.int/hac/ techguidance/tools/response/en/index.html Médicins Sans Frontières. http://www.msf.org/ Sphere project. http://www.sphereproject.org/
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US Centers for Disease Control and Prevention. http://www.cdc.gov/ UK Department of Health Emergency Planning. http://www.dh.gov.uk/en/Policyandguidance/Emergencyplanning/index.htm UK Health Protection Agency Centre for Emergency Preparedness and Response. http://www.hpa.org.uk/emergency/default.htm This chapter contains material previously published in the Journal of the Royal Army Medical Corps (www.ramcjournal.com) and is used with permission
12. Health Risk Management Matrix: A Medical Planning Tool Martin C.M. Bricknell and Gareth Moore
Introduction NATO medical policy defines Medical Force Protection (MFP) as the conservation of the fighting potential of a force so that it is healthy, fully combat capable, and can be applied at the decisive time and place. It consists of actions taken to counter the debilitating effects of environment, disease, and selected special weapon systems through preventive measures for personnel, systems, and operational formations (Allied Joint Medical Support Doctrine 2002). British military medical doctrine describes a planning process, Health Risk Management (HRM), that facilitates the creation of a MFP plan (Joint Medical Doctrine 2000). As such, it is also a key element of the Medical contribution to the overall Medical Planning process. Existing UK legislation (Health and Safety at Work Act 1974) and MOD policy (JSP 375 The MOD Health and Safety Handbook) on Health and Safety determine that commanders at all levels have a permanent responsibility for ensuring that military activities are undertaken in the safest possible manner and with due regard to any risks to their personnel. This responsibility applies in barracks, during training, and on operations. Thus Health and Safety policy is subordinate to, but an integral component of, the concept of Force Protection. The application of HRM should ensure that medical staff provides commanders with the necessary advice and practical support to enable them to meet their legal responsibilities under Health and Safety legislation consistent with the practical realities of military operations. This article describes the “Health Risk Management Matrix” that teaches military personnel to identify, assess, and manage risks to the health of a military population. This framework is currently taught to all members of the Defence Medical Services who attend training and courses delivered by the Department of Environmental and Occupational Health at the Defence Medical Training Center. Students have found it an effective learning aid, and instructional staff has noted a substantial improvement in the quality of plans to protect health in exercise scenarios.
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Health Risk Management British Army medical doctrine summarises HRM as a linear process with 5 stages. This is shown in Fig. 12.1. The dotted lines represent a feedback loop to ensure that any adverse changes in the health of the population at risk (PAR) are accompanied by actions to improve the management of the health risks identified during the HRM process. We found from our experience from teaching HRM that students were aware of service policies in regard to specific hazards but had difficulty converting this knowledge into a practical plan for implementation. Furthermore, the linear description of HRM benefited from the introduction of the idea that Risk Management should be accompanied by a process of monitoring the interventions designed to reduce risk rather than waiting until the medical surveillance systems had detected health effects. We designed the HRM matrix to provide a format for the collation of background information and to encourage students to interpret background policies into a list of positive actions. The use of a matrix rather allows students to consider how to monitor their risk management plan concurrently with their interventions, thus introducing the idea that their responsibility as a medical planner includes ensuring that their plan actually works. Figure 12.2 shows the HRM matrix completed for malaria at unit level involved in a disaster relief operation in Africa for use by a Regimental Medical Officer or Unit Health Adviser. The completion of each element of the HRM matrix is discussed below.
Identification of the Hazard The first stage in HRM is to identify all of the potential hazards to the health of the PAR. The Medical Intelligence Assessment and the Medical Warning Notice should provide this information, but this may need to be complemented by other sources of information. Hazards should be considered in the following hierarchy:
Fig. 12.1. Health risk management process.
Disasters, Public Health, and Populations Population At Risk Op & Activity Dependent (Humanitarian Op) All Own Tps/Pers C2 / C3 & Specialist Friendly Forces/NGOs Locally Employed Civilians Displaced Persons / Refugees Displaced Persons/Refugee Children
MALARIA Refs: SGPL 10 /10. JSP 371. Theatre MIA Med Wng Notice
RISK ASSESSMENT
HAZARD
191 Risk Assessment Theatre, Op & Activity Dependent
Very High Very High Very High Medium Medium High
−1 −1 −1 −3 −4 −2
MONITORING ACTIVITIES (Audit and Surveillance)
CONTROL ACTIVITIES
Physical • Avoidance or removal of breeding sites: - Drainage or removal of mosquito breeding sites. - Camp/unit dry day – once a week. - Camp siting & segregation. • Use nets on windows and doors of accommodation / tents Chemical • Residual insecticide on structures, harbourage or resting areas. • Knockdown insecticides: - Swing fog dawn & dusk - Knockdown aerosols in accommodation. • Larvicidal treatment of mosquito breeding sites (Abate). • Vector control carried out as per JSP 371.
INFORMATION, TRAINING & POLICY TREATMENT
• • • • •
•
Individual Bite Avoidance Physical • Bite prevention : - Use of bed nets. - Clothing - long sleeves and trousers at dawn and dusk. Chemical • Peripel for clothing and nets (JSP 371 – Chap 46B) . • Insect repellent on exposed skin.
MEDICAL COUNTERMEASURES
RISK MANAGEMENT
GENERAL CONTROLS
Communal Vector Control
• •
•
Health Intelligence & Med Recce. Health Education (MHIT Pre-deployment). o Bite avoidance o Communal measures o Chemo-prophylaxis regimes Vector & Hygiene control specialist trained personnel. Divisional SOP’s to be prepared, according to health intelligence. In-theatre reinforcement of Health ed/trg. Appropriate Chemo-prophylaxis for own tps. (MWN or DCI JS172 / 2001), incl alternative regimes. Removal of individual from theatre if severe reaction occurs to C-P. Warning cards.
• • • • •
Early identification of suspect cases. Appropriate symptomatic treatment/care. Diagnostic sample and analysis to confirm parasite . Definitive treatment/care. Treatment arrangements for DPs.
• • • • •
• • •
Local Med Int. Case Identification/Reporting. Breeding site surveys. Bite rates / reports. Camp /site inspections. o Op Sanitation & Camp Hygiene o Screening/Netting o Knockdown insecticide use Hygiene Diary / Vector Control Log entries: o Unit dry days. o Swingfog routines. o Site inspections. o Peripel issue / treatment: - Clothing - Nets o Abate dosing. o Residual spraying. Use and serviceability of bednets. Pesticide application recorded and effectiveness assessed. Check dress states/SOPs.
• • • •
Local Med Int. Arrival/Induction Trg. Vector control operatives. Examples of reinforcing information sources, SOPs and orders. • Warning Cards carried.
• • • • • • • • • •
Chemo-prophylaxis issue / parades. Monitoring of drug related adverse effects. Warning Cards carried. Case Notifications - FMed 85 UNHCR/NGO/HN case reports. Lab IDs / reports. Morbidity returns (J97). Adherence to treatment protocols. Evac of cases. Post deployment - case ID and tracking.
Fig. 12.2. Health risk management matrix completed for malaria.
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Conventional battle hazards, e.g., bullet, bomb, blast Nonbattle traumatic hazards, e.g., road accidents, training accidents Infective hazards Chemical hazards Radioactive hazards Environmental hazards Psychological hazards Ergonomic hazards
The medical planner should generate a HRM matrix for each of the hazards identified. It is suggested that these should be organized on paper or electronically so that they can be readily reviewed, updated, and retrieved for audit. At this stage background reference material and policies should also be obtained and reviewed for each of the hazards identified. These might include Surgeon General Policy Letters, Joint Service Publications (JSPs), the theater Medical Intelligence Assessment, the theater Medical Warning Notice, or other publications.
Definition of the Population at Risk (PAR) The medical planner should identify all of the PAR for whom he is responsible. The definition of the PAR may need to be categorized in order to distinguish between difference levels of exposure or vulnerability to a threat, or to distinguish between the significance between different levels of impact of failures in MFP measures. Examples of such PAR groupings might include the following: 1. Own forces (i.e., OPCON – under operational control), e.g., headquarters, acclimatized/unacclimatized, occupational or trade groupings (e.g., catering staff, staff in special protective equipment, medical staff), specific operational tasks (reconnaissance, guarding, flying) 2. Grouped Joint and Combined forces (i.e., all other states of command) 3. Civilians, e.g., UK civil servants, UK contractors, nongovernmental organizations, locally employed civilians, local liaison personnel 4. Enemy forces and prisoners of war This stage of the process may include plotting locations of hazards and PARs on a map to provide a graphical illustration to support the risk assessment process.
Risk Assessment Risk Assessment helps commanders and their staff to prioritize and allocate resources for MFP. The primary purpose is to evaluate the importance of health hazards and to compare the risk between different hazards. These will normally be expressed as a composite of qualitative judgments regarding the likelihood of exposure to a hazard and the potential severity of the outcome. The two-dimensional matrix described for the general assessment of operational risk shown in Table 12.1 may be utilized for this
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Table 12.1. Matrix for assessment of operational risk Probability Severity Catastrophic Critical Marginal Negligible Chronic
Frequent
Likely
Occasional
Seldom
Unlikely
Extreme Extreme High Moderate Differed
Extreme High Moderate Low
High High Moderate Low
High Moderate Low Low
Moderate Low Low Low
purpose. In the example shown in Fig. 12.2, the risk to deployed forces and NGOs from malaria is considered to be both very high and high priority. The risk to children in the displaced population is the next highest risk and priority and so on. Under health and safety legislation, commanders have a general duty to reduce all risks “so far as is reasonably practicable,” which in turn will depend greatly on the prevailing operational circumstances and imperatives (Health and Safety at Work Act 1974). As an example, many communal antimalarial measures are impractical when conducting a reconnaissance patrol in the jungle where the consequence of being discovered and shot at by an enemy is greater than the consequence of catching malaria. However, individual measures such as the use of insect repellants and taking antimalarials are therefore extremely important and should be actively supervised. Other legal standards may apply such as for occupational exposure to chemicals where “exposure should be reduced so far as is reasonably practicable and in any case below the maximum exposure limit” (Control of Substances Hazardous to Health Regulations 2002), or for exposure to ionizing radiation when the standard is “as low as reasonably achievable and must not exceed certain exposure limits” (Ionising Radiation Regulations 1985). The extent to which control measures can be implemented and enforced will be highly variable, dependent on the nature, phase, and intensity of operations. Commanders therefore need to be aware of the inherent risks in order to make valid risk decisions and place proper emphasis on implementation and monitoring of remedial control measures.
Risk Management: Control Activities There are a number of components to Control Activities listed within Risk Management. These have a defined hierarchy in UK legislation. The components are shown below: General Control Measures. These are measures taken to reduce the probability of personnel suffering ill-health from the hazard. Table 12.2 shows the hierarchy of control measures that should be considered (Murray and Bricknell 1999) and examples of their application for malaria. Information, training, and policy. The provision of information, instruction, and training is a critical element of the implementation of UK legislation (Health and Safety Executive INDG213 7/97) that must be reflected in military MFP. All personnel must be
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Table 12.2. Hierarchy of control measures Control measure
Malaria control
Remove the hazard.
Use of Swingfog or other insecticide to kill mosquitoes. Avoid or remove all standing water.
Remove personnel from the hazard.
Deploy only those personnel strictly needed for the operational task. Exclude those for whom malaria would be medically catastrophic, such as pregnant personnel and those who have had a splenectomy.
Isolate or enclose the hazard.
Put high-risk areas (e.g., undrainable standing water) outof-bounds.
Isolate or enclose personnel.
Fit insect screens to fixed accommodation. Use bed nets.
Control exposure (e.g., work/rest cycles).
Withdraw personnel from high-risk areas from dawn to dusk.
Provide personal protective equipment.
Issue Permethrin-impregnated clothing. Use insect repellents.
educated and trained in regard to the health hazards of a specific deployment and how to minimize the risk of personal ill-health. Military Annual Training Tests specifies mandatory health promotion training that all army personnel should receive each year. This should provide a background level of knowledge. The Mobile Health Instruction Team will supplement this with a “just-in-time” predeployment health brief covering the health hazards specific to a particular military operation. This can be reinforced during the theater arrival brief. Individual aide memoirs and entries in Theater and Unit Standing Orders may also be used. Finally, health warning cards such as the Malaria Warning Card (F Med 568) may be issued to all personnel prior to their return to UK. Medical countermeasures. Medical countermeasures are prophylactic immunizations or medications that can be prescribed to reduce the risk of an adverse health event. This may involve immunizations (e.g., tetanus, typhoid, and polio), pre-exposure drug treatment (e.g., antimalarials, NAPS, BATS), post-exposure prophylaxis (e.g., use of human immunoglobulin to prevent Hepatitis B after a needlestick injury). This will be promulgated in the Medical Warning Notice, with medical staff being responsible for the prescription and supply of these drugs. In the worked example, the Medical Intelligence Assessment will advise on the choice of antimalarial for a particular region and population. Treatment resources required. The amount, nature, and disposition of the treatment resources required will relate to the risk assessment. Medical staff will need to ensure that a robust plan is in place to treat any individual who succumbs to the health hazard. Treatment resources may be tailored to a specific casualty estimate or may be considered as an “insurance policy” which requires a critical mass whatever the magnitude of risk. In the worked example in Fig. 12.2, specific arrangements for the rapid investigation and treatment of febrile service personnel in case of malaria are required. The medical facilities need to have appropriate therapeutic and supportive therapies (possibly including intensive care and access to urgent aeromedical evacuation) readily available.
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Risk Management: Monitoring Activities The effectiveness of MFP must be measured by monitoring activities based on a combination of audit of policies and procedures and health surveillance to detect failures in risk management. As an example, Unit Environmental Health Duties personnel may be tasked to inspect camps for standing water and other potential mosquito breeding sites as part of their duties in pest control. Individual blister packs of drugs can be checked at random to check tablets have been used. Nominal roles can be used as registers to record the application of insecticides to issued equipment in accordance with policy. There are a number of tools that assist health surveillance. In the example, individual cases of malaria should be reported using an F Med 85 and any local casereporting system with other epidemiological systems being used to record cases of febrile illness on a population basis. Commanders and their staff must ensure that they make maximum use of such tools to provide feedback on the effectiveness of MFP measures.
Conclusion This chapter has described a practical approach to Health Risk Management using a structured matrix as a prompt to assist a medical planner in the production of a Medical Force Protection (MFP) plan. This is demonstrated as a worked example using malaria. The methodology described has been used in training courses at the Defence Medical Services Training Centre and is reported to improve students’ abilities to produce a MFP plan. This chapter contains material previously published in the Journal of the Royal Army Medical Corps (www.ramcjournal.com) and is used with permission.
References Accident Reporting System. Issue 2. Joint Service Publication 442. Directorate of Safety, Health, Environment and Fire Policy, Ministry of Defence: London. April 2000. AJP-4-10. Allied Joint Medical Support Doctrine. NATO: Brussels. 2002. Control of Substances Hazardous to Health Regulations. SI 2002/2677 Stationary Office: London. 2002. Jun 2000 – AMS Core Doctrine, Vol. 1. Army Medical Directorate: Camberley. 2000. (AC 71700) – ADP Vol. 3 Logistics – Medical Supplement. Jul 2000 – The Management of Risk. Force Protection in Joint Operations. Joint Doctrine Publication 1/99. Joint Doctrine and Concepts Centre: Shrivenham. 1999. Health and Safety at Work Act (1974). Ionising Radiation Regulations. Health and Safety Executive. 1985. Joint Medical Doctrine. Joint Warfare Publication 4-03 2nd Ed. Joint Doctrine and Concepts Centre: Shrivenham. 2006. JSP 375 The MOD Health and Safety Handbook. Ministry of Defence: London. Mandatory Annual Training Tests – No. 6. Directorate of Individual Training Policy: Upavon. 2006. Murray JW and Bricknell MC. Health Risk Management within Force Protection, ADTN No. 12. Nov. 1999, 29–30. 5 Steps to Information, Instruction and Training. Health and Safety Executive. INDG213 7/97.
13. Surveillance and Control of Communicable Disease in Conflicts and Disasters Tim Healing
Objectives
●
●
●
●
●
To describe the principles of health surveillance in conflict and disaster situations To assist in organizing a health surveillance system in conflict and disaster situations To describe the principles of control of communicable diseases in conflict and disaster situations To assist in organizing a response to outbreaks and epidemics To introduce the challenges associated with health surveillance and communicable diseases in conflict and disaster situations
Part A – Introduction There are five fundamental principles for the control of communicable disease in emergencies: ●
● ● ●
●
Rapid assessment – identify and quantify the main disease threats to the population and determine the population’s health status Prevention – provision of basic health care, shelter, food, water, and sanitation Surveillance – monitor disease trends and detect outbreaks Outbreak control – control outbreaks of disease. Involves proper preparedness and rapid response (confirmation, investigation, implementation of controls) Disease management – prompt diagnosis and effective treatment
Rapid assessment has been dealt with elsewhere in this book as have the prevention aspects of disease control (adequate shelter, clean water, sanitation, and food, together
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with basic individual health care). This chapter therefore covers surveillance, outbreak/epidemic control, and public health aspects of disease management. The topics are dealt with in general terms. More details can be found in references.
Disasters and Disease Disasters, particularly conflicts, by damaging or destroying the infrastructures of societies (health, sanitation, food supply) and by causing displacement of populations, generally lead to increased rates of disease. Outbreaks and epidemics are not inevitable in these situations and are relatively rare after rapid-onset natural disasters, but there is a severe increase in the risk of epidemics during and after complex emergencies involving conflict, large-scale population displacement with many persons in camps and food shortages. In most wars more people die from illness than from trauma. Preventing such problems, or at least limiting their effects, falls on those responsible for the health care of the population affected by the emergency. They must be able to ●
●
● ● ●
● ●
assess the health status of the population affected and identify the main health priorities monitor the development and determine the severity of any health emergency that develops (including monitoring the incidence of and case fatality rates from diseases, receiving early warning of epidemics and monitoring responses) plan and set up programs identify and take action to prevent or control outbreaks and epidemics monitor the progress of health interventions and their impact and modify them if required ensure the provision of appropriate aid (and prevent inappropriate aid) provide information for relevant agencies (e.g., national Ministry of Health (MOH), UN, NGOs, donors) for use in planning, funding applications, etc.
At first sight, undertaking public health activities in emergencies, especially in conflicts, may seem to be difficult or impossible. The destructive nature of warfare may prevent or inhibit the provision of adequate food and shelter, of clean water and sanitation and vaccination programs. Despite the difficulties that warfare imposes, it is generally possible to undertake at least limited public health programs, including disease surveillance and control activities. In other types of disaster public health activities may be expected to be less affected by the security situation than in a war (although aid workers may be at risk if populations are severely deprived of resources such as food, shelter, water, or cash), and with limited access and damage to communication systems and other parts of the infrastructure assessment, surveillance and control activities can be severely restricted. For example, following the Pakistan earthquake late in 2005 access was severely restricted for some time and the urgent need to treat the injured and provide food and shelter meant that the limited transport available was heavily committed.
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Part B – Health Surveillance Features The surveillance and control of communicable disease require data which can be collected in one of three ways: 1. Surveillance systems – covering all or at least a significant proportion of the population 2. Surveys – in which data are collected from a small sample of the affected population considered to be representative of the whole 3. Outbreak investigations – in-depth investigations designed to identify the cause of deaths or diseases and identify control measures Although the latter two can provide valuable information for disease control and form part of the surveillance process, proper control of disease requires regular monitoring of the overall disease situation, which in turn requires the establishment of a properly designed health surveillance system. It is important therefore that responsibility for surveillance activities is defined at the beginning of planning for an aid mission. Generally speaking, a team will be required, including a team leader (often an aid agency health coordinator), who should ideally have surveillance experience, clinical workers, a water and sanitation specialist, and representatives of the local health services and communities. The team may also need clerical, logistic, information technology and communications specialists. The World Health Organization defines health surveillance as “the ongoing systematic collection, analysis and interpretation of data in order to plan, implement and evaluate public health interventions.” Data for surveillance must be accurate, timely, relevant, representative, and easily analyzed, and the results must be disseminated in a timely manner to all who need to receive them. In addition the data collected, the methods used for collection and the output must be acceptable to those surveyed (health-care professionals and the population). In emergencies the time that can be given to surveillance by medical personnel is likely to be limited and surveillance activities will be far from the minds of most of those involved. Therefore the methods used need to be rapid, practical, and consistent, and while the greatest possible accuracy must be achieved, “the best must not be the enemy of the good.” It is necessary to strike a balance between collecting large amounts of information (“what we would like to know”) and collecting too little which can lead to an ineffective response. Those responsible for establishing surveillance programs must therefore try to determine what is really needed (“what we need to know”). It is better to err on the side of too much than of too little. Ideally any existing surveillance system should be used. There is no point in establishing a system if one already exists, unless the existing one is inadequate or inappropriate or has broken down irretrievably.
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Surveillance systems for use in conflict and disaster situations should therefore adhere as far as possible to the criteria given in Table 13.1. Notes on these criteria: 1. As simple and flexible as possible Complexity and inflexibility are incompatible with surveillance systems generally and particularly when operating in emergencies where collection of data may be difficult and where situations can change very fast. 2. Appropriate in terms of the information required Defining what you “need to know” will allow you to set up the appropriate data collection methods (questionnaires, sites, etc.) and to design the system so that it can obtain and handle the information required. 3. Capable of providing such information in a timely manner Information that is accurate but out of date is useless for immediate disease control purposes and of little value for forward planning. Communications therefore form an integral part of any surveillance system. 4. Appropriate in terms of the resources available Do not try to overreach when setting up a system. For example, expatriate staff may best be used to recruit local staff for the system and in supervisory activities rather than in collecting data.
Table 13.1. Criteria for surveillance systems 1
As simple and flexible as possible
2
Appropriate in terms of the information required
3
Capable of providing such information in a timely manner
4
Appropriate in terms of the resources available
5
Sustainable in the long term within local resources
6
Based on standardized sampling methods
7
Based on agreed case definitions
8
Capable of providing regular information from defined sites
9
Capable of covering the whole affected area
10
Compatible with existing systems
11
Use existing systems as far as possible
12
Use existing records as far as possible
13
Involve collaboration between agencies so as to avoid duplication
14
Involve collaboration with local services so as to avoid duplication
15
Acceptable to those surveyed
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5. Sustainable in the long term within local resources This criterion is certainly a goal to aim for as sustainability must be the target for all aid work. However, there may be situations where an emergency system is needed rapidly and where it cannot readily be integrated into existing systems or be developed as a new long-term system. 6. Based on standardized sampling methods The sampling system must use the same data collection methods throughout if data are to be comparable. Ideally this should be methods that are internationally agreed and approved. Agreement should be sought for the methods from the other agencies on the ground to ensure consistency. 7. Based on agreed case definitions Without case definitions that are agreed by all parties the likelihood of success of a surveillance system is very low. This is especially so when laboratory support is minimal or absent since clinical case definitions have to be drawn very tightly if different diseases are not to be confused. 8. Capable of providing regular information from defined sites Routine surveillance requires more than material from ad hoc sources. Sites such as medical centers (in towns, villages, or refugee camps), hospitals, and/or public health units should be recruited. 9. Capable of covering the whole affected area The more comprehensive the coverage of the system, the more likely is it that the data will be accurate and complete and that problems will not be missed. Such coverage can be problematic. The coverage of the different systems that can be used is discussed below. 10. Compatible with existing systems The data collected and the methods used should ideally fit in with systems that are operating or have previously operated in the area. 11. Use existing systems as far as possible Following from Criterion 10, if systems are already in existence or in abeyance but revivable then this should be done so as to ensure compliance by local health-care services and continuity of data collection and analysis. 12. Use existing records as far as possible Existing records are of considerable value for predictive purposes. Knowledge of past problems makes it possible to anticipate future trends and problems and allows for early planning decisions. 13. Involve collaboration between agencies so as to avoid duplication If several health agencies are operating it is essential to ensure collaboration among them in surveillance activities to avoid confusion and duplication of effort.
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14. Involve collaboration with local services so as to avoid duplication As above, early involvement of local health and surveillance services will reduce workloads and avoid duplication of effort. 15. Acceptable to those surveyed If those from whom the data are collected, those who are collecting the data, and those who will receive the results are unhappy with the system, the system is unlikely to operate effectively. These criteria can be used to evaluate a plan for a surveillance system and also, with some additions, to evaluate an existing system. However, failure to fulfil all these criteria need not rule out a system. In many emergencies it can be difficult to meet such a wide range of “best case” criteria, and the question that must be asked is whether the proposed system is capable of fulfilling its purpose – can it provide sufficiently accurate essential information to those who need it when they need it? The emphasis of an emergency surveillance program may need to be altered as the situation changes especially if a particular item emerges as being of key importance. Those running the surveillance program should use the data gathered and a continuous assessment of the general running of the system, to alter the program as required (preferably after consultation with relevant stakeholders).
Designing Health Surveillance Systems When designing health surveillance systems, it is essential to do the following: ● ● ● ● ● ● ●
Define the population under surveillance Determine what type of system can be established Set surveillance priorities Identify sources of data Set up agreed case definitions Establish data-handling systems Establish a protocol for evaluating the surveillance system as a whole
Each of these is examined in more detail.
Population Under Surveillance The population under surveillance may be relatively small and well defined (such as the population of a refugee camp) or a much less defined group such as mobile groups of refugees or IDPs or the population of a village, town, or region, the size of whose population may be unknown or may be fluctuating because of a disaster. Establishment of denominators may therefore be difficult. Even refugees or IDP camps may present a challenge as, while the size of the population may appear to be (or actually be) stable, its makeup may vary over time because of movements in and out. If the age or sex makeup of the camp alters, the pattern of disease may also alter.
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Demography: Numbers vs. Rates Both the number of cases detected and the rate of factors such as morbidity or mortality per unit of population are important values needed to inform emergency programs. Those responsible for all aspects of health care need to know what numbers of cases are involved so as to ensure adequate provision of services (amounts of medicines, numbers of hospital beds, etc.). However, simple numbers are of little value in assessing trends and patterns since increases or decreases in numbers of cases (or numbers of deaths) may reflect changes in population size (resulting, for example, from population displacement) rather than a trend due to (for example) a particular disease. In addition, several rates (such as the crude mortality rate) are key indicators in defining health emergencies (see below). Knowing the demography of the affected population is therefore important and all agencies working in an emergency should agree on and use the same population figures. The essential demographic data needed include the following: ● ●
Total population size Population structure – Overall sex ratio and the sex ratio in defined age groups – Population under 5 years old, with age breakdown (0–4 years) – this group has special needs and is usually a key factor in planning the emergency response – Age pyramid – Ethnic composition and place of origin – Number of vulnerable persons (e.g., pregnant and lactating women, members of female-headed households, unaccompanied children, destitute elderly, disabled and wounded persons)
●
Average family/household size
In situations where populations are displaced and extensive population movements may be occurring, it is also necessary to know the following: ● ●
The number of arrivals and departures per week The predicted number of future arrivals at the sampling sites
At the outset it is therefore important to establish methods to obtain demographic data. Often the best that can be managed initially is a rough estimate, but this can usually be refined later. It is helpful to use several methods and cross-check the figures to obtain the best estimate. Surrogates of the whole population (such as those attending a clinic) may be the best that can be achieved early on. The ease with which such data can be obtained usually depends on the size and scale of the population under consideration. The demography of a well-run refugee camp is quite easy to obtain but that of a larger area may be much more difficult. A lack of knowledge of the size of a displaced group can be confounded by a lack of knowledge of the size of the resident population. In many countries with poor infrastructures, accurate census data are not available. In some instances tax records may be helpful if these can be obtained. It should be noted that demographic data, especially if they
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involve refugees and IDPs, can be politically sensitive and interested parties may place undue weight on any figures that are given.
Types of Surveillance System Comprehensive Systems Ideally, communicable disease surveillance should be nationwide (or at least “affected area wide”), drawing information from a range of health-care centers that cover a sufficient proportion of the population to ensure that the great majority of cases (preferably all) of the relevant conditions are reported. A surveillance system in a refugee or IDP camp is effectively a miniature comprehensive system as it is possible to cover the whole population.
Sentinel Surveillance Systems There are situations where comprehensive surveillance is not possible and these often arise in disasters. Damaged access and communications and staff shortages frequently mean that only limited numbers of reporting sites (sentinel sites) can be used. As far as possible these should be chosen to ensure a wide coverage of the area and also to maximize the proportion of the population that is covered. Sentinel surveillance systems are inherently less satisfactory than comprehensive systems largely because they provide a much less complete coverage. The calculation of rates can sometimes be difficult or impossible; such systems can be very labour intensive, and important events may be missed. Both types of system may rely on notification of cases based solely on clinical evidence (and this is the most likely situation in conflicts and disasters at least in the early stages), or may include laboratory verification of some or (preferably) all diagnoses. If there is more than one center involved in establishing the diagnosis (for example, a clinical department, a hospital laboratory, and a reference laboratory) the channels of reporting must be very carefully set up so as to avoid duplicate reporting.
Setting Surveillance Priorities Surveillance must provide information on key health indicators, which should include the following: ● ● ● ● ● ● ●
Morbidity Mortality Nutritional status Immunization status Vital needs Health sector activities, including local health services Activities in related sectors
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The selection of information sought in these categories must be done carefully. It is neither possible nor desirable to monitor everything, especially in the early stages of a disaster response. At that stage (the acute phase) the priority of surveillance is the detection of factors that can have the greatest and most rapid effect on the population. In terms of communicable disease this means diseases that affect large numbers of people and have epidemic potential. In most instances this also means diseases for which effective rapid control measures exist. While gathering data on other largescale disease problems should not be excluded, the main surveillance and control efforts should be aimed where they can do the most immediate good. In the very early stages, only clinical information may be available since laboratory diagnostic services will probably be damaged or simply unavailable. However, this need not be a problem if the medical response is also geared to a syndromic approach. As the situation stabilizes, laboratory support becomes available, and longer term control measures can be supported, the surveillance can become more refined and additional diseases (for example, those which can cause severe morbidity and mortality in the longer term – such as tuberculosis, HIV or AIDS, and STDs) can be added to the list.
Morbidity The main morbidity figures that are routinely sought are as follows: ●
●
●
●
Incidence – the number of new cases of a particular disease reported over a defined period Attack rate (used in outbreaks – usually expressed as percentage) (also called incidence proportion or cumulative incidence) – number of new cases within a specified time period/size of the population initially at risk (×100). (e.g., if 30 per 1,000 persons develop a condition over 2 weeks, the AR/IP/CI is 30/1,000 [3.0%]) Incidence rate – number of new cases per unit of person-time at risk. In the above example, the IR is 15/1,000 person-weeks. (This statistic is useful where the amount of observation time differs between people, or when the population at risk varies with time) Prevalence – the total number of cases of a particular disease recorded in a population at a given time (also called “point prevalence”) (NB: Prevalence “rate” is the number of cases of a disease at a particular time/population at risk)
There are a number of ways of estimating morbidity. Health information systems based on health center attendance are the most common but are passive and rely on who presents to the services. Other ways of gathering morbidity data include the following: ●
●
Surveys – in which data are collected from a small sample of the emergencyaffected population deemed to be representative of the whole (or from a particular group for a specific purpose) Outbreak investigations – which entail in-depth investigations designed to identify the cause of deaths or diseases and identify control measures
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Mortality As with disease, changes in numbers of deaths may reflect changes in population size. Determination of rates is needed because mortality rate is an important surveillance indicator in an emergency. Often the first indication that a problem is developing is an increase in death rate, especially in particular vulnerable groups. All deaths occurring in the community must therefore be recorded. The following indicators can provide the essential information to define the health situation in a population: ●
●
●
●
Crude mortality rate (CMR) is the most important indicator as it indicates the severity of the problem, and changes in CMR show how a medical emergency is developing. CMR is usually expressed as number of deaths per 10,000 persons per day. If the CMR rises above 1/10,000 per day (>2/10,000 per day for young children) an acute emergency is developing and the emergency phase lasts until the daily CMR falls to 1/10,000 per day or below. Age-specific mortality rate (number of deaths in individuals of a specific age due to a specific cause/defined number of individuals of that age/day). In children this is usually given as the number of deaths in children younger and older than 5 years/1,000 children of each age/day). NB: If population data for the under 5s are not available, an estimate of 17% of the total population may be used. Maternal mortality rate. Maternal mortality is a sensitive indicator of the effectiveness of health-care systems. A maternal death is usually defined as the death of a woman while pregnant or within 42 days of the termination of the pregnancy (for whatever cause) from any cause related to or aggravated by the pregnancy or its management. The 42-day cut-off is recommended by WHO but some authorities use a time of up to a year. Maternal mortality rate = (number of deaths from puerperal causes in a specified area in a year/number of live births in the area during the same year) × 1,000 (or ×100,000) Cause-specific death rates (case fatality rates – usually given as a percentage). Proportion of cases of a specified condition which are fatal within a specified time. Case fatality rate = (no. of deaths from given disease in a given period/no. of diagnosed cases of that disease in the same period) × 100
Nutritional Status The following indicators must be measured: ●
Prevalence of global acute malnutrition (includes moderate and severe malnutrition) in children 6–59 months of age (or 60–110 cm in height) (percentage of children with weight for height under two standard deviations below the median value in a reference population and/or edema)
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Prevalence of severe acute malnutrition in children 6–59 months of age (or 60–110 cm in height) (percentage of children with weight for height under three standard deviations below the median value in a reference population and/or edema) Prevalence of micronutrient deficiencies Estimate number of children needing to be cared for in selective feeding programs Estimate number of additional calories per day provided by selective feeding programs
Immunization Immunization programs are a vital part of the public health measures undertaken following disasters. For example, measles vaccination is one of the most important health activities in such situations. The need for campaigns may be assessed on the basis of national vaccination records if they exist. In the absence of such records questioning of mothers may provide the information required, or children or their parents may have written vaccination histories with them (rare). The effectiveness of the programs undertaken can be assessed in defined populations by recording the percentage of children vaccinated. In less well defined populations an assessment of coverage may be made using the numbers of children attending clinics as a surrogate for the population as a whole.
Vital Needs Items such as water, sanitation, food, and shelter are essential to maintain a healthy population and prevent communicable diseases. Depending on the circumstances it may be necessary to monitor these elements in the affected population.
Health Service Activities Indicators such as number of consultations per day, number of vaccinations, number of admissions to hospitals, number of children in feeding programs are typically reported. Other factors such as effectiveness of the supply chain, maintenance of the cold chain, and laboratory activities may also be surveyed.
Activities in Related Sectors Activities in related sectors such as water and sanitation, shelter and security may also be included.
Sources of Data The major sources of health data will be hospitals and clinics (both national and those established by aid agencies), individual medical practitioners, and other health-care
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workers. Specialized agencies should be able to provide data on particular needs (e.g., food, water, sanitation, and shelter).
Case Definitions Case definitions are an essential part of surveillance. If the diseases (or syndromes) that are to be covered by the system are not clearly defined, and if the definitions are not adhered to, the results become meaningless – changes from week to week are as likely to be due to changes of definition as to real changes in numbers of cases. This is especially important when laboratory confirmation is not possible. It is therefore important that all agencies working in an emergency agree to and use the same case definitions so that there is consistency in reporting. Case definitions must be prepared for each health event or disease or syndrome. If available, the case definitions used by the host country’s MOH should be used to ensure continuity of data. Several different sets of case definitions already exist, either in generalized form (for example, those produced by the Centers for Disease Control in Atlanta) or sets prepared for specific emergencies (e.g., the WHO Communicable Disease Toolkit for the Iraq Crisis in 2003). Standard case definitions may have to be adapted according to the local situation. It should be noted that such case definitions are designed for the purposes of surveillance, not for use in the management of patients, nor are they an indication of intention to treat the patients. When case definitions based purely on clinical observations are used, each case can only be reported as suspected, not confirmed (see Table 13.2). Although lacking precision, such definitions can make it possible to establish the occurrence of an outbreak. Samples can subsequently be sent to a referral laboratory for confirmation. Once samples have been examined and the causative organism has been identified, a more specific case definition can be developed to detect further cases. Table 13.2. Types of cases Type of case
Criteria
Suspected case
Clinical signs and symptoms compatible with the disease in question but no laboratory evidence of infection (not available, negative, or pending)
Probable case
Clinical signs and symptoms compatible with the disease in question and also epidemiological evidence (e.g., contact with a known case) or some laboratory evidence (e.g., the results of a screening test) for the relevant disease
Confirmed case
Definite laboratory evidence of current or recent infection, whether or not clinical signs or symptoms are or have been present
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Establish Data-Handling Systems The following issues should be considered: ● ● ● ● ●
Methods of recording and transferring data Methods of verifying data Frequency of reporting Who will analyze the data and how often Methods for disseminating results
Recording and Transferring Data Visits to surveillance sites and discussions with staff involved will help define the recording and data transmission systems required. The great advances in information technology that have been made in recent years have greatly facilitated the collection, recording, transmission, and analysis of surveillance data, but care must be taken that the systems put in place are appropriate. In areas where electricity supplies are problematical and communications poor it may be better to use a paper recording system and verbal data transmission by radio than a computerized system.
Verification Data verification is essential for the credibility of a surveillance system. Those responsible for surveillance systems must ensure good adherence to case definitions if a symptom-based system is in operation and that laboratory quality control systems operate where appropriate. Regular assessments of record keeping and the accuracy of data transfer are required. Triangulation of results from several sources can sometimes help to detect anomalies.
Frequency of Reporting Frequency of reporting will usually depend on the severity of the health situation. In general, daily reporting during the acute phase of an emergency will be needed, although in an acute medical emergency (such as a severe cholera outbreak) even more frequent reporting may be necessary, especially if the situation is fluctuating rapidly. The frequency may reduce to (say) weekly as the situation resolves.
Data Analysis Who is to analyze the data and how it is to be analyzed must be established at the outset. In a relatively defined area such as a camp, a data analysis session may be the last of the daily activities of the person responsible for surveillance. If record keeping and analysis protocols have been carefully worked out initially this task is not necessarily a large additional burden. Surveillance systems that cover larger areas and bigger and more diffuse populations usually rely on a central data collection point
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where designated staff analyze the data. Use of such a system requires good data transmission systems.
Output of Surveillance Systems Output is as important as input. Collecting data without dissemination of results is a sterile exercise and tends rapidly to demotivate those who are collecting the data. There are some important points to consider: ● ●
The results of surveillance must be presented in a readily comprehensible form. Surveillance reports should be produced regularly and widely distributed to aid agencies, and to national and international governments and organizations. This will help those involved to understand the overall picture, rather than just that in the area where they are working, and will allow them to take informed decisions about future actions.
Evaluation of Surveillance Systems Surveillance systems should be evaluated constantly to ensure that they are working properly, that the data are representative, analysis is appropriate and accurate, and that results are being disseminated to where they are needed.
Part C – Control of Communicable Disease Introduction The public health aspects of communicable disease control can be broadly divided into preventive activities (such as vector control and vaccination programs) and the investigation and control of outbreaks and epidemics. Experience from many emergencies and disasters has made it possible to identify a number of syndromes or diseases that are most likely to occur in such situations (Table 13.3). This makes it possible to plan activities and interventions on the basis of likely occurrences, even before those involved are present at the scene of the disaster, and to make initial purchases and establish stockpiles of appropriate medicines and equipment.
Prevention “Prevention is better than cure” and proper attention to preventive measures from the earliest stage of the response to the disaster will greatly reduce the risks to the health of the population from infectious disease.
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Table 13.3. Syndromes or diseases that occur commonly in disasters Bloody diarrhea
Suspected meningitis
Acute watery diarrhea
Acute jaundice syndrome
Suspected cholera
Acute hemorrhagic fever syndrome
Lower respiratory tract infection
Trauma/injury
Measles
Malnutrition
Acute flaccid paralysis A few others, such as malaria and other vector-borne diseases (e.g., typhus and leishmaniasis), are also likely to occur but are region specific. TB and HIV or AIDS can also cause major problems in the longer term
Provision of Appropriate Physical Conditions A key method of preventing communicable disease is the provision of shelter, adequate amounts of clean water, sufficient safe food, and proper sanitation (latrines and facilities for personal hygiene, clothes washing, and drying).
Control of Disease Vectors Arthropod vectors (mosquitoes, ticks) can be controlled by appropriate spraying programs and also by habitat management (e.g., the removal of places where water can accumulate and mosquitoes breed). Provision of bed nets, particularly nets impregnated with insecticide, is effective for reducing infection with agents such as malaria and Leishmania. Control of rodents, by proper control of rubbish, by rodent proofing food stores, by attention to domestic hygiene and by use of rodenticides, will reduce the risks of transmission of rodent-borne diseases such as plague and Lassa fever.
Disposal of Contaminated Materials Medical waste includes laboratory samples, needles and syringes, body tissues, and materials stained with body fluids. This requires careful handling, especially the sharps, as infectious agents such as those causing hepatitis B and C, HIV and AIDS, and viral hemorrhagic fevers can be transmitted by these materials. Used sharps should be disposed of into suitable containers (proper sharps boxes are ideal but old metal containers such as coffee or milk powder tins are adequate). Medical waste should ideally be burned in an incinerator. This should be close to the clinic or hospital but downwind of the prevailing wind. A 200-L oil drum can be used for this purpose with a metal grate half way up and a hole at the bottom to allow in air and for the removal of ash. Larger-scale and more permanent incinerators can be constructed if necessary. Burning pits can be used in emergency. If burning is not possible items should be buried at least 1.5 m deep. This is more suitable than burning for large items of human tissue such as amputated legs. Ensure there is no risk of groundwater contamination.
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Dealing with the Dead This is a complex process involving not just considerations of infection risk but also legal, sociocultural, and psychological factors. There are a number of specialist publications which can be of help.
Health Aspects After almost every natural disaster, fear of disease has encouraged authorities to dispose rapidly of the bodies of the dead, often without identifying them, and this sometimes seems almost to take precedence over dealing with the living. However, in sudden impact disasters (such as the Indian Ocean tsunami in 2004), the pattern and incidence of disease found in the dead will generally reflect those in the living. The situation is much the same in wars and other long drawn out disasters, although these may affect disease patterns and create vulnerable groups. In fact dead bodies pose little risk to health (with some exceptions listed below) since few pathogenic microorganisms survive long after the death of their host. The diseased living are far more dangerous. The decay of cadavers is due mainly to organisms they already contain and these are not pathogenic. Those most at risk are those handling the deceased, not the community. The most likely risks to them are as follows: ● ● ● ● ●
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Blood-borne viruses (Hepatitis B and C, HIV) Enteric pathogens (especially cholera) Respiratory pathogens (e.g. TB) Spore-forming bacteria (anthrax, tetanus) Some vector-borne diseases (plague, typhus) because the vectors may be present on the cadaver Acute hemorrhagic fevers (Ebola, Marburg, Lassa)
Those handling cadavers should do the following: ● ● ● ● ● ●
Take universal precautions for blood and body fluids Dispose of or disinfect used gloves Avoid contamination of personal items Wash hands after handling bodies and before eating Have hepatitis B vaccination Ensure disinfection of vehicles and equipment
Mortuary facilities may need to be provided where the dead can be preserved until appropriate legal proceedings have been undertaken and where relatives, etc., may easily attend to identify and claim the deceased. Cold stores and refrigerated vehicles can be used as temporary mass mortuary facilities. Alternatively such facilities can be provided in buildings, huts, or tented structures, but refrigeration will be needed. The dead must always be treated with dignity and respect. As far as possible the appropriate customs of the local population or the group to which the deceased belonged should be observed. If the dead have to be buried in mass graves then the
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layout of the cemetery must be carefully mapped to facilitate exhumation if needed. When an individual may have died of a particularly dangerous infection, then body bags should be used (and also for damaged cadavers). In general, bodies should be buried rather than cremated (as exhumation for purposes of identification may be needed). Bodies should be buried at least 1.5 m deep or, if more shallowly, should have earth piled at least 1 m above the ground level and 0.5 m to each side of the grave (to prevent access by scavengers and burrowing insects). Disinfectants such as chloride of lime should not be used. New burial sites should be at least 250 m from drinking water sources and at least 0.7 m above the saturated zone.
Vaccination Programs Vaccination programs are an essential part of disease prevention. Information about existing vaccination programs must be obtained during the assessment process and this should include information from external assessors (e.g., WHO, UNICEF, NGOs) as to the effectiveness of the vaccination programs that have been undertaken in the past. It cannot be assumed that simply because children have received vaccines that these vaccines were effective.
Vaccination Priorities in Emergencies Measles kills large number of children in developing countries and is one of the greatest causes of morbidity and mortality in children in refugee and IDP camps. Mass vaccination of children between the ages of 6 months and 15 years should be an absolute priority during the first week of activity in humanitarian situations and can be conducted with the distribution of vitamin A. A system for maintaining measles immunization must be established once the target population has been covered adequately in the initial campaign. This is necessary to ensure that children who may have been missed in the original campaign, children reaching the age of 6 months, and children first vaccinated at the age of 6–9 months who must receive a second dose at 9 months of age are all covered. Some of the children vaccinated during such a mass campaign may have been vaccinated before. This does not matter and a second dose will have no adverse effect. It is essential to ensure full coverage against measles in the population. Other EPI vaccinations for children are not generally included in the emergency phase because they can only prevent a minor proportion of the overall morbidity and mortality at that stage. However, should specific outbreaks occur then the appropriate vaccine should be considered as a control measure. Vaccination programs require the following: ● ● ●
● ●
Appropriate types of vaccines. Appropriate amounts of these vaccines. Equipment (needles, syringes, sterilization equipment, sharps disposal). Emergency immunization kits, including cold chain equipment, are available from a number of sources, including UNICEF and some NGOs (e.g. MSF). Logistics (transport, cold chain). Staff: a vaccination team may be quite large. It must include the following personnel:
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The Cold Chain Maintenance of the cold chain is particularly important. This is the system of transporting and storing vaccines within a suitable temperature range from the point of manufacture to the point of administration. The effectiveness of vaccines can be reduced or lost if they are allowed to get too cold, too hot, or are exposed to direct sunlight or fluorescent light. Careful note should be taken of the conditions needed to transport different vaccines because these can vary. The essential cold chain equipment needed to transport and store vaccines within a consistent safe temperature range includes the following: Dedicated refrigerators for storing vaccines and freezers for ice packs (fridges and freezers powered by gas or kerosene are available as alternatives to electric machines, and solar-powered fridge/freezer combinations specially designed for vaccine storage are also available) A suitable thermometer and a chart for recording daily temperature readings Cold boxes for transporting and storing vaccines Ice packs to keep vaccines cool Insulating material to separate ice packs from the vaccines when in the cold boxes (e.g., bubble wrap or expended polystyrene foam)
●
● ● ● ●
If possible, vaccines should be stored in their original packaging because removing the packaging exposes them to room temperature and light. Check the temperature to ensure the vaccines have not been exposed to temperatures outside the normal storage ranges for those vaccines (see Table 13.4).
Table 13.4. WHO-recommended storage conditions for different vaccines Vaccine
Primary
Region
District/health center
OPV
−15 to −25°C
−15 to −25°C
+2 to +8°C
Freeze-dried vaccines (BCG, measles, MMR, MR, yellow fever, Hib freeze dried)
+2 to +8°C
+2 to +8°C
+2 to +8°C
Other vaccines (HepB, DTP-HepB, Hib liquid, DTP, DT, TT, Td
+2 to +8°C
+2 to +8°C
+2 to +8°C
Max. storage time at the different levels: primary, 6 months; region, 3 months; district, 1 month; health center, 1 month; health post, daily use – max. 1 month Diluents must never be frozen. Freeze-dried vaccines supplied packed with diluent must be stored between +2 and +8°C. Diluents supplied separately should be kept between +2 and +8°C
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Vaccine Storage Vaccines must be kept at the correct temperature since all are sensitive to heat and cold to some extent. All freeze-dried vaccines become much more heat-sensitive after they have been reconstituted. Vaccines sensitive to cold will lose potency if exposed to temperatures lower than optimal for their storage, particularly if they are frozen. Some vaccines (BCG, measles, MR, MMR, and rubella vaccines) are also sensitive to strong light and must always be protected against sunlight or fluorescent (neon) light. These vaccines are usually supplied in dark brown glass vials, which give them some protection against light damage, but they must still be covered and protected from strong light at all times. Only vaccine stocks that are fit for use should be kept in the vaccine cold chain. Expired or heat-damaged vials should be removed from cold storage. If unusable vaccines need to be kept for a period before disposal (e.g., until completion of accounting or auditing procedures) they should be kept outside the cold chain, separated from all usable stocks and carefully labelled to avoid mistaken use.
Diluents Diluents for vaccines are less sensitive to storage temperatures than are the vaccines with which they are used (although they must be kept cool), but may be kept in the cold chain between +2 and +8°C if space permits. However, diluent vials must never be frozen (kept in a freezer or in contact with any frozen surface) as the vial may crack and become contaminated. When vaccines are reconstituted, the diluent should be at same temperature as the vaccine, so sufficient diluent for daily needs should be kept in the cold chain at the point of vaccine use (health center or vaccination post). At other levels of the cold chain (central, provincial, or district stores) it is only necessary to keep any diluent in the cold chain if it is planned to use it within the next 24 h. Freeze-dried vaccines and their diluents should always be distributed together in matching quantities. Although the diluents do not need to be kept in the cold chain (unless needed for reconstituting vaccines within the next 24 h), they must travel with the vaccine at all times, and must always be of the correct type, and from the same manufacturer as the vaccine that they are accompanying. Each vaccine requires a specific diluent, and therefore, diluents are not interchangeable (for example, diluent made for measles vaccine must not be used for reconstituting BCG, yellow fever, or any other type of vaccine). Likewise, diluent made by one manufacturer for use with a certain vaccine cannot be used for reconstituting the same type of vaccine produced by another manufacturer. Some combination vaccines comprise a freeze-dried component (such as Hib) which is designed to be reconstituted by a liquid vaccine (such as DTP or DTP-HepB liquid vaccine) instead of a normal diluent. For such combination vaccines, it is again vital that only vaccines manufactured and licensed for this purpose are combined. Note also that for combination vaccines where the diluent is itself a vaccine, all components must now be kept in the cold chain between +2 and +8°C at all times. As for all other freeze-dried vaccines, it is also essential that the “diluent” travels with the vaccine at all times.
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Effectiveness of Vaccination Programs The effectiveness of a vaccination program will need to be assessed. The program can be evaluated both by routinely collected data and, if necessary, by a survey of vaccination coverage. Routine data on coverage is obtained by comparing the numbers vaccinated with the estimated size of the target population (and clearly depends on accurate assessment of the latter). A coverage survey requires the use of a statistical technique called a two-stage cluster survey details of which can be found in the appropriate WHO/EPI documents. Information about the effectiveness of the campaign should be obtained from routine surveillance of communicable disease. If, for example, large number of measles cases continue to occur, or there is an outbreak, then data on coverage should be reexamined. If this is shown to be good (over 90%) then the efficacy of the vaccine must be suspected. If the field efficacy is below the theoretical value 85% (for measles vaccine – data on efficacy of other vaccines can be obtained online) then possible causes of a breakdown in the vaccination program must be investigated (failure of the cold chain, poorly respected vaccination schedule). Methods for measuring vaccine efficacy can be found in the WHO/EPI literature.
Chemoprophylaxis Mass chemoprophylaxis for bacterial infections such as cholera and meningitis is not usually recommended except on a small scale (for example, the use of Rifampicin may be considered to prevent the spread of meningococcal meningitis among immediate contacts of a case), but the difficulties of overseeing such activities and the risks of the development of antibiotic resistance outweigh any benefits that might be gained. The use of chemoprophylaxis for malaria must be undertaken with care. It may be indicated for vulnerable groups of refugees/IDPs (for example, children and pregnant women) arriving in an endemic area, particularly if they come from a nonmalarious area, but care must be taken to provide drugs to which the local strains of malaria are sensitive. The spread of resistance means that many of the standard drugs are ineffective and the replacements are both costly and may have unwanted side effects.
Public Health Education Public health education and information activities play a vital role in disease prevention. Vaccination programs will not work unless there is acceptance by the public of the necessity for such programs. Individuals must be informed as to why these programs are necessary and also where and when they need to take their children for vaccination. Such activities are also essential to inform people about particular health programs (for example, feeding programs or vector control programs) and about the steps they can take to protect their health and that of their families (e.g., good hygiene). Information can be propagated in many ways:
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Posters Radio/TV/Film Lectures Songs/poems, etc. Leaflets
Staff who are trained in this type of activity therefore play a key role in disease prevention. Heath education also requires transport and equipment (such as video or film projectors, screens, generators, blackboards, etc.).
Treatment Details of the treatment of individuals for various infectious diseases and the facilities needed are covered elsewhere in this book and in many textbooks covering disasters and disease response. In terms of the population aspects of the treatment of disease, important requirements are to ensure that there are ●
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appropriate laboratories (microbiological, parasitological, hematological, biochemical) available to confirm diagnoses and monitor treatment. adequate supplies of appropriate antimicrobial agents available and the facilities to transport these, store, and distribute them under appropriate conditions (e.g., controlled temperature), together with relevant instruction for use.
Laboratories and Specimen Transport The provision of laboratory facilities in emergencies is usually limited to basic tests such as those for malaria. More advanced tests, including identification of microorganisms and the determination of antimicrobial sensitivities, require more sophisticated facilities. These may be available in the affected country but are unlikely to be operating in the disaster-affected area. It is more likely that specimens will have to be transported to laboratories abroad. Collection of specimens requires appropriate equipment. This will include items such as swabs, transport media, needles, syringes, or vacum sampling systems for blood sampling, different blood collection bottles (with and without anticoagulants) and other sterile specimen tubes, and containers for faeces and urine. Transporting specimens must be done safely, and packing specimens for shipment requiring specially trained personnel.
Antimicrobials Treatment of disease requires good supplies of appropriate antimicrobial agents. It is important to ensure that the agents chosen are suitable for use in the area. It is common for doctors in affected areas to ask for the latest therapeutic agents. However, these agents, although effective, are often expensive and not part of the normal treatment programs in the region. The local doctors may not therefore be familiar with the use of these agents, nor may laboratories be capable of monitoring their use. It is better to
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use funds, which are often limited, to supply larger amounts of older (generic) agents. One caveat is the possibility that regular use may have allowed resistance to certain agents to develop in a country. Data on this may be available from local surveillance records. Antimicrobials should always be supplied with relevant guidelines in a language that can be understood locally. If local laboratories are unable to test microbes for resistance to antimicrobials, isolates or specimens should be sent as soon as possible to appropriate reference laboratories for testing.
Response to Outbreaks and Epidemics Features Outbreaks of communicable disease may occur before preventive measures can take effect or because the measures are in some way inadequate or fail. An epidemic is generally defined as the occurrence in a population or region of a number of cases of a given disease in excess of normal expectancy. An outbreak is an epidemic limited to a small area (a town, village, or camp). The term alert threshold is used to define the point at which the possibility of an epidemic or outbreak needs to be considered and preparedness checked. The areas where vaccination campaigns are a priority need to be identified and campaigns started. The term epidemic (outbreak) threshold is used to define the point at which an urgent response is required. This will vary depending upon the disease involved (infectiousness, local endemicity, transmission mechanisms) and can be as low as a single case. Infections where a single case represents a potential outbreak include the following: ● ● ● ● ● ●
Cholera Some viral hemorrhagic fevers (Ebola, Marburg) Yellow fever Measles Plague Typhus
Infections where the threshold is set higher, usually based on long-term collection of data, and will vary from location to location, include the following: ● ● ● ● ● ● ●
Shigellosis Typhoid Hepatitis A Malaria Meningococcal meningitis Human African trypanosomiasis Visceral leishmaniasis
A surveillance system that is functioning well should pick up the signs that an outbreak or epidemic is developing and should therefore allow time for measures to
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be introduced that will prevent or limit the scale of the event. However, this may not always work and it is essential therefore that plans are made to combat outbreaks or epidemics. In addition to the establishment of surveillance, outbreak preparation involves the following: ●
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Preparing an epidemic/outbreak response plan for different diseases covering the resources needed, the types of staff and their skills that may be needed and defining specific control measures. Ensuring that standard treatment protocols are available to all health facilities and health workers and that staff are properly trained. Stockpiling essential supplies. This includes supplies for treatment, for taking and shipping samples, other items to restock existing health facilities and the means to provide emergency health facilities if required. Identifying appropriate laboratories to confirm cases and support patient management, make arrangements for these laboratories to accept and test specimens in an emergency, and set up a system to ship specimens to the laboratory. Identifying emergency sources of vaccines for vaccine-preventable diseases and make arrangements for emergency purchase and shipment. Ensure that vaccination supplies (needles, syringes, etc.) are adequate. Make sure the cold chain can be maintained. Identifying sources for other supplies, including antimicrobials, and make arrangements for emergency purchase and shipment.
Confirmation of the Outbreak If the number of reported cases is rising, is this in excess of the expected number? Ideally work with rates rather than numbers (see above) because (for example) the number of cases in a refugee camp could increase if the number of people in the camp increases without an outbreak occurring. Verify the diagnosis (laboratory confirmation) and search for links between cases (time and place). Laboratory confirmation requires the collection of appropriate specimens and their transport to an appropriate laboratory.
Outbreak Control Team In the case of a limited outbreak this team should be set up by the lead agency with membership from other relevant organizations, including MOH, WHO, other UN organizations, NGOs, etc. In the case of an epidemic the MOH will probably take the lead or may ask WHO or another UN agency to do so. The team will need to include a coordinator, and specialists from the various disciplines needed to control the outbreak. This may include health workers, laboratory staff, water and sanitation, vector control, and health education specialists, representatives of the MOH or other local health authorities, representatives of local utilities (e.g., water supply), representatives of the police and/or military, and representatives of the local community.
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This team should meet at least once a day to review the situation and define the necessary responses. It has additional responsibilities, including implementing the response plan, overseeing the daily activities of the responders, ensuring that treatment protocols are followed, identifying resources (both material and human) to manage the outbreak and obtaining these as necessary, and coordinating with local, national, and international authorities as required. The team should also act as the point of contact for the media. A media liaison officer should be appointed and all media contact should be through this individual. This will allow team members to refer media representatives to a central point and reduce interference with their activities. It will also ensure that a consistent message based on the most complete data is given to the media.
Information The appropriate national authorities should be informed of the outbreak. In addition to their responsibilities to their own population and to any refugees within their borders, they have a responsibility under the Revised International Health Regulations (2005) to report outbreaks of certain diseases. These include four diseases regarded as public-health emergencies of international concern: ● ● ● ●
Smallpox Polio (wild-type) New strains of human influenza Severe acute respiratory syndrome (SARS)
In some cases, Member States must report outbreaks of additional diseases: cholera, pneumonic plague, yellow fever, viral hemorrhagic fever, and West Nile fever, and other diseases that are of special national or regional concern (e.g., dengue fever, Rift Valley fever, and meningococcal disease).
Investigation Once the diagnosis has been confirmed and the causative organism identified, then there are a number of steps that must be taken in addition to continuing to treat those affected: ●
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Produce a case definition for the outbreak. This is primarily a surveillance tool that will reduce the inclusion of cases that are not part of the outbreak and prevent dilution of the focus and activities of the main control effort. Collect and analyze descriptive data by Time, Person, and Place (time and date of onset, individual characteristics of those affected – age, sex, occupation, etc., location of cases). Plot the distribution of the cases on a map (can help locate source(s) of an outbreak and determine spread) and plot outbreak curves (which will help estimates of how the outbreak is evolving). Determine the population that is at risk. Determine the number of cases and the size of the affected population. Calculate the attack rate.
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Formulate hypotheses for the pathogen about the possible source and routes of transmission. Conduct detailed epidemiological investigations to identify modes of transmission, vectors/carriers, risk factors). Report results and make recommendations for action.
Outbreak Investigations The two main statistical tools used to investigate outbreaks are as follows: ●
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Case–control studies in which the frequency of an attribute of the disease in individuals with the disease is compared to the same attribute in individuals without the disease matched in terms of age, sex, and location (the control group) Cohort studies in which the frequency of attributes of a disease is compared in members of a group (for example, those using a particular feeding center) who do or do not show symptoms
However the design and methods involved in such studies are often too complex for the austere environment of conflict and disaster.
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Implement prevention and control measures specific to the disease organism (e.g., clean water, personal hygiene for diarrheal disease) Prevent infection (e.g., by vaccination programs) Prevent exposure (e.g., isolate cases or at the least provide a special treatment ward or wards) Treat cases
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Evaluate the outbreak detection and response – were they appropriate, timely, and effective? Change/modify policies and preparedness to deal with outbreaks if required What activities are needed to prevent similar outbreaks in the future (e.g., improved vaccination programs, new water treatment facilities, public health education, etc.)? Produce and disseminate an outbreak report. The report should include details of the outbreak, including the following: – – – – –
Cause Duration, location, and persons involved Cumulative attack rate (number of cases/exposed population) Incidence rate Case fatality rate
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– Vaccine efficacy (if relevant) (no. of unvaccinated ill − no. of vaccinated ill/no. of unvaccinated ill) – Proportion of vaccine-preventable cases (no. of vaccine-preventable cases/no. of cases) – Recommendations
Epi Info™ 6 This is an easy-to-use tool which is of great value for handling epidemiological data and for organizing study designs and results, which can be downloaded free of charge from the Internet. It is produced by the Centers for Disease Control (Atlanta) and is a series of microcomputer programs which can be used both for surveillance and for outbreak investigation and includes features used by epidemiologists in statistical programs, such as SAS or SPSS, and database programs such as dBase.
Further Reading Bres P. Public Health Action in Emergencies Caused by Epidemics. Geneva: WHO, 1986. CDC Atlanta. Case definitions for infectious conditions under public health surveillance. Morbidity and Mortality Weekly Report May 2002, 1997/46 (RR10):1–55. CDC Atlanta. Updated guidelines for evaluating public health surveillance systems. Morbidity and Mortality Weekly Report 2001/50 (RR13):1–3. Coggon D, Barker D, Rose G. Epidemiology for the Uninitiated (5th ed). Oxford: Blackwell BMJ Books, 2003. Connolly MA (Ed). Communicable Disease Control in Emergencies – A Field Manual. Geneva: WHO, 2005. Gregg MB (Ed). Field Epidemiology. Oxford: Oxford University Press, 2002. Last JM (Ed). Dictionary of Epidemiology. Oxford, Oxford University Press, 2001. Medicins Sans Frontieres. Refugee Health – An Approach to Emergency Situations. London: MacMillan, 1997. Merrill RM, Timmreck TC. Introduction to Epidemiology (4th ed). Sudbury, MA: Jones and Bartlett, 2006. Perrin P. War and Public Health. Geneva: International Committee of the Red Cross, 1996. Redmond AD, Mahoney PF, Ryan JM, Macnab C. ABC of Conflict and Disaster. Oxford: Blackwell BMJ Books, 2006. Sphere Project. Humanitarian Charter and Minimum Standards in Disaster Response. Geneva: the Sphere Project, 2004.
14. Health Planning in Action: Rwanda Crisis Alan Hawley EDITOR’S NOTE – The Rwanda crisis took place in 1994. More recent examples exist; however, the lessons that can be learned from this intense humanitarian crisis are still highly valuable for today’s approach to the public health challenges in conflict and disaster.
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To examine the concept of medical intervention in conflict and catastrophes To discuss decision making To describe risk assessment To describe the problems associated with intervention
Introduction In this chapter, the concepts of medical intervention in the event of a catastrophe or a conflict will be examined and analyzed. A convenient starting point, therefore, is an understanding of the terms involved. A medical intervention is an action taken by an agency in order to remedy a medical shortfall or problem. As such it does not necessarily have to be purely clinical in nature. Rather, it must simply address a medical requirement in the target population. Its delivery may be undertaken by a variety of nonmedical agencies such as food-relief programs. Similarly, a catastrophe or a conflict is an event which has produced an inability to cope with the extra humanitarian demands consequent upon the incident. Such a mismatch between demand and supply may be temporary, as in earthquake recovery in developed nations like Japan, or be long term and seemingly intractable, as in many cases of internal conflict in Africa. While there are some clear differences between a natural disaster in a developed country and a postconflict situation in a developing nation, there are also some similarities. First, both events are likely to produce the same mixture of shock, bewilderment, and loss among the affected population. Such a combination may at least compromise, if not render impossible, coherent and effective immediate responses from that unfortunate group. Thus additional assistance will almost certainly be required, and this may come from the national government and its agencies or from the international community. A myriad of possible helping hands can be proffered from the small nongovernmental organizations (NGOs), through to the established international organizations (such as the International Committee of the Red Cross or Médecin sans Frontières) or even intergovernmental or international coordinated responses possibly involving the military. Equally, this scale of response will have A. Hopperus Buma et al. (eds.), Conflict and Catastrophe Medicine, Second ed., DOI 10.1007/978-1-84800-352-1_14, © Springer-Verlag London Limited 2009
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been at least partially generated by the shared sense of shock and sympathy which cataclysmic events evoke in the global public. Such a response is likely to impel, and possibly compel, governments (particularly those of liberal democracies) to offer humanitarian intervention as an answer to the problem. Such a reaction may paradoxically aggravate the problem. Hastily mounted expeditions to alleviate obvious human distress and devastation may themselves become part of the problem. Inadequate preparation, poor equipment, ill-focused priorities, and sheer logistical nonsustainability may lead to the helpers needing help themselves and so detract from the main effort. In the maelstrom of an immediate response to a crisis, philanthropy is a poor substitute for professionalism – ideally you need both. Yet since the Berlin Wall came down, symbolizing the ending of the Cold War, the need for humanitarian intervention has mushroomed. In many cases, this has been due to the increased regional political instability that has accompanied the loss of surrogate control consequent upon the passing of the Soviet Union. In addition to this, there has been a more than usually high incidence of natural disasters as well as major industrial accidents such as Chernobyl and Bhopal. Governments and NGOs have responded to these needs with a varying record of success. All possible combinations of agencies have been deployed during these responses and much has been learnt. Working together under the difficulties of humanitarian relief has generated mutual understanding and respect between uniformed and civilian agencies. Preconception and prejudice are uncomfortable bedfellows with success in a multiagency response to a clear human need. It is entirely likely that this process of coordinated response between all agencies will continue. Accordingly, it behooves all involved to ensure that both professionally and personally they are able to undertaken their part of the enterprise.
The Decision to Intervene Regardless of whether the projected humanitarian team is uniformed or civilian, a decision process will have to be followed prior to deployment. Naturally the process will be dependent upon the culture and standing operating procedures of that particular organization. Equally, these will differ both within NGOs and between military and civilian agencies. However, the end point of the process will be to decide whether to deploy, and if so what to deploy. A key consideration will be the likely and foreseeable effects of deployment by that particular agency: ● ● ●
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Can they offer something worthwhile to the situation? If so, can this be delivered at an affordable cost? Will this cost be purely financial, or are there foreseeable opportunity costs (there will always be a potential for unforeseen opportunity costs)? Are there other predictable constraints? What are the consequences of deployment for the organization?
This is a sample of the questions which an organization will have to answer before committing itself to the rigors and challenges of a humanitarian operation. Many of these questions are hard-nosed issues of cost–benefit analysis. Disquieting as this may be to pure humanitarians and philanthropists, it reflects the reality that resources are finite and the decision to commit them needs careful consideration and justification.
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Responses to human need in catastrophes and conflicts are essentially concerned with facets of the human condition. These are at heart people decisions made by people for people. Care is an intensely human concept with profound ethical and practical underpinnings. At the center of all decisions to commit humanitarian resources to a specific operation is this commitment to care. Yet in the rush to actually deploy, the continuing requirement to care for the deploying team may be missed. The pace of events, the excitement, and the anticipation may cloud the normal approach to the duty of care. This is the commitment which all organizations must have to their individual members. Not only there is a clear moral basis for this, but increasingly there is also a legal requirement. In order to ensure its correct application, the example of risk assessment familiar to many in occupational medicine is a suitable approach to adopt. First, two small definitions to aid the application of risk assessment methodology. A hazard is a substance (or for our purpose an exposure) which has the potential to cause harm to individuals. A risk is a measure of the probability of harm actually resulting from an exposure. Although originally designed for application within the Control of Substances Hazardous to Health legislation, this process of analyzing risk is very useful when applied to all exposures which are likely to be encountered. The method is shown in outline in Table 14.1. This shows the initial stage as being the identification of a hazard.
Table 14.1. The risk assessment process in outline Hazard identification Physical: heat, light, cold, radiation Chemical: gases, vapors, dusts Biological: animal, plant, bacterial, viral Mechanical: lifting, posture Psychosocial: stress, isolation, lack of support Risk identification Which of the hazards actually exist and in which form? Risk assessment High, medium or low risk, dependent upon degree of exposure to risk and individual Vulnerability Risk management Avoid exposure Control exposure Rotate individuals through exposures Substitute harmful substances/procedures with lower risk options Protect individuals by other means Personal protective measures Vaccinations Surveillance Health surveillance relevant to risk Routine examinations Blood markers Psychological support
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Following this, an estimate of likely exposures is required which, when taken in conjunction with hazard identification, allows some sort of assessment of the risk. Risk management follows risk assessment, which allows a number of different techniques to be tried. These include hazard elimination, containment of the exposure, limiting the duration and concentration of exposures to individuals, and finally complete protection of the personnel. Some imagination is required to adapt the process to the requirements of humanitarian operations, but a suitable context can be derived from the methodology. The types of hazard normally considered are shown in Table 14.2. They are conveniently considered as a set of separate types of hazard. However, experience shows that operations will invariably involve more than one type of hazard in each scenario. Equally, individual susceptibilities will vary as a result of biological variation as well as: ● ● ● ●
Previous operational experience Past medical history Family and social circumstances Earlier exposures to hazards
All these will need consideration and due weighting must be accorded. Prior to deployment to Rwanda in July 1994, this particular process was followed by the British Army contingent deploying as part of the United Nations force (UNAMIR). All potential hazards were identified and possible corrective actions considered. As a result, a plan for the management of foreseeable risk was put together as well as the beginnings of a health surveillance plan for the eventual return to the United Kingdom. This process is shown in detail in Table 14.3. Points of particular note include the significance of the biological and the psychosocial aspects. While most people will be familiar with the biological hazards of refugee work in tropical Africa, the psychological aspects are rather more covert and provide a suitable example to demonstrate the risk assessment tool. The psychosocial hazards were split into a number of separate specifics: separation, apprehension, problems dealing with refugee populations, problems dealing with orphans, difficulties with death, genocide and murder, and finally dealing with unexpected incidents of maximum stress. Next, an assessment of the susceptibility of different components of the force to these hazards was made, so that the engineers and medics were expected to be maximally exposed to them while it was recognized that all components were exposed to some degree. This had to be further refined to identify susceptible individuals within the components since such qualities vary greatly within populations. Having achieved this stage, it was then necessary to develop a risk management strategy. The initial Table 14.2. Types of hazard Physical: Heat, cold, climate, light, dryness, wetness, electricity, other radiations, vibrations, noise Chemical: Gases, vapors, solids, dusts, solvents Biological: Large animals, smaller animals, plants, bacteria, virus, fungi, other microbiological entities Mechanical: Lifting, loading and unloading, pulling, pushing, trips, falls, dropped objects Psychosocial: Stress, bereavement, isolation, fear, uncertainty
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Table 14.3. Risk assessment process for the UK military contingent to RWANDA 1994 Hazard identification Physical Climate (dry season followed by wet season halfway through deployment) Light (subequatorial Africa) Heat (subequatorial Africa) Trauma (conflict) Chemical Usual range of solvents and preservatives in workshops Biological Insects (biting and local lesions) Range of disease entities including cholera, dysentery, typhus, malaria, rabies, HIV, tuberculosis, meningitis Mechanical Usual activities involved in loading, unloading, moving and deploying a unit Psychosocial The unknown Genocide and war Separation from loved ones Stress of working in refugee camps Risk identification As per hazard identification Risk assessment Some of the elements of the force were more likely to be exposed to some risks than others. Thus, the medics were more likely to be exposed to the full range of biological and psychological risks than those involved in supporting the operation from HQ. Equally, some groups have a traditional closeness and support mechanism enabling them to cope with risks better than others. Notable in this regard were the Royal Engineers, who have a tightly knit organization with a strong support ethos Risk management Fit for deployment, including personal circumstances and social relationships Safe food and water Vaccinations against all the major biological hazards Malaria prophylaxis (including covering up at biting times, use of mosquito nets, insecticides, no standing water, etc.) Open attitude to stress and its management, briefings to all (including loved ones), monitoring of all personnel throughout deployment, regular contact with home through telephone and mail, adequate breaks from duties in refugee camps, follow-up on return to UK Surveillance Regular monitoring of all personnel throughout deployment Ready access to medical and psychological assistance in the deployment Psychological follow-up by questionnaire and personal consultation Random stool sampling
step was a full briefing given both to members of the contingent and to their families. This explained the nature of the deployment and the likely tasks and the conditions to be met. The psychological aspects of the operation were covered so that there was complete transparency of the possible difficulties. The responsibilities of team leaders to ensure the health and the safety of their personnel were emphasized, and the channels of support within the unit for both the leaders and the other individuals were rehearsed. In the case of the problems in dealing with refugees and orphans and the consequences of genocide and murder, the total elimination of exposure was impossible
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by virtue of the humanitarian task to be undertaken. Instead, a policy of controlled exposure on a rotation basis of working in refugee camps was employed, along with a focused and active leisure time program. In addition, a welfare strategy allowing frequent contact by letter and telephone with loved ones in the UK helped to support everybody in the trying circumstances of the camps. Such a policy helped those left behind at home to continue to play their part in supporting the deployed force. An important element of this process was the production of weekly videos, which were sent back from Rwanda and showed the contingent at work. Prior to return to the UK at the conclusion of the deployment, all individuals took part in repatriation groups where the accumulated experience of months work in Rwanda could be put into context with the normal pressures and tensions of home life. Simultaneously, the families of the deployed force received leaflets explaining the circumstances under which the tour had been completed and the normal range of reactions to be expected. On returning home, the entire contingent worked as usual for 3 weeks while staying together, and then going on leave. Lastly, there was a follow up of personnel by questionnaire, with referral to psychiatric assistance as identified either by this means or by medical attendants. Such a complete program of psychological risk assessment and management is unusually detailed and full. This was partly due to the inclusion of a consultant psychiatrist as part of the contingent, as well as a high index of suspicion of the psychological aspects of the operations that was entirely in keeping with the accumulated experience of the force. Psychological aspects are discussed further in a later chapter. However, this process of risk assessment is required of any command element about to commit its personnel on operations of whatever kind. Failure to follow it, or something like it, constitutes a neglect of the duty of care.
The Act of Intervention Essential questions, which must be posed and answered before the deployment, are listed below: ● ● ●
What is our aim? What are we trying to achieve? Why are we trying to achieve it?
Again, these fundamental concepts can be overlooked in the race to respond rapidly to an actual or an emerging humanitarian crisis. However, they are crucially important, since they define the ethical and practical context of the proposed action. In essence, what is required is a mission statement. A mission statement gives the task and its purpose. You are to provide such and such in order that this may be enabled. Again considering the British Contingent in Rwanda in 1994, the initial deployment saw the medical element, with some engineering and communications support, being deployed to the northwest of the country. They were told to provide medical support to refugees in that region. Since the situation was extremely fluid, with over 1 million
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refugees living at Goma Camp just over the border in Zaire, and with sporadic continuing violence in the area, this mission was reinterpreted as: To provide humanitarian assistance in the northwest of the country in order to encourage Rwandan refugees to return from Zaire. This statement gives a clear task (to provide humanitarian assistance, note not just medical support) and an equally clear purpose (to encourage Rwandan refugees to return from Zaire). Accordingly, a basis for planning and prioritization has now been provided. All actions can be measured against this mission. Anything which does not assist its successful completion should be disregarded. Conversely, success can be assessed by how far this mission is met. In the case of Rwanda, the British contingent treated 4,500 people in 10 days (as well as repairing hydroelectric facilities and water supplies). At first sight this is a good return on the investment. However, closer inspection revealed that none of those treated were refugees; they were local people. While there was an undoubted medical need, it lay outside of the mission statement. At the same time, in the south west of the country, the French military were preparing to withdraw from the humanitarian protection zone (HPZ) that they had established earlier in the year. In the HPZ there were an estimated 1.5 million internally displaced people (IDPs). These were overwhelmingly Hutu people who had fled their homes on the advance of the Rwandan Patriotic Army (RPA). This was a largely Tutsi dominated army and was victorious in the war which had followed the genocide of Tutsis and moderate Hutus. The occupation of the HPZ had led the RPA to stay outside its borders. As a result, the Hutu IDPs had been reassured by the overt French military presence, which was taken as a guarantee of their continued safety from Tutsi revenge attacks. The projected withdrawal of the French now threatened to undermine that confidence, with the consequent fears that the IDPs would follow the troops into Zaire and the catastrophic problems of Goma would be repeated. In order to prevent this, the British element in the northwest was redeployed to the HPZ. Its mission was recast as follows: To provide humanitarian assistance in order to persuade the IDPs to stay in Rwanda. Again, a clear distinction between task and purpose can be seen. Using this mission, a new plan was developed which recognized the changed circumstances of the new location and its political, demographic, geographical, and humanitarian factors. It was also useful as an audit measure. Within 1 week of deploying and operating in the HPZ, the British contingent had the satisfaction of seeing the exodus of IDPs fall from 20,000 a day to 0. The mission was being accomplished, and in so doing untold thousands of lives were being saved by the avoidance of inadequate humanitarian provision in Zaire. The mission statement goes a long way toward answering the fundamental questions of how and why. There will remain other queries about what. Any major catastrophe or conflict will produce many different needs. It is understandable that medical personnel will see these needs as being largely medical in nature. After all, it is precisely this dimension in which healthcare professionals have been laboriously and expensively
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trained. However, rather than resorting to a default-type response, a dispassionate view of the circumstances is required. An ability to provide a specific capability is not a necessary justification for actually employing it. Rather, there needs to be an actual requirement on the ground. As has previously been pointed out, most of the need (even if not actually medical) has significant health implications and consequences. We are, after all, considering the needs of a population in distress. As such, it is useful if healthcare professionals always keep in the back of their mind the different elements which comprise the usual range of human needs. In extremis, human needs focus on food, shelter, water, sanitation, security, and health. Health needs and interventions will be considered in the section “Medical Interventions.” The others will be discussed below. Security is an underpinning requirement, especially in postconflict situations. Even in natural disasters there may be elements of opportunistic criminality. When all has been lost and a sense of shock and bewilderment surrounds everything, the need for a sense of personal security can be enormous. Naturally this requirement extends to the other members of a family or similar tightly knit group. Equally, in many conflict and postconflict situations, security may only be guaranteed by the presence of some sort of law enforcement capability. It must also be remembered that a uniformed presence may not always be reassuring to a displaced population, particularly if similar armed groups have been responsible for the refugees’ plight. So security is more than a situation of law enforcement. It is a perception and belief that the needs of the individual and the social group are met, including the requirement for personal safety. It is the aggregation of all the factors and dimensions together which comprise a sense of well-being and fulfillment. The usual enabler for this circumstance is an acknowledged and accepted rule of law. Sadly, postconflict situations, particularly civil wars, frequently result in the complete tearing up of the social fabric and all the corresponding instruments of law and order. In such a time of human despair and shortage, it is hardly surprising if some elements take advantage of the situation to gain some advantage. However, the evidence suggests that this is a relatively infrequent occurrence; most people respect the social norms as regulators of conduct. Insecurity and violence affect not only the refugee or displaced population, but also may directly impinge on the operations and safety of the humanitarian workers. There has been a steady and tragic loss of life among the humanitarian community. Violence against them has become a perennial feature. This may result from a sense of the political implications of their work, particularly if they are being successful. This is especially relevant in the confused but heightened political tensions accompanying a conflict. In such circumstances, humanitarian assistance may make the difference between life and death for many people. This presents a clear opportunity for the application of power and leverage over a target population. After all, in starvation conditions, food is power, food is life. The control of these resources has an obvious political attraction. Such a situation prevailed in the refugee camps set up in the northern region of the former Zaire following the 1994 Rwandan genocide and war. The Hutu militants attempted to control the provision of humanitarian assistance in the camps as a vehicle for political organization and control over the Rwandan Hutu refugees. This posed a real ethical dilemma for many of the NGOs, since to continue the delivery of aid would be to assist the establishment of the political legitimacy of
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the perpetrators of the genocide. Without such assistance, many of the refugees would suffer further. This is truly a dilemma whose resolution needs consideration of the ethical, legal, and security factors. Therefore, security can be increased by the usual techniques of providing law and order. Existing and acceptable organs of law enforcement may be reinforced or assisted, depending upon the legitimacy and degree of popular support. Care may need to be exercised to ensure that any external forces brought into the country do not arrive with any residual or historical connotations. Thus, some nations with a long or bitter history of mutual antagonism and mistrust would hardly be appropriate either to receive or to provide security elements. There has to be some sort of acceptance by the population of the right and ability of an external force to act. Impartiality and adherence to an accepted corpus of law are crucial foundations for this relationship. Clearly, trust between all sides is an ideal. At the very least there should be some sort of acceptance on behalf of the displaced population. An example of a successful use of soldiers in resolving a problem with violence was seen in the British Army’s deployment in the north of the HPZ in Rwanda during 1994. In this area, two of the camps were proved to be the targets of violence, intimidation, and attack by militia groups. Reasonably enough, the civilian NGOs assessed the situation as being too uncertain for their personnel to operate there. Accordingly, the military deployed a mixed force of medical staff, engineer resources, and infantry. By virtue of their presence, the militia were deterred and the threat was removed, so that within 3 weeks the civilian agencies returned to the area and restarted their work. Conversely, there are times when the military may not be helpful or successful. Thus, in the demanding and confused political cocktail of Somalia in 1992, the initial success of the military in support of humanitarian efforts quickly changed into a bitter and unhelpful conflict situation. In humanitarian terms, the military became part of the problem rather than the vehicle for greater efficiency in humanitarian relief. The UN may also have a role to play by deploying additional professional policing capabilities from other member states with recognized expertise and no history that might offend susceptibilities. Recently, this has increasingly been recognized as a crucial enabler for nation-building, and hence the creation of a stable and peaceful situation. Nevertheless, while uniformed elements may be necessary, they are not sufficient. A full sense of security can be reached only by meeting all the needs for human fulfillment. This requires all the components of a state to be provided. Thus, economic, educational, health, and social systems require attention. Again this will be especially pressing after a civil war. Quite clearly, such events have often led either to the overthrow of an existing social system, or a degree of damage to it such that its operation is compromised to some degree. It is this endeavor that demands the full participation of all the agencies in the area. There will also be a corollary, since the very profusion of these agencies will similarly require coordination. That leads to another set of concerns about leadership and legitimacy. Fortunately, recent operational experience has seen a much closer integration of all elements in situations of need. Such joint approaches are vital to the creation of a real sense of security. Even so, it may be an extended period of time before real and substantive progress is achieved. In the meantime, other requirements will need to be managed and met. Security is a critical enabler of the entire humanitarian effort.
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Shelter is an important element of well-being and health. It provides physical and psychological reassurance to a displaced and dispossessed population. Naturally, the better the shelter then the better the effect achieved. Equally, there is a clear link between the provision of shelter and the sense of security engendered. A sense of ownership and the possession of an anchor in a changing and threatening situation is an important underpinning of stability. Accordingly, there are different ways to achieve an appropriate level of shelter. Climatic factors are self-evidently important drivers of the type of shelter required. Thus, in cold or mountainous regions, the needs are markedly different from those in desert or tropical locations. The more adverse the conditions, then the more demanding is the logistic bill for shelter. At the same time, there is a smaller margin for failure, since the climate will be more unforgiving of shortfalls in provision. Such vulnerability among the displaced population will inevitably be increased by the very fact of displacement. Adversity is a multiplicative process in a displaced people, since climatic, nutritional, disease, and security dimensions all seem to conspire against the population. An important start in redressing the balance can be made by tackling the shelter requirement appropriately and with dispatch. Usually, a displaced population will move to another place with a preexisting infrastructure and people. Accepting that difficulties between the indigenous society and the newcomers can be resolved, the central question then concerns the ability of the location to absorb the influx. Naturally enough there is a correlation between the numbers and needs of the displaced population and the state of development, investment, and circumstances of the existing community. The ability of a rural society employing subsistence agriculture methods to accommodate a sudden, large inflow of needy people is likely to be severely constrained. Such a circumstance could reduce both communities to desperation and destitution. In such unhappy straits, the situation can rapidly disintegrate into conflict and strife between two needy peoples. Such was the experience in northern Zaire in 1994 after the arrival of one and a half million Hutu refugees from Rwanda. Such a massive influx completely swamped the ability of the local Zairian community to cope. Inevitably, conflict followed as competition for scarce resources occurred. The international attention that the needs of the refugees attracted, and also resentment at the presence of armed Hutu militia among the refugee population, fuelled this hostility between refugees and locals. Clearly, the lesson of this unhappy episode is that the needs of the total population at risk (refugee plus local) must be considered as part of the aid package. However, if these tensions do not exist and the needs of the displaced people are modest, then the most effective and efficient solution is for them to be absorbed into the local community. Such a process is greatly aided if there are ethnic links between the two populations. Again the Rwanda crisis furnishes examples of successful aid from the local population to the refugees. In the southwest of the country, in the HPZ, many small villages took complete families of refugees into their homes, sharing all their facilities with the newcomers. Accordingly, many of these villages became small camps with no hint of conflict between the two populations. This process was largely possible because of the identification of the local Hutu people with the plight and difficulties of the displaced Hutu population. It was the shared ethnic foundation and heritage that made the process possible. Equally, a policy of village improvement and
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assistance was instituted by the British military in order to encourage the assimilation and so avoid the unhappy experience of similar refugees in Zaire. Should the local infrastructure be incapable of receiving the incoming people, additional assistance will be necessary. Frequently this requires the planning and the provision of camps with associated individual shelters. While shelters themselves may be improvised from locally available sources, they are often supplemented by other means such as the UNHCR shelter materials. Such means have to be tailored to the rigors of the climate and need to be easily erected and maintained. Happily, the process of improvisation lends itself to both these requirements. Indeed, the act of building a shelter may be of considerable assistance to the sense of well-being among a refugee population since it represents evidence of self-help and a return to responsibility and hence dignity. Such initial positive outcomes are clearly dependent upon other factors such as the previous circumstances of the migrants. Thus, an educated urban elite is likely to find the harsh realities of temporary shelters in a mass of similarly dispossessed people much harder to endure than would people from a background of subsistence farming. For the latter, the hardship of a refugee camp may not be far removed from the experience of normal life. Refugee camps are frequently the consequence of mass population movements. Such migration patterns often end at the first convenient location regardless of its suitability for any extended occupation. As a result, these camps are often unsustainable without considerable external assistance. The sudden imposition of 100,000 needy people in an area will understandably lead to eventual resource depletion and exhaustion. Thus, aid in providing shelter is an initial imperative. This will serve to stabilize the situation and allow the population movement to be controlled. However, such dependence may soon become a two-way street, since not only does the refugee population rapidly become reliant upon external aid, but also the providers of that assistance become trapped into that commitment by the continued deprivation and need among the migrants. This dual dependence may serve to confuse the existing situation since it sets up its own political dynamic. Thus, refugee camps always run the risk of becoming centers of political and military action. Nor is this process restricted to the indigenous population and security forces. The experience of living in a camp may act as a powerful source of political unrest as a sense of injustice and exasperation grows. Consequently, refugee camps may not provide the ideal method of dealing with the problem of shelter provision. The permanence of many such concentrations has served to aggravate existing political uncertainties and conflicts so that their successful resolution becomes increasingly difficult. Examples of exactly this unhappy situation abound in the Middle East, where Palestinian refugee camps have become spawning grounds for the young disaffected and nurture an increasingly hostile and militant outlook against the Israelis, who are seen as the agents of the Palestinian misfortunes. Such a cycle of a sense of grievance and injustice, violent action, violent counteraction, an increased sense of grievance and injustice, heightened violent action, and heightened counteraction is the pernicious and tragic outcome of permanent refugee camps existing in a political vacuum. It is a possible outcome for many such camps. Nevertheless, for the migrant population, such concentrations of their own people has an obvious appeal. The shared experience of dispossession, migration, and hardship
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acts as a bond which links them together. Thus, it is entirely understandable that by living together in unfamiliar (and possibly hostile and dangerous) circumstances some degree of reassurance and comfort is achieved. Such are the strengths of these psychological imperatives that refugees will willingly run the risks associated with camps (e.g., disease and food shortage) in order to live with their own people. For the humanitarian worker, then, shelter as part of a refugee camp is likely to be given in the complex patchwork of human need in a migrant population. Water and sanitation (which are covered in detail in previous chapters) are critical requirements for displaced populations. Many enteric and vector-borne diseases may be avoided or ameliorated by adequate provision of safe water and appropriate sanitation. Similarly, the supply of safe water may allow the stabilization of an uncertain situation, thus going some way to meeting a psychological need in migrant populations. However, ensuring safe water and effective sanitation is not without problems. The initial difficulty is to estimate the water requirements of a community based upon average consumption rates. Having established the total required volume, it then needs to be produced, which is dependent upon the local resources. Water is necessary for bathing, cooking, washing, and sanitation, as well as for drinking. The total requirement is clearly an aggregate of these subtotals. However, the climate and the geography of the location will further define the volume which needs to be produced. Thus, hot climates will need more water than temperate climates. A useful rule of thumb is 20 L daily per person in hot climates, but this may be halved in cold temperate conditions. These totals may be revised and prioritized in the face of a water shortage, so that drinking and cooking may take preference over washing. Equally, water-recycling measures may help to reduce the total required. In addition, the quality of water necessary for each activity varies. Hence, drinking demands a much higher level of microbiological scrutiny and survey than water for cooking or cleaning. This difference in water quality may help the supply of water since higher levels of purification need more expertise and sophistication. The means of purification may range from the ultimately safe but very energy-intensive reverse osmosis methods to the simple chlorination of a supply. Clearly, assessments have to be made as to the suitability and the sustainability of the chosen technique. In addition, there is the question of the acceptability of some methods. For instance, the residual chlorine taste commonly experienced with some methods of drinking water production may be unacceptable to a community which is suspicious of chemical agents following attack by such weapons. In order for a strategy of water production to be successful, some measure of cooperation with the population needs to be established. By such means, a degree of trust and sustainability can be forged. In these circumstances, a partnership between provider and receiver is most helpful. The same considerations surround the institution of an effective sanitation plan. Custom, modesty, and convenience all impinge on the utility of a sanitation and sewage-disposal process. The techniques available vary from permanent or semipermanent structures based upon the principles of sedimentation and purification which underpin such systems in developed situations, to the cat scratch or temporary latrines of austere field conditions. The choice of approach will depend upon the projected lifetime of the camp, whether it is a new camp or an absorption of the displaced people within an existing infrastructure, and the religious sensibilities,
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social customs, and mores of the population, as well as the availability of resources. It is impossible to be prescriptive when there is such a wide set of variables. The only certainty is that lack of attention at the earliest possible stage to the requirements of sanitation will cause a greatly increased risk of avoidable diseases. Food provision is of fundamental importance to migrant peoples. The lack of adequate nutrition is a recognized accompaniment to the hardships of mass population movement. Thus, evidence of malnutrition is frequently found in such circumstances, as are the more extreme manifestations of starvation. A deficiency in energy and protein will also render an individual more susceptible to other afflictions such as infection and disease (particularly measles). This means that a food strategy will need to meet a variety of needs ranging from therapeutic feeding to normal daily nutritional requirements while being sensitive to the political dimension of food delivery in certain postconflict situations. It will also require a calculation of the total requirements in order to inform the considerable logistic effort that normally underpins such programs. As with many such humanitarian ventures, a hard-nosed assessment of need and the matching of resources provide the basis of success. Some assessment of need is a vital initial step. Widespread protein-calorie deficiencies will be obvious to all. In such circumstances a complete therapeutic feeding campaign may be necessary, although such a venture is very resource-intensive and complex. Repeated drought aggravated by conflict has seen such tragic situations in the Horn of Africa over the last 20 years. More usually, malnutrition is experienced in specific vulnerable groups of a migrant population, at least initially. Such depravation may subsequently become more general. Those elements of a community that are especially at risk include the young, pregnant, and lactating mothers, and the elderly. The young always attract much attention. Within this group, weight/height ratio and mid-upper arm circumference are two indices commonly used to assess nutritional status. Of these, the weight/height ratio is the more reliable and is assessed by reference to standard tables. Generally, if the young are well nourished then the population will tend to be sufficiently resourced. Therapeutic feeding programs are complex and require detailed collaboration between a number of agencies to ensure success. There is an initial nutritional assessment, followed by a specialized logistic effort and augmented by a medical supervisory role. All of these elements are crucial at the beginning of the program. Subsequent success and future needs have to be addressed by continued surveillance and audit. The intention of a therapeutic program should be to correct the nutritional imbalance as quickly and effectively as possible in order to allow the victims to return to normal feeding and hence life activities. Accordingly, a therapeutic (or supplementary) feeding program is a short-term intervention. Frequently used combinations of foodstuffs are corn–soya milk (CSM), wheat–soya blend (WSB), dried skimmed milk (DSM), and fish protein concentrate (FPC). The exact combination will depend upon cultural, religious, financial, and logistic factors. Commonly, a number of these factors will be acting simultaneously. A system of surveillance should be instituted on the commencement of a therapeutic feeding program. Such a system of surveillance will necessarily focus on the groups most at risk, and will require a sound sampling strategy. An important element of this process will be a medical review of nutritional deficiency as revealed in clinical cases.
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Medical Interventions The medical needs of a displaced population may well be both huge in scale and complex in detail. This poses considerable challenges to both logistics and actual medical care. As a result, it is depressingly easy to be confused and even paralyzed by the task. The pressures of decision making are compounded by the almost universal goad of time. Complicated actions frequently have to be initiated against a backdrop of an elevated mortality rate and a climbing morbidity rate. In such circumstances, clear thinking is at a premium. An essential foundation for this process is information. Information usually exists but may not be easily available. Equally, the sources of the information may be variable in terms of both reliability and quality. Hence, some care needs to be applied in evaluating the information. However, the incidence and prevalence of disease is clearly a critical element of the information requirement. The World Health Organization (WHO) will normally be able to provide reliable indicators of disease incidence and prevalence in particular regions. According to circumstances, this information may be both accurate and up to date, particularly when attention has been focused on the location for some time. Equally, reliance upon official government statistics may not be well placed. Sadly, accuracy in such data may be difficult to achieve because of administrative shortcomings, or may be compromised by political expediency. After all, the admission of endemic disease and an underresourcing legacy may not be helpful or profitable in all circumstances. Consequently, official government sources may need to be interpreted with caution. Other agencies may well be able to provide reliable data. Such sources include NGOs operating within the area as well as UN agencies. Help may also be available from relevant academic units such as schools of tropical medicine or academic departments dealing with particular groupings. In any event, the collation of such information from as broad a range of sources as possible within the available time will prove invaluable in the initial planning of an operation. Hazards, risks, and priorities can all be initially assessed at this stage. Equally, any information will need to have caveats applied prior to deployment. These caveats can be confirmed or revised once information becomes available on deployment. This requires a strategy for data collection and collation within the operational area. Naturally, collaboration between all the agencies working in an area will greatly enhance the utility of the data. However, this approach brings with it all the complications of an agreed set of clinical definitions and diagnoses. Despite the apparent simplicity of this requirement, it can prove difficult to institute such a system given the disparity in resources, expertise, and motivation which may exist in the humanitarian community. In such circumstances, the best should not be allowed to become the enemy of the good, and a reliable but partial solution should be accepted. Thus, the majority of the humanitarian agencies could provide clinical and epidemiological data which would be adequate to inform decisions on prioritization and resource allocation. Priorities will usually have been allocated prior to deployment using the best available information. These priorities will have to be constantly reassessed in the light of additional information that will follow deployment. Such a regular review of tasks and their relative importance is not a sign of weakness. Rather it is evidence of a sensitive
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and realistic approach to disaster planning and action. Nevertheless, the key to effective assistance in a disaster situation is a clear list of priorities and a sequencing of measures to implement them. Equally, the temptation to use a set template for all situations must be resisted. Each situation is different in detail from the preceding ones, and indeed will posses its own set of dynamics and drivers. These have to be recognized in the setting of priorities. In addition, priorities may well vary within a locality, reflecting different sets of local circumstances and needs. Hence, the whole process of priority setting is both complex and dynamic; it is never completed. Medical intervention may take the form of therapeutic or preventive measures. Thus, the preventive measures may include a suitable vaccination program tailored to the threat and its incubation period. Often this is a difficult judgment, since the data on which decisions to initiate vaccination programs are based are themselves invariably imperfect and incomplete. Yet the commencement of such a program may represent a substantial commitment of resources in material, human, and financial terms. The common vaccination programs encountered in many refugee situations include measles and meningitis. While the organization of the program may take time, it is a relatively simple process. Nevertheless, while it is simple, it may not be easy. The requirement for cool storage to protect the vaccines and the actual organization of the human resources, both medical and refugee recipient, are potentially fraught. Hence, a simple but robust plan to achieve the purpose must be adopted. Complicated planning will invariably be a hostage to fortune in the uncertainty and organizational maelstrom of a displaced population. Frequently, the widespread use of the displaced population itself in the organization and delivery of the program achieves the best results. Therapeutic interventions will also be determined by the nature of the problems and the resultant needs. Clearly, there will need to be a balance between surgical, emergency, and medical provision, as well as age- and sex-specific programs. Areas in which conflict has been, or continues to be, a concern are likely to need continuing trauma care. Equally, tropical zones are likely to generate considerable numbers of medical cases from endemic disease. In addition, enteric disease is an ever-present danger in displaced populations regardless of geographic zone and climate. A frequent finding in displaced populations is the special vulnerability of some groups. Thus, the young, pregnant, and lactating mothers, and the elderly are particularly vulnerable. They may require specific medical support and expertise in their reduced circumstances. The provision of pediatric, midwifery, and geriatric services will have to be addressed in some form so that those needs may be both effectively targeted and managed. Failure to accommodate these groups within the overall plan would be to exclude those with the greatest need. All people involved in a disaster situation are likely to be subject to a degree of psychological stress. Self-evidently, the greater the stress, the greater the likely psychological reaction. Thus, genocide and expulsion are generally likely to cause more psychological stress than an industrial spillage in a confined area. This psychological dimension may be overlooked or inadequately resourced, particularly in the acute phase of a disaster. Necessarily, any attempt to offer support or psychiatric attention needs to recognize cultural and religious sensitivities. While this is true of all therapeutic interventions, it is particularly apposite to psychiatry, given the cultural determinants of many behavior types and coping mechanisms. This transcultural dimension
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of psychiatric care in refugee situations is particularly demanding. A mixture of inpatient and community care approaches may be required in order to achieve effective intervention. Necessarily, a reality check will need to be applied so that the clinically ideal is tempered with what is actually feasible. There are likely to be difficult and distressing decisions with no obvious clear basis for decision making. Yet, psychological well-being is critical to the creation of some stability and hope for the future. This general hope may be underpinned by effective psychiatric provision at the individual level. Accordingly, the psychiatric care of a displaced population is a crucial component in the overall effectiveness of the intervention. Another area of difficult therapeutic intervention is with the problem of sexually transmitted disease. This may be difficult for religious, social, or medical reasons. However, the incidence of sexually transmitted disease in displaced populations may be very much higher than the predisaster level. Nor should this be a surprise given the degree of disruption that the society may have undergone. Social norms, even the social fabric, may have been entirely lost in the trauma of genocide and displacement. Given a reservoir of preexisting sexually transmitted disease, desperation and destitution may lead many into part-time prostitution in order to eat or provide for their families. Trying to quantify the size of the problem is likely to be impossible in a refugee situation. Equally, the difficulties of confidentiality, contact tracing, and continuity of treatment complicate management. At the same time, the specter of HIV has to be managed, since exposure to a sexually transmitted disease must raise the possibility of infection with HIV as an accompanying risk. It is unlikely that sufficient resources will be available for any meaningful intervention against HIV to be made in any refugee situation. Thus, an emphasis on education and prophylactic measures will almost certainly be required. Reference has been made in the above discussion to cultural aspects. These are important elements in any plans for disaster relief since they will define the acceptability, and ultimately the success, of specific measures for the target population. There may well be a range of factors which have to be considered, including religious, social, ethical, and historical dimensions. The relative importance and significance of these will need assessment and accommodation. Such measures as modifying dietary provision to reflect religious practice, or special provision of clothing and personnel for intimate medical examinations, especially of females, may need to be implemented. At all times the plan for disaster relief must be culturally appropriate. Another aspect that needs early recognition is the disaster–development continuum. This is a theoretical construct that seeks to show the relationship between disaster relief and development. The response to the acute phase of a disaster is nakedly utilitarian; the greatest good for the greatest number. It should also reflect the need for cultural appropriateness. This combination requires some forethought in order to avoid initiating interventions, both preventive and therapeutic, which are not sustainable. Equally, the relief strategy must not use techniques and methods that may skew or compromise subsequent development. An example of this might be the use of external fixators in refugee situations where there was no previous use of these techniques and no possibility of imminent acquisition of them. The commitment of resources in the acute relief stage must recognize the realities of subsequent development potential. This is aided by using the disaster–development continuum as a
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working model. Simplistic though it is, it serves to ground decisions on interventions on a bedrock of reality (see also Chap. XX).
Conclusions The decision to intervene in a natural or man-made disaster is not the one to be undertaken lightly. The range of medical needs in any displaced population will be almost infinite. Thus, there is no place for a prescriptive answer; one size does not fit all. Instead, there must be a dynamic approach to priority and task-setting. In the light of particular and changing circumstances, planning must reflect reality against a background of constant change. It is the common approach which is crucial, not the common answer.
15. Health Planning in Action “Operation Phoenix”: A British Medical Aid Program to Sarajevo Tony Redmond and John F. Navein EDITOR’S NOTE – Operation Phoenix started in 1994 but it serves well as a timeless medical example for humanitarian assistance. It offers many practical examples and the lessons identified from this operation are still valuable for the present and future planning of similar operations.
Background In February 1994, a mortar bomb exploded in a crowded market place in the center of Sarajevo. 64 civilians were killed and many more were severely injured. The horrifying televised images transmitted around the world provoked a wave of revulsion culminating in a cease-fire agreement achieved against a backdrop of the threat of air strikes. Prime Minister John Major and President Bill Clinton announced a “UK/ US initiative” for Sarajevo to balance the stick of air strikes with the carrot of substantial aid. It was hoped that by capitalizing on the cease-fire and rapidly returning the city to some semblance of normality, the momentum for peace would gather quickly and eventually become unstoppable. Tony Redmond, who had previously worked in the city, was a member of the UK/US mission dispatched to Sarajevo in March 1994 to identify those areas where further aid would be most effective in quickly restoring the life of the city. Included in its report were a number of recommendations concerning health that had been agreed in full consultation with the Bosnian Ministry of Health and World Health Organization (WHO) in Sarajevo. The British Government, through its Overseas Development Administration (ODA), agreed to fund a number of these initiatives, including a medical program that became known as “Operation Phoenix.”
Introduction Sarajevo has two main hospitals, the Koševo Hospital (a tertiary teaching hospital with 3,000 beds) and the State Hospital (420 beds), which had been a military hospital until the war. Hospital practice had developed as a mixture of local, Russian, and European techniques. Emergency medicine as such did not exist. Before the war, A. Hopperus Buma et al. (eds.), Conflict and Catastrophe Medicine, Second ed., DOI 10.1007/978-1-84800-352-1_15, © Springer-Verlag London Limited 2009
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at the Koševo Hospital, emergencies were admitted directly to one of the several specialty clinics that ran independently of others on the same site. Each surgical clinic had its own anesthetists and ICU. Pediatric surgery, including aspects of children’s plastic surgery, ran in isolation. There was no Emergency Room at the Koševo Hospital. Although the shortcomings of this system were recognized, it took the pressures of a war to effect a chance. At the start of the war, casualties were taken into “Traumatology” (orthopedic trauma), where plastic surgery alone was in the same building. Because of a recognition of the need for a multidiscipline approach to the severely injured patient, and also to conserve heat and reduce the size of the target for snipers, after about a year of war the causalities were received in one central “Emergency Room” in the Department of General Surgery. And casualties there were many. The doctors quickly became adept at life and limb saving surgery. Before the war, the Department of General Surgery at Koševo Hospital had a well-recognized European Centre; however the Professor and leading members of his team were Serbs, and after a year of war many of them, with their equipment, moved to the Serb side, while others went to Austria and the USA. Therefore, when the need for reconstructive surgery was greatest, the city had few who could help. There had been understandable resistance within the medical community in Sarajevo to outside interference. Some of those who had come to help in the past proved to be less experienced than local doctors, and some attempted surgery beyond their capabilities or when it was inappropriate to the circumstances. Furthermore, their need for material medical aid made them very sensitive to any inference that they might need aid in professional development. Not unreasonably, they considered themselves at least the equal of those who came to help. However, the dire need for reconstructive surgery and the loss of local specialists provided a unique opportunity for foreign specialists to work alongside local doctors without any implied criticism of competition. There was simply no alternative. British Plastic surgeons have been associated with the Department of Plastic Surgery at the Koševo Hospital for many years (Barron 1987). After 1992, several British plastic surgeons worked in Sarajevo prior to “Operation Phoenix,” while others worked in Tuzla in 1993. Médecins Sans Frontières (MSF) had also tried to address the problem of reconstructive plastic surgery in Sarajevo but had difficulty recruiting surgeons and anesthetists of sufficient experience, and in sufficient numbers. The concept at the core of “Operation Phoenix” was that the British NHS had the numbers and the experience, and any limitation on their availability might be compensated for by running short-term missions, back to back, with a small resident staff to coordinate work there on the ground. This approach was very different. One of the tenets of foreign medical aid has been that if you cannot stay for at least 6–12 months, then it is not worth doing. Any shorter stay is likely to mean that by the time you have begun to settle into things, it is time to go home. However, experience in other large-scale emergencies has revealed that well-aimed specialized medical aid can be effective, even if applied over a relatively short period of time (Redmond 1989; Redmond et al. 1990; Redmond and Jones 1993). The key to success lies in the skills and experiences of those who give, and the cooperation and receptiveness of those who receive. The rules of engagement in all foreign disasters/emergencies still apply (Box 15.1).
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Box 15.1. Rules of engagement for foreign medical teams – Only go if you are asked – Only do what you are told – Prepare, practice, and have a plan – Cooperate and do not compete
You are unlikely to achieve very much if the local authorities have not recognized the need for your services or agreed that you can enter their country and work in their institutions. The importance of working with local health systems and building on established local resources, co-coordinating relief efforts and co-operating with other agencies has been stressed by others working in the former Yugoslavia (Carballo and Vuori 1995). You will only antagonize and confound the work of local people if you follow your own agenda. You have to discuss their needs with the local people and do what they ask. You must already have some experience of working in a hostile environment or foreign country, and understand the waste of effort that follows when aid agencies compete rather than cooperate with each other.
Operation Phoenix Once it was established with the Bosnian Ministry of Health, the WHO, and the ODA that support should be given to reconstructive surgery, the British Association of Plastic Surgeons (BAPS) was approached and responded immediately and enthusiastically to the request for further volunteers. The Association of Anesthetists of Great Britain and Northern Ireland was approached and responded the same way. In addition to supporting reconstructive surgery in the city and developing the Emergency Room at the Koševo Hospital, “Operation Phoenix” would seek to tackle areas not covered by other agencies (Box 15.2). The WHO, MSF, the International Committee of the Red Cross (ICRC), and Pharmaciens sans Frontières had supplied emergency drugs. However, the priorities enforced by war had meant that those with rarer but curable conditions, such as some forms of cancer, had failed to receive treatment. It was agreed to respond to a request by Bosnian doctors to supply certain cytotoxic agents. There were many “hidden” casualties of war. In addition to those with facial injuries, many elderly patients who did not get cataract surgery because of the war had increasing blindness added to the terrors of snipers and shelling. Ophthalmic surgeons and equipment could help local surgeons reduce the number waiting for operations. Nutritional deficiencies increased dental disease in a city with an already high rate of dental decay. The war prevented dental supplies getting into the city and increased their price out of the reach of most when they did. There is an association between oral hygiene and stress (Kurer et al. 1995). Re-establishing a dental service
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Section Two Box 15.2. The principal aims of “Operation Phoenix” – Support plastic surgery – Develop the emergency room at Koševo Hospital – Supply specialist drugs – Support ophthalmology – Supply dental materials – Support postgraduate medical education – Supply specialized material aid
was also intended to have a simple but significant effect on morale. The provision of dental materials was included in the mission. The war had greatly threatened medical education in the city. Local doctors were killed, conscripted, or escaped. Opportunities for teaching took second place to the needs of the injured. Medical students found themselves acting as doctors and junior doctors as specialists. Everyone was hungry for knowledge and training. The professional achievements of the war were dulled by an uncertainty brought on by isolation from the rest of the medical world. Every member of the mission was asked to give a lecture or tutorial and provide continuous on-the-job training. Modern warfare exposes the vulnerability inherent in our dependence on technology. Clinical Centre Koševo was a modern high-tech hospital, relying on a high turnover of sterile disposable items and equipment that needed regular and sophisticated maintenance. The medieval siege of the city made anesthetic and monitoring equipment an early casualty of the war. An earlier ODA-funded mission had identified the spare parts needed for all the equipment in the hospitals. “Operation Phoenix” included the purchase of these parts and the dispatch of technicians from manufacturers in Europe.
The Mission “Operation Phoenix” began in May 1994, with the first team of surgeons, anesthetists, and nurses working in both the Koševo and State hospitals. A senior advisor to the Ministry of Health was appointed as liaison officer and interpreted when necessary. A Head of Office was appointed in September 1994. These, and two local secretaries, were the only paid members of the mission. The Ministry of Health supplied an office and after the first month an apartment was rented near the Koševo Hospital. Medical training in Bosnia required knowledge of English but communication was not a problem. Local doctors interpreted for those patients who did not speak English. Each team was briefed several weeks before dispatch, both in person and in writing. They were given information on the historical and the political background to the war and their mission. The content of the briefings was well received but some would have liked still more information. Some team members visited on more than one occasion
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and were the greatest source of information and reassurance for others, both before departure and while on the ground. As the operation progressed, each team briefed its successor, specialty by specialty. Although there was a cease-fire in name, it was very fragile. The world’s media may have turned their gaze away from the city for a while but not so the snipers. The airlift into the city was still a target and likely to be halted at any time. Any sudden breakdown of the cease-fire could result in a rapid assault on the city. All these factors were a source of continuing stress for the teams. There were only two relatively near misses, ironically involving those more used to the city. Conveying the degree of risk to volunteers was difficult. The city was safer than it had been for some time but was still dangerous. The risks were described before leaving the UK but only a few people dropped out. It was important to maintain confidentiality and only the program director and the individuals involved knew who they were. The reasons were always pressure from family. In addition to equipment already identified as requiring replacement, team members were instructed to take in other items they required or had been told by previous teams were missing, e.g., disposable theater equipment. After further consultation with the WHO and local oncologists, certain cytotoxic agents and other highly specialized drugs were transported into the city. The cases chosen for treatment would have been treated in Sarajevo in normal times and could still be treated there if these drugs were supplied. An added benefit was the avoidance of medical evacuation for these patients with all the problems of split families and repatriation that follow. The decision to supply cytotoxic drugs was criticized by some as a relative waste of resources given the small number of patients involved. In the context of the cease-fire, however, it was another window of opportunity that could close without warning or herald a return to normality. The arguments in favor were taken to outweigh those against. The doctors and patients involved had no doubts and this particular action had a very powerful effect on morale. The local media vociferously echoed their sentiments. In July 1994, a British anesthetist held the first postgraduate medical symposium in the city since the outbreak of the war. The 2-day event drew its faculty from the British doctors in the city and was considered a great success by the more than 60 local doctors who attended. Of perhaps equal impact was the introduction of Advanced Trauma Life Support (ATLS) techniques and teaching. In the same month, a modified ATLS course was held in the Koševo Hospital and run by an eight-person faculty of the Royal College of Surgeons of England. The constraints of war and local unfamiliarity with this type of teaching precluded a formal ATLS course. Before the war there had been no resuscitation training programs and no co-coordinated approach to the reception and care of the critically ill and injured. The course was run as a demonstration of a style of teaching and was greeted with enthusiasm by the 40–50 local doctors who attended over the 2-day period. The remit of the mission was to provide medical aid to Greater Sarajevo, which included those areas then under Serb control. A principle of the mission was that aid would be given according to need and not according to any arbitrary or politically motivated quota. Contact was made with the Serb-held areas and assessments carried out. The level of need between the two sides was incomparable.
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Any shortcomings in medical care on the Serb side were relatively few and related to long-standing prewar problems that affected the whole of the former Yugoslavia (Redmond 1992). Their situation could not be compared to a people who had suffered the inhumanity of a siege that choked off supplies of water, fuel, electricity, food, and medicines. Nevertheless, considerable attempts were made to see and be seen on both sides of the divide. These efforts initially appeared to bear fruit with the first meeting of senior health officials from both communities since the outbreak of the war taking place at Sarajevo Airport in July 1994. On the previously agreed agenda were “the future development of highly specialized medical services in the two communities” and “the exploration of areas where highly specialized medical services can be exchanged between the two communities.” However, the Serb position of only accepting a separate healthcare system confounded any further developments. They were intransigent in their view that Sarajevo should be divided and all services, including health care, duplicated on either side of that divide. This was contrary to the principles of the mission and an obvious waste of the limited funds available to both communities. Cooperation with the Serb side was further compromised by the stealing of equipment. Early on in the mission a consignment of aid destined for Sarajevo was confiscated at the last Serb checkpoint into the city. High-level negotiations eventually led to its release but not without a period of threat to certain team members. An even more serious incident occurred later. As described above, the Koševo Hospital was struggling to cope with the casualties of war in a makeshift receiving room. Refurbishing the room was to be carried out as part of the mission. £100,000 worth of emergency department equipment was dispatched from the UK under the aegis of the WHO. The convoy was stopped at the same checkpoint. The drivers were arrested at gun point and the shipment confiscated. Demands by the Serb authorities that the stolen consignment should be divided between the two communities were unjust, impractical, and ultimately insincere. The equipment has never been returned, either in whole or in part, and the incident marked the end of further involvement of the mission with the Serb side. The mission had an added twist. An independent television production company had asked if they could film the team members and patients throughout their mission. This would (and did) add a further strain to the burden of working in the city, but after discussions with the Bosnian authorities, the ODA, and WHO, it was agreed that there might be considerable advantage for the people of Sarajevo if another side to their suffering was shown to the world. Every team member and patient had the right to refuse to be filmed and /or withdraw their permission for broadcast later. No one did. In fact the opposite was the case. Patients and their relatives were so desperate that they seized every opportunity for broadcasting their plight. From May 1994 until December 1994, the British medical aid workers of “Operation Phoenix” made more than 60 person to journey into the city to work alongside their Bosnian colleagues in the operating theaters, classrooms, clinics, physiotherapy department, and wards. Ten surgeons and eleven anesthetists performed/assisted at/were involved in over 200 surgical procedures and over 1,000 consultations. Many of these patients could not have received treatment without this program. Furthermore, the British doctors contributed to the training of local doctors and plastic surgery has since been maintained in the city.
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One of the most prominent symptoms among residents of Sarajevo at that time was exhaustion (Jones 1995). Team members were surprised at how exhausting the constant high level of arousal provoked by living in a still dangerous city and the pressure of working in a strange environment proved to be for them. Rest and relaxation, “R & R,” is an important part of any mission. One of the advantages of “Operation Phoenix” was that “R & R” was taken back in the UK while a fresh team carried on the program. Nevertheless it was important that members were allowed to unwind together with an overnight stop en route home and express their feeling to each other before meeting their families. Debriefing is a very important part of any mission, even those of a relatively short duration. We have found that informal debriefing is just as effective as a more formal approach. One or two weeks after their return, contact was made to talk through the experience in safe and social environment. There were no significant psychological problems consequent upon the mission. Two members had suffered coincidental psychiatric illness that had preceded their mission, which they only revealed after the mission. The mission was conceived in optimism and a hope that the cease-fire would hold. Initially efforts were directed toward supporting healthcare reform in the belief that the coming peace would allow development. A program for healthcare consultants was established with senior managers from the public and private sectors in the UK and recruited as volunteers to enter the city and brief officials of the Ministry of Health. The chief executive of BMI, a British private healthcare company, was extremely well received and it was hoped his visit would herald the start of a larger management program. Sadly the slide back into war made it inappropriate to consider changes in the healthcare system and efforts were concentrated instead on shoring up what was left in place. As the months went by, the fragile cease-fire slowly crumbled into war. Moving large numbers of people into, around, and out of the city was difficult and dangerous. The airlift was frequently cancelled, living up to its epithet of “Maybe Airlines.” The numbers in a team were reduced accordingly at times. The deteriorating security situation at the end of the year finally put a halt to the airlift altogether. Relatively safe and reliable overland access to the city was not available at that time and the mission had to be suspended. The NHS was lending its staff on the understanding that they would be back at a certain time. Once no guarantee could be given regarding the duration of the mission, it was impossible to continue. The mission was monitored and guided throughout by the Overseas Development Administration, and its impact and relevance continuously evaluated. Senior advisors to the ODA made regular visits to the city to carry out these on-site assessments. Contacts with the city were maintained, and both authors returned in September 1995. The mission was resumed in January 1996, with groups of British ophthalmic surgeons and anesthetists helping local colleagues with the backlog of ophthalmological conditions that had accumulated during the war. Once again, the replacement of worn out and damaged equipment and on-the-job training was an integral part of the mission. Of the £1.8 m donated by the ODA to implement the medical recommendations of the UK/US mission, £1.2 m was allocated to “Operation Phoenix.” The specific costs of supporting the reconstructive and ophthalmic surgery services in Sarajevo reached
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about £300,000. The remaining money has been spent on drugs and equipment for the hospital service in general, including a small amount to purchase computers for the Ministry of Health. These have been placed in Health Centers throughout the city to improve data gathering. Those considering such work must recognize the special costs incurred by working in a war zone. In addition to the car purchased at the start of the mission, the safety of team members demanded that we purchased a specially armored vehicle, sophisticated communications systems, flak jackets, and helmets. Taking expensive and precious healthcare workers, equipment and armored vehicles into a war zone demand appropriate insurance. Securing any, let alone adequate, life, goods, and vehicle insurance for an active war zone is not easy and already expensive premiums rose as the situation on the ground deteriorated. The mission was responsible for ordering all its own supplies and delivering them directly to the city. Crown agents proved experienced and reliable colleagues in this regard. Occasionally, by ourselves we reduced the time from agreeing the needs with local doctors to delivering the drugs and equipment to the hospital to less than 2 weeks. The only holdups we encountered were secondary to the logistics of the UNHCR airlift into the city or literal in respect of the Serbs.
Achievements Like others before (Keene 1994), these British workers left behind them more than mended limbs. “Operation Phoenix” helped begin the redevelopment of the city’s reconstructive surgery service and provided training in surgery and anesthesia to the local doctors that will sustain them for the future. Large numbers of medical journals and books have been delivered to the city. Teaching aids, including video players and educational cassettes, have been supplied. The benefits of the mission will clearly be felt long afterward. Each patient treated was a potential candidate for medical evacuation (“Medevac”) from the city. This is a very complex area. Governments at war do not want to lose their population even for treatment. Countries not at war are reluctant to take on the burden of treatment for unknown numbers, for an unspecified time and for a potentially unlimited cost. Even when achieved, “Medevac” separates families and makes refugees out of the sick and injured. Treating people in their home cities is usually preferable, and the work of the mission in supplying drugs, equipment, and doctors helped to relieve some of this burden. Although immeasurable, one of the most obvious achievements was to bridge the siege with the hand of friendship. Local doctors knew they were not forgotten and somebody cared. The frequent journeys into and out of the city brought news of the outside. Team members helped maintain communication between friends and family separated by war. The mission also showed it was possible to deliver a different type of aid in certain circumstances. Highly skilled professionals can be transported in a “protective bubble” provided by a specialist agency and dropped into an area of need for short but highly productive periods. The NHS is a particularly rich pool of talent and could be drawn
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on more frequently if this style of aid provision was adopted more widely. There is no shortage of altruism in the NHS. What prevents its members from volunteering their services in aid of those less fortunate than themselves is not a lack of compassion, but a lack of opportunity. Those who can take career breaks are usually in less essential parts of the service or at the start of their career. Those with the most to offer are usually unable to be spared from the service for more than a few weeks at a time. However, the type of work required in Sarajevo called for reconstructive surgeons, anesthetists, clinicians, and others of the highest skill and experience. There were local doctors available for training. What they needed were trainers. “Operation Phoenix” attempted to square this circle by taking teams of senior doctors for 2 weeks at a time but running them as near as possible back to back to provide an almost continuous service. The television documentary of the mission appeared to have an overall good effect. It was independent of the mission. The producers selected images to represent their view of the teams’ efforts and their relationship to the city. There was a risk that the work could have been misinterpreted or even misrepresented. However, although the films could only show a fraction of what was being done, it was agreed by all who took part in the mission that they gave a valuable and novel insight into the complex problems of the war in Sarajevo. This view was also shared by those in the lay press who reviewed the series. There was criticism in the one medical review of the program (Mckenzie 1995) based on a preview of only the first five programs. This reviewer questioned why the money was being spent in Sarajevo when it could have gone so much further in the third world. This is an important point and one that all of us in the medical profession must address at some point, because helping others always involves choices. Clearly governments make choices about who receives aid and therefore who does not (Solferino to Goma 1995). But we as individuals also make choices. All of us, when we work in a developed country, have made a choice between the needs of one group and the needs of another. However, choosing between Sarajevo and “the Third World” was not a real option for the members of this mission. They were not presented with an open cheque book or a menu of good causes from which to choose. This money was only available for Sarajevo. They were simply presented with a window of opportunity through which they could help the people of Sarajevo. Their choices were to climb through that window, watch somebody climb through, or simply watch it close. There are many people in Sarajevo whose physical quality of life has been improved dramatically by the work of the British healthcare workers who gave so freely of their time in 1994. This alone made the mission worthwhile. Whether it was cost effective begs the question “How much is one life worth?” Philosophically this seems unanswerable but we give our answers every day in the choices we make. Every penny we spend on ourselves, both as individuals and as nations, is a choice between our needs and those of others. Perhaps the better question is “How can I make life worth more?” In a macabre echo of the market place atrocity that heralded the start of this mission, an almost identical mortar attack heralded the events that led to NATO air strikes, the involvement of NATO troops on the ground, and the signing of a peace agreement in Bosnia. These events enabled “Operation Phoenix” to resume in January 1996, reuniting old friends and colleagues, and letting others witness for the first time the impact
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of emergency aid. The next phase of the mission completed the ophthalmology program. As part of the mission, European engineers were dispatched to Sarajevo to repair and service the anesthetic and monitoring equipment in the two hospitals. British plastic and ophthalmic surgeons complemented the work of colleagues from Britain and other countries, which provided support to this much beleaguered city. Medicine cannot relieve all the suffering from all the sick. It will help some. Humanitarian aid cannot solve all the problems of the entire world. It will solve some. In the end there are probably only ever two choices: do something or do nothing. And doing nothing is never neutral.
Acknowledgments Dr. M Kapila, Senior Emergency Aid Advisor, ODA, has been of special help in establishing and running the program and in the preparation of this manuscript. Jeremy Llewellyn-Jones, Emma Bowman, and everyone at Touch Productions did much more than make a film. They made their own very valuable contribution to the work of the mission and independently did much to relieve the suffering of the people of Sarajevo. This mission represented a small part of the enormous humanitarian efforts in Bosnia by ODA, WHO, UNHCR, MSF, Crown Agents, and many others under the protection of UNPROFOR and IFOR. Special thanks to: M.V. Prescott, M.J. Timmons, M.E. Ward, F. Konjhodzic, B. Nakas.
References Barron JN. The Yugo Saga. In: The History of the British Association of Plastic Surgeons. The First Forty Years. Edinburgh: Churchill Livingstone, 1987:24–5 Carballo M, Vuori H. Humanitarian action reassessed. Lancet 1995; 346:54 Humanitarian Olympics: Solferino to Goma (editorial). Lancet 1995; 345:529–30 Jones L. On a front line. BMJ 1995; 310:1052–4 Keene G. Sarajevo surgery. Ann R Coll Surg Engl (Suppl), 1994; 76:124–6 Kurer JR, Watts TL, Weinman I, Gower DB. Psychological mood of regular attenders in relation to oral hygiene behaviour and gingival health. J Clin Periodontol 1995; 22:52–5 Mckenzie K. A piecemeal impact. BMJ 1995; 311:396 Redmond AD. The response of the South Manchester accident rescue team to the earthquake in Armenia and the Lockerbie Air Diasaster. BMJ 1989; 299:611–12 Redmond AD. Report of Humanitarian Aid Mission to Serbia and Montenegro, Geneva: World Health Organisation, 1992 Redmond AD, Jones J. The Kurdish refugee crisis – What have we learned? Arch Emerg Med 1993; 10:73–8 Redmond AD, Watson S, Nightingale P. The South Manchester accident rescue team and the earthquake in Iran. BMJ 1990; 302:1521–3
16. Health Care of Prisoners and Detainees Maarten Hoejenbos and Adriaan Hopperus Buma
Objectives
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To realize which specific problems doctors can encounter in health care of prisoners and detainees. To understand specific dilemma’s in the medical work for prisoners. To give some guidelines for medical personnel who are asked to help prisoners in conflict and emergencies.
Introduction Prisoners do not have the same freedom to move around and to decide their destiny as do free people. Their lives (food, lodging, sports, and work) are organized by the government. This has an impact on their health. Their health care is the responsibility of the government, who decides which healthcare system is applicable and which caretaker is available for them. In a situation of conflict or catastrophe, NGO or military medical personnel may become involved in the (decisions about) health care for prisoners. For instance, when there is an emergency (fire) in a prison and medical help from outside is needed or when an NGO is asked to treat (or to not treat), a person taken as hostage. It is important to know the different status of people in conflict and emergency situations as this status influences their “rights” under international treaties and their access to health and health care. To understand the specific problems of health (care) and prisoners, it is essential to understand the terminology, human rights, and specific problems.
Terminology It is important to know some terminology for a better understanding of the legal status of prisoners and detainees. The health care consequences of the different status are determined by the national laws and may be very different from one situation to another. This terminology is also important because medical personnel can become an instrument of a government or of the suspect in trying to find justice. In this dilemma the doctor should know how to act. A. Hopperus Buma et al. (eds.), Conflict and Catastrophe Medicine, Second ed., DOI 10.1007/978-1-84800-352-1_16, © Springer-Verlag London Limited 2009
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Prisoner (http://www.wikepedia.com) may refer to one of the following: – – – –
A person incarcerated in a prison or jail or similar facility (national law). Prisoner of war, a soldier in wartime, held as by an enemy (Geneva conventions). Political prisoner, someone held in prison for their ideology (national law?). A person forcibly detained against his will, such as a victim of kidnapping; such prisoners may be held hostage, or held to ransom, but not necessarily in a prison or similar facility (no law applicable).
Detainee is a controversial term used by certain governments and their military to refer to individuals held in custody, such as those it does not classify and treat as either prisoners of war or suspects in criminal cases. The word became common during and after the War in Afghanistan (since 2001) as the U.S. government’s term of choice to describe captured members of the Taliban and Al-Qaeda. They were classified as “detainees” because there was no consensus about whether the combatants were “prisoners of war” under the definition found in the Geneva Convention. The controversy arises because the Geneva Convention protects “prisoners of war” but says nothing about “detainees.” These detainees are allowed a trial, but with strong procedural limitations. It is also used to refer to adolescents who are in police custody, to note that they are juveniles (as opposed to being placed formally under arrest). A prisoner of war (POW, PoW, or PW) is a combatant who is imprisoned by an enemy power during or immediately after an armed conflict. Only the captured service members who have conducted operations according to the laws and customs of war are entitled to the prisoner of war status, i.e., be part of a chain of command, wear a uniform and bear arms openly. Thus “terrorists” and “spies” should be excluded. In daily practice, these criteria are not always strictly interpreted. For example, guerrillas may not wear a uniform or carry arms openly yet are typically granted POW status if captured. However, guerrillas or any other combatants may not be granted the status if they try to use both the civilian and the military status. Thus, the importance of uniforms is to gain protection under this important rule of warfare. Some groups define POW in accordance with their internal politics and world view. Since the special rights of a POW, granted by governments, are the result of multilateral treaties, these local definitions have no legal effect and those claiming rights under these definitions would legally be considered common criminals under an arresting jurisdiction’s laws. However, in most cases these groups do not demand such rights. The United States Army only uses the term POW to describe friendly soldiers who have been captured. The US Army’s term for enemy prisoners captured by friendly forces is Enemy Prisoner of War or EPW. A political prisoner is someone held in prison or otherwise detained, perhaps under house arrest, because his/her ideas are deemed by a government to either challenge or threaten the authority of the state. It may be a prisoner of conscience, deprived of freedom of speech. In many cases, political prisoners are imprisoned with no legal veneer directly through extrajudicial processes. However, it also happens that political prisoners are arrested and tried with a veneer of legality, where false criminal charges, manufactured evidence, and unfair trials are used to disguise the fact that an individual is a political prisoner. This is common in situations which may otherwise be decried nationally and internationally as a human rights violation and suppression of a political
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dissident. A political prisoner can also be someone who has been denied bail unfairly, denied parole when it would reasonably have been given to a prisoner charged with a comparable crime, or special powers may be invoked by the judiciary. Particularly in this latter situation, whether an individual is regarded as a political prisoner may depend upon subjective political perspective or interpretation of the evidence. A hostage is a person or entity that is held by a captor, originally handed over by one of two belligerent parties to the other or seized as security for the carrying out of an agreement, or as a preventive measure against certain acts of war, but in modern days more often seized by a criminal abductor to compel another party such as a relative, employer, or government to act, or refrain from acting, in a particular way. This is often under threat of serious physical harm to the hostage(s) after expiration of an ultimatum. A party that seizes hostages is known as hostage-taker; if they are present(ed) voluntarily, then the receiver is known rather as a “host.” A suspect is a not yet convicted person. So he should not be treated as if he is already a prisoner. In trying to find the truth, the police (or others) use different methods of interrogation and questioning. Sometimes the gap between interrogation and torture is narrow. A doctor can be asked to declare a person fit to undergo interrogations. There are, nevertheless, international rules about the human rights (What is torture? http://www.irct.org; http://www.2ohcr.org/english/law/index.htm). The verdict: The conclusions and the conviction pronounced by the judge are based on evidence and declarations of witnesses and experts. Because a doctor can become part of the juridical system to get the truth or to punish a convicted person, it is important to realize that different nations have different systems to come to a conviction and punishment. The methods for trial, evidence, and conviction depend on national law-systems. After conviction, there are four possibilities (sometimes in combination) for the suspect: 1. 2. 3. 4.
No punishment (no or not enough evidence, no proven guilt) Punishment Measurements to protect the society Treatment and/or rehabilitation of the convicted person
If a psychiatric problem has caused the unlawful act, (forced) medical treatment can be given. But adequate treatment is sometime not possible in some countries. Forced Psychiatric Treatment: Sometimes, it is difficult to decide whether psychiatric illness contributed to the crime. In different nations, there are different laws and rules to sort out specific psychiatric problems and the way to incorporate (forced) psychiatric treatment in the punishment. When a doctor is asked to treat mental illness of prisoners, he should know the specific rules in that nation about the treatment options. Torture: The infliction of severe physical or psychological pain upon an individual to extract information or a confession or meant as punishment. This is prohibited by international law and illegal in most countries (What is torture? http://www.irct.org). Death penalty: There is much controversy about the death penalty as punishment or method to protect the society from future crimes. If this “punishment” is regulated by law, doctors can become part of the system, to give information about health situation of the person (“fit to die”). Also a doctor should declare someone “dead” or give information about the cause of death. This could well lead to serious ethical dilemmas.
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International Laws Several international conventions protect the welfare of prisoners (http://www2. ohchr.org/english/law/index.htm). Prisoners lose liberty but retain certain rights in prison. These include protection from harm and access to a standard of health care equivalent to that provided in the community. In practice, few prison authorities comply fully with these conventions. Low standards of general custodial care and of health care are common. Despite the often limited information available on the health of prisoners, there is an increasing recognition of the health needs of prisoners.
Human Rights Human rights refer to “the basic rights and freedoms to which all humans are entitled, often held to include the right to life and liberty, freedom of thought and expression, and equality before the law.” The United Nations Universal Declaration of Human Rights states: “All human beings are born free and equal in dignity and rights. They are endowed with reason and conscience and should act towards one another in a spirit of brotherhood.” A doctor may be witness to acts breaching human rights so needs to know what internationals rules are applicable, and how he should act. The United Nations is the only international entity with jurisdiction for universal human rights legislation. All UN organs have advisory roles to the Security Council. Article 1–3 of the United Nations Charter states “To achieve international co-operation in solving international problems of an economic, social, cultural, or humanitarian character, and in promoting and encouraging respect for human rights and for fundamental freedoms for all without distinction as to race, sex, language, or religion.” United Nations Human Rights Council is involved with the investigation into violations of human rights. The International Court of Justice (ICJ) is the principle judicial organ of the United Nations.
Human Rights Legislation: Treaties and National Legislation Where it has been adopted, legislation commonly contains: Security rights that prohibit crimes such as murder/“enforced” involuntary suicide, massacre, torture, and rape Liberty rights that protect freedoms in areas such as belief and religion, association, assembling, and movement Political rights that protect the liberty to participate in politics by expressing themselves and protesting. Due process rights that protect against abuses of the legal system such as imprisonment without trial, secret trials, and excessive punishments Equality rights that guarantee equal citizenship, equality before the law and nondiscrimination Welfare rights (also known as economic rights) that require the provision of, e.g., education, paid holidays, and protections against severe poverty and starvation
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Group rights that provide protection for groups against ethnic genocide and for the ownership by countries of their national territories and resources
The United Nations Convention Against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment The United Nations Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment (Fig. 16.1) is an international human rights instrument, under the purview of the United Nations, which aims to prevent torture around the world. The Convention requires states to take effective measures to prevent torture within their borders, and forbids states to return people to their home country if there is reason to believe they will be tortured. The Optional Protocol to the Convention against Torture and other Cruel, Inhuman or Degrading Treatment or Punishment, adopted by the General Assembly on 18 December 2002 and in force since 22 June 2006, provides for the establishment of “a system of regular visits undertaken by independent international and national bodies to places where people are deprived of their liberty, in order to prevent torture and other cruel, inhuman or degrading treatment or punishment,” to be overseen by a Subcommittee on Prevention of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment (“Subcommittee on Prevention”).
Committee Against Torture The Committee Against Torture (CAT) is a body of independent experts that monitors implementation of the Convention by State parties. The Committee is one of seven UN-linked human rights treaty bodies. All State parties are obliged under the Convention to submit regular reports to the CAT on how the rights are being implemented. Under certain circumstances, the CAT may consider complaints or communications from individuals claiming that their rights under the Convention have been violated.
The Convention Against Torture is one of a series of UN agreements that seek to protect human rights. The most relevant articles on torture are articles 1, 2, 3 and the first paragraph of article 16.
Article 1 1. Any act by which severe pain or suffering, whether physical or mental, is intentionally inflicted on a person for such purposes as obtaining from him or a third person information or a confession, punishing him for an act he or a third person has committed or is suspected of having committed, or intimidating or coercing him or a third person, or for any reason based on discrimination of any kind, when such pain or suffering is inflicted by or at the instigation (continued)
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of or with the consent or acquiescence of a public official or other person acting in an official capacity. It does not include pain or suffering arising only from, inherent in or incidental to lawful sanctions. 2. This article is without prejudice to any international instrument or national legislation which does or may contain provisions of wider application.
Article 2 1. Each State Party shall take effective legislative, administrative, judicial, or other measures to prevent acts of torture in any territory under its jurisdiction. 2. No exceptional circumstances whatsoever, whether a state of war or a threat of war, internal political instability or any other public emergency, may be invoked as a justification of torture. 3. An order from a superior officer or a public authority may not be invoked as a justification of torture.
Article 3 1. No State Party shall expel, return (“refouler”) or extradite a person to another State where there are substantial grounds for believing that he would be in danger of being subjected to torture. 2. For the purpose of determining whether there are such grounds, the competent authorities shall take into account all relevant considerations including, where applicable, the existence in the State concerned of a consistent pattern of gross, flagrant or mass violations of human rights.
Article 16 1. Each State Party shall undertake to prevent in any territory under its jurisdiction other acts of cruel, inhuman or degrading treatment or punishment which do not amount to torture as defined in article I, when such acts are committed by or at the instigation of or with the consent or acquiescence of a public official or other person acting in an official capacity. In particular, the obligations contained in articles 10, 11, 12, and 13 shall apply with the substitution for references to torture of references to other forms of cruel, inhuman or degrading treatment or punishment. Fig. 16.1. Example of International humanitarian law (http://www.2ohchr.org/english/law/index.htm).
Health and Health Care Statistics show that although 57% of inmates in state prisons reported using drugs during the month before committing their offence, only 20% participated in substance abuse programs while in prison. Federal prisons echo this trend with reports
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stating that of 63% of inmates being held for drug offences, only 15% participated in prison-based drug treatment programs. HIV/AIDS and hepatitis (often related to the drug scene) are also frequent in prison populations. Furthermore, alcoholism and other addictions are often seen among inmates. Moreover tuberculosis is common in many prisons worldwide, and treatment is often ill-informed and inadequate. Prisons form a reservoir of tuberculosis, including drug-resistant tuberculosis. Tuberculosis is a problem both inside prisons and outside in the wider community, since people enter, leave, and reenter prisons. Other communicable diseases are often seen in prison, where people live close to each other. Finally mental health problems, inclusive self-harm and suicide, are common among prisoners. The specific physical and psycho-social environment has great influence on the health status of many prisoners. These special problems require healthcare personnel who understand the situation of prisoners and know the routes to give them the optimal care. In many countries, there are special doctors or specialized centers for health care for prisoners [For instance: The Center for Prisoner Health and Human Rights at the Miriam Hospital Immunology Center (www.prisonerhealth.org) was established in 2005]. There is much knowledge on the impact on health in prison and health of prisoners. Specialized centers investigate the effect of prison on the health and well-being of prisoners and the influence of prisoner culture (e.g., forced sex and prison social hierarchy). They encourage research into health issues experienced by the whole prison population including women, migrant, and ethnic minorities. They consider the impact of prison conditions on staff health and look holistically at the prison setting in the context of public health and in terms of a health promotion approach as developed by the World Health Organization. They bring together research and practice to inform the development of health policy and practical approaches within the prison environment, using evidence-based studies (Feron et al. 2005; International Journal of Prisoner Health. Taylor & Francis. Frequency: 4 issues per year. Print ISSN: 1744-9200. Online ISSN: 1744-9219). Good comparable global datasets are rare. This also applies for data about the health status of prisoners, and data about effects of different prison/punishment systems on health and rehabilitation. However in recent years much has been done for a better quality of prison health care (Ramsbothom 2002). The information that is available indicates that this substantial group is mostly from a disadvantaged socioeconomic background, often has poor physical and mental health status, frequently engages in risk-taking behavior and, as result, has specific health needs. Important findings from some surveys (Australian Institute of Health and Welfare 2004) include: more than half of all male and female prisoners surveyed, reported a history of injecting drug use. Regular drug use at the time of incarceration, which may include injecting, was reported by 67% of male prisoners in New South Wales (NSW), Australia, as well as 74 and 63% of female prisoners in NSW and Queensland, respectively. In both surveys, high proportions of prisoners tested positive for communicable diseases, particularly hepatitis C, which is strongly associated with injecting drug use. The NSW survey found 40% of males and 64% of females had Hepatitis C, while the Queensland survey found 45% of females had hepatitis C. Approximately, 80% of
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prisoners were current smokers, which was over four times the rate of the general population. Mental health concerns were common among inmates. In NSW, 41% of males and 54% of female inmates reported having received some form of psychiatric treatment during their lifetime; while in Queensland 61% of female inmates had received treatment. National data on causes of deaths in prison are published for instance by the Australian Institute of Criminology. In 2002, there were 50 prison custody deaths.
Advocacy Some people (Leitch 2004) believe that physicians are an essential component of correctional institutions and that they should have a responsibility to advocate for effective and humane treatment for inmates. While looking at the steady increase of incarcerated individuals in the United States, which has resulted in record high inmate numbers, some authors point to the inadequate treatment of mental illness and addiction in the community as a source of this increase – especially among women. They say that the natural history of untreated addiction and mental illness often results in illegal activity, and persistently inadequate treatment perpetuates a cycle of crime and incarceration. The correctional system should view incarceration as an opportunity to link inmates with effective therapy such as mental health services, high-quality drug treatment, and support services for reentry into society upon release. Punishment is often favored over rehabilitation in many prisons, which may cause harm to a prisoner’s physical and mental health. In addition, in situations where effective therapeutic services are available, they are often underused. Physicians should encourage to campaign for sentencing laws, policies, and procedures that directly affect the health and well-being of their patients and to encourage more humane and effective treatment alternatives for addiction and mental illness.
Forensic Medicine “Forensic” comes from the Latin word “forensis” meaning forum. During the time of the Romans, a criminal charge meant presenting the case before a group of public individuals. Both the person accused of the crime and the accuser would give speeches based on their side of the story. The individual with the best argumentation and delivery would determine the outcome of the case. In other words, the person with the best forensic skills would win. Forensic medicine (http://www.forensicmed.co.uk) is the medical knowledge that is used to help finding out what/who caused the death, wound or unlawful act. This may include the findings of torture. In most countries, this needs a special education and diploma. In other countries, a regular doctor can be asked to give his opinion about the circumstances that caused the illness, wounds, or death. It is good to know exactly where the doctor’s responsibility lies to patients, police, lawyers,
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and government. Also doctors can be asked to give advice about the punishment. For instance if one is “healthy enough” for the death penalty, or if one should get psychiatric treatment.
Ethical Dilemmas There is a natural controversy between being a prisoner and having (all) human rights. Because there are so many ethical dilemma’s in health care for prisoners, it is good to have some guidelines. Several organizations make guidelines for specific situations. For instance, the World Health Organization (WHO) and the International Committee of the Red Cross (ICRC) have joined forces to produce some guidelines (WHO 1998) for tuberculosis and guidelines for HIV infection and AIDS in prisons. The guidelines apply wherever people are in custody: prisons, police statios, remand centers, detention centers for asylum-seekers, secure hospitals, penal colonies, and prisoner-of-war camps. Other examples of situations with ethical dilemmas are health care for people in hunger-strike (World Medical Association Declaration on Hunger Strikers 2006) and asylum seekers [The Istanbul Protocol in Asylum Procedures. Amnesty International, Dutch section; Care full-Medico-Legal Reports and the Instanbul Protocol in Asylum Procedures. UN Office of the High Commissioner of Human Rights (
[email protected])].
Practical Guidelines 1. Treat the prisoner as a normal patient. Use the normal professional skills to diagnose and to propose treatment. 2. Keep in mind what the background problems of prisoners are, and what the epidemiological situation is. 3. If your treatment of choice cannot be given, because the guards do not allow it, try to adjust the treatment within the limits of what is possible. 4. If you think, that the health situation cannot be solved properly find out who is responsible and try to give your professional opinion. Try to find collegial advice how to act in this specific situation. 5. Stay alert for specific signs of torture.
Conclusions Doctors can well get involved in health problems and health care of prisoners. It is important to know the different positions in the juridical process of the suspect, lawyer, judge and the doctor. There are many (international) rules about the law process and the rights of the prisoner. The health situation of a person can influence the actions that caused the juridical problem. But also the conviction can have influence on the health status.
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References J M Feron, D Paulus, R Tonglet, V Lorant and D Pestiaux. Substantial Use of Primary Health Care by Prisoners: Epidemiological Description and Possible Explanations. Journal of Epidemiology and Community Health 2005;59:651–655 Ramsbothom D. The Health of Prisoners. studentBMJ 2002; 10:1–44 Februari ISSN 0966-6494 Australian Institute of Health and Welfare. Australia’s Health No. 9. Published 22 June 2004; ISSN 10326138; ISBN-139781740243827; ISBN-10174024382X; Australia Leitch R. Appropiate Medical Monitoring.Column on www.USMedicine.com May 2004. http://www.forensicmed.co.uk WHO. Guidelines for the Control of Tuberculosis in Prisons(World Health Organization/WHO, International Committee of the Red Cross, 1998). WHO Publications, Distribution and Sales, 1211 Geneva 27, Switzerland or ICRC Public Information Division, 1202 Geneva, Switzerland World Medical Association Declaration on Hunger Strikers. Adopted by the 43rd World Medical Assembly Malta, November 1991and Editorially Revised at the 44th World Medical Assembly Marbella, Spain, September 1992 and Revised by the WMA General Assembly, Pilanesberg, South Africa, October 2006 The Istanbul Protocol in Asylum Procedures. Amnesty International, Dutch section; Care full-Medico-Legal Reports and the Instanbul Protocol in Asylum Procedures. UN Office of the High Commissioner of Human Rights (
[email protected])
17. Populations and People David R. Steinbruner
Baghdad June 10, 2006 It is quiet and dark tonight in Baghdad. The gibbous moon peaks out above us, scared perhaps to show us her full face. There is a gentle, hot breeze sweeping through the palms of the IZ. An Arabian night; our helicopter pad is silent, waiting patiently. No hurry here, death will come eventually and the calmness will break, but not yet. Nights like this are a chance to catch up with our laundry, finish that novel, or just sit and let the mind and soul rest. It does feel a bit like the calm before the storm, but I try not to dwell on that. It is hard, though, to ignore the news swirling in from all sides: Haditha, 50 kidnapped from Baghdad’s streets, more explosions, the frustration and promises of Al Maliki and the new government. The big questions come to mind on nights like this. The answers are elusive and beyond us here at Ibn Sina To what do we owe our humanity? To what deep instinct do we owe our kindness, charity, ability to love, or to lift another up gently when they have fallen? Is that God at work? Is that the purest expression of the human soul or is it merely the millions of years of evolution, which has made us the social creatures we are? Perhaps it is both. Then the darker question creeps in. What takes away this tendency, if it is indeed something we possess inherently? Do we learn to be humane? Are we molded to this by our parents and grandparents? Can we unlearn it? As I watch the reports about the Marine unit at Haditha, all of these questions spring to mind. Inevitably, thoughts of Vietnam and My Lai force themselves into our national consciousness. Can this be happening again? Let me tell you some stories. On Memorial Day, a car, packed with explosives detonated in a small traffic circle in one of the districts of Baghdad. It was an AO (area of operations), which the unit was familiar with. They had been there often and established what they thought was a good rapport with the people who lived there. The day before the VBIED (vehicle born improvised explosive device), a smaller IED had exploded. It was to this scene that Kim Dozier, her camera crew, and several soldiers were going. I believe the plan was to interview some of the local Iraqi’s about what had happened and how it had affected them. They were standing outside of their vehicles when the car blew up. Several were killed instantly. Dozier and several other soldiers suffered severe wounds. Nearing death, they arrived at our hospital. Her shattered body was already laid out on the gurney when I walked into the room. My friend had called me down to help when he heard about the number of injured coming to us. I stepped to her side and touched her A. Hopperus Buma et al. (eds.), Conflict and Catastrophe Medicine, Second ed., DOI 10.1007/978-1-84800-352-1_17, © Springer-Verlag London Limited 2009
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face. She was conscious but already in that desperate place that the seriously injured go. I picture it as a narrow edge between life and death. She was alert enough to tell me her name, though I had no idea who she was. She kept pulling her oxygen mask from her face, trying to rise up from the pain. It is at that moment that one can see the most primal desire in all of us: the desire to survive. It was as if she were rocking back and forth on the edge, her hand grasping for purchase. The slightest push might let her slip backward, lost forever. “I am going to put you to sleep Kim” I said. And I did. Many hands were around her now, each performing a critical task. We pushed blood into her veins. For 30 s her pulse disappeared and we did CPR to keep the blood going. A little epinephrine and blood and her pulse came back; Back and forth, on the edge. Tourniquets bound her legs and kept what little blood she had left from spilling out onto the trauma room floor. Back and forth, on the edge, not yet ready to relax, to fall backwards into the darkness. The surgeon on call stood next to me. We looked at each other and said together “Let’s get her upstairs.” On to the surgery suite where the intricate dance of surgery and anesthesia kept her alive. I told ABC news later that no one single person saved her life. It was a chain of care that began with a young medic putting tourniquets on while under fire and has not yet ended. And do not forget Ms. Dozier herself, standing alone on the edge, not yet ready to fall. On that terrible day, my friend, a doctor with that Battalion who often spends his day off helping us in the ED, stood in our trauma room in disbelief. He gave a cry of anguish and asked how the Iraqis of that neighborhood, whom they had watched over for months, let someone plant a bomb and not warn them? This is a man with a deep faith and powerful sense of responsibility for the mission here, for his soldiers, and for the people of Iraq. He felt betrayed that day. So many eyes watching, so many people aware of who does not belong in that neighborhood, yet no thought to warn us. Is their fear that great, is their hatred that deep? Who, then, is our enemy here? Who then is our friend? A day or two prior to the explosion, a small girl of age 4 or 5 had been brought in by a Medevac unit. She had been shot through the foot. Apparently here family had gotten too friendly with the American unit operating in their neighborhood. For this transgression, the family was annihilated by the local insurgency. Only the child survived, pulled from the massacre by a neighbor who then risked his life to bring her to us. We admitted her to the hospital to buy ourselves some time to figure out where she would then go. Her wounds will heal, but her family is gone. It is that kind of war. One of our medics, who look capable of single-handedly avenging her death, stood over her, cooing and calming her quietly. He turned to no one in particular and said that he would adopt her if no one else came forward. We told him that he should probably discuss this with his wife before making any plans. The physical trauma of this conflict is a pale reflection of the deeper, psychological trauma, which is inflicted daily. Two nights ago, the stillness was shattered by two children brought in by our forces. They had been innocent sons of an IED mastermind, who preferred to go down in a blaze of glory, his family all around him, rather than surrender. It is the ultimate selfish act of the jihadist. One child, the youngest, looked about 2-months old. He was laid on the trauma room table in front of me, gray and bloody with a shattered left leg, and loops of his bowel exposed. Oh God, I thought, what can I do with this little body? He gave a soft little gasp for air. I placed a tube into his trachea, the medic at my side
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gently breathing oxygen into the little lungs. Unable to get an IV into so little a frame, I pushed a stiff needle into the bone of his leg. There was no blood pouring from the wounds for he had no more to give. Why are you still alive little one? How are you still alive? The surgery and anesthesia team came down to the bedside. With a long, sad look the anesthesiologist sighed. “Let’s get him upstairs David.” For several hours, the surgeons and anesthesiologist worked. The orthopedic doctor removed the remains of his leg, and the general surgeons repaired his bowel. Throughout the case, the chief of anesthesiology and a nurse anesthetist kept the child alive. I slept all day. Upon waking I went downstairs and asked about the child. He had died nearly 12 h after he had first been shot. The physician’s assistant for the unit that brought him in pulled me aside. He wanted me to know that they never targeted the kids. They tried to get the father to surrender but he started firing at the soldiers. The medic who found the kid was shattered by what he had seen. “We know,” I told him. I put a hand on his shoulder. The conflict on his face was easy to see. It is that kind of war. I suspect that the Marine unit at Haditha was not attacking innocent civilians in their view. At that moment, they were avenging their friend’s death by attacking “The Enemy,” for that is what the town had become to them. The ghost of My Lai reveals itself. For in this conflict, only the very young and very old can claim true innocence. The most painful fact for the rest of us is that all good things done will unravel in a sudden burst of gunfire. No matter how many soldiers here hold their fire, risk their lives to keep a shopping district open, supply water and electricity, or go out and train the Iraqi soldiers and police, all will be overshadowed by innocent deaths. Every day Iraqi soldiers are brought in to our hospital, often by their American comrades in arms, to be treated. The bonds between our forces and the Iraqi soldiers are growing stronger even as the mistrust grows within the civilian population. For every act of kindness and moment of peace between the Americans and the Iraqi civilians, there is another checkpoint shooting born of miscommunication and poor driving skills. The mistrust grows on both sides. Who is the enemy? Who is an insurgent? The surviving son that I treated that horrible morning will grow up. What will his mother, shattered by the deaths of her family, tell her son about us? It will not be kind. Another enemy perhaps? It is that kind of war. I write these chronicles not to protest my presence here, for I am proud of what I have been fortunate to help do. I write this to understand what I see and do and feel. I want to get a better understanding of what one small corner of Iraq is like and to draw from these experiences a deeper understanding of life and death, war and peace, and the complicated place we now find ourselves as a nation. Each of us will bring to the news coverage our own prejudices and assumptions. Know that it is probably a lot more complicated than any one of us can understand. The Iraqi themselves have no clear idea of what the future will bring. The motivation, politics, and circumstances, which brought us to this place, are for the historians to argue and decide. Our place is to determine how to best see this country to some semblance of peace. It is that kind of war.
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Introduction: Living and Working Adriaan Hopperus Buma, James M. Ryan and Peter F. Mahoney Associate Editor - JJ Reilly 18.
Getting There and Being Involved A – Hello folks B – Getting involved C – R&R: Moving between Worlds C – Team building and maintenance
19.
Safety and Security A – Staying safe B – Thinking ballistic C – Mines and ordnance D – The oil camp
20.
Voices from the Field A – Just a word about toilets B – Conflict Medicine – a view from the ground
21. 22.
Applied Communications in Conflict and Catastrophe Medicine Mental Health A – Practical psychological aspects of humanitarian aid B – Psychosocial resilience and distress in the face of adversity, conflict, terrorism or catastrophe C – Requiem-going home
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This section is looking at the deployed experience from the perspective of the individual aid worker. The section considers how to get involved and the potential implications for a conventional career path, the threats and stresses within the deployed environment, and how to stay safe. The authors were asked to write from personal experience and encouraged to use their own writing style. Some overlap between the chapters is inevitable, but hopefully a lesson emphasized here will mean an error avoided out in the field.
18. Getting There and Being Involved Part A – Hello Folks David R. Steinbruner Christmas was not peaceful here in Baghdad. The calm of the elections and the days before the holidays were shattered by several rounds of IEDs and firefights. One suspects that they were placed to hit us on Christmas day. By 10 a.m. the slightly desperate sound of Medivac requests crackled from the radio, followed by the drum of rotors passing over the hospital and landing at our helipad. The wounded came in three and four at a time. Just as one group was sent up to surgery another would land on our doorstep. One felt drained physically by the end of the day, sapped from the emotional toll of so much pain on Christmas, rather than the actual exertion of repeated resuscitations. The work is exhilarating and terrible at the same time, and I do not know how to respond to the excitement and dread we all feel upon hearing the radio call: “three litter urgent, 4 minutes out.” It takes several hours for the true impact of the experience to sink in. The wounded begin to blur in my memory, and even the next morning I cannot easily remember exactly who had what injury and when I saw them. We are at war, make no mistake about that. Everyday young men (and women) place body armor on and patrol the streets and suburbs of this sprawling city. Helmets are strapped on, ballistic glasses and earplugs in place. They look very much like modern day Samurai preparing for battle. They drive or walk knowing that someone in their unit will stumble across an explosive at some point during the day. Hopefully they will recognize and defuse it. Perhaps it will go off and no one but the hapless triggerman will be injured. Or, maybe, a friend with whom they just shared a joke or memory or cigarette will have his body torn by shrapnel, legs amputated, or life quickly ended in a flash. Imagine that a part of your daily routine and you begin to understand exactly what sort of strain these soldiers are under. Yet they are remarkably free of the tortured doubt and dread that you would believe all to harbor. Each brings to the anticipation of violence a fatalistic humor that defuses the greatest threat in this conflict: fear. There will be some difficult homecomings, I imagine. The ramifications of what they have seen and done will not end for many years. One soldier in particular sticks in my mind. He came into our trauma room, his body torn, but his will to live powerfully strong. His lips were deathly pale as he struggled to speak to me. I could never make out the words. I placed a tube in his throat to help him breathe as we placed him in a chemically induced sleep. We put lines deep into his body and wrapped him tightly in a sheet. With blood, saline, and oxygen, his skin turned soft pink and his face look calm. His blood pressure and pulse improved, and we quickly pushed him up to the operating room. I was proud of my team and A. Hopperus Buma et al. (eds.), Conflict and Catastrophe Medicine, Second ed., DOI 10.1007/978-1-84800-352-1_18, © Springer-Verlag London Limited 2009
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how quickly they were able to stabilize this young soldier. I spoke to his commander who looked so young himself. “If you get them in here alive, I promise we can save them,” I told his unit. He died on the operating table before the end of the hour; too much damage. Nothing could have been done. Christmas Day in Iraq. It is New Year; the Iraqi celebrates by firing Kalashnikov’s into the sky. Occasionally the deeper thump of a .50 Cal or some equivalent can be heard. Tracers streak up as the city celebrates a new year. Miraculously, no one is yet injured. I think one bad holiday is enough. Tonight we will just celebrate quietly and think of everyone at home. Have a safe and peaceful New Year.
Part B – Getting Involved Steve Mannion
Introduction When questioned, many a medical student or nursing student will profess a deep desire to work in the field of international humanitarian aid overseas at some time in their future career. In practice, for a variety of reasons, only a small proportion ever gets to realize this ambition. Some will accrue family and financial commitments which prevent it; others will feel that such work may be detrimental to their career progression; yet others may perceive that the personal safety risks associated with such programmes are too great. Even for those who maintain their enthusiasm and ambition for such work, getting a first foot in the door can be a difficult and daunting prospect. This chapter aims to examine some of the issues associated with making this first step and tries to offer some practical advice.
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Part A: Getting Involved This first part of the work is concerned with how to get started and how to begin working in the field of humanitarian assistance in a hostile environment, be that working in the field of humanitarian medicine overseas, or in other potentially hostile environments such as the oil and gas industry.
Motivation Before embarking on the quest for an overseas post, it is wise to consider your own motivation for doing so. These may include the points listed below. ● ●
● ●
Altruism – a determination to help needy populations. Religion – medical missionaries undertake this work as an expression of their religious faith. Career – to gain experience that will help NHS practice and advancement. Adventure – the chance to see and do unusual things.
In practice most people undertake aid work for a complex combination of these factors and others (Johnstone 1995). It is perhaps unwise to pursue this work purely out of disaffection with NHS practice. Only a small proportion of expatriate health professionals will find their true long-term vocation in aid work (Banatvala and Macklow-Smith 1997a); the remuneration is often poor, living conditions are difficult, and there is no security of tenure. The majority, therefore, will be obliged to return to a NHS or equivalent practice which, if they found it to be unsatisfactory prior to departure, will no doubt be more so following their return. Care should also be exercised with regard to one’s personal life (Chaloner and Mannion 1995). In crisis situations, it is rarely appropriate for aid workers to be accompanied by their partners and children. With the minimum duration of a first mission for many agencies being 3 months or longer, the strain of separation needs to be considered. Where partners can live in the country, their needs should also be addressed. For example, the difficulties of social isolation can be reduced if your partner is professionally qualified; some agencies will offer dual appointments at one location if both parties hold appropriate qualifications.
Qualifications and Skills Increasingly, aid organisations are demanding greater levels of experience, qualification, and evidence of accreditation from their candidates for overseas posts (Johnstone 1995). This is appropriate, as the expatriate must be able to contribute significantly to the programme concerned. Most agencies will not consider newly qualified or newly qualified doctors or those having only completed the foundation years of training (in a medical role; people with additional qualifications in, say, logistics may be suitable for other roles). The minimum for doctors is usually 2 years post foundation scheme, including work
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in an Accident and Emergency Department, and/or obstetrics and gynaecology. This proof of experience will also be demanded of other health professionals. There are additional courses and qualifications that make the candidate more attractive to potential employers. These include the DTM&H (Diploma in Tropical Medicine and Hygiene, a 3-month full-time course offered by the London and Liverpool Schools of Tropical Medicine), the DMCC (Diploma in the Medical Care of Catastrophes, a modular diploma qualification run by the Society of Apothecaries of London) and Masters degrees in aid-related subjects such as public health, international community health and epidemiology. (Further details of courses and institutions can be found in the resources section.) The requirements for specialists (such as surgeons and anaesthetists) are more exacting. Médecins sans Frontières (MSF) looks for a minimum of 2 years experience at Specialist Registrar (SpR) level. The International Committee of the Red Cross (ICRC), who recruit for their surgical programmes via Red Cross National Societies, usually look for people at Consultant level. The prospective first-time candidate cannot be expected to have direct experience of humanitarian aid work, but previous overseas trips (such as a medical elective or independent travel) are well looked upon by employing agencies. Most of the employing agencies offer some form of further training before sending anyone into the field. MSF run a Preparation Primary Departure (PPD) course. The British Red Cross runs an introductory course for potential delegates. These courses cover aspects of professional skills, general skills, and the individual agency’s health care and aid philosophy.
Integration of Overseas Experience with an NHS Career As long ago as 1995, a circular from the NHS Executive (NHS Executive 1995) drew the attention of NHS Trusts to the potential professional development obtained by medical staff who participates in humanitarian aid work overseas. The document sought to encourage trusts to develop schemes whereby staff could be allowed time off to undertake such projects, with a guarantee of reemployment on their return (current procedures for the mobilization of reserve military personnel include such agreements with employers). Similar More recently similar sentiments have been echoed by Lord Crisp, former Chief Executive of the NHS, in a report commissioned by the then Prime Minister, Tony Blair. Lord Crisp made a series of recommendations of how the NHS might contribute more to healthcare in the developing world and recognised the potential mutual benefits. Although some trusts have started local initiatives in response to Lord Crisp’s recommendations, the durations of visits supported in this way are typically short, and it remains difficult to integrate any substantial period of work overseas with mainstream career progression. This contrasts sharply with that in many other European countries, where time off for aid work is encouraged and facilitated. In contrast the Modernising Medical Careers (MMC) scheme in the UK has been criticised for making it more difficult for UK doctors in training to work in the developing world (Cooper 2007).
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So, How to Combine Aid Work with Career Progression? Discuss your plan with mentors and referees. It is helpful to have someone within the system who understands what you are doing and why, and who can explain it to their colleagues and support job applications. At junior professional level it is sometimes possible to engineer a 3 or 6-month gap between appointments (ideally arrange a job to come back to in order to avoid losing time searching on your return or having to take an unsuitable position). For more senior trainees, it can be more difficult. Particular times may be more suitable for taking time out, such as after successfully passing a membership or fellowship examination. Negotiate with the local Director of Training and College Tutor. They and the trust will need time to adjust the training rotation allocations in your absence and arrange internal cover or appoint a locum. Some programmes factor in OOPE (Out of Programme Experience) and it may be that aid work can be seen as suitable. The possibility of doing research during the mission may also help your negotiations with the NHS or similar employing body. Talk to people who have recently been in the country to see what projects are running or could be set up. The best options are to carry on a project that is already running, or have people in the country who begin preparations before you arrive (it is also important not to be too ambitious, and to remember that many field projects cannot be completed because of a multitude of different factors, so do not be too disappointed if this happens). Unfortunately, owing to minimal/absent levels of supervision, overseas aid work is unlikely to count toward higher surgical or medical training (although some specialities do permit up to 3 months for professional development or specialist military medical training if agreed in advance with the relevant training authority), and accreditation dates will probably be put back by an appropriate period. Another possibility is to combine annual and personal study leave allocations, but this will only allow limited durations of deployment. For consultants and general practitioners, contracted sabbatical periods are a good way of participating in overseas missions (Abell and Taylor 1995). A number of senior people realize their overseas aid work ambitions after retirement but a clean bill of health will be required.
Which Organisation? There are an ever-increasing number of nongovernmental organisations (NGOs) employing health care professionals in aid projects. Each will differ in a number of aspects, such as the following: ● ● ● ● ● ● ●
Type/duration of project Qualifications required Predeployment preparation and briefing Predeployment medical/vaccinations (and who pays for these) Salary (or no salary) Living conditions in the field Insurance
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Communications (to and from the field) Medical evacuation in the event of illness or injury
These factors are critical to the individual deploying. Talk to people who have worked for the organization(s) you are considering and ask if their expectations were met. This will be considered further in the preparation section below. Find out if the organization adheres to the “People in Aid Code of Best Practice in the Management and Support of Aid Personnel” (http://www.peopleinaid.org/). After deciding which organisation(s) you would prefer to work with, the next step is to make contact and register with them. This is often an interview-based process, after which references will be taken up. For some organizations, a successful interview leads to a further assessment and training course before a decision on your suitability for working with them is made. Appointments to a programme depend on a number of factors. If you are multiskilled and available for an unlimited period at short notice, you are likely to be placed quickly. If your availability is more limited or for short periods and your skills are specialized, it may be more difficult. Keep in regular contact with the organization’s head office/personnel department, so they will consider you when vacancies arise. RedR (http://www.redr.org) is an organisation which helps recruit, train and retain health workers for relief and development projects overseas. Another useful source of information is the Tropical Health Education Trust, (THET, http://www.thet.org.uk) which promotes links between NHS institutions and the developing world.
Part B: Preparation Once appointed to an overseas programme, gather as much information about the country and programme as possible. A good organization will assist by providing briefing sheets, including postmission reports from previous volunteers. Speak to someone who has recently returned from the same programme to discuss the nature of the work and get recommendations regarding personal clothing and equipment. Read guide and travel books about the area you are going to. Remember, however, that areas and routes recommended before a conflict may not be safe or usable during and after a conflict. Look at internet sites, particularly those of reliable news services working in the country. One delegate’s report is worth reiterating: I was due to deploy with an NGO but read in The Economist that the place I was going was back in rebel hands. The organisation could not confirm this but did admit they were having difficulty contacting their people on the ground. I decided not to go. Decide in advance what degree of personal risk you are prepared to accept.
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Dealing with Families There is a degree of risk of injury, illness, or death in most worthwhile activities. Not all overseas missions are fraught with danger, but some are. You will have to judge for yourself how much to discuss with your partner and family, although for many a rational and realistic discussion is far more reassuring than leaving them wondering and filling in the blanks for themselves. Emphasize how much you will rely on them when you are away for moral support, mail and just knowing that matters at home have been left in capable hands. Leave your partner/family/solicitor a list of the following: ●
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● ● ● ●
Contact names, addresses, and telephone numbers for the employing organization (both UK and overseas) Contact names, addresses, and telephone numbers of your employer in case your plans change while you are in the country Bank details Passport number/photocopy of passport Travel plans/photocopy of travel documents Location of important documents (e.g., the car may need taxing in your absence; insurance premiums may need to be paid; General Medical Council (GMC) registration must be maintained)
Make a will and leave it with someone who will be notified in the event of your death. Give the employing NGO the contact details for this person.
Medical Preparation A good organization will assist with predeployment medical preparation. The independent worker should consider contacting specialist organizations such as Interhealth, the Travel Clinics run by Hospitals of Tropical Medicine, or those run by travel companies (see Resources section). Below is a list of areas to consider. ● ● ●
●
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● ● ●
General health advice for the country or area you are travelling to. A dental check-up. Vaccinations and supporting certificates (remember – if a number of vaccinations are required they may need several separate visits to the clinic). Yellow fever vaccination certificates are required at the port of entry in many African countries. Personal medical supplies (enough for the duration or until the next guaranteed re-supply). Anti-malarial precautions and prophylaxis. Check that the medicines you are taking will be allowed into the country. Consider the purchase of a traveller’s IV pack, which contains needles, syringes, and IV cannulae: most countries will let you bring these in provided the seals on the packs are unbroken.
Possession of recreational drugs carries life imprisonment or the death penalty in many countries.
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If you have a preexisting medical condition (such as asthma, diabetes, or ischaemic heart disease) discuss this with the organization or their medical service. It can be very difficult to manage even mild medical problems when working in the field. If your health deteriorates you may put yourself and others at risk. Remember that the health service in a conflict area or developing country may be limited or nonexistent. Ask what arrangements the organization has for medical treatment and evacuation (both in-country and for repatriation) and if preexisting illness is covered. Keep copies of the relevant policy documents and contact telephone numbers to hand.
Insurance There are two main types of insurance – for yourself and for your personal effects. Again this should be provided by your employing agency, but find out. Check that the level of cover is suitable for your needs and that the type of work you are intending to do is covered. Contact details for insurance and repatriation agencies are given in the Resources section.
Passport and Visas Your passport must be up-to-date with at least 6 months to 1 year until expiry. Visas and travel arrangements should be handled by the employing agency. Keep photocopies of the key pages of your passport in case, it is lost or stolen as this helps the local embassy if a replacement is needed. If you are travelling independently remember it takes time and effort to get visas. Special visa agencies can be employed to do the queuing and leg work. Visas may be needed for transit countries, especially if you need to stay overnight before travelling onward. Check the political situation regarding existing stamps and visas in your passport. Once in-country, travel permits or local identity papers may be needed. Having extra (about 20) passport-size photographs with you speeds this up.
Travel Documents Travel in the developing world and in conflict areas is subject to disruption and delay. Transit through isolated or dangerous areas is unpredictable. A competent NGO will plan your travel arrangements accordingly. Check tickets when you receive them. Check that accommodation is booked for overnight transits and stays.
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Check that connecting arrangements are satisfactory and that there is adequate time between connections. Ask if you are being met at the airport or other point of entry to the country and by whom. Take photocopies of travel documents in case the originals are lost or stolen.
What Clothing and Equipment to Take? Here is another quote from an experienced delegate: In 1992 I set out for Afghanistan to provide medical support for the HALO trust, a mine-clearing charity. It was my first trip abroad in the “aid game”. I was, however, confident I could look after myself in Afghanistan. Unfortunately when I arrived in Kabul airport my rucksack was still on the tarmac at Heathrow and still at Heathrow when I got back 3 months later. All I had was my hand luggage and duty-free. I learned never to put all my eggs in one basket, how few items you actually need to survive and the trading value of duty-free. What to take depends on the type of job you are going to do, the duration, the likelihood of resupply, the quality of your living conditions, the security situation, the climate, access to communications, luggage allowances, and whether or not you will have to carry everything around in-country on your back. The organization you are working for should brief you on these points. Travel light if possible. There is a 20-kg weight restriction on most aircraft and you will probably want to bring souvenirs back, so leave space. In most places there will be shops (of some sort). In most circumstances, you will get the chance to wash yourself and your clothes. If you are not deploying with the military, do not take clothing or rucksacks that look even vaguely military (particularly olive green, camouflage, or with military insignia and patches) or you may be mistaken for a mercenary and killed. Remember the local culture and customs where you are going, and that revealing clothes may cause offence, particularly around religious sites.
Luggage Luggage will get rough treatment by baggage handlers, by being dropped from vehicles and by being squashed under other loads or people. Options include strong trunks, suitcases, or rucksacks. A trunk is good for working in a static location, but take a suitcase or rucksack if lots of moves/carrying belongings are expected. All should be lockable but easily opened by you for customs inspections and checkpoints. Rucksacks can be protected by lockable covers or metal meshes. A small day sack is useful for hand baggage and day trips in-country.
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Clothing Additional clothing can usually be bought in-country if needed. Clothing needs to be practical, hard wearing, easily washed in a bucket and nonmilitary in appearance. Several layers that can be put on/taken off according to the climate are practical. Some suggestions are given below. Boots: Robust good-quality lightweight boots (broken in before hand) that can be worn all day but are suitable for difficult terrain if necessary. Training shoes Flip-flop type sandals Trousers: light-weight walking or climbing trousers with lots of zipped pockets Thermal vests: silk or polypropylene T-shirts/cotton shirts Shorts/Tracksuit bottoms Good quality fleece jacket or (if very cold) down jacket Waterproof clothing (depending on the area of work) Sun hat Sun glasses (prescription ones are useful) Individual mosquito net (although most organisations set them up in the residences, the ones in hotels/transit areas may be full of holes) Some people use ops waistcoats with lots of pockets, but these can look military Surgical scrub suit(s) and shoes (if not supplied by the organisation) Coordinators/delegation heads may need a jacket and tie (or the female equivalent)
Personal Kit This can make all the difference between comfort and misery. Remember that personal kit is just that – personal so it is your choice. Here are some suggestions. Wash kit: Soap/shampoo/shaving kit. Soap can be purchased/bartered for in most places. Sleeping bag: Depends on the quality of accommodation in-country. Glasses: Take spares and a copy of the prescription (and leave a copy of the prescription with family/partner). Contact lenses: Remember that working conditions may be unhygienic and dusty, and a new supply of contact lens fluids cannot be guaranteed. Books/journals: Check that these are not banned in the country of destination (some medical texts are). Books and journals are of two types – those specific to your task and
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those for leisure. In the Resources section there is a list of medical books that contributors have found essential. The rule with paperbacks for leisure is to take as many as you can, they can always be left in-country and if you do not read them some one else will. Torch: Take a high-power head torch. Power supplies are frequently erratic. A head torch can also be used to operate by when the theatre lights fail. Radio: Get a good quality compact short-wave radio (cost around £70) that will pick up the BBC World Service. Camera: The use of cameras will depend on the organization’s rules and the security situation. For medical workers, photographs are the key to presenting your work on your return (and impressing the medical establishment so they will let you or a colleague do this work again in the future). A quality, compact single lens digital camera is good for both clinical and travel pictures and need not be expensive. Remember the need to get consent to use clinical pictures. Batteries: May or may not be available in-country. Think of batteries for your camera(s), radio, personal CD/cassette player, torch (and laptop computer for the discerning/well-paid aid worker). Personal stereo: Great for delays/waits/periods of isolation/mentally recharging after a hard day. Personal laptop computer: Good for data collection and e-mail (although modems are not permitted in some places), but risk damage or theft. Some electrical items are subject to import taxes in some destinations unless the original receipts can be produced. (Check with the employing agency.) Dictation machine/tapes: Good when compiling reports or making rapid comments when assessing the scene of a disaster or major incident. Airmail paper/envelopes/address book: Even if there is no local postal service, other expatriates will take letters out for you and post them when they get home. Sewing kit Nail clippers (especially for surgeons) Inflatable neck pillow Swiss Army Knife/Leatherman or equivalent Games: Travel chess/backgammon/cards Gifts: Tea/coffee/chocolate/cheese/processed meats/wine/recent video releases/recent newspapers. Any or all of these will start you off well with your new colleagues. Small gifts of sweets/pens and pencils/cigarettes may be useful en route. Postcards/photographs of your home area (if appropriate) to show local people how and where you live. Money: US dollar, Euro and Pound Sterling are widely accepted. Take small-denomination notes for taxis, tips, and other expenses (see section on arriving). Most
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organizations will provide pocket money in local currency and money spent as dollars/euro/sterling will usually get change etc. Communications: Find out in advance what communications facilities are like. If you are taking a mobile phone, check that the area concerned is served by your network. E-mail is rapidly becoming available in many locations. There is further discussion about this in the communications chapter.
Packing Lay all the kit out on your floor and prioritize it. Try packing the rucksack/case and see what will and what will not fit in. Pack your pockets, bum bag, and hand luggage with essentials (e.g., travel documents, passport, medical kit, essential books, camera, film). Assume hold luggage may be delayed or at worst lost en route, so pack this with items that are desirable but not essential (at least for the first few days).
Part C: Arriving Arriving and negotiating ports and airports can be a tedious and trying part of the mission. Here is a quote from experienced delegates. I don’t smoke but I buy cheap cigarettes at the airport as they are useful to give as presents. When you pack your rucksack leave a couple of packets on top of all the stuff. If you get searched at the other end the guard will often just pocket the fags and let you through without rummaging through your other stuff. (Ed C, medical aid worker.) Individual organizations will have their own advice and policies for how they want their employees and representatives to negotiate their way through customs and immigration. Generally this boils down to “just show your ID and explain who you are working for; they know us and you will have no problems.” Sometimes this works. Most state officially that you must not offer presents, however hard the officials press you, but in practice may acknowledge privately that small-denomination dollar bills or cigarettes are an unofficial arrival and departure tax. If this is the case, do not be too generous as people coming through after you will get pestered all the more. Ideally the organization should send someone to meet you, and it is a major bonus if they can meet you before customs and immigration with a translator to smooth your arrival. It is valuable to question coworkers and returnees in detail about what to expect and what procedures need to be followed at your destination. Check with up-to-date travel guidebooks or internet groups.
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General Advice ●
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● ●
● ●
Always be polite and very patient. Do not rise to any provocation. Do not ignore official’s questions. Answer clearly and precisely, backing what you say with documentation if available or necessary. Do not be over friendly, but do not appear cold and arrogant. Always be ready to have your property searched and have keys to cases readily available. Keep a vigilant eye on your property while you are waiting. Talk with your companions quietly and do not laugh loudly or shout to avoid drawing unnecessary attention to yourselves. As soon as possible make contact with your organization’s local representative. Check that nothing is missing from your luggage before you move on to your accommodation.
Part D: Coming Home If you take mail out for your friends when you leave your mission, it is a sacred duty to post it as soon as possible. It is also helpful to ring the relatives of your friends to let them know everything is OK. Do not take mail out for strangers or carry packages when you do not know what they contain. The return home from an overseas mission can be traumatic for some volunteers. Initial euphoria on being reunited with family and friends often gives way to a feeling of mild depression and a desire to return to the overseas project. Having a job to come back to undoubtedly helps in this regard, enabling the individual to refocus their efforts on new tasks and challenges. However, there is the potential for psychiatric morbidity among returned volunteers. Adjusting to coming home may be aided by a debriefing process organized by the employing agency. MSF has the psychological support (PS) network under which returned volunteers are contacted by a member of the network (who has previous field experience) so that emotions and concerns can be discussed confidentially with someone who has insight into the types of situations that have been encountered. Note that the British Red Cross runs “Homecoming Seminars.” In the first part of this chapter, the question of combining aid work with career progression was considered. Presenting clinical cases and a summary of your experiences to colleagues on your return to the UK helps make this work acceptable to the medical establishment and may even inspire others to undertake something similar. A small proportion of returnees go on to pursue careers in the field of international healthcare. Although no defined career path exists, this may involve further missions with the same or other nongovernmental organizations, progressing to
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become a location manager or country project manager, working in a head office and maybe obtaining a paid position with a governmental or international organization (Easmon 1996).
Conclusions International medical humanitarian aid work has the potential to be very challenging and professionally rewarding. Very few of those who engage in such projects regret doing so, and there is increasing recognition of the potential benefits of having undertaken such work to one’s First World medical practice (Banatvala and MacklowSmith 1997b). The degree of experience and qualifications needed to participate in these programmes is increasing. It is difficult to integrate this work with standard medical employment and career progression, but with determination and single-mindedness it can be achieved. Overseas work has its down side. It can be very hard work, living conditions are Spartan, and there may be risks to personal health and security. The chance to make a real difference in a challenging environment is very worthwhile.
References Abell C, Taylor S. The NHS benefits from doctors working abroad. BMJ 1995;311:133–4. Banatvala N, Macklow-Smith A. Integrating overseas work with an NHS career. BMJ 1997a; classified supplement 24 May. Banatvala N, Macklow-Smith A. Bringing it back to blighty. BMJ 1997b; classified supplement 31. Chaloner E, Mannion SJ. Working overseas – salvation or suicide? Surgery Scalpel supplement 1995; July. Christie B. NHS staff should work in the developing world says princess. BMJ 1995;311:77–8. Cooper E. New training scheme threatens overseas working. BMJ on line 31 March 2007 Easmon C. Working overseas. BMJ 1996; classified supplement 5 October. Johnstone P. How to do it – work in a developing country. BMJ 1995;311:113–5. Lord Crisp. Global health partnerships: the UK contribution to health in developing countries. Department of Health, 2007. NHS Executive. Overseas work experience and professional development. Leeds: NHSE, 1995; EL 9569.
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Part C – “R and R”: Moving Between Worlds David R. Steinbruner
Baghdad April 5, 2006 Back in Baghdad. And someone turned the heat up. I have been back now for about a month. It was good, though jarring, to go home. Everyone who is here for more than 8 months gets two weeks of “Rest and Recuperation” – R&R. For most of us this means a trip home. Although the journey drags on several days and nights and requires multiple aircraft, it really is disturbingly quick. One moment I am sitting in Iraq, wrapped in a heavy cocoon of kevlar plates with a hundred rounds of ammunition strapped to my body and an M-16 slung over my shoulder and then? I am back. Stripped of all the tools of war, I step off the plane in Dallas wonderfully unencumbered and wondering if I have just been having a strange, uncomfortable dream. Returning is exciting, awkward, and moving. The world at home has continued on without any powerful indication of my absence. Life did not pause while I was gone. My children, at that age where they seem to grow overnight, are now not nearly as young as I remember. I landed in Dallas around 10 a.m. on March 19th, many hours and half a world away from my last shower, with an aching need to be in San Francisco. After two days of travel, this need was stronger than hunger or sleep, as if everything in my life had come down to those next few hours. Emma, my very talkative two-year old, was having a birthday in several hours and there was no way in hell that I was going to miss it, not if I had anything to say about? Relax. This must be a pretty common feeling for a returning soldier. I was met in Dallas by a very nice mother/daughter team that told me when the next flight to SFO was and which airline and where to go. I made the flight with time to spare. Many odd stares on the plane. There just are not that many soldiers flying back to SFO. The new uniform is not immediately recognized and most look puzzled. “Are you in the Army?” “Yes, just coming back from Iraq” “Wow” Then silence. They want to say so much, to ask, but they are not sure where to go with it. Most just say thank you. I just smile and say “You’re welcome, my pleasure” Do not worry, I am thinking, I know the dilemma you’re wrestling with and I don’t take it personally. It is the dilemma of a professional, volunteer soldier in a conflict that defies easy answers. Wrestle away, I think, you are citizen of the Republic and it is your right and responsibility. Good luck. I make it in time for the party. In a time-zone hopping induced haze, my father-inlaw picks me up at the airport and deposits me at the door to Chuck E. Cheese. Now that is a bit of culture shock. Four days ago, I was resuscitating wounded soldiers fresh
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from the deadly roads of Iraq. Now here I stand, dozens of kids blasting around in a sugar-induced frenzy. I am having trouble processing all this, when in walks my son Ryan and my daughter Emma. Behind them comes Gilda, slightly distracted and looking so beautiful it hurts me a little. If you ever forget how important your family is to you, I have a remedy. It may take some time and distance, but it will recharge your soul and remind you what really matters most. Gilda sees me first and smiles. It is amazing what your wife can say to you without words. She bends down to Ryan and whispers in his ear. He looks over to me, blinks once, and seems to shake his head, just to make sure I am real. Then it is a sprint through the crowd and up into my arms. You know your child’s smell, like a memory that you had nearly forgotten but now seems so familiar. Emma follows slowly, confused, but curious. Ryan knows this man, who is he? I crouch down and smile, but wait for her to come to me. “Emma, its Daddy.” She pauses, unsure but the voice sounds familiar. Where has she heard that before? I walk over to here, kneel, and put my arms out. “It’s Daddy, Emma, remember?” Please God, let her remember, it has not been that long. Something clicks. She remembers the voice from the phone (she was listening) and she comes over. She lets me pick her up as she might a family friend who seems nice. Ryan is coming over and touching me, just to make sure. Now Emma understands, this is Daddy, the Daddy who talks on the phone to Ryan, the Daddy in the pictures. This is my Daddy. Suddenly all the hesitancy is gone. I cannot put her down for long before she turns to say: “Up Daddy, hold” And so I do. Home just in time. Therein follows two weeks of reconnection, remembering, and reunions. I switch back to being a father again. Each morning Ryan wanders into the bedroom, to my side of the bed, and puts his head up next to mine. “Daddy?” “Uh, yes Ryan?” It’s 5:30 by the way. “Why did Anakin turn to the dark side of the force?” This and other important questions need answering every morning for two weeks. Just checking in to see that I am still there that I have not slipped off in the night, back to the other side of the world. I love you too Ryan. I have missed you as well. Emma, still locked into the crib at night, calls each morning: “Daaaddy, Daaaddy” And I get up happily, stumbling around their apartment, looking for where Gilda keeps the diapers. It is never too early to start training your father, apparently. For two weeks, I get to give baths, read stories, and walk to the park. I remember what living is about. What my real purpose is. In a gesture of cruel irony, our dog, Chief, chooses the moment of my return to stop eating. He has been sick for a long time, but had not shown it until this week. It is cancer. Death follows me home. It is not a difficult decision for me, given those with which I have been wrestling this past year. Yet the pain of watching him fall to sleep one last time is surprisingly sharp. We have him cremated. The pet cemetery and mortuary in Colma is run by a Vietnam vet. When Gilda and I go to pick up the ashes, he makes a point of coming over to me and shaking my hand. The pain of that conflict
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plainly shows on his face as he grips my hand. “Good luck over there. Take care.” The air is thick with what is not said. “I will.” I reply. We scatter Chief ’s ashes at Ocean Beach, the site of our first date. And then it is over. Back to the war. There is a terrible feeling of life interrupted. I have been warned about the second farewell, about how difficult it can be. I leave them again, nearly the same place that I did the first time, standing by the security line. The pain of it is ragged across my wife’s face. She keeps it together for my son who has no such need to be strong. Ryan squats down on the floor, his back pressed to the glass window and cries. His sobs penetrate through the noise of the crowd and clutch at me. The vision of his little body, crumpled with sadness, fills me with overwhelming guilt. Emma, completely unaware, waves at the cars outside. “Bye bye cars.” She will ask about me in a few days. “Where did Daddy go?” The guilt springs partially from my mixed feelings. I am, after all, a volunteer. What is happening to my family has a great deal to do with my choices. I am a coconspirator in their pain. I am also eager to get back to work. It sounds strange, but my job in Iraq may turn out to be the most professionally satisfying moment of my life as a doctor. As I have said before, there is clarity of purpose, a sense of mission that is intoxicating. Whatever the political realities of this country, what we do and why we do it are made painfully clear with each IED explosion, with each fire-fight. There is a somber tone of resignation on the flight back to Kuwait. Most of the soldiers sit quietly. All of us seem to be reflecting on the previous two weeks. It was so brief. With unusual efficiency, I find myself on a C-130 flying back to Baghdad the next morning after arriving in Kuwait. After several gut-wrenching aerobatics, we land at BIAP (Baghdad International Airport). By midnight, I am bouncing along route Irish, the airport road, in a massive armored bus called a Rhino. The driver and security detail chat about the IEDs that were found on the same road the day before. Now I know I am back. Strangest of all to me is how familiar this seems. That is perhaps the most disturbing thing. I arrived at that CSH at 3 a.m., completely awake. My entire trip to home begins to fade like an early morning dream, so lovely but now slightly out of focus. In honor of my return, Iraq, quiet for several weeks, erupts in a spasm of violence. Each day for the next few weeks brings death to our trauma room. The weight of these losses sits heavy upon us and my colleagues ruefully suggest that I go back home for the good of the country. Nothing would please me more. Take care
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Part D – Team Building and Maintenance Kenneth I. Roberts
Introduction The provision of effective medical care to conflicts and catastrophes is essentially a team effort, since no single individual can provide all of the skills involved. As will be discussed, although true teams can be a very efficient type of group, they can be relatively delicate, especially during the early stages of their formation and require nurturing and maintenance. This is important, given that teams for this type of work are frequently formed at relatively short notice.
Teams and Groups A team is essentially a group of willing and trained individuals who are: ● ● ●
United around a common goal Dependant upon each other to achieve that goal Structured to work together Empowered to implement decisions. And who have a shared responsibility for their task
The team itself is important, since (in addition to providing an appropriate mix of skills): ●
● ● ●
It meets the psycho-social needs of its members and, once-formed, can be relatively self-sustaining and satisfying. It provides mutual support to its members. It enables division of tasks amongst its members. It can produce originality.
Groups are characterized by an evolutionary life-cycle (Table 18.1), which must be understood if they are to deliver their task effectively without damaging their members. The stages of group evolution are summarised below:
Team Building The potential risk in the evolution of the team (and the time taken for the team to form) can be reduced by a number of considerations. Team Selection: Procedures must be put into place to ensure that the appropriate individuals are selected for the team. Although, clearly, this will be on the basis of the skills required, this should not be the only criterion. It is important that team players
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Table 18.1. Life-cycle of groups Stage
Characteristics
Outputs
Forming
Shyness, uncertainty, tentative
Little visible output. Members are attempting to orientate themselves within the group
Storming
More open, complaining, criticising, disagreeing, questioning of goals
Little visible output Members are confronting others within the group
Norming
Resolution of internal conflicts, division of responsibilities within group being resolved, emergence of group norms
Little visible output
Performing
Collaboration, commitment, self-regulation
Group productivity increases. Group has evolved into a team
Dissolving
Sense of loss and lack of worth
When tight-knit groups/teams dissolve Little visible output
Nature of the group beginning to emerge
with an enthusiasm for the task are chosen, and any selection procedure must take this and any health considerations into account. Team Building: Teams must have mutually agreed ground rules if they are to thrive and be effective. These should include the following: ● ●
●
The recognition of equal respect for all members. The recognition and acceptance of differences between individuals (whether that be on the basis of gender, religion, or ethnicity). The absolute intolerance of nonteam behavior, such as dishonesty and inappropriate sexual behavior.
Further, everyone needs to understand and accept procedures within the team for emergencies and for the reporting of perceived grievances and difficulties. Team Training: The team needs to be confident in its individual and collective competence, and this can be nurtured by appropriate training. This should not merely involve ensuring that individuals’ professional skills are kept up top date, but should also include basic survival techniques such as safety, personal and collective hygiene drills, and defensive driving. Training in the correct use of protective equipment and communications systems is vital, and a degree of cross-training between team members can be useful. Team Maintenance: It is important that all members of the team are aware of its mission, goals, and what outputs it should be achieving. Everyone needs to be aware of their contribution to the overall effort, and what their responsibilities are. The team can be further maintained by a fair division of tasks (that is, everyone does some of
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the seemingly menial chores, irrespective of who they are). Regular progress discussions (what have we done today? What went right; what went wrong? What will we do tomorrow?) are useful, provided they are conducted in a nonconfrontational way. A good idea is to structure these around communal meal times, when everyone can relax somewhat. The morale and cohesion of the team will also be enhanced by attention to administrative issues such as the provision of contact with home (by mail or telecommunications). Leadership (not necessarily in the traditional hierarchical sense) is an important “glue” for any team, although these aspects would be the subject of a separate book! Dissolving Teams: It is important to reduce the stress of the grieving process by dissolving teams sensitively. Members should be encouraged to celebrate the team’s achievements, and to keep in touch after the team has dissolved.
19. Safety and Security Part A – Staying Safe and Effective: In a Humanitarian Context (Or as Safe as Is Reasonably Possible When You Know You Should Have Stayed at Home!!!) Garry M. Vardon-Smith
Objectives
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Personal Safety Driving and getting about safely Checkpoints and road blocks Local corruption Hostage taking and ambush
Personal Safety This is a huge topic that I can only hint at here and will be mentioned elsewhere in the book under various headings, but one key message is that it is often briefed but rarely practiced. It is important that you see your education in personal safety as an ongoing feast with many flavors and regional differences. Like all types of education it will also never end; you will never be expert enough; there will always be gaps and to remain proficient requires practice and reflection. There are also a few good books on the subject, and developing an all-round knowledge of survival skills will help your confidence in staying alive, even if no one is trying to kill you. Your organization should ideally run Hostile Environment’ Training for you before you deploy, failing that many private security companies offer bespoke training in exactly this topic. Make sure that it is contextually relevant for your circumstances, that the bona fides of the company are verifiable, and that it has a proven reputation. You also need to listen to your own advice; a colleague reported attending a briefing about working in the former Soviet Union. It included a warning about being met at the airport by a luxury limousine; this pleasing occurrence concludes with the hapless aid worker being abandoned shortly after, stripped of all valuables and clothing, with the “limousine” being a cover for a kidnap gang. Sometime later the speaker himself fell victim to this ploy, fortunately only to his eternal embarrassment! I reminded my A. Hopperus Buma et al. (eds.), Conflict and Catastrophe Medicine, Second ed., DOI 10.1007/978-1-84800-352-1_19, © Springer-Verlag London Limited 2009
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colleague of the old proverb that if it looks to good to be true it probably is! Any experienced aid worker or even military or civilian specialist who has deployed would know that a luxury limousine ride only ever happens to the chairman or the general, never to the workers! From the outset it is also worth emphasizing that personal guarantees from local leaders, movers and shakers, and religious leaders are not worth the paper they are written on; never rely on them or acknowledge them. You may have to identify a deflection tactic or strategy to defend your “no go” rule; I invented all sorts of rules and protocols and this ruse works fine. If you choose to ignore this key fact, do not bother reading the rest of the book; put your affairs in order and do not worry about that credit card bill, because you are not coming back! Secondly, there are places in your hometown – wherever that may be –where you would not go at night and would think twice about during the day. Where you are about to deploy is no different and most likely far worse; it is your duty to find out where these areas are and never ever go there. If you do then you deserve the fate that may well await you, and no one should be endangered to recover your arrogant or naive carcass. That may offend some of you, if it does I am glad because it may cause you to stop or reflect for a brief second before you commit to a course of action that will embarrass your organization, your family, or endanger your life unnecessarily. Simply by deploying you have raised the risks and threats to your health anyway, so remember those first 2 weeks where you flinched at every noise and your eye balls resembled those of a referee at a ping pong (table tennis) game and never forget them; ideally, keep a diary and reread the first 2 weeks whenever you feel safe and/or comfortable! Clothing: As a basic rule do not wear ex-military fatigues; do not look like a mercenary or Indiana Jones, and do not show more flesh than is culturally acceptable and this may include bare legs for the guys as well as the more often exposed “female” flesh. As a good contingency have extra “discrete” clothing for all travelers including head coverings, because being able to cover up quickly may placate an angry guard or militia man and save further grief. When you are off duty the same rules apply; it can be very offensive to have sunbathing or partying aid workers when locals and their relatives may still be recovering their dead or looking for their next meal! Camp safety: Where you are billeted or based should be within a “safe” zone or encampment; if it is not ask difficult questions of your senior staff members or of your parent organization. It may not resemble a four-star hotel but basic sanitation, water, and physical security are some minimums that will allow you to carry out your task more easily. Continually looking over your shoulder or waking scared at night every night will have a disabling effect on your capacity to help others and ultimately will defeat the objectives of your mission. It may be a good practice locally to share security facilities with other aid organizations but do be careful about having the local military or militia providing security or being too close, unless they are seen as a supportive agency within the cultural context in which you are operating. Information security: I am inherently suspicious, it may well be in your interests to be the same, that all too often sensitive information is left lying around or pinned on notice boards in plain view. I would recommend that you maintain a “security” office
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and that all personal information, plans, maps, and code words are protected by lock and key; I will discuss more under the driving section but traveling is your most vulnerable time in mission and often when you will be at your most complacent. Airports are key areas where you will be vulnerable for compromise and most obvious as a new arrival. Details and arrangements for your transport need to be kept secure. If you have been given arrangements stick to them; local taxis anywhere, including the first world, are not beyond being the front for a criminal or terrorist enterprise; have key words and code words by which you can identify your proper arrangements or best of all arrange to be met by an experienced colleague who is already “in-country” and “acclimatized” to the security situation. The “other side” “does intelligence” just as well as we do and locally, better! Food: Traditionally western travelers take many of their culinary customs with them wherever they travel! It may be useful if you at least attempt to explore aspects of the local cuisine before you fly, and if you have any “sensitivities” then you should try and overcome them or identify strategies that may help. I always travel with a lot of curry powder, Oxo/Bovril, bouillon cubes, and decent tea bags just in case they will be all I recognize at dinner! Always take responsibility for food hygiene yourself until such times as you are satisfied that it can be safely delegated, ideally under a western trained cook! This can also include where you eat; human excrement is often used to “fertilize” crops or allowed to dry in the sun; that “dust” that is often blowing around may not be sand, so do not leave your food out or eat outdoors!! It helps if you do not bite your nails any more either! Weapons: Even basic culinary items can cause you problems (a) getting them out of your own country by plane and (b) importing them into your place of operations. So in short do not bring them; a small pocket knife may be permissible but be guided by your deploying organization. Most organizations will insist on a full inventory of equipment carried both operationally and personally; this will include personal medical kits. Some equipment, medicines, etc. will require letters of authority to travel or enter your destination from the host nation or at least your sponsoring NGO. You may well end up being arrested at the entry port if you do not comply with this requirement or even if you do, so my advice is do not take anything expensive or personal that you would not mind disappearing! Most incidental things can still be bought locally even in the most difficult of circumstances and you will be contributing hard currency to the local economy. Do not carry weapons for personal protection; be guided by your local security officer on this but if you personally need to be armed to do your mission or think you do, you are on the wrong mission; the mission is badly prepared or you are in the wrong frame of mind. Fraternization: Always sticky, you will all be aware of stories or colleagues who have arrived home with (a) a partner or (b) a child or (c) both or in anxious anticipation of the latter! This is of course personal choice but one that will inevitably involve much heartache, form filling and problems back home. At a professional level it may even cause severe problems for your mission and NGO. Internationally several NGOs have faced severe criticism of staff who have committed criminal acts including rape, acts that would be considered child abuse, encouraged prostitution, and spread sexual
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diseases. From a perspective of reputational management all of the aforementioned acts are gross misconduct of the highest order and should result in your instant removal from any mission and preferably prosecution (personally I would shoot you myself!). However, true love does blossom in the most obscure and trying of circumstances; if this is the case then absolute transparency and honesty are required both with your supervisors and with local leaders and officials. My advice would be to try and avoid any compromise of your integrity or impartiality at all costs; avoid the risk of innuendo about any such liaisons and concentrate on the mission! Bring a good book and exercise! Mental health: This will be dealt with more completely elsewhere in this book but every mission requires a medical component and this ought to include staff experienced in counseling, critical incident management, and debriefing. You cannot complete your mission if you are too involved in your own issues, psychologically troubled by what you encounter or what you bring with you. If your psychological health is not as robust as your physical health do not go; send money or provide support back at home base; a nervous breakdown is unpleasant wherever you are; in a disaster or aid mission it may well be life threatening and incredibly disruptive for your colleagues.
Driving and Getting About Safely If there is any activity guaranteed to bring conflict it is driving; just imagine the familial arguments that occur on a road trip, the logistic nightmares of toileting, fuel, and feeding, forgetting for the moment the possibility of mechanical breakdown of your vehicle (or mental breakdown of the driver). If you take these daily demands that at home we take for granted and then apply them to the rigors and inherent dangers of driving in a humanitarian, NGO, or disaster relief context, then the problems multiply exponentially. To approach this huge subject in a fashion that will hopefully make for an easier read I have broken it down into several key areas; like any topic each has a subjective element that requires the reader to put themselves in the position of the “reasonable man” or “woman”; however, “gender” does add an additional and significant dimension that we will look at later in the chapter.
Drivers One way that many NGOs get around a lot of the difficulties of driving in a foreign climate is the use of local drivers. This is often a useful way of circumventing some problems but it can create many more. A simple list of “positives” seems to highlight the benefits: Local knowledge of roads Local knowledge of customs Local maintenance/provision of vehicles Local language speaker
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These positives can easily be seen as negatives: Over enthusiastic driving, eagerness to “show off ” Local knowledge of whose customs? What about other tribes, ethnic/religious groups; are you dealing with a “westernized” individual who may not be popular locally. Risks for corruption in maintenance or poor standards of safety Do you know what your driver is telling everyone about your habits of safety and security? Plus: How much are you paying him? (yes it is likely to be a “him”); will this make him popular or a target for the huddled masses? How much do you really know about his alliances and allegiances? How much do you really know about his habits, drink, drugs, pornography, weapons? If you do use a local driver it is highly recommended that you establish their credentials, provenance, and career history at least as much as those you put your trust in for your compound or camp security, as when you leave your safe location, your very lives and those that you intend to care for will be in the hands of your driver. So do you drive your self? Well that is a decision that you may have to make and should make in consultation with the Local Emergency Management Agency if one exists, or representatives of the local government. You will be less tempted to wander off; you will stick to the highways and better-known areas and you would not be tempted to drive recklessly through unfamiliar locations. Also the provision as an absolute must of a high-quality GPS system means that you will never actually be lost; you may just not know where you are in relation to where you have been or want to go! Of course driving yourself means that you may be ignorant of local customs and the language. These can often be overcome by taking a translator with you or “Terp” (short for interpreter). The benefits of having someone who can speak your language and the local language, at least main dialect, cannot be overemphasized; it is also likely that the provenance of the “Terp” will be easier to establish; they may well have worked with agencies such as yours before, and you will probably have or be spending a significant amount of time in their company to get to know them. Now often many Terps are women, and this does need to be judged locally with some circumspection; it is unfortunate but a harsh reality that the status of women throughout the world is “different” than that in the west, and although locally well educated they may be less well connected or respected, dependent on the local culture! Well if you are reading this book and keen on providing humanitarian assistance, you can obviously “cope” with the complexities of such a mission or be with colleagues who can, and no one ever said it would be easy. So let us just assume that you have identified a good local interpreter, or driver interpreter whom you believe you can trust. You have sat them down and explained how you would like them to behave: not driving recklessly, not taking risky short cuts, and not “showing off” the “financial” benefits of working with an aid agency or group, and established that your whereabouts, routes, and equipment are neither to be divulged nor discussed with his friends or posted on notice boards. What else do you need to do? Well, here is a not exhaustive list of additional requirements:
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Vehicles The vehicles, notice I said vehicles, you should never, never travel in a sole vehicle; a minimum of two is required at all times with backup support available. The vehicle must be suitable for the terrain and weather. An open top car may be fine for the city road but on a cold night, lost, off road it will be much less appealing than a sturdy covered 4 × 4. Vehicle equipment: This depends on the terrain, but must include water and food for at least twice as long as the worse case scenario you have envisaged for your trip, extra fuel, spare tires and wheels, jacks and self-recovery equipment, bedding, clothing, basic mechanical consumables, lights, bulbs, oil, coolant, emergency repair kits for radiators, oil coolers, brakes, etc., tools, hammers, jimmies, and more. If you have excellent recovery plans and capabilities you may be able to cut some of these down; however, your life may depend on it being there when you need it. Vehicle servicing: If possible have this supervised by a member of your group with the mechanical knowledge to do so; corners are often cut in remote climes and the provenance of genuine parts will be suspected. As a minimum, brakes, tires, fuel, coolant and radiators, all fluids, steering and suspension mountings, gearbox, and drive shafts should be checked before each journey. Radios (and GPS): As a minimum handhelds (plus extra batteries) that are effective for the distance you will be traveling from your base of operations, my recommendation and preference is vehicle-mounted antennas and radios, plus handhelds and a satellite phone. Its pointless knowing where you are if you cannot tell anyone about it! An often overlooked point here is that although ex-military and police personnel may be familiar with radios it is absolutely necessary that all staff know how to use all the radios and technical equipment on the vehicles, plus call signs and emergency contact numbers. Regular radio drills and practice are necessary to allow your staff to be comfortable with radio communication, including “discrete” communication and brevity; you never know who is listening nor why. Vehicle history and color: It is pretty much standard practice to try and avoid traveling in anything that was, is or looks like it was a military vehicle unless you absolutely have no other option, or the local environment and culture would accept and not take a dim view of this type of travel. There may be a well-established Emergency Management Agency that has its origins in the military or it may be a military-led humanitarian operation where the military personnel are not seen as internal oppressors; either way check and recheck and if in any doubt then there is no doubt, do not do it. Driving: In the West (for the most part) we have such niceties as driving licences, speed limits, vehicle safety testing, road signs, good roads, and “highway codes.” In the humanitarian context never assume that any of these are present. In fact driving may be the most dangerous part of your mission other than flying in old Soviet era helicopters and aircraft!
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Consequently unlike at home you should consider each journey as a mission and should not undertake journeys lightly. Each trip should be properly planned, with contingency plans written and established, resources and permissions obtained, and all equipment tested. Ideally an advance party of trusted locals in radio contact should go down your route first; in radio contact they can spot trouble before you get to it, and identify road hazards, checkpoints, and the “temperature” of local feeling toward outsiders. On a recent deployment I was asked if all this was really necessary as some NGOs may not be able to deploy such resources and take such precautions (this was during a discussion with nearly 20 different NGOs none of whom had any response plan for kidnapping of their staff in a country renowned for kidnapping/hostage taking). I stated that I believed that it was, and if an NGO or organization is incapable of such basic preparations they should not be “in theatre” at all! You should obey all speed limits and drive courteously and defensively; if in convoy, you should drive at the pace of the slowest vehicle and on difficult terrain take regular breaks. Off-road driving is inherently dangerous and slow! Never assume a quick turnaround or journey. Often you will be confronted by oncoming heavier, faster moving vehicles on narrow roads; the driver needs their wits about them and needs to be well rested; you do not want someone who has just worked a double shift or is holding down three jobs in that position. They also need to “know” their vehicle and be comfortable and competent with all the controls that are obvious but often overlooked criteria in an era of automatic gears! The route: This should not be announced beforehand and details of your journey should be part of your information security plan. If you make the journey regularly you should vary the route if possible, definitely vary the timings and preferably restrict your visits to make interception more difficult. In most countries where you can envisage being deployed, you as a westerner will be seen as a potential hostage and opportunity for acquisitive crime. Your religious, humanitarian, or other status is unlikely to provide any protection from theft or kidnap or possibly worse! Driving companions: You will most likely be some distance from the civilized niceties such as a police force you can trust, ambulances and major trauma centers, fire brigades, main dealerships for your vehicle, radio technicians, cooks, and diplomats. Consequently, unless you have a superb support network your team, yes team, not just you and your driver/interpreter will need to have these skills when you travel. Plus all of you will need to understand how the vehicle equipment works for breakdown and self recovery. As a basic minimum everyone should also be first-aid trained to a fairly high standard for high-risk situations, have some knowledge of fire fighting, basic vehicle mechanics, how to use a radio, GPS, Sat Phone, etc., and be able to explain the humanitarian aspects of their mission while remaining calm, impassive, and culturally tolerant during what will probably be “trying” circumstances. Mines and IEDs: Knowledge and awareness of unexploded ordinance and weapons that might be present is also to be highly recommended as unless you are in a disaster area of natural occurrence, humanitarian need is often accompanied by civil war, insurrection, criminal/military gangs, or warlords or fierce intertribal conflict. At least knowing what a mine looks like may stop you driving over one or picking it up!
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Never be the first to use a road that “was” mined and never kick/run over cans, or boxes or anything else in the road. If there is a significant threat on your route, I suggest that you (a) should not be on it and (b) you need to review your security arrangements. If the threat is active and directed at westerners then peacemaking is probably still ongoing and humanitarian aid efforts will be severely hampered; make contact discreetly with western forces and seek their advice and intelligence. They will welcome this and normally be able to provide some form of reassurance by way of points of contact or even some form of QRF (quick reaction force) or route assessments. Before leaving your base of operations and in addition to all the aforementioned points you must search the vehicles. Now this may sound crazy but unless you do search the vehicle yourself you do not know what any further checks by others may find! Examples of “stuff ” to ensure you leave behind include the following: Alcohol: not just a “no no” in Islamic countries but you do not want to get lured into providing it to locals, local cops, or militia, or drink it yourself when on a mission. Pornography: that western magazine that you can buy in the airport may be considered pornography or at least insensitive if not illegal where you are; remove it. Weapons: if you are unarmed by charter it will only damage your reputation if not your chance of survival if you have a weapons cache in your vehicle; you will also need to search your driver/interpreter and other locals before they travel with you for similar items. Drugs: now you may think western drug policy to be flawed and an affront to your personal choice; however, you risk death and imprisonment for life if you are in possession of prohibited drugs let alone drugs that you may have in your medical inventory. It is necessary to have a full checklist of authorized drugs in your possession including medicines for every trip, again do not forget to search your locals traveling with you. Contraband: now that local artifact may be a bargain, but it may also be stolen, or prohibited for sale or export, or be made from a protected species of any genus. Save your souvenir hunting for the airport on your way home, and remember that it may be legal to export but illegal for you to import it to your home country. Also check any tapes, CDs or laptops you have with you in the vehicles for banned music, pornography, political comments especially local politics, compromising photos of yourself or team with political figures, opposition members, certain tribes or leaders of warring religious/military factions, pictures of military installations, airports, military equipment or poses of you with weapons. At gunpoint, you have no rights to privacy nor a phone call!
Checkpoints and Road Blocks If you do not think you will encounter these then you are most likely ill prepared; western aid groups are viewed as easy targets for almost any group to harass, steal from, or take hostage if they choose to, and one of the most popular opportunities to
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do any of the these is at the checkpoint. If your planning is good you will be aware via your local contacts where the official checkpoints are and what cultural niceties you will have to observe to pass through unmolested. If there is law and order and a system of legitimate government then the roadblocks may hold little fear for you; however, they are opportunities for disaster to strike the unwary, and false or compromised checkpoints are often used by criminal groups and opposing factions to impose control or the appearance of legitimacy of their actions. It is always a good policy to approach checkpoints slowly and deliberately; if you have the opportunity to avoid them take it, providing you know where you are going and what lies ahead. Communicate quickly and discreetly the facts and location of the checkpoint to your remaining convoy members, your control base, any escort or security detail by radio (radios can often look like weapons, so do not put them on view but do so out of sight); lock your doors and roll up your windows and smile. Have your flag or aid group identification and passes ready to hand and possibly even hold them up to the windscreen so they can be seen; stop when you are told to do so. If you are unarmed and unarmored, you will have no success in “running” a well-prepared checkpoint. If the circumstances are believed to be a cover for a kidnapping it may be better to stop short and attempt to “bug out” the way you came. This contingency should have been discussed and planned for with the remainder of your team long before this eventuality happens as part of your contingency planning processes. However, a well-placed checkpoint will make this potentially difficult to achieve. If you can avoid opening or unlocking windows and doors do so, try and communicate through the glass or at the most a crack. If ordered at gunpoint to get out you will have no choice but to cooperate and this is where having a team leader will become a necessity. The tendency to panic must be overcome, most illegal checkpoints and some legal ones will be an opportunity for the locals to assert their influence and independence, and some may resent your intrusion and interference in “sovereign” issues. Now is not the time to hold a political dialogue; you are most likely “a stranger in a strange land,” and your sole thoughts should be achieving your humanitarian mission safely and espousing that exactly and clearly to your would-be tormentors. Seeing that they can exert influence and control over the “interlopers” who are cooperative and nonthreatening may be enough for the checkpoint to let you go as they have achieved “satisfaction.” If they insist in searching your vehicle you will have been glad that you have done so before them, but you must still accompany the searcher or at least one of you will need to, in order to avoid anything being planted and to reduce the likelihood that something will be stolen during the search. The legitimate checkpoint: This may be your first taste of this but it is likely that “sweeteners” have been employed before you even arrived in country, at immigration control and locally to set up your base. However, you will need to establish the local pecking order of politicos, guards, commanders, and “police.” You do not want to waste your “friendship” on someone with little or no influence over you or your ability to roam freely. So everyone brings your “duty free” cigarette allowance to the next crisis you attend and make sure you have plenty of cigarettes on board your vehicle.
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Local Corruption Bribes: It is almost a universal policy among all humanitarian agencies to prohibit the giving of bribes by its staff. It is also probably true to say that most aid staff provide “bribes” one way or another when deployed. The simple reason for this is that there is often no other way around it. In many parts of the world this is just such a common practice that to deny it would fly in the face of the realities you will encounter. So compromise your moral and professional horror up front and get used to the idea of a little “sweetener” being part of your daily business. Thankfully in the main this will revolve around cigarettes, especially the most famous American brands, a few cigarettes will often be all that is needed to smooth your way and “make friends.” Of course “bribing” a local official is probably illegal and may cause even more of a problem for you, so it is highly desirable to have done your homework beforehand about what you can and should not do and what other “influencing” strategies you might be able to employ. Always start out “innocently” with cigarettes, and do not pay too much too quickly. If you flash a lot of cash the price will go up; you will get stopped more often and you may make the problem worse for those who come after you. Money: Unfortunately there are times when you may need more than a cigarette break with a local to “overcome” some perceived sleight or cultural faux pas you or your team have committed. Then I am afraid you will need money, money already broken up and strategically placed so you know how much is where and which pocket to go to under what circumstances. Each member of the team will need to be aware and understanding of what the team leader will be trying to achieve. During negotiations for your safe passage is not the time to engage the locals in an argument about the benefits of anticorruption measures in local government and freedom of speech for oppressed minorities. The amount will vary but you should have an awareness of a days pay for a “police” officer or soldier, a days pay for a local commander, a weeks pay for more difficult encounters, and everything you have when you may be paying for your lives. The circumstances when a bribe is or becomes payable will differ; however, one thing is universal – never ever call it a bribe; you may want to make amends for causing offence; you may want to make a contribution to a useful charity or project that the target of your affections may be interested in; you might want to contribute something for the feeding of the “group” as you have delayed them from going home by making them hold you up at gunpoint and they will have missed out on a meal, etc. The target will need to be the “man in charge” not an underling; you will need to do this out of earshot of the underlings and in such a way that you both know it is a bribe without ever saying so. The cigarette packet is also a useful prop in delivering the bribe discretely. If your lives are threatened you will need to have planned beforehand with one speaker, with access to all the money and the wit to lie, negotiate, and ignore any personal issues with helping a military unit, militia, or torture gang; compromising your values against having one of your team members being killed or kidnapped is a “no brainer” or at least should be.
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Hostage Taking and Ambush For most westerners this causes the most fear and panic; sometimes this is with good reason as in parts of the world it is often common place and regularly ends up in the murder of the “innocent” hostage. That said even in Iraq around 70–80% of western hostages end up released by negotiation or military intervention. Compared with the local community most western hostages are treated relatively well, and in some parts of the world hostage taking, while an anathema to western feelings, is a “businesslike” arrangement designed to bring disagreeing parties to negotiations. If you can, please never legitimize kidnapping and murder by referring to it as an execution; only a state backed by its own laws can execute someone, and everything else is murder plain and simple! The most dangerous time for the hostage is in the initial ambush/contact with the hostage takers and transport to the place of confinement. If things have already got to this stage then you will have little opportunity or option to do anything other than cooperate. If you have anything on you that is compromising now would be a good idea to get rid of it discretely but quickly, even a tie tack can get people killed or a commemorative coin or picture in your wallet! You will be surprised that if you appear accommodating, remember, you really have no choice, most untrained attackers will forget to search you. If, however, you cannot smell alcohol, have been quickly reduced into captivity, and are expertly searched, handcuffed/tied up, hooded, and not excessively manhandled, then you are probably in the hands of a ex-military or fairly professional gang or group; your short-term survival is probably guaranteed as you have become a commodity with a value; the downside is that they probably have a plan for you and you may not like it. On the road a particularly well-placed ambush will be disorientating and disabling; most likely, you would not know what is happening until you are being led away; if ex-military or well-trained paramilitary units are used you may not even see your attackers until all your guards and drivers are dead; in one case over ten guards and two drivers were killed in under a minute by hostage takers and two workers kidnapped unharmed. Do not become complacent about your security. If things go less well and you have time to react then attempt to get away; this will of course depend on your mindset, your drivers, and any guards. Having an advance detail of locals will give you the warning you need to deviate, detour, or abort your mission. I have no experience of an “ambush” personally; sound advice would include not getting caught in the first place; remember keeping your route and timings a secret, listening to local intelligence, and heeding local advice about where not to go. If ambushed, leaving as quickly as possible, if possible, consider how safe it is staying in the vehicle if it becomes disabled; they may be armored but that will not stop a rocketpropelled grenade; try and become aware of the situation developing around you if not then take solid cover from fire first, or cover from your attackers view second. A full size tree will stop a bullet, not much else will and I include single brick walls, adobe, breeze blocks/cinder blocks, or wood paneling. The only “bullet proof ” parts of your car are the engine block and possibly the suspension parts directly behind the hub of each wheel. Ignore “Hollywood” misperceptions; hiding behind a car door is like hiding behind a sheet of paper when being shot at; also, you are highly unlikely ever to outrun bullets or dodge them or survive being shot by even a single round.
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Try inconspicuously calling for help via your radio or emergency beacons if equipped and if captured look as helpless and nonthreatening as possible. Removing any headgear is meant to be useful and not moving quickly when challenged may help avoid your being shot when the adrenaline/drugs (or alcohol) fueling your attackers is at its peak. Moving slowly and obviously rather than panic-stricken may also be personally calming and help you focus on survival or escape. Eye contact does depend on culture but as a rule avoid it as it can be percieved as threatening or aggressive; minimize your stature, and attempting to make yourself as weak as possible may discourage some attackers from further hurting you. You may attempt to appeal to their better nature and emphasize the humanitarian nature of your mission; do not force this as they will probably get bored and use your bleatings as an opportunity to chastise you; if you can think of a subterfuge to convince them to release you then go for it, including knowing where all the money is or handing over vehicles, goods, drugs, radios, etc. If professionally carried out then they already know what you are worth, and unfortunately it will be a lot more than what you have on you. If you are in the boot/trunk of a car (a surprisingly common mode of transportation) you may want to consider removing the access panels to the rear lights and removing the bulbs; a police car may stop them, removing or breaking the rear lights if possible and signaling for help. Some cars boots/trunks can be remotely opened by a cable; you could attempt to find it and open the lid, if you can wait until you are stopped or traveling very slowly. Leaping out of a car trunk traveling at high speed is most likely very fatal with the added risk of following traffic, so look and gain your bearings if you wish to attempt to escape. I have no experience of a rescue attempt but from the stories the bottom line is keep your head down, lie down, and wait for a western voice to tell you what to do. Jumping around like a headless chicken is guaranteed to attract completely the wrong kind of attention. Much western philosophy and experience in how a hostage should behave is based on western kidnap gangs that have no interest in adding a murder charge to their kidnap. In the west, provided you cooperate, you are most likely to be released or be discovered unharmed after the event. Little or none of this experience may be of any benefit with extreme fundamentalist groups or the lawless paramilitaries. You personally will have little idea whether you have been kidnapped for ransom or for another “theatrical” purpose with your fate already sealed. Ideally if you are working or preparing to work in a country where there is a risk of kidnap then you must prepare for that eventuality. The organization must have contingency and response plans for such an occurrence; your team should have drills and have rehearsed procedures; you should have completed an “isolated personnel” information sheet, which will have your picture, personal details, proof of life questions and answers already prepared, with next of kin details and a press strategy. Ideally if you become a hostage your kidnap will involve a negotiation or media release to make some use of your humiliation and capture, normally to embarrass your organization, your government, and your country before release. Unfortunately some kidnappings are merely devices to carry out the above before they kill you. Ideally your “in country” briefing should identify the most likely scenario you may encounter. That may change your mind on (a) staying, (b) how you do your job, or (c) trying to escape! It is unfortunate but stands repeating again and again that in many places in the world your humanitarian or independent/religious or neutral status will afford you
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Fig. 19.1. No weapons sign, ICRC hospital, Sierra Leone © PF mahoney
no protection whatsoever and dependent on your country of origin may even make you more attractive as a target for kidnap, often based on how your organization/ country deals with ransom. It is unfortunate that many organizations and some countries believe that by paying up and not involving “organizations” that could assist will somehow help. It has been my experience in Iraq that this was never beneficial. Paying up quickly just means you will have to pay more; paying what your kidnapper asked just means you have raised the stakes for the next member of staff and you will inevitably be funding a criminal or terrorist organization intent on murdering people, including your colleagues, friends, countrymen, and women – a sobering thought perhaps? In conclusion if there is ever any doubt about your safety then there is no doubt, do not do it, for your own sake, your family, and those who may have to come and rescue you or at least recover your remains. You may be saving my life as well as your own!
Further Development and Reading Without doubt this is one area where you will never and can never stop learning; the uniqueness of each humanitarian disaster means that you will need new processes and plans to overcome the problems you encounter, and that said underlying principles and procedures can be applied provided you adopt a principle of constant checking, refocusing, and reorienting yourself and your decisions. Little external formal training can adequately prepare you for this and most develop their skills through experience with NGOs and/or official government, military, or other humanitarian organizations. Some professional companies do provide suitable (although expensive) training and checking with your parent organization, and experienced professionals and colleagues will help you identify the best products for your money. That said I would recommend a broad reading of camp-craft, survival guides, and techniques that you can find in good bookshops; however, in my experience there is little substitute for actually being there and doing it, progressively, safely, and in a gradual manner. That may mean you start at home in the organization’s office, working on logistics, something that can kill you just as quickly if you get it wrong in the field as not being able to cook a hot meal or prepare clean water for drinking.
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Personally speaking I believe we will be called on to carry out more humanitarian assistance in the future rather than less, so be prepared, volunteer and learn your trade now so when the time comes you are ready and able and not a liability to yourself or those who may depend on you. Best wishes and stay safe.
Part B – Thinking Ballistic: Aspects of Protection Kenneth I. Roberts
Introduction The aim of this chapter is to give a very brief introduction to the subject of ballistic protection for the individual, vehicle, and dwelling. The section on housing will include issues that need to be considered when choosing a team base.
Ballistic Protection Ballistic protection can be provided for both individuals and vehicles, but in neither case is this an inexpensive, entirely effective, or uncomplicated issue.
Individual Protection So-called “bullet proof ” (more accurately “ballistic”) or “flak” jackets are designed to give some protection against blast and (with the addition of ballistic plates for the chest and back) against small arms ammunition of up to 7.62 mm. There are, however, a number of negative issues associated with their use: ●
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They will only provide protection to limited parts of the body (i.e. those covered by the jacket). They can provide the wearer with a false sense of security, and may encourage unnecessary risks to be taken as a result. They are heavy (approximately 12 kg), and can reduce mobility. They prevent heat loss and can therefore contribute to heat illness and injury. They are expensive. A direct bullet strike can still produce serious bruising and effects of shock even if the plates are not penetrated, although this can be reduced by the use of (even more expensive) “trauma” plates.
Helmets are an important piece of individual protective equipment, and should always be worn when the use of a ballistic jacket is indicated. Although they will protect the wearer against blast, shrapnel, and general jolts and bumps, they will not stop a direct bullet hit. They must be worn with the neck strap securely fastened.
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It is important that those who may need to wear these types of item are trained in their use, and that they are aware of the circumstances under which they should be worn. Further, these items should be individually issued, as they need to fit properly.
Vehicle Protection The cabs and other vulnerable parts of a vehicle can be protected by armor if required, although this can incur a significant weight penalty. This can reduce stability and make driving more difficult. This is also an expensive option. A compromise can be to cover the floor of a vehicle with sandbags or specially designed ballistic protection blankets, although both of these options will not afford significant protection against Antitank (AT) mines, but only against grenades or Antipersonnel (AP) mines. The added weight burden should not be underestimated.
Choosing Housing Accommodation (particularly in a conflict or catastrophe setting) serves a number of purposes. Clearly, the most important is protection from the elements, but other considerations need to be taken into account. What follows is a description of the requirements tending toward the ideal, and inevitably there will be a necessity for compromise based on a consideration of the risks to which your team is exposed.
Location The following should be taken into account: ●
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Proximity to vehicle access routes: Consider if these could be affected by adverse weather conditions, and/or by conflicting parties. Also identify potential evacuation routes. Proximity to active conflict areas, and the implications for collective safety/ security. Availability to electricity, water, and sanitation. Proximity to potential targets (such as military installations). Availability of secure parking for vehicles. Implications for radio/telecommunications reception.
Building ●
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Is the building big enough to accommodate your team and its stores and vehicles, and to provide whatever services you are there to deliver? What is the state of repair of the building, and what repairs would need to be carried out to make it fit for purpose? Can the building provide appropriate protection from the threat of locally available weapons?
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Enhanced Protection The threat from small arms, bombardment, air attack, and even chemical, biological, radiological, and nuclear weapons will need to be considered. An area of the building may need to be identified as a shelter against direct attack or collateral munitions strike. This could be an interior windowless corridor or (ideally) a cellar. However, the latter should be avoided if a chemical threat is considered to be likely, since many chemicals are heavier than air. The protection of areas of the building with windows can be enhanced by the use of the following: ● ● ● ●
Heavy net curtains Use of heavy adhesive transparent tape to prevent the shattering of glass panes Use of existing shutters Use of wooden planking across windows
Consideration should be given to increasing protection to the shelter area, using such items as sandbags and beams, although this is a specialist area, and expert advice should be sought. In addition, it is manpower- and material resource intensive, and may take some time to complete effectively. This type of shelter should be made as small as possible (to encourage intrinsic strength), and should have at least two entry/exit points, preferably protected against blast. Those accommodated in the building will need to be aware of when to occupy the shelter. This implies that an agreed alarm system will need to be used, and that the location of the shelter is known by everyone. The shelter may need to be occupied for some time, and should be provided with the following: ● ● ● ● ● ● ● ●
Food and water Torches, lamps, or candles Sleeping bag Means of heating Portable radio Chemical toilet or other appropriate sanitation Medical/first-aid kit Fire extinguishers
Further Reading Cutts M, Dingle A. Safety first: A guide for NGOs on effectively protecting their staff in areas of armed conflict. ISBN 1 84187 065 X. www.savethechildren.org.uk Roberts DL. Staying alive. Safety and security guidelines for humanitarian volunteers in conflict areas. www.icrc.org Cooper G, Gotts P. Ballistic protection. In: Ballistic Trauma: A Practical Guide. Springer, 2005
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Part C – Mines and Weapons Awareness Kenneth I. Roberts
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To give an introduction to the threats of mines and other other explosive weapons.
The Threat The inherently indiscriminate nature of the widespread use of mines is well recognized, and both the Ottawa Convention1 and the 1980 Convention on Certain Conventional Weapons2 attempt to control this threat. However, the Conventions are only binding on States and not on non-State actors, and even then not all States have ratified them. The threat from mines and uncleared weaponry and ordnance is very real: it has been estimated that 110 million mines (mainly, but not exclusively, antipersonnel types) remain in 68 countries. Although attempts are being made by a combination of national, international, and NGO agencies to clear this threat, the sheer size of the problem (allied with the economics involved, since a landmine costs $3–30 to manufacture, but $300–1,000 to clear) suggests that it will be around for the foreseeable future. Indeed, the problem is currently assessed to be increasing: for each mine cleared, 25–30 new ones are thought to be planted!
Types of Mines There are essentially two types of mines: antipersonnel (AP) and antitank (AT). The former, which (as their name suggests) are designed to cause injury to people rather than to vehicles, are the ones that pose the most acute threat to aid workers. There are a number of variants: Pressure Mines. These explode if stepped on. They tend to be circular in shape, made of metal (or plastic, to help avoid detection), and typically colored to blend into their surroundings. Air-delivered AP Mines3 are typically winged to facilitate their dispersal from the air. They tend to be blue or green in color, but can also be camouflaged. They pose a
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The 1997 Convention on the prohibition of the use, stockpiling, production, and transfer of antipersonnel mines and on their destruction. 2 Strictly Protocols II and V. 3 Sometimes referred to as “butterfly mines.”
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Fig. 19.2. Minewarnings azerbarjen refugee camp. © PF mahoney
particular threat to children who are attracted to their unusual shape. They explode when disturbed/picked up. Bounding/Jumping Mines. These are of two major types: those triggered by a very fine trip-wire, and those triggered by direct contact. The mine springs up to approximately (adult) waist height and then explodes, thereby scattering fragments over a wide area. Fragmentation Mines. Again, these tend to be triggered by trip-wire. They are typically cylindrical, and placed into the ground by means of an integral stake or spigot, leaving approximately 20 cm of the casing above ground. When triggered, the perpendicular grooves in the exposed casing cause the dispersal of razor-sharp squares of metal in all directions around the mine. Anti-Tank Mines are much larger (up to 300 mm in diameter) than AP variants, and are designed to disable vehicles. They tend to be circular or square in shape, and are made of metal or plastic. They require the relatively heavy weight of a vehicle to trigger them, but this can be reduced if they have been laid for some time. AT mines are often laid in large numbers (frequently in conjunction with AP mines to prevent their removal) and observed or covered by fire. Some have antihandling devices built into them. Directional Mines. These are also referred to as “Claymore” mines, and are convex in shape supported on their own set of legs. They can be triggered by trip-wire, or remotely by command wire, and are designed to spread fragments in a limited arc of about 60°.
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Danger Areas The following pose particular risk areas, particularly for AP mines: ● ● ● ●
Old front-line and defensive positions Deserted houses (particularly undamaged ones) Tracks Gardens/cultivated areas
Dealing with Mines AP Mines. The most important precautions are avoidance and awareness. Always seek local advice before entering a new area. In particular, do not be the first to use a track, and do not drive at night. Take the following specific precautions: ●
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Be aware of any local signs used as warnings of mined areas. These tend to be red and triangular, with “mines” in the local language/alphabet in the center. Never touch what appears to be a mine Stay well clear of mines Let others know that mines are around. Place signs at a safe distance from any suspected mined areas Do not use any radio devices within 100 m of a mine
AT Mines. Again, take local advice. Specifically: ●
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Do not leave marked roads and tracks. In particular, do not attempt to drive around obstructions or onto verges. If you inadvertently drive into a minefield, do not get out of the vehicle (there may be AP mines) or turn the vehicle around, but reverse slowly out retracing your own tracks, guided by a team member looking out of the rear window and guiding.
Unexploded Military Ordnance4 Inevitably, a proportion of ammunition fired during a conflict will fail to explode. In addition, stockpiles of munitions may have been abandoned. This type of material can become very unstable, and must be avoided and reported to anyone else who may be affected.
Further Reading McGrath R. Landmines – Legacy of Conflict. Oxfam, 1994. Croll M. The History of Landmines. Leo Cooper, 1998. 4
Also known as “explosive remnants of war.”
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Part D – The Oil Camp Bob Mark
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To describe the practicalities of running a camp or secure base in an insecure environment.
Introduction Undertaking oil and gas exploration or aid work requires a secure base. This chapter is written with the oil and gas industry in mind but the lessons are applicable to other areas.
Camp Standards Food and Drink Food handlers should be screened for infectious diseases and trained in the safe preparation of food. Set standards for food supplies together with those for storage, preparation, and cooking. Safe drinking water must be provided. This may require the importation of bottled water or the chemical sterilization or filtration of local supplies together with boiling.
Camp Hygiene Set standards for living quarters, toilet and washing facilities, lighting, ventilation and temperature control, and the safe disposal of sewage, laundry effluent, water and rubbish including kitchen leftovers. Arrange for the safe disposal of clinical waste including “sharps.”
Mosquito Control and Bite Avoidance In malarial areas prevention of this disease will be a crucial task. Site the camp at a distance from, and upwind, of open water. Breeding grounds should be eradicated as far as possible. Windows should have intact mosquito screens. Insect repellents should be used and fogging with insecticide carried out. Dress must be appropriate (e.g., long trousers and long-sleeved shirts). Permethrin-impregnated bed nets should be fitted in particularly high-risk areas, especially in tented camps. Closing windows and staying indoors at dusk can further avoid bites.
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Other Hazardous Animal and Plants Reduce the risk of animal bites through education, suitable clothing (especially calf length boots in areas where snakes are found), and by examining the camp judiciously. Stinging and spiky plants will call for the wearing of robust clothing that covers the arms and legs.
Local Diseases Determine the prevalence of infectious diseases. Minimize their impact by strategies including immunization courses, which must be commenced before leaving the home country. Resist the temptation to swim, wash, or paddle in open water in areas with water-borne diseases such as schistosomiasis. In malarial areas give advice on the options for chemoprophylaxis, depending on the risk of exposure, the species of malaria present, the existence of drug resistance, the efficacy of recommended drugs, and their side effects. The final choice of regime must be determined by the patient and his or her physician, taking into account individual patient factors as described in the current issue of the British National Formulary. Emphasize bite avoidance methods. Nonmedical personnel must be educated in the recognition of the early symptoms of these diseases and medical personnel must be trained in their diagnosis and treatment, which should follow WHO guidelines (http://www.who.int/topics/malaria/en/). Consideration must be given to providing the diagnostic aids that will be required such as bedside immunochromatographic testing kits for malaria together with the drugs needed for treatment. Once in-country disease surveillance will highlight the efficacy of preventative measures.
Lifestyle Habits The abuse of drugs and especially alcohol can be a problem in workers who are under stress, away from home, and with little else to occupy their leisure hours. In some cultures, the social pressures to drink one’s self into oblivion can be extreme. Strategies must be developed, implemented, and monitored to prevent drug and alcohol abuse.
Fitness for Work In 1923 Macklin a medical officer with Shackelton’s 1914–1915 Trans-Antarctic Expedition, wrote: “The chief work of the surgeon of a polar expedition is done before the ship leaves England, and if it has been properly carried out, there should be little to do during the actual journey” (Macklin 1923).
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This sentiment still holds true for remote area operations particularly in ensuring that personnel are fit for the job. The oil industry requires that its workers in remote areas are medically examined before deployment and at intervals thereafter to ensure that they meet agreed medical standards (see References). Failure to do this will lead to unnecessary illness, injury, or death amongst the workforce, with the attendant problems of lost working time, the search for a replacement worker, and the cost of repatriation. Occasionally the company will employ a worker who does not meet the usual standards if his particular skills are commercially necessary. Both parties must take this decision on the basis of informed consent. Medical screening on returning home is advisable and is covered elsewhere. The need for dental fitness must not be forgotten. Severe toothache will prevent the toughest worker from performing his duties, not to mention sleeping. Dental care before departure can prevent personal misery, an extraction in the field, and unnecessary and embarrassing repatriation.
Sexually Transmitted and Blood-Borne Diseases There will often be high local rates of infection with these diseases. Control measures will include education, restraint in personal relations, and the availability of goodquality condoms, appropriate clinical working practices, and the use of universal precautions.
Work and Work Environment Stress, Fatigue, and Work Cycles The project planners must consider equipment standards, ergonomics, and conditions of work, physical fitness, time for adaptation to the workload, recreation, and sleeping conditions.
Heat, Sun, Cold, and Altitude The debilitating effects of these phenomena can be ameliorated through education, appropriate clothing, acclimatization, and realistic working patterns (see References).
Chemical and Physical Hazards These must be identified and the relevant technical and procedural control measures put in place. Appropriate personal protective equipment must be provided together with education and training.
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Transportation and Driving Accidents Road traffic accidents are the commonest cause of major trauma in remote areas. Vehicles must be maintained and inspected regularly. Pay particular attention to tires, tire pressures, and brakes. Learn how to conduct the necessary daily checks yourself. Do not use vehicles that do not conform to minimum standards. Speed limits for the project must be set and rigorously enforced. Defensive driving will be called for at all times and risks must never be taken. Vehicles must carry written instructions for emergencies, safety equipment, and survival kits. The skills required for both defensive and off-road driving should never be underestimated or assumed. Training programs are often required for both local and expatriate drivers. Initiate a journey management system. This is a simple scheme whereby all departing vehicles log out from a central control point recording the persons traveling, their route, and expected time of arrival. Drivers report in at their destination and any available checkpoints en route. The control point using radio or telephone should confirm their safe arrival. Failure to arrive will trigger a search.
Personal Hygiene The facilities required to maintain high standards of personal hygiene must be provided, particularly in hot environments. Anyone whose standards start to lapse should be tactfully encouraged to address the problem.
Health Management System A health management system is used to ensure that policy and objectives are agreed and achieved. An organizational structure will be needed. Responsibilities must be agreed and resources acquired. Standards and procedures should be developed and plans implemented. Performance monitoring will lead onto the improvement of processes, thus completing the cycle of audit.
Medical Support: Local, Imported, and International To ascertain the acceptability of local medical facilities they must be audited using recognized standards. Comparing the level of medical care available locally against the environmental and occupational health risks will enable you to decide whether to contribute to the upgrading of local medical facilities, to import medical care, or to combine both approaches. Requirements will change as the project develops. Whichever system is used international medical support will also be required. Arrange an itinerary in advance when visiting local facilities and personnel. Appointments should be sought with the most senior staff available. Provide a candid explanation of the purpose of the visit and the nature of the project. Find out what the local view is on what improvements are needed. Emphasize that mutual cooperation
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is sought for the good of all parties. However, remember that your agenda and that of the local community are unlikely to be the same.
Local Medical Support Training It can be possible to upgrade the standards of the existing medical infrastructure by providing training for the local health carers. This must be done diplomatically. It is crucial to remember that they are professionals in their own right and will have their own unique experience and expertise. It is all too easy to give offence by adopting a high-handed approach: relations must be nurtured over time. Remember that the locals will have much to teach the incoming staff.
Facilities The buildings used for healthcare may need improving. Alternatively new buildings might be constructed. Hygiene practices may need attention.
Drugs and Equipment It may be necessary to contribute equipment and supplies but this approach must be carefully controlled. It has been known for drugs and equipment to be donated through the front door and then to go straight out of the back door as a source of extra income. Ensure that the use of these drugs and other supplies is clinically appropriate.
Administration Agree procedures for inpatient and outpatient treatment in local facilities before the event. This may include a method of payment.
Communications and Transport Do not take these aspects of the infrastructure for granted. Reassurances that everything required is in place should not be taken at face value. It is far better to see the system in action.
Imported Medical Support The need to import medical care will increase with the number of personnel on the project and its hazardousness and isolation together with the paucity of the local medical support.
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First Aiders and First Responders All staff must be qualified in first aid or as emergency first responders (see References). Arrangements must be made to ensure that they maintain their qualification. An accredited first aid trainer can do this in the field. This is both cost effective and occupies time when workers are off shift. Small, low-risk projects may rely solely on first aiders, some of whom may require advanced training.
Remote-Area Medic As the requirement for dedicated medical support increases, medical professionals will be required. The commonest requirement is for a nurse or “paramedic.” The latter will not usually have the same skills profile as, for instance, a UK National Health Service paramedic. A better title might be “remote-area medic.” The person filling this role will have a wide range of duties. These can include supervision of environmental health, catering hygiene and other aspects of illness prevention, routine general medical care, emergency medical care, aeromedical evacuation, disaster planning, first aid training, and storage, supply, and resupply of medical equipment and drugs. He may also be called upon to act as a social worker during episodes of personal stress. The medic will work closely with the staff responsible for safety. If his other duties allow he may also fulfill other roles such as in camp administration. The ideal candidate for this job is a mature and sociable character who is accustomed to working on his own in the middle of nowhere. Medically trained former military noncommissioned officers are often right for the job. In the UK the Offshore Medic’s Certificate course is designed for medics operating on the North Sea. The qualification is issued under license from the Health and Safety Executive. It is also the most frequently recognized qualification for remote landbased projects. In this environment medical and traumatic emergencies are rare but particularly demanding. Therefore frequent refresher training in emergency medical care is necessary. Trauma courses such as Pre-hospital Trauma Life Support (PHTLS); Basic Trauma Life Support (BTLS); Anaesthetic, Trauma and Critical Care (ATACC); or Medicine in Remote Areas (MIRA) should be considered. The Pre-hospital Emergency Care Certificate and the Diploma in Immediate Medical Care are ideal prehospital emergency qualifications. Advanced Life Support (ALS) or Advanced Cardiac Life Support Courses (ACLS) are equally important, as medical emergencies are more frequently encountered than major trauma on most projects. Training in pediatric emergencies may be required for some projects.
Doctors Doctors may sometimes be found in the field. This may be because the project is large, isolated, or hazardous or a combination of these factors. Occasionally a doctor may be employed from the host or another third-world country in preference to an expatriate Western medic solely on the basis of cost. Doctors may be employed when particularly
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extensive projects employ other subordinate medical or paramedical staff. At times a local doctor may be managed by an expatriate paramedical professional.
The Camp Clinic This should be housed in a clearly identifiable, prefabricated, or other temporary buildings. This should be sited close to the camp’s administration and communication center. There should be good vehicular access and if possible aircraft should be able to land nearby. The entrance should allow access and egress for a stretcher. Air conditioning and/or heating should be installed and functioning. A telephone, with a hand off function, and a radio with the same channels as used by the project and any relevant aircraft are invaluable assets. In addition to equipment for routine medical care the clinic should be equipped to a high standard for the management of medical and traumatic emergencies. Remember that seriously ill or injured patients may have to be treated for some hours before evacuation. Supplies of oxygen and intravenous fluids must be extensive if patients are to be treated along ATLS/BATLS guidelines.
Medical Transport A four by four ambulance, purpose built or converted, is an expensive but often necessary provision. It must be fitted with communications equipment, a suitable stretcher, and medical equipment including oxygen. It must have the air conditioning or heating equipment appropriate to the climate. Extreme environments may require mechanical adaptations. In some projects local evacuation may be by fixed wing aircraft or helicopter. It is very unlikely that these will be dedicated air ambulances. Rather they will be multipurpose “work horses.”
Emergency Planning Draw up plans for medical emergencies, then test, develop, publish, and practice them on a continuing basis. These plans should concentrate on defining responsibilities, alerting procedures, communications and getting the medic to the casualty’s location or vice versa. The medicine is often more straightforward than the logistics. The project will have plans for major incidents including fire, security threats, and technical problems such as blowouts. It is important that you develop plans for multiple casualty incidents: command, control, and much of the casualty care will be delegated to others who are not medically trained (Mark 1998).
Substandard Medical Provision Regrettably medical planning sometimes does not take place. The remote area project will then rely solely on the existing local medical support, whatever its standard.
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International Medical Support Although it might sometimes feel like it you should not be operating in splendid isolation.
Repatriation Expatriate workers must be insured for medical repatriation and carry their membership card with them. You should keep a register of these and the relevant procedures. Plan how to get your patient to the nearest airport, which the evacuation agency can use, and how to care for him there while awaiting their arrival. The company’s country head office should be involved and the services of a locally retained physician can be of great assistance. It is essential that you maintain control of your patient until he is handed over to the personnel responsible for his aeromedical evacuation. Do not allow him to be sidetracked into an unsuitable local hospital.
Topside Support Access to specialist medical advice by telecommunication is invaluable in assisting the remote professional in coming to the right medical management decision in difficult cases. It will also make you less anxious. Confirm voice conversations and instructions in writing by fax or e-mail. Reliable international communications and the availability of the right senior colleague are essential if the arrangement is to function. Telemedicine is covered in detail elsewhere.
The Oil Camp In contrast to its surroundings the oil camp may appear luxurious. The more permanent installation will have air-conditioned semipermanent offices and accommodation with a modern kitchen, dining rooms, and opportunities for recreation. The communications room will contain an array of various radios, satellite phones, and fax machines. The staff will include expatriates from the developed world who will often be on a four or six week on/off rota. There will also be personnel who have been hired incountry. They may live locally or be accommodated in the camp. There may also be workers from elsewhere in the third world who work on site for months at a time. Access to the camp may be controlled by security staff. There is great scope for social interaction and both formal and informal professional cooperation between the oil workers and those providing medical care for the local population. Take the time to visit each other and talk.
Acknowledgments The author gratefully acknowledges the invaluable advice and assistance of Mr. Mark Tomlins, Operations Director, Exploration Logistics plc & Mr. Leo Aalund, Technical Editor of the Oil and Gas Journal.
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References Macklin, A.H. 1923. Medical appendix V. In Wild, F. (ed.), Shackelton’s Last Voyage, the Story of the “Quest.” London: Cassell, 352. Mark, B. 1998. None but ourselves: Medical Management of Major Incidents in the Oil and Gas Industry in Remote Areas. SPE 46746. Society of Petroleum Engineers International Conference on Health, Safety and Environment in Oil and Gas Exploration and Production, Caracas, Venezuela, 7–10 June 1998.
20. Voices from the Field Part A – Just a Word About Toilets David R. Steinbruner
Baghdad January 2006 Just a word about toilets. Something we tend to take for granted back home. We have it pretty good at Ibn Sina. For the most part they work pretty well, never mind that we cannot put any toilet paper into them (Fig. 20.1). Tends to clog them up with predictably disastrous results. We do have plenty of them, however, which is more than can be said of the line units in the various forward operating bases, or FOBs, scattered around the country. “Hey Doc, you know how good you got it?” Oh, yeah, I know. Our water is trucked in. We do not rely on the Baghdad water supply. It is the same for the electricity. You can imagine how difficult it would be to run a hospital with the inconsistency of the Baghdad power grid. In our isolated world in the IZ, water, power, and supplies are pretty consistent. The steady throb of generators, so constant a sound that I no longer hear it, reminds me of what it takes to keep it this way. Occasionally a generator goes down and we have to scramble a bit to keep things running… such as ventilators and the like. The ambiance of the hospital is somewhere between a youth hostel and a prison. I like to call it club Mesopotamia. It is pretty nice, but you cannot leave all that easily. We have communal bathrooms in every residence hall, which are cleaned daily by very nice Iraqi women. They laugh and smile a little like high school girls, amused by the doctors and nurses shuffling around in their bathrobes and pajamas. One can only wonder what they say to their friends about our living habits. I try my few words of Arabic out everyday and have gotten to know some of them in passing. Trust remains an issue with all of us. These women live outside of the walls of the IZ. They must travel back and forth keeping a low profile so that they are not identified as “collaborators.” Our reluctance to get to know the Iraqis stems more from a concern for their safety than that of ours. Iraq still has a long way to go. After work, I occasionally head to the roof and sit and gaze across the IZ and Baghdad beyond. It helps to gain a little perspective and lets me reflect a bit on the trauma I have seen. Put the IPOD on and drift away a bit. The other night I headed up, alone, gazing back over the LZ. Two Blackhawks, inky black against a dark sky, popped up like giant hornets and cruised off into the night over Baghdad. No lights. Swift and lethal. I like to look over Baghdad and reflect on the day, what I have seen and done, the soldiers, civilians, men, women, and occasionally children who have the misfortune of needing our help. A. Hopperus Buma et al. (eds.), Conflict and Catastrophe Medicine, Second ed., DOI 10.1007/978-1-84800-352-1_20, © Springer-Verlag London Limited 2009
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Fig. 20.1. Notice at 10th CSM Ibn Sina hospital, Baghdad 2006.
I think the view from the roof helps to put it all into perspective, and see it as part of the large tapestry of history in the making. I generally sit facing west or what I affectionately refer to as “sniper-free” seating. Ahead of me, somewhere in the dark are the large crossed-swords, which Saddam erected in memory of the war with Iran. The helmets of dead Iranian soldiers are embedded in the pavement around the base of the swords. Beyond them rises the large disk of the tomb of the unknown soldier, a tribute to the dead from that disastrous war. Sarah McLachlan’s Angel is playing in my ears: … and it’s hard at the end of the day I need some distraction … Oh.… beautiful release Memories seep from my veins… My eyes sweep southward, to the carcass of the Baath party headquarters, blasted early in the war. Its rotting hulk with bright blue dome is still menacing a few buildings away. … maybe, I find some peace tonight In the arms of the angel Fly away from here… Still farther, due south and to the belching flame from a refinery stack sitting on the other side of the river, deep in the unfriendly neighborhoods of Baghdad. It is always there, flickering with what I imagine is angry indignation. It seems a barometer of the city’s mood. Now I look back over my left shoulder, to the east and the tall buildings on the other side of the Tigris. Unlikely that anyone could actually get a good shot off at that distance, but my imagination creeps up and grabs me a bit. I push myself next to the wall and the shadows.
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…In this sweet madness, this glorious sadness that brings me to my knees. Lyrics by Sarah McLachlan © Tyde Music/Sony/ATV Songs Administered by Sony/ATV Music Publishing All rights reserved. Used by permission Thanks Sarah, could not have said it any better myself. Good night Baghdad. Please sleep quietly. Lyrics with kind permission of Sony/ATV Music Publishing
Part B – Conflict Medicine: A View from the Ground Luke J. Staveley-Wadham
Introduction After completing a Law degree I decided to undertake Full Time Reserve Service (FTRS) with my parent unit, 4 PARA (V). During this period I completed tours in Bosnia and Iraq. It was on these operations that I realized how much I enjoyed all things medically related. As a result I undertook exercises and courses in order to broaden my basic medical knowledge. Prior to deploying to Iraq I completed the Team Medic course, which covers basic first aid. This course and my subsequent deployment confirmed my wish to peruse a career in medicine. Once I completed my FTRS commitment I redeployed to Iraq as a security operator. On my return to the United Kingdom I completed an Access to Medicine course and was accepted to study medicine as a mature student. During my initial year at medical school I once again returned to Iraq as a security operator and was able to undertake volunteer hours in the infamous “Baghdad ER,” located in a US Combat Support Hospital within the International Zone.
Security Operator During my time as a security operator in Iraq I worked in small teams consisting of ex-forces personnel. Generally, our movements originated from the locality of the International Zone in Baghdad, most commonly the short trip along Route Irish to Baghdad International Airport. However, during this period my team and I were also tasked with various deployments throughout the city and to other locations all over the country. Often our work would include close liaison with Multi National Forces (MNFI). Sometimes this would mean moving our personnel amongst military convoys or in military aircraft.
Training The medical training that I received while working as a security consultant involved input from the senior medics employed on our teams and the US Military itself. I was able to complete the US Army’s “Combat Lifesaver Course.” This was extremely useful
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in that it introduced combat medicine from a slightly different perspective than training I had received from British Army. Generally, the concept involved aggressive and decisive provision of first aid. The American ethos also included returning the casualty back into combat if he or she was capable after undergoing initial stabilizing treatment. This theory proved to be an essential requirement for many security operators working in small and isolated teams across Iraq. The training organized by the team medics often involved classroom sessions followed by thorough practical scenarios to test knowledge learnt. Because of the changing operational climate and the specific nature of our role I found that our medical training was constantly adapting and evolving to meet the threat. Principles and updated SOP’s were being constantly refined from operational lessons learned by other teams, with all team members encouraged to offer advice and guidance. During my later deployments to Iraq I was given the opportunity to take the Emergency Medical Technicians (Basic) Course (EMT B). I found this course to be highly rewarding as it combined both principles of anatomy and physiology with cutting-edge lifesaving medical interventions. I was also able to put some of the knowledge gained during my first year at medical school into a more robust combat medical setting. Finally, the most comprehensive training was gained at the Combat Support Hospitals Emergency Room located in the center of Baghdad’s fortified International Zone. It was here that after nearly 150 h of volunteer work I gleaned the bulk of my experience. I should therefore highlight that the best way to become a confident, proficient, and experienced medic is to gain real-time practical hours treating casualties.
Experience I learnt a number of vital lessons while I was deployed in Iraq as both a soldier and security operator. I learnt some of these lessons through colleagues or third parties. However, I learnt other lessons for myself as a result of situations that I have experienced. Operating in small isolated teams with as little as four men in hazardous environments far away from any effective QRF demonstrated the importance of having the correct medical equipment to hand. In these situations it is definitely better to have more than less. As a result each vehicle or call sign should have a central med pack and also loose supplies stuffed into easy access storage areas. Further to this, every individual should carry personal medical equipment in clearly marked pouches about their person. Medics themselves should be distributed evenly across the convoy and/or patrol. This gives the group the best possible chance to prevent all of the medical knowledge being taken out in the event of an attack. When at all possible, medics should also be excused command roles and also specialist roles such as signals or the manning of crew-served weapons, for example. It should be made clear to any personnel joining that particular group and supporting elements who the medically qualified personnel are. Lastly, the whereabouts of medical supplies and the basic SOPs in relation to taking casualties should be discussed before deployment. In relation to the type of medical supplies required in areas of conflict it is essential to have a lot of the basics rather than complex equipment. Medics must have as much
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equipment as possible to be able to treat as many possible injuries. However, initial lifesaving treatment can be delivered using the simplest of supplies. There should always be an abundance of first field dressings, which are extremely versatile. From experience, gunshot and fragmentation wounds have a tendency to bleed excessively; as a result, a large number of dressings should always be close to hand. Another essential item is the simple cloth triangular bandage, which can be adapted for a number of different roles. Lastly, thick gauze can be used to pack the more serious wounds and assist in the clotting pathway. In the event of a substantial bleed a medic’s best method of intervention is to be confident, fast, and to an extent aggressive. Direct pressure should always be applied with as much strength behind it as possible. In areas where this allows your full body weight should be transferred onto the bleed. There is often a need to adapt, for example, treating casualties in the prone position during an attack will require an improvised application of direct pressure. These situations should be loosely practiced in order to get medics used to thinking out of the box.
Case Study 1 When treating a US soldier I had to kneel on casualty’s upper chest in order to slow the flow of blood and help the wound clot. This allowed me to apply a large surface area with my entire body weight on the casualty in order to stem the bleeding. Each situation is different and it might require you to adapt in order to get achieve the best possible results. Once again, the key message is to be confident and ready to adapt. When limbs have been either damaged or removed medics should not be afraid to use tourniquets. If direct pressure has been applied and or a field dressing used then there should be no hesitation to follow on using a tourniquet if the bleeding has been unsuccessfully controlled. If the patient has suffered from a traumatic amputation then a tourniquet should immediately be applied to the base of the missing limb. I once treated a small boy who had lost both his arms and legs. However, with the application of tourniquets to all his missing limbs the bleeding was rapidly controlled and the child’s condition stabilized. Because of the diameter of the upper sections of the leg it is an extremely difficult area to isolate using a tourniquet. This is further complicated by the large number of major vessels in the region and their susceptibility to significant bleeding. As a result, in operational conditions whereby there is imminent threat larger tourniquets can be loosely prepositioned before deploying onto the ground, although a morbid method of operating this could have the potential to offer lifesaving results. Once again, it is an example of medics in areas of conflict thinking about ways in which to develop SOPs to prevent loss of life.
Case Study 2 On treating an Iraqi policeman who had received several gunshot wounds to his thorax it was clear that he had a serious arterial bleed, which was leaking from his back. Using several rolls of dressing I assisted in stuffing it into the wound using my fingers. This not only applied a form of pressure on the wound but it also helped the
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blood to clot around the soft material. It should be noted that this procedure was extremely painful, however, potentially life saving. When treating gunshot wounds they will often bleed uncontrollably. Added to this they will often have carved an extensive cavity both via its entrance site and exit. To combat this and to assist quick clotting the wound should be thoroughly packed using suitable dressings. Although extremely uncomfortable for the casualty it is an effective way of forming a base for the wound to clot and as a result prevent further bleeding. No matter how small the wound is it can be packed, whether it is using forceps to insert gauze or entire wads of dressing packed in using your fists. Wounds that are packed can then be further secured by external dressings.
Case Study 3 The vast majority of US Soldiers whom I attended as a result of exposure to explosive blasts had been wearing glasses as part of their unit SOPs. With a small number of exceptions these men suffered minimal injuries to their eyes. In most instances it was clearly evident where the glasses had been, as around the region would be a clear line of burnt and lacerated flesh compared with relatively untouched skin. During vehicle-mounted operations there is often a significant threat from a vast array of explosive devices. No matter what mode of transport you are traveling in it is vital to wear some form of protective eyewear. Whether they are clear glasses in the winter or sunglasses in the summer it is an essential item of personal protective equipment. Not only do glasses offer some level of protection from fragmentations but also from the damaging effects delivered from the flash and burn on the explosion.
Case Study 4 While treating a US soldier who was driving when his vehicle was struck by an IED, I began to remove his clothing. He was complaining of wounds to his stomach and arm. These injuries were clearly blooded through his clothing and the medics were immediately drawn to treating them. On removing his boots I found that they had both been riddled by the blast and were bleeding excessively. The boots had completely hidden the extent of the injuries below. Only when a casualty has been fully exposed and rolled can the full extent of their injuries and resulting treatment pathway be decided upon. It should also be noted that rolling a casualty is paramount to the thorough inspection and treatment of a casualty. No matter how serious you perceive a casualty’s injury to be it is always a good protocol to entirely expose the patient. This is especially important if the casualty has been involved in a blast of some form or has suffered a gunshot wound. Vital equipment for carrying is a set of medical shears. Often the casualty will misinform you of their injuries and be simply unaware of other locations on their bodies that have been affected. As a result, you need to look and feel your way around every possible surface inspecting for signs of trauma.
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Case Study 5 During many incidences either the positioning of troops or the type of vehicles they are traveling in will obscure injuries or make triage extremely difficult. In one situation I helped attend at a convoy of three vehicles that had been attacked ten or so minutes prior. They had several casualties and had assigned their medic to the one they thought was the most serious. This appeared to be a good decision at that time as the casualty was pale and not making much noise compared with the others. When I got around to the less serious of the casualties he was remarking that he was okay and to go and treat his sergeant. I realized that the initial triage had been influenced by the individual’s own assessment of his injuries. As the solider I attended was sitting down in the passenger seat he was unaware due to the shock of the attack and the following commotion that a large section of his backside had been completely blown off. It is therefore highly important to carry out a thorough triage as soon as possible. You cannot assume, for example, that because a solider is sitting down, his front is the only place that could be affected.
Case Study 6 While helping to treat a US Paratrooper who was bleeding from a shrapnel wound to the neck it became clear that the medics were struggling to apply enough pressure via a dressing to stop the bleeding. After several attempts by the lead medic to halt the bleed he actively asked the other medics present for any of their suggestions. There is little time for pride when trying to deliver lifesaving treatment. When dealing with casualties it is always essential to work as a team. It is also vitally important that as a medic you are prepared to take advice or even seek assistance in instances when you are unsure on what action to take. Even colleagues with far less clinical experience can offer advice in how to manage the more complex of injuries.
Case Study 7 In a period shortly after a car bomb had hit a busy US Military checkpoint leading into Baghdad International Airport I was confronted by a dazed and confused US Soldier. The blast had ripped through a line of static’s vehicles killing and injuring a number of civilians. Charred remains of body parts and twisted metal were strewn over the immediate vicinity. It was evident that the soldier was in shock as he was jabbering complete nonsense and completely unable to carry out his job. This was concerning as he was armed and at the very front of what is an extremely dangerous checkpoint. It is therefore imperative that after such incidences medics get around all personnel, including the uninjured and make sure they are in a suitable state to carry out their duties. Although sometimes considered of secondary importance in emergency medicine the need to reassure and communicate with casualties is vital. This not only helps prevent the onset of shock but it also builds a level of trust between the casualty and the medic. When treating casualties you can even get them to help you out, getting them to hold a dressing in place for example. This helps them take their mind of
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things and eases the onset of shock. There are some instances whereby soldiers require immediate orientation and relief of their duties in order to prevent further injury. This is usually as a result of large-scale complex attacks. For a number of years combat medicine has suggested giving casualties who are suffering from fluid depletion as a result of hemorrhage immediate fluid via IV access. Although I have not witnessed evidence to the contrary I have heard on many occasions that soldiers who have been given fluids have as a result rehemorrhaged. Once a casualty has been stabilized to the best of the medic’s ability it is always a good idea to secure IV access so that medics along the treatment pathway can give drugs or fluids. The decision to give fluids immediately should be made taking into account the specific need and injuries of the casualty. It is always good protocol to correctly secure the IV point and use a saline flush to clear it through in preparation for immediate use if required. When handing over to a senior medic the site and nature of the access point should always be passed on along with basic vitals. As well as taking and recording a pulse and respirations per minute it is also good to be able to take the casualties’ blood pressure. There is a useful estimation, which can be employed if time and or circumstances prohibit an accurate recording. This principle uses peripheral pulses to estimate blood pressure. If the casualty has a radial pulse then his or her systolic blood pressure should be a minimum of 90 mmHg, for a femoral pulse it is 80 mmHg, and for a carotid it is 70 mmHg. Although very broad this is a useful piece of information when handing the casualty over to more senior medical personnel.
Conclusion Emergency medicine in areas of conflict is a rapidly evolving trade, which should be carried out in a confident, rapid, and dynamic manner in order to save life. When not dealing with actual casualties time should be invested in honing practical skills and also learning from prior experience. The thing to remember is to go back to basics and logically work through the casualties’ injuries according to the threat they present to their life. In basic livesaving intervention if things are not working out they can always be removed or reversed.
21. Applied Communications in Conflict and Catastrophe Medicine John F. Navein and Simon J. O’Neill
Objectives
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The aim of this chapter is to provide an introduction to different types of communication systems that the humanitarian volunteer may encounter.
Introduction Good communications are a fundamental requirement of everyday life. Whether they are at the basic level of the telephone, newspaper, or radio broadcasts or more sophisticated mediums such as video teleconferencing (VTC) and the Internet, people are becoming ever more reliant upon them to live their lives. In the emergency or disaster situation, uncertainties increase and with them the need to communicate also increases, sometimes dramatically. At the same time though, the communications infrastructure required to support that need often becomes overloaded or crashes altogether. Disaster medicine has been defined as the application of various health disciplines to the prevention, immediate response, and rehabilitation of the health problems arising from disasters, in cooperation with other disciplines involved in a comprehensive disaster management (Gunn 1994). Good communications are essential to enable the cooperation between disciplines to occur and are crucial tools for effective and comprehensive disaster management. The first part of this chapter will look at the practical aspects of communicating in remote or austere environments and list the various modalities available along with their relative merits. This second part will look at how those technologies can be applied to conflict and disaster medicine. It will take a problem orientated approach to communications in each of the three phases of an emergency or disaster (Llewellyn 1995) and suggest ways in which the rapidly growing capabilities of technology could be used to reengineer the way we practice. The reengineering of healthcare delivery by telemedicine is one such concept. Telemedicine has been described as the use of communications and information technology to provide health care remotely (Lilley and Navein 1999). Within that definition there is a broad spectrum of applications some of which are applicable in the disaster situation, many others, however, are not. We will discuss the pros and cons of A. Hopperus Buma et al. (eds.), Conflict and Catastrophe Medicine, Second ed., DOI 10.1007/978-1-84800-352-1_21, © Springer-Verlag London Limited 2009
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telemedicine, provide guidelines by which to judge the applicability of emerging technologies in the context of conflict and disaster medicine, and suggest some principles to guide planning for developing technological solutions to operational problems.
Communications Technology for the Layman Communication is defined as the ability for two or more parties to exchange information either directly or remotely, with or without the use of accessories or equipment. Within this definition, communication can either occur face to face through the senses of sight, sound, touch, and smell, or by using technology to exchange information at a distance. Generally this technology uses sound only, although increasingly sight too. Since the invention of the telephone, humans have become adept at communicating using sound alone. We feel the other person’s emotions and even sense their honesty without the need to look them in the eyes. However, the old adage that a picture paints a thousand words still holds true, and indeed some data elements would be very difficult, if not impossible, to communicate without the addition of a visual element. How would you describe the Mona Lisa for example? Perhaps it would say “…an attractive young woman in her mid-twenties, posing against a rural background with a wry smile on her face.…” Immediately each of us would conjure up a different picture in our minds due to a variance in interpretation of the description given, whereas a picture, even a low resolution or black and white picture would leave us with much less room for confusion. There is a natural tendency to want the best tool for any given job, the highest levels of quality, total reliability, and all at the lowest price. In the real world, there has to be some degree of compromise, and in the world of conflict and catastrophe medicine a key question is what capability do you really need. In addition, the very best technical capability may well be totally inappropriate to both the task in hand and the environment in which that capability would be destined to operate. In this section, we will describe the range of communications technology available and the pros and cons of each so that planners and practitioners of conflict and catastrophe medicine can get the biggest and the most appropriate bang for an ever limited buck. We will cover the following areas: ● ● ● ● ●
Choosing the right technology – an overview Fixed wire links Wireless systems Satellite networks The future
Choosing the Right Technology The key to good communications is choosing the right equipment for the job. The spectrum ranges from two tin-cans and a piece of string through to satellite-based
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video teleconferencing. Each achieves its goal but neither is applicable to the austere environment of the conflict and the catastrophe situation. Between the two is a range of technologies in both capability and cost, each of which may be the right solution in one situation but may well be wrong in another. Some factors to consider are listed below.
Functionality People buy technology for a variety of reasons. We tend to buy a car based on the right look, the right color, and the right image. But when we buy a washing machine, we are more interested in the wash temperatures, the spin speed, and the economy. Communications equipment should be the washing machine and not the car. It is merely a tool to deliver your requirement. If you get it wrong it could be analogous to transporting the Manchester United supporters club to an away match on bicycles. Functionality should determine choice, not what is latest or looks best.
A Word About Bandwidth Bandwidth is a key concept and describes the communications capacity of a transmission line. An useful analogy is to regard bandwidth as the size of your communications pipe. For example, you will require a 15-mm pipe to provide the flow of water to a kitchen sink, whereas a mains pipe will be substantially bigger. These sizes could be described as the bandwidth of the connecting pipes. Obviously, a narrow point anywhere along the network will be rate limiting and will define the capacity of the whole system. Communications technology can be either digital or analog. Digital equipment transmits information as the ones and zeros of computer language and each one or zero is called a “bit” of information. Analog equipment, on the other hand, transmits the flowing energy sine waves of amplitude vs. time. ●
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The capacity of a digital system to transmit data is its bandwidth and is expressed as the data transmission rate, measured in bits of data transmitted per second (bit/s) – Do not get confused with bytes which are eight times bigger than a bit (i.e., 1 byte = 8 bits). The traditional telephone systems generally use analog circuits where the bandwidth is expressed in hertz (Hz). For the sake of simplicity in this chapter we will use digital units throughout.
From Table 21.1 it becomes clear that bandwidth and time are on opposite sides of the same equation. If you increase the bandwidth you both increase the capability and also reduce the time it takes to transmit a given amount of data. Less time generally means less cost. For instance, a high-speed data link across a satellite link transmits 64 kbits of data every second but it costs about 4× as much per second as a low-speed data link transmitting one-seventh the amount of data. The message is that bigger may, in fact, be cheaper in the long run.
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Table 21.1. A rough idea of the functional capability for a given bandwidth is as follows Bandwidth
Capability
Typical medium
Time to transmit A4 page (s)
2.4 kbit/s
Voice, fax, data
Mini-M satphone
90
9.6 kbit/s
Voice, fax, data
Thuraya/iridium
30
33.4 kbit/s
Voice, fax, data
Standard phone
8
64 kbit/s
Voice, data, VTC
ISDN
3.5
128 kbit/s
Voice, data, VTC (good)
RBGAN
2
1.34+ Mbit/s
Broadcast quality video
Fiber optic/VSAT
0.2
Synchronicity1 Communications can be either synchronous or asynchronous. This is an important distinction. Synchronous communication occurs when both parties are communicating in real time such as when people talk to each other face to face or on the telephone. Letters and email are asynchronous. Asynchronous communication is easier to manage as it does not mean two people being in a given place at a given time, an important practical point when the link is poor or when they are in different time zones. On the other hand synchronous communication can allow faster development of an idea or faster decision making through discussion in real time. However, it takes longer on line, again perhaps an important factor when it comes to cost. A standard email message will take less than a minute across a low bandwidth satellite phone at around US$1.40 whereas a standard phone call of say 10 min using the same equipment will be about US$14.00. Minutes can add up very quickly. Note that email can be synchronous (e.g., chatrooms) and hence asynchronous clinical email is called “store and forward” to differentiate from the real-time alternative.
Wire vs. Wireless The answer to the question of wire vs. wireless varies considerably according to circumstance. Normal wire-based telephone networks are notoriously unreliable in areas afflicted by conflict or catastrophe and maybe subject to eavesdropping but they are also one of the first utilities to be repaired. An area with a telephone network, especially if linked to the Internet, can provide the basis for a very reliable, cheap, and comprehensive range of capabilities. 1 This definition refers to synchronicity in its message sense rather than its communications sense. The relative communications definitions are Synchronous – transmission in which data bits are sent at a fixed rate with the transmitter and the receiver synchronised. Synchronised transmission eliminates the need for start and stop bits, whereas Asynchronous is a transmission in which time intervals between characters may be of unequal length, and the transmission is controlled by the addition of start and stop bits at the beginning and end of each character.
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Wireless communication can be either via GSM (Global System for Mobile communications) or via satellite links. Satellite phones are independent of local infrastructure and relatively secure from eavesdropping. GSM (mobile) phones are less secure and coverage is very unlikely in an area where the telephone network is not working. Where telephones are available GSM can be more convenient and more reliable than the traditional telephone network as the infrastructure is generally much more modern.
GSM vs. Satellites An important difference between GSM mobile phones and satellite phones is that GSM is under the control of the country that you are in when you make or receive calls. The way the billing works means that the local mobile phone company (and therefore the local economy) gets a share of the revenue. Satellite communications are under the control of international companies and the billing generally excludes a contribution to the economy you are in. The practical consequence of that is that many governments are not at all keen on satellite phones and may confiscate them on entry. This is potentially a serious problem, and the situation in a given area changes frequently with time. Therefore, if you are planning to go to a country that you do not have recent practical experience of, contact your supplier or the network operator before deciding which system and manufacturer to choose. An important practical consideration for satellite phones is that although they work virtually anywhere in the World, they have a low building penetration. This means that they do not work indoors and will not work without a direct line of sight from the aerial to the satellite. GSM phones on the other hand work well indoors but suffer from poor geographical coverage. We cover this important factor in more detail under the relevant section.
The Box Itself Communications equipment is getting smaller, faster, and better all the time. The weight and volume (wt/cube) of the equipment is obviously important, and for larger pieces practical things such as whether it has wheels, whether is it rugged, whether it will run from multiple power sources, e.g., car batteries and a car lighter socket, or whether it will only operate with special batteries with limited life. Also make sure it is easy to use, although most modern systems are pretty good.
Cost Calculating costs can be tricky and we recommend that you form a close relationship with an established independent communications company and take advice.2 The main elements of cost are the capital cost of the equipment, the bandwidth/time equation
2 Simon O’Neill, the technical author of this chapter is happy to advise on the question of relative costs or any other technical aspect of communications and can be contacted at
[email protected] or +44 (0)1494 489111.
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discussed above, and the cost to use per minute. Drive a hard bargain and shop around for the best rates and if your usage is higher than you anticipated then renegotiate. Renegotiate annually anyway. The competition is intense and costs are coming down all the time. GSM networks are also expanding rapidly and there are GSM mobile networks in some of the most unlikely places. GSM is often cheaper than satellite and increasing coverage may take in an area where you are operating making a changeover sensible. However, you must remember to include in the equation that GSM operators usually charge you for the cost of incoming calls when roaming on your GSM phone which may be the international element of the whole call. Incoming calls on a satellite phone are free. Beware of the pricing structure. On some systems (e.g., Inmarsat) you will get charged a fixed rate regardless of the destination or time of day whereas in others (GSM, Thuraya and Iridium) the price will vary considerably depending upon where the call is to and where you are calling from. Some you will win, some you will lose. So, if you are not sure then ask, but remember your decision will almost certainly be a compromise to match your needs with the available tariffs, so be prepared to review your options as your requirements change. Finally, be aware that the costs can vary dramatically depending on which way you are calling. This is particularly the case when calling into an area from a “first world” landline. There is fierce competition in the overseas market, especially with the emergence of “resellers” who buy bulk bandwidth from the major carriers and resell it at a discount. Hotels often charge a big markup for calls out but not for calls in. Check out the differences, in and out, for the areas in which you are working and adjust your communications plans and procedures accordingly.
Fixed Wire Links Fixed wire links, as already discussed, can be divided into either analog or digital. Simple digital circuits and the more common analog systems both generally operate across ordinary copper wires. The more advanced modern fiber optic cables usually have very high data transport capacities, or bandwidth, well into the Mbit/s (megabits or a million bits of information per second).
Analog A conventional analog telephone line operates at the digital equivalent of around 9.6 kbit/s. This is fine for telephone conversations and transmissions from a fax machine. Although the early telephone equipment restricted the data flow to a digital equivalent of around 9.6 kbit/s, modern technology now enables multichannel ISDN and broadband to operate over a simple pair of copper wires. It is also possible, however, to transmit digital data from a digital device across an analog network by passing the data through a modem which converts the digital signal into a signal recognizable by the analog network. Fax machines use internal modems to operate across standard telephone systems. Standard modems and fax machines sample the input signal about 6,000 times per second, leading to a digital capacity over
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a conventional telephone line in the region of 33 kbit/s. This is ample for most domestic applications including email as well as for the live transmission of basic vital signs used in telemedicine. At 33 kbit/s, a 1 Mb file will take around 10 min to transmit. VTC is possible at this bandwidth, e.g., webcasting. This can provide a very cheap (the cost of a local call at both ends) and imaginative method of communication but the quality is currently not good and is referred to as “talking heads” VTC.
Broadband Broadband is the definition given to higher magnitude bandwidth obtainable using digital asynchronous transfer modes (ATM), which greatly improves the bandwidth of copper conductors. If broadband is available then virtually everything that you need to do can be delivered across it.
Digital We have established that analog communications have their limitations and the more advanced user may need additional bandwidth. This can be achieved by the installation (where available) of an integrated services digital network (ISDN) line. A few years ago, ISDN was rare and expensive but it has since spread to many countries, at least in the capital cities and that trend is likely to continue. A note of caution is that many countries are encouraging deregulation of their telecoms industries. While this should ultimately mean better quality services it can lead to difficulties with intercarrier connectivity. For example if you are using Carrier A which does not have an ISDN gateway to Carrier B, you will be unable to exchange data via ISDN to Carrier B subscribers. Many companies also use their ISDN lines for voice and fax as well as data, so be aware that while the voice element will almost certainly work every time, fax and data may experience difficulties to certain destinations. This problem is certainly improving with time as carriers get their own house in order and develop links and agreements with each other. In the meantime, if you are experiencing problems, check with your carrier before assuming that any problem you have with connectivity is the result of your faulty equipment. An alternative to the standard “dial on demand” service is to pay a rental or lease fee for the line with no additional charges for the traffic across them. This is known as a “nailed up” or leased line and is ideal for a point to point connection such as one organization office to another, or from Hospital to Health Center. Once installed, any calls made across the link are effectively toll free, and so the more it is used, the better value it becomes.
The Internet The Internet was born in 1969 when the US Department of Defense got together with a few academics and industrialists to develop a new way to send messages. The aim was to develop their own private network to pass around nuclear secrets. It all went well and the first email message, which included the famous @ sign, was sent in 1972.
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ARPAnet, as it was then called, continued to develop steadily but it was not until 1993, when Marc Andreeson came up with a way to make Web browsing pictorial and easy and the Web as we know it today became a reality. The Internet is rather like the road network but for information. It is a collection of public and private networks that are linked together using a set of protocols called transmission control protocols/Internet protocols (TCP/IP). The Web is the Internet with pictures. It is that bit of the Internet that exchanges multimedia information, pictures, sound, and video using hyper text transport protocol (HTTP). The Internet has transformed our lives and specifically our capability to prepare for and manage humanitarian and emergency projects. Cyber cafes, where anyone can gain access to the Internet are available worldwide and enable anyone to gain access to vast amounts of data for educational, research, or planning purposes or to share and develop ideas, good and bad. Real-time news is available through newspaper and news corporation sites and it is possible to use the Web as a modality for telephone calls and talking heads VTCs, all for the price of a local phone call. There are concerns about security on the Internet, especially if you are using local Internet service providers, but for practical purposes the Web is a safe and reliable means of communications, it was after all designed to pass around nuclear secrets and it certainly beats telephones and the mail on both counts.
GSM Many of us already use GSM mobile telephones. The handsets are now common place in most walks of life and across all generations. Currently GSM usually operates at low bandwidth with data transmissions for email and Web surfing possible at up to 15.4 kbit/s for standard mobiles although the emerging 3G networks provide up to 384 kbit/s. From the telemedicine perspective, ECGs and photographs have both been successfully transmitted across the GSM network (Freedman 1999) and videoconferencing is commonplace across 3G. The GSM network in a given area will operate on one of the three different bands (900, 1,800, 1,900 kHz) and whereas there is usually a single bandwidth for a given country, some countries have a number of operators who operate on different frequencies. Most handsets are dual band or triband and will work anywhere in the World where there is a network. Where you can communicate using your domestic mobile phone therefore depends on the handset you have, which service provider you are signed up with, and which overseas networks they have reciprocal arrangements with. When you are abroad and away from your home network, you are deemed to be “roaming.” This works with little or no input from the user and often provides a choice of host network providers. But, beware of call costs. When you roam, you as the subscriber are responsible for all your outgoing calls, which are charged at the local cellular rate plus the international call charge to your destination. In addition you will also be charged for the international leg of any incoming calls. This presents most of us with a new billing concept that is easily forgotten at the time of a call but comes flooding back when the bill arrives! The advantage, however, is that anyone at home can call your mobile number as normal and get through to you wherever you are, at
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the cost to them of a normal national mobile call. However, check costs for both incoming and outgoing calls before you go. GSM has excellent building penetration which means that it can be used easily in cities and on the move, a great advantage over satellite systems which require a clear line of sight to the satellite. Mobiles are also very easy to use and familiar, especially if you take your own phone away with you when you travel. GSM coverage is patchy and often very poor, especially during the active phases of conflict or catastrophes. Check before you go. As has already been mentioned, GSM is terrestrial based and requires a sophisticated and intact infrastructure in the area where the phones will be expected to work. GSM will therefore not be suitable for many conflicts or during the acute phase of disaster although they may have a place in the pre- and postdisaster phases in some countries, and in the management of the acute phase of an isolated catastrophe in an otherwise functioning locality.
The Emergency Override The UK mobile phone networks operate a system called ACCOLC. This stands for ACCess Over Load Control and is a way of ensuring the emergency services, and other priority personnel such as local authorities and coastguard can have a priority access to the network during an emergency. Invariably a local disaster will attract a great number of media operators that also require telephone lines to their offices in order to keep the world up to date with developments. Journalists’ standard practice when there is the opportunity for a scoop is to establish a link with their office and then keep the line open in order to guarantee it is there whenever they need it. As there are a finite number of lines in any given area, this type of practice could easily flood the network and prevent the emergency services from getting any access to the system. There is a procedure for gaining access to the ACCOLC system and applications need to be approved by the Home Office. They decide who is eligible for the service in order to control numbers. Similarly, ACCOLC is not in automatic operation all the time. It has to be invoked by an authorized police officer or local authority representative.
Satellite Networks In 1945, the author of 2001: A Space Odyssey, Arthur C. Clarke, produced a feasible theory on how communications satellites could act like a mirror by bouncing the signal from one place to another on the planet’s surface within seconds. With that the idea was born and the first Sputnik satellite was launched in 1957. Since then over 4,000 satellites have been launched and in the next 2 years another 280 are expected to be launched for communications alone! Satellite communications offer substantial advantages over GSM and satellite telephones (satphones) are now cheap enough to buy and use and to be considered the technology of choice in many situations. Building penetration is poor but coverage is, more or less worldwide regardless of infrastructure on the ground. Broader bandwidth
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systems offer greater bandwidth than GSM up to 432 kbit/s and beyond. The potential functionality of a satellite-based system is therefore now much greater than GSM. Although their main application is in support of conflicts and catastrophes overseas where other forms of communication are not available, satellite communications may be appropriate in first world catastrophe situations too. They are independent of the GSM and radio networks and rarely get overloaded. They also operate effectively in GSM black spots where GSM coverage is patchy or absent altogether. Traditional satellites orbit at an altitude of some 35,000 km above a specific point on the equator. In this position, they will orbit the earth once every 24 h and therefore appears to remain stationary in the sky when observed from the earth. This is known as a geosynchronous or geostationary earth orbit (GEO), and the footprint of each satellite is over a fixed region of the world’s surface. The footprint of geostationary satellites often overlaps and so in many parts of the world it is possible to access two satellites. This can be important in the emergency situation when multiple users are accessing the same satellite at the same time. Rarely the satellite will get overloaded and by simply turning around and accessing the next satellite around you can regain connectivity. Some handheld systems operate via low earth orbit (LEO) satellites which will be on the edge of space at an altitude somewhere between 640 and 1,600 km. At this height they have an orbital period of around an hour and therefore move very quickly relative to the ground. Visibility is limited to a few minutes at a time so LEO systems operate a “hand-off facility” whereby calls are handed on to the next satellite in the orbit to provide an uninterrupted service. Unlike GSM, most reputable satellite operators will not charge for either incoming calls or unsuccessful calls such as unobtainable or busy. Most are subscription-based services with monthly access fees to pay.
Inmarsat Mini-M Mini-M originally bought satellite communications within reach of most global travelers. Launched in 1995, the combination of a light portable terminal at an affordable price, with worldwide coverage and ever reducing airtime rates, this has been the forerunner of the newer hand-held systems. Although no longer in manufacture, there are thousands of Mini-M’s still in regular use throughout the world. The Inmarsat-based service is dial-on-demand, which means you pay for what you use in 1 s increments at a rate which should be under US$2.00 per minute which, in many parts of the World is cheaper than a Hotel phone. Call charges do not vary with time of day or destination, provided the call is to a fixed line phone and not to another satellite telephone (Fig 21.1).
Inmarsat B Inmarsat B Portable systems come in a number of different shapes and sizes and in its basic form, data is transmitted at 9.6 kbit/s, with an option to expand this to High Speed Data (HSD) at 64 kbit/s. Although referred to as a portable system, the Inmarsat
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Fig. 21.1. The Inmarsat coverage map showing the virtually global availability of their services, applicable to Mini-M, “B,” and M4.
B is really a transportable system, with a basic volumetric size equivalent to a tea chest, or large packing case. Although there are a number of these terminals still in active service they have generally been superseded by the RBGAN and BGAN.
Inmarsat M4 Originally launched in the final quarter of 1999 with a full service available during 2000 the M4 provides a considerably enhanced capability over the Inmarsat B and is considerably smaller and cheaper too. Designed to provide data at 64 kbit/s on a terminal about the same size as the Mini-M, it gives subscribers full and portable access to the Internet, connection to their local or wide area network, transmit real time, and store and forward video, and send pictures and broadcast quality voice on a plug and play platform. Inmarsat then added the Inmarsat packet data service (IPDS). IPDS offers a full time data connection to the network which is only charged when it is used and the tariff is per transmitted Mbit of data rather than by the minute in much the same way that ADSL or broadband works. Most users of M4 have now migrated to the Inmarsat BGAN due to its lower cost and greater ease of use but many are still in operation in specialist applications such as Media and Military where an ISDN-based link is required.
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Inmarsat RBGAN Launched as an interim system to the now developed BGAN, Regional BGAN or RBGAN is smaller and lighter than a notepad PC and is very easy to use. Data is sent using the RBGAN’s “Always on” technology which means that you are charged for the amount of data you send and receive rather than the amount of time you are online. Originally hosted on the Thuraya satellites, the RBGAN service was transferred to Inmarsat during 2004, but then as the BGAN service developed throughout 2005 and beyond it has become somewhat obsolete and will be switched off at the end of 2008, leaving the now matured BGAN service as the option for high-speed data and voice.
Inmarsat BGAN BGAN effectively provides a global broadband service, enabling access for data applications at speeds up to half a megabit with simultaneous voice calls. BGAN terminals are compact, lightweight, and can be carried as easily as a laptop – the smallest BGAN terminal weighs less than 1 kg. A fully functional broadband mobile office can be set up and shut down in minutes. BGAN supports the latest IP services, as well as traditional circuit-switched voice and data offering seamless integration with other networks. Terminals start at US$2000 and the price of the airtime is around US$7.00 per Mb with a monthly subscription of US35.00. As with any airtime there is always a deal to be struck and so you should always see what is on offer as this is a very competitive market that has seen prices tumble to a fraction of where they were 10 years ago in order to compete with the growth of the terrestrial GSM networks.
Fig. 21.2. The 2007 coverage map for BGAN with the extension to include the Pacific areas throughout 2008.
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Iridium Iridium were the first hand-held satphone operators, operating 66 LEO satellites in a birdcage pattern around the earth,. Because these satellites orbit every hour or so, it is necessary for the system to perform some quite complex interspacial hand-off’s to pass your call from one satellite as it sets over your horizon, to the next as it comes into view. Iridium terminals are hand-held and a little bulky compared to GSM mobile phones. As with Inmarsat there is little building penetration and so they cannot be used indoors or between tall buildings without the addition of external antennas. This is a subscription-based service at about US$35.00 per month plus then a call charge of US$1.30 per minute for calls to landline telephones wherever they are in the world. Iridium offer an attractive rate of US$0.65 per minute for calls from one Iridium handset to another, so consider this for a truly global, hand-held alternative particularly if you want to call from one terminal to another (Fig 21.3).
Thuraya Designed to complement existing GSM networks and expand usage beyond conventional network coverage areas, Thuraya’s mobile satellite services offer a broad range of services that include voice, data, fax, short messaging, GPS through its dual mode handsets. Thuraya has the fastest growing subscriber base of all the satellite networks due to its effective and reliable service, albeit with limited coverage. If you are operating within the coverage area and require voice and basic data services then this should be your first choice. With two geostationary satellites the service is robust and very competitively priced. Boasting the smallest satellite telephones in the world the handset price starts under US$800. The airtime rates are rather complicated and depend on where you are in the world when you make your call and where the destination of the call is, however, they start at US$0.62 per minute for Thuraya to Thuraya calls and are between US$0.76 and US$1.40 for calls to standard landlines (Fig 21.4).
Fig. 21.3. Low earth orbit satellites provide a truly global coverage for the Iridium network.
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Fig. 21.4. Thuraya coverage map as at the end of 2007 showing the optimal and suboptimal areas of serviceability. There are currently no plans to extend the coverage beyond this.
Radio This section must also include the many private mobile radio (PMR) networks in operation. The most common are those used by the emergency services. Although expensive to install and generally restricted by their regional coverage, there are no call charges and so the operational costs are limited to maintenance and servicing. Radio connections are always point to point, in other words you must have at least two transceivers on the same frequency to be able to communicate. Local networks will be VHF or UHF and come as either hand portable or mobile (to be installed in a vehicle) The range is limited to 4–5 miles in open countryside and significantly less in a built up area. It is possible to extend this range with repeaters and high-level antennas but it is still essentially a local network. UHF provides higher penetration through obstacles such as buildings or dense forestry but the overall range is reduced. There are products such as iconics that enable individual radio networks around the world to be linked to each other using the Internet as the long distance carrier. Access to the Internet is provided either by local terrestrial suppliers or by using a satellite terminal such as Inmarsat BGAN. In essence, this means a local radio user can communicate to another iconics subscriber anywhere in the world regardless of frequency or type, simply by using his hand-held portable radio. HF radio provides an ideal solution for remote, emergency, and security communications needs and is capable of communicating over distances of 3,000 km or more. Unlike conventional, Voice Over IP (VoIP), cellular and satellite telephony, which all rely upon land-based infrastructure, an HF radio network requires minimal
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infrastructure is simple and quick to deploy and provides communications capability for users no matter where they are. It can even be used to communicate with existing VHF and UHF radio systems, cellular telephones, and land-based telephones through developments in cross-patching technology that make this as easy as dialing a telephone number. Once the initial investment in equipment is made, there are no call costs or ongoing monthly line or equipment rentals making the ongoing use of HF very economical. Where communications are sensitive, HF radio offers technologies to ensure the security of voice and data transmissions. The military uses HF radio as its primary communications medium and from the military have come a number of enhancements in voice encryption and frequency hopping which guarantee secure communications. For nonmilitary use, different levels of encryption are available to suit the individual organization’s security requirements.
Summary Table 21.2 summarizes the relative merits of the various options available for communicating around the world.
Table 21.2. The relative merits of the various options available for communicating around the World
POTS
Time (s) to transmit one page of A4
Needs intact Building local infrastruc- penetrature tion
Geographical coverage
V, D b
12
Y
N/A
++++ ++
Cost per minute London– Cost of kit Lagos
Bandwidtha (kbit/s) Capability
Very low
15
$0.50
GSM
$200
$2.10
9.6
V, D
28
Y
Y
PMR radio
$150
N/A
9.6
Vc
N/A
N
N
++
VHF/UHF radio
$250
N/A
9.6
V, D
32
N
Y
++
HF radio
$3,000
Free
9.6
V, D
32
N
Y
+++
Inmarsat MiniM
$1,700
$2.00
2.8
V, D
89
N
N
++++
Inmarsat RBGAN
$500
N/A
144
D
2
N
N
++++
Inmarsat BGAN
$2,500
$0.80
464
MV, D, VTC
1
N
N
++++
Iridium
$2,000
$0.99
9.6
V, D
32
N
N
++++
Thuraya
$800
$1.11
9.6
V, D
32
N
N
+++
a
Or equivalent for analog services Data with the addition of a modem c Public service radio domestically or VHF for overseas links V voice, MV multiple phone lines, D data, VTC video teleconferencing b
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The Spectrum of Capability The range of communications modalities described above enable a range of capabilities around which providers can build support for an operation. As with the enabling technology they can be divided into low bandwidth and high bandwidth capabilities.
Low Bandwidth Paper Paper-based communication such as newspapers or letters remains a mainstay of communications. It is cheap and easy to produce and can be easily archived as a permanent record. On the other hand, paper-based information is difficult and slow to transmit, difficult to update and time consuming to collate into any form of useful database. Most people, however, are more comfortable accessing information by reading from a piece of paper than they are from a screen.
Broadcast Simple one-way communications by broadcast, either by radio or by TV, is the other main way most people gather information and even the Pentagon is known to rely on CNN for much of its real-time information gathering during a crisis. Although broadcast can be a useful information source it is also a very effective way of projecting information to affected populations in time of crisis, radio being less powerful but also less fragile and more ubiquitous than television. Important questions surrounding manipulation of the press and the sometimes fine line between information and propaganda need to be considered when using broadcast mediums to inform.
Simple Voice Communications Voice is the most basic form of communications and probably the most important. It is real time and interactive and most interactions between people can be done in person, by telephone or by radio. Voice does have disadvantages; however, in that it requires two people to be together or at either end of a link at the same time for it to work and there is generally no “hard copy” for the record. Voice alone is also sometimes inadequate and fails to get enough information over accurately or quickly enough. It is difficult to accurately describe a scene of a catastrophe or the clinical situation in a hospital and succinctly by voice alone. Also, visual cues such as body language are lost which can lead to misunderstanding even between people who know each other well. By and large though voice works, it is cheap, reliable, and low tech. Audio teleconferencing is a cheap, efficient, and underused medium which enables any number of people to share in the same telephone call and to hold a virtual meeting. In its simplest form, it entails using an extension or desktop conference phone but most
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teleconferencing utilizes a multipoint bridge into which participants can call on the same number at the same time and teleconference. Audioconferencing feels uncomfortable between people who have not met and, in line with traditional conferences needs a good chair and degree of discipline. Most major telecoms companies offer this service and many also offer translation or transcription as an additional service. Although there is a slight premium over normal calls, the host can elect to cover the whole cost, ask participants to pay a local call charge, and cover the difference or ask them to pay for the whole cost themselves. Teleconferencing provides considerable savings in travel time and costs and will work with calls from abroad or from mobiles.
Email Email has transformed communications. Although it has been used by the military and research establishments since 1973 it is only in the last 10 years that it has become a mainstream method of communication. You can access your mail wherever and whenever you want and can reply at your convenience wherever you are. Email is generally asynchronous which can be a distinct advantage over the telephone. Email also makes it easy to copy messages to a wide distribution at the click of a button. Email etiquette is much simpler than the traditional written form so that the reply to a message may be a single word. Less time, no paper, and much quicker than mail. It is ease; however, can also be a problem. Because it is so easy for people to copy messages they tend to do it without really thinking with the potential for information overload amongst the recipients. It also tends to create an “ad hocracy” out of a hierarchy as the normal management chains are short cut by “information” copies. The ease of sending email messages and the short reply time also means that disagreements and misunderstandings can easily get out of hand as the calming influence of time (mail) or having to deal direct with people (telephone) are avoided.
Store and Forward Store and forward is a telemedicine term for clinical email with attachments. In this context, store and forward attachments can include documents, digital photographs, X-rays, or video clips. Clinically, store and forward can be used for up to 80% of telemedicine consults and takes less specialist time and resources than traditional practice. Because distance ceases to be a consideration, store and forward consultations can go the next available or more appropriate specialist rather than the most local. In time, store and forward will lead to a substantial change in the way medicine is practiced but in the setting of a conflict or a catastrophe it provides the vehicle for importing a whole range of expertise into the situation which would not otherwise be available. The same principle also holds for other disciplines such as engineering where the same communications system used to send clinical details and a photograph of a patient can also be used to send the engineering equivalent say of a damaged bridge.
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Administratively, digital photographs can be used in lieu of lengthy descriptions and the technology exists now whereby a picture can be transmitted and discussed in real time by voice at the same time. White boarding, where the correspondents highlight features on the picture rather like sports commentators highlight a play can be a valuable adjunct.
The Internet The Internet can be used to communicate as well as to gather information. New services such as Skype enable people to talk to anyone else across the Internet who have the same package with little or no additional cost. Conference calls and VTC are also common. Some Web sites include chat sites where people from around the world with a common interest can exchange ideas and develop new concepts. It is transforming the scientific process from one of the peer reviewed articles and text books such as this, to the one where ideas are posted on the Web and developed by discussion until a consensus is reached.
High Bandwidth VTC adds a two-way, real-time video image which can be valuable in certain circumstances. Although VTC is possible at low bandwidth, the quality is poor; clinically useful VTC needs to be at 64 kbit/s as a minimum. VTC is difficult between people who do not know each other but is a good tool for enhancing communications between those who do. The addition of video is reassuring to people at the distal end and can provide a valuable “situational awareness” tool for reporting purposes. VTC is used increasingly as a routine means of holding virtual meetings and obviating the need for the participants to travel. As with voice only teleconferencing up to 32 different sites can call in simultaneously. Input can be via wire, GSM or satellite links. Costs can be high, but so can the costs in time and money of moving up to 32 people to the same place for a meeting. Nevertheless, the question should also always be asked whether the video element is worth the extra cost relative to a voice only link. VTC can also be used for clinical consultations (telemedicine), distance learning, and a variety of administrative functions such as career interviews.
The Communications Plan Adequate planning and preparation is essential in all aspects of conflict and catastrophe medicine, none more so than with the communications plan. Maintaining an up-to-date communications plan is not easy because of the rapidly changing technical capabilities and cost structures available and a rule of thumb is that technical capability doubles and costs halve every 2–3 years. The growth of LEO satellite systems will only compound the problem. Given the pace of change, it is not helpful for this text book to define what the communications solution for a given situation should be, you should use the Internet for that.
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Underlying Principles There are two underlying principles and one set of rules which should underpin any communications plan. The underlying principles are: ● ●
That the plan must be based on a user requirement To recognize that communications is a specialist area which should be planned by a specialist.
Establishing the User Requirement The user requirement should underpin the design of any technology-based solution. It is the process by which the users at all levels define what it is that they wish technology to do, what attributes it will need to have to be useful to them, and where they will use it. It is best worked out as a team. The process should produce a prioritized list of capabilities on the one side and constraints on the other. Examples of capabilities might be that two (or three or four) people at given locations need to be able to communicate freely with each other or that there is also requirement for the movement of data between certain locations. The constraints will include the Rule of the 8 R’s. Security may be an important constraint (Table 21.3). It is important to note that there is no mention at all about technology, no mention of satellites, radios, bandwidth, or anything else technical. In fact the user requirement could be met in some circumstances by face to face meetings, couriers, and the mail. From the user requirement comes the technical solution which should be based purely upon it. Any temptation to add capability just because it is possible should be resisted especially if they make the solution less robust or more expensive. Table 21.3. The rules governing a communications plan in austere environments is the rule of the 8 R’s The rule of the 8 R’s A communications solution must be appropriate for the situation in which it is expected to operate. Specifically it should be Required
It should be designed around a user requirement, i.e., those who will use the system should define what they will need it to do and the technical solution should answer that requirement
Reasonable cost
Communications costs can be high, both in terms of equipment and call charges and the capability it provides must justify the cost. Sometimes, however, high bandwidth equipment may provide better value over low bandwidth because it transfers higher volume of data per minute and, beyond a certain break even point, can be cheaper
Robust
The equipment and its supporting network must be robust yet light and portable
Reliable
Network overload can be a particular problem, especially across mobile phone networks
Really easy
To use with no requirement for technical support in country
Resource constrained
Equipment and networks must be appropriate to a resource constrained environment. Equipment should be able to operate from multiple power sources including batteries and generators, be weather proof and not rely on local infrastructure if that is likely to be destroyed or overloaded
Routine
Communications systems should be used routinely, preferably as a part of daily work practices but at least on regular exercises if they are to be expected to work in the event of a disaster
Reviewed
The capabilities and costs of communications solutions are changing at an increasing rate and therefore plans should be regularly reviewed
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Communications is a Specialist Area Communications in an austere environment is a specialist area and specialist input will be needed to convert a user requirement into a technical solution. In addition to the technical expertise, there is also a need for logistical support to get the equipment across borders, especially in regions where there is armed conflict and where satellite equipment can be attractive. Call tariffs for satellite phones can be very complex and solutions can differ by a factor of 2 or 3. Even within one technology, the cost of calls can differ by a factor of 20% depending upon which service provider you choose. Larger organizations can afford to have their own communications staff but individuals or smaller agencies should develop a relationship with a specialist communications companies used to working in austere environments. The choice should be a company which offers a wide range of technologies and therefore has no vested interest in a particular solution. Some will offer discounts and may even offer a leasing service or short-term rental so that customers do not need to buy capital equipment which may soon become obsolete. After sales service is important and problematic. Most companies will offer a return to base (RTB) warranty and will dispatch a replacement as soon as a unit breaks down. It is wise to get any agreement in writing but most specialist providers are very aware of the environment in which agencies work and will do their best to help.
Conclusion Good communications are crucial to the effective response to and management of conflicts and catastrophes. Planning is the key to delivering a solution which will meet your needs. The authors are happy to answer any specific questions from readers and can be reached via email.
Glossary Term
Definition
ATM
Asynchronous transfer mode: a dell-based data transfer technique in which demand determines packet allocation. ATM offers fast packet technology and real-time, demand-led switching for efficient network resources
B-ISDN
Broadband ISDN offering 30 × 64 kbit/s channels plus two network control channels. Total user rate of 1,920 kbit/s and often referred to as a 2 Meg link
BRI ISDN
Basic rate interface allowing 2 × 64 kbit/s and 1 × 16 kbit/s channels to be carried over a single pair of copper wires. Through the use of bonding techniques the 64 kbit/s channels can be aggregated to create more bandwidth
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Broadband
A term describing any network that can multiplex several, independent network carrier frequencies on to a single cable thereby producing a high data transfer capability
CODEC
(COder/DECoder) A device that converts analog signals into a form suitable for transmission on a digital circuit. The signal is decoded back into analog form at the receiving end of the link
Ethernet
A LAN and data-link protocol based on a packet frame. Usually operating at 10 Mbit/s, multiple devices can share access to the link
GEO
Geostationary earth orbit. A satellite orbiting the earth at some 35,000 km and apparently static in the sky to an observer on earth
GSM
Global system for mobile telecommunications (originally it was the French, Group Speciale Mobile, but was changed as it became the global standard)
Inmarsat
Now a private company offering global satellite services via a number of land earth station operators (LESO). Inmarsat was formerly a multinational cooperative with some 88 member countries until privatization in April 1999
Internet
A group of networks that are interconnected so that they appear to be one continuous network
Iridium
New generation satellite operator. First to launch hand-held satellite telephones (November 1998) with true global coverage using LEO satellites
ISDN
Integrated digital services network is a switched digital net work capable of handling an amalgam of digital voice, data, and image transmission
LAN
Local area network is a communication system that links com puters into a network
LEO
Low earth orbit satellite. Typically transiting the world at an altitude of about 800 km, just at the edge of space
LESO
Land earth station operator. Usually operated by the national PTT, responsible for landing satellite traffic from space and distributing it to its destination
Packet
A collection of bits, including the address, data, and control information that are switched and transmitted together. The terms frame and packet are often used synonymously
PMR
Private mobile radio such as that operated by the ambulance service
344 PSTN
Section Three The public switched telephone network is the ordinary tele phone network for switched access to local and long distance services
Store and forward Clinical email with attachments, not in real time VTC
Video teleconferencing link. Often referred to as video confer encing, this is the ability for a group of operators to be inter linked so as to share real time conversation and video
References Freedman S. Direct transmission of electrocardiograms to a mobile phone for the management of a patient with acute myocardial infarction. J. Telemed. Telecare 5:67–69, 1999 Gunn J.W. Humanitarian, non-combatant role for the military. Prehosp. Dis. Med. 9(2):546–548, 1994 Lilley R., Navein J. A Telemedicine Toolkit. Radcliffe Medical Press, Oxford, 1999 Llewellyn C.H. The role of telemedicine in disaster medicine. J. Med. Sci. 19(1):29–34, 1995
22. Mental Health Part A – Practical Psychological Aspects of Humanitarian Aid Ian P. Palmer
●
Objectives
●
●
To raise issues about the predeployment phase To discuss psychological problems arising during deployment To heighten awareness of problems arising in the postdeployment phase
Introduction The psychological aspects involved in the provision of medical aid in hostile environments relate to general issues and those specific to the location to which you deploy, as well as the phases of that deployment. ● ● ●
Predeployment – preparation Deployment – separation Postdeployment – repatriation, reunion, and readjustment
Any deployment leads to a constriction of your world that creates a unique experience for those involved, the importance of which becomes clearer on your return home. Your experience may be positive, negative, or anything in between, and will change you.
Deciding to Go This may seem an odd issue, especially if you have already bought this book and read this far, but it is the key to the psychological aspect of the whole process. Remember – any deployment leads to a constriction of your world. You will be spending time with people you may not know and may not like, but with whom you have to coexist and, at times, even rely on. Emotions can run high and interfere with missions – remember isolation brings out the best and worst in humans! So ask yourself about the motives, drives, and personalities of those with whom you are going, and whether you share a common agenda. A. Hopperus Buma et al. (eds.), Conflict and Catastrophe Medicine, Second ed., DOI 10.1007/978-1-84800-352-1_22, © Springer-Verlag London Limited 2009
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Try to assess what you hope realistically to achieve, as the reality on the ground may be vastly different from your expectations of predeployment. Understand and accept from the outset that you (along with everyone else) will be changed by undertaking this work. Despite the hardships, unpleasantness, and difficulties encountered, most people find it a positive experience. It may lead to a deeper understanding of humanity, the workings of the world and your place within it, yet for a minority the experience will be less positive.
Preparation: Predeployment Preparation for Separation Your aim is to deploy in good physical and mental health in order to complete your mission. Your ability to perform well on a mission is diminished if you are preoccupied with worries about home (money, legal, relationships, etc.) and compounded by the boredom inherent in many deployments, which will lead you to ruminate about them. So, sort things out now!
Systems Deployment will lead to changes in your social system. The moment you decide to go, preparation begins in order to accommodate to your loss from this system. Your exit may be supported, wished for, resented, or not desired, but whatever the reason, a degree of emotional distancing in relationships is bound to occur. This may be reflected in quarrels or disagreements, a less than satisfactory sexual life, and so forth. It is important not to misrepresent events or words at this time – full and frank discussion is the best way to deal with the situation. While you are away life goes on as normal, but those left behind will change during your absence. There is a natural tendency to hold a fixed view of life at home as a place that will be the same on your return. While this is helpful during the deployment, it can cause problems afterward if it is not reality based. There may be many frustrations before you even leave your country of origin. If possible, it is important to have a departure deadline after which you will actually leave, as numerous farewells are upsetting for all involved, especially children.
Partners It is important to share your thoughts, knowledge, and opinions of the proposed endeavor with your partner. Will you have any concerns or worries about their ability to cope in your absence and vice versa? Can, or should, you reconcile their wants, needs, and desires? It may prove helpful to work through a few vignettes, e.g., about how they will cope in your absence with various important events such as illness, financial
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problems, and the deaths of family members. The possibility of you being taken hostage or your death should also be addressed, and you should include the NGOs policy in such circumstances in your discussion. Dependable lines of communication will allay many fears. Access to them should be clearly understood by everyone.
Children If you have children, it is important to get them involved from the outset with your decision to go. If they are old enough to understand, they may well support your decisions wholeheartedly, but the younger they are the more difficult this may be. It is important to answer any questions they may have honestly but without causing needless anxiety. Whether or not they understand, it is important for them to be made part of what is happening. They need to be reassured of your return and that frequent communication by letters, videos, and telephone calls will occur. Each child should be written to individually. Give them something of yours to care for and look after, and ensure that the family does not forget you in their discussions on a daily basis, for example children should have photographs of you in their room and bedtime rituals should include you. While potentially stressful and difficult, it is important that proper farewells should always occur. Young children have very little concept of time, so a calendar of your deployment is extremely important. The children’s school should also be informed. Underpinning all of this is an avoidance of too much change in the children’s routines, which would unsettle them.
Relatives Do not forget your other relatives. Wherever possible, draw on the support they can provide for you, your partner, children, and friends. Maintain contact with them to ensure that they do not become reliant on the media, as this may increase their anxieties. Do take time to discuss with family and friends their concerns as well as your own before you leave; uncertainty is very stressful for all concerned.
Deployment Work-Related Issues Interpreters If you do not understand the language in your country of deployment it is essential to have good interpreters. Working with interpreters, especially in very hostile areas, can be very difficult and stressful for all concerned. In some situations, the interpreter
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can become the focus of anger, aggression, and even violence; protect them as best you can. You are likely to develop close relationships with them, with all the attendant benefits and drawbacks that entails.
Stressors Different situations and work practices provide differing stressors. You may find yourself questioning your involvement from the outset. Have you been properly prepared for this work you propose to undertake? How flexible are you or can you be, and what are your strengths and weaknesses? Is your skill base up to the job given the constraints that you will encounter in theater? How comfortable do you feel with the moral and ethical dilemmas of work such as triage where the “greater good” may disadvantage the individual, or the expenditure of finite resources on individuals will lead to greater suffering for the majority? Remember, however, that for the vast majority of aid workers, their experiences add to their knowledge, skills base, confidence, insight, and ability to cope generally.
Cultural Views of Illness It is important not to impose your own illness beliefs on others and to try to understand how local populations view illness. The emotional way in which societies and cultures deal with illness, pain, suffering, and death can compound or relieve the stress of your working practice. Some of those you treat will be refugees, displaced persons, and involuntary migrants. Some will have been persecuted and even tortured, and some of those you treat may have perpetrated atrocities. Do not forget the psychological aspects of their plight, and wherever possible help them to find support from their communities who have shared the same experiences, if they have not done so already. In the field of posttraumatic mental distress, attend to social therapies above medical ones, and be sensitive to the fact that simply talking about their experiences with you will be inadequate and possibly damaging.
Types of Patient Do not assume that everyone who presents themselves with physical complaints has a medical disease. Across the globe, patients present with symptoms that are impossible to explain medically. This is termed somatization, and is a universal and common presentation of psychological distress. Remember that wherever you practice, patients attend medical facilities for physical, psychological, or social reasons (or a mixture of all three) and if you do not accept or realize this you can become very frustrated. If individuals keep coming back with the same physical complaint it may be they are coming for psychological and/or social reasons which are of course extremely valid given the situation they find themselves in.
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Expatriate Issues Isolation and Intimacy The “constriction” of life that occurs when you deploy may initially be enjoyable. However, close proximity and the difficulties involved in such work may lead to problems within the group. An unexpected intensity of emotions may be forged by proximity, shared adversity, hardships, and experiences (both good and bad). This may lead to the formation of intimate relationships, which may or may not survive the return to base. On the other hand, such work may lead to difficulties in interpersonal relationships becoming worse by the inevitable occurrence of gossip which may be corrosive, divisive, and damaging. Wherever possible do not be drawn into speculation and gossip; learn to keep quiet.
Psychological Many individuals feel homesick. Some get anxious or miserable, especially if things are going badly, which may in turn alter their use of alcohol or drugs. The events you have seen or become involved with may affect the way that you react in future situations, and how you relate to people within theater and following your return home. It is important to be aware that your co-workers may have, or may develop, frank mental illness or drink- or drug-related problems, and that some of them may have personalities which make them extremely difficult to get on with.
Alcohol Be careful in your use of alcohol. Alcohol is often available easily and cheaply in expatriate communities. It is a social lubricant and serves to ease emotional upsets and help you to unwind, but it can lead to its own problems. While its use at the end of a busy and difficult day is perfectly acceptable, if it becomes the preferred way of dealing with emotional difficulties it is less helpful. For example, following exposure to unpleasant events you may re-experience thoughts or images of the event in the daytime or in the dreams. Alcohol is often used to help sleep or the anxiety engendered by such phenomena, but it can only add to the problem in time.
After-Work Issues It is natural to wonder what is happening at home, and there may come a time when you question what you are achieving in-country. Such thoughts may become ruminations and lead to anxiety, worry, and distress, especially if there are problems in-country, poor communications with home, isolation, and boredom. It is therefore
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important to take time away from the work. Organize group support wherever possible and try to ensure that relationships do not become either abusive or difficult. Isolation may lead to increased loneliness, heightened vulnerabilities, and emotional distress, especially if you witness, or are involved in, dreadful and unpleasant events.
Home Comforts and Support from Home When things are particularly difficult, it is good to able to draw on moral, practical, financial, and even spiritual help from home. Unless you are a masochist or a stoic it is important to have some home comforts, as they help to relieve feelings of isolation. Access to a reliable postal service is highly desirable, if not essential! Letters not only form a diary for the future but also form a tangible record for friends and family to read and re-read. Unlike telephone calls, letters also allow a more measured exploration of emotions and difficulties, in addition to which, people like to receive letters. In theater, you will become rapidly demoralized if no one writes to you – so make sure you write to them! While at times it is very useful, telephone communication can be quite problematic and it is often advisable to work out what you want to say before you make the call.
Own Support Network In-Country Maintain a sense of proportion from your knowledge of the overall aims and performance of your NGO and your role and position within the effort. Acknowledge the highs and lows and the events that have had a psychological and emotional impact and meaning within the group and how you and the group has, or has not, dealt with them. Aim to draw support from those sharing the same situation.
Repatriation, Reunion, and Readjustment: Postdeployment Repatriation is about readjustment to your previous life and the accommodation of change in both yourself and those who remained behind. In general, the more problematic the deployment, the more problematic the readjustment is. Just as you had expectations when you deployed in-country, you will have expectations of your return which may vary in their level of reality. Seldom, however, will your plans for return work out exactly as you planned. Wherever possible, it is advisable to prepare realistically for repatriation. While in-country, start to wind down and review the deployment as a group, exploring good and bad events, how the experience will benefit you, what you would do differently next time, and what you would tell other people going to the same area. Do not underestimate your achievements. Write a report and keep a copy.
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In preparing for return and reunion, it is important to think what those at home will expect and what you will tell them. Consider how you will deal with the feeling that “no one understands” what you achieved, experienced, saw, and felt. Following repatriation, the recent “constriction” of your existence will become obvious to you. There is often an initial period of euphoria when all goes well, followed by a desire to be in the company of those with whom you shared the experience. There will be jokes, language, and events which only they can understand; it is important to recognize this and ensure that wherever possible you meet up again. (Of course the obverse may happen – you may wish never to see these people again!) On return you will be asked about your experiences and initially this may be a very positive thing, but eventually people will expect you to stop talking and listen to the events in their life in your absence. If you have had particularly unpleasant experiences you are in a dilemma. Generally, traumatic events will upset you when you think about them, and this will naturally lead you to avoid talking about them. While this is understandable, it may not be the best thing in the long run. But what do you actually tell people if you do not want to upset or even traumatize them? If you have witnessed dreadful and unpleasant events you may become angry and irritable, which only adds to your difficulties and problems in relationships. There may be a feeling that “you weren’t there, so you won’t or don’t understand”, and while this is an obvious statement of fact it is unhelpful. It is important to find someone who can listen. People often say that they would not wish to tell their partner things which are unpleasant for fear of upsetting them, but what would you want to know if your partner had deployed somewhere? Whatever you do, do talk and/or write about it. Some people may be envious of your experience, others deeply interested, but you may find that you do not want to talk about it and you have moved on psychologically speaking. Either way, in most cases, things resolve with the passage of time and by talking. The return to work can be quite difficult, with a loss of excitement and arousal, a dissatisfaction with the mundane nature of the job, the lack of stimulation, petty bureaucracies and envy from those who did not go. It is possible that you may become unsettled and even move on.
When to Seek Help? If you have had a problematic time, do not forget that it is counterproductive to bottle things up – seek help if: ● ● ●
You want help Someone you respect or care about suggests that you have “changed” The following phenomena are severe or are not settling (or are getting worse) after 6–12 weeks and are interfering with your life: – Intrusive thoughts, images, smells triggered by people, places, media, etc. – Avoiding such “triggers”
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Where to Seek Help? 1. Those who shared the experience – where appropriate 2. Family and friends – where appropriate/available 3. Through your NGO – who should have access to, or be able to direct you to, psychological support 4. Through your family doctor (general practitioner) 5. Private psychiatric and psychological professionals 6. A traumatic stress service such as those run at University College Hospital, London and the Maudsley Hospital, London 7. If you have been tortured you can contact the Medical Council for the Victims of Torture, 96–98 Grafton Road, London NW5 3EJ
Stress Stress may be defined by the following equation: Event (stressor) + Meaning (to you) = Stress reaction, where the key to the development and resolution of a stress reaction is the meaning of the event to you. Meaning is derived from your background, life experiences, coping strategies and abilities, and the psychosocial environment before, during, and after the event. Cultural aspects are also important. There are only a finite number of symptoms of stress reactions, all of which everyone has experienced at some stage. Lists are difficult to remember, and an easy way of recognizing stress reaction is by an individual’s change in personality or character as revealed by their behavior.
Acute Stress Reactions Psychological reactions, which occur during overwhelming critical incidents, may range from blind panic, fear, or agitation through to withdrawal or stupor. These symptoms may be seen in a minority of individuals, and the worse the event, the more likely they are to occur. They settle rapidly when the stimulus is removed.
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Post-traumatic Mental Illness, Post-traumatic Stress Reaction, and Post-traumatic Stress Disorder Most individuals cope well under even extreme adversity. While all will be changed by their experiences, it is wrong to assume that most individuals will be “traumatized” by traumatic life events. Personal “growth” is not uncommon following adverse life experiences, but some individuals may develop problems. It is commonly assumed that the only mental reaction to such exposure is posttraumatic stress disorder (PTSD). This is erroneous, as any mental reaction or illness may occur – PTSD is only one.
Genesis of PTSR Traumatic stress reactions are the product of a complex interaction between the individual, the traumatic event, the environment during and after exposure, and the culture from which the individual and group hail and to which they return.
Factors Involved in the Genesis of Post-traumatic Stress Reactions Normality and Ubiquity Post-traumatic stress reactions (PTSRs) are normal. Indeed anyone who has had the break up of a meaningful relationship has had the symptoms of a PTSR. You re-experience thoughts and images of your loved one which may be triggered by events, places, or people. You may avoid going to places which remind you of the relationship. It may be more difficult to get off to sleep and you may become more emotional or angry. Some individuals turn to drink and some “suffer” more than others. PTSR seem to be universal and most people cope extremely well with adversity; only a few go on to develop a post-traumatic mental illness (PTMI).
Recognition of PTSR PTSRs reveal themselves to others through changes in behavior and personality. These may be subtle, and individuals are often able to continue at work. The better you know your fellow team members, the easier it will be to spot the early signs of problematic PTSR. Your “reactions” to such changes in character are important clues in identifying those with problems. The three pillars of the PTSR are re-experiencing, avoidance, and arousal phenomena. They vary in intensity between individuals, but are basically the same for mild, moderate, and severe PTSRs and disorders. 1. Re-experiencing phenomena 2. Avoidance phenomena. See the ***box overleaf
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3. Arousal phenomena 4. Associated behavior
Postincident Support Early In the early days after an incident, human kindness and support should be offered. Individuals should be listened to with empathic interest. An environment should be created in which they can talk if they wish to, both at the time and afterward. Do not “force” individuals to talk, but try to get a picture of what happened to them. Team leaders should lead by example and get involved appropriately. It is advisable to normalize the situation by keeping survivors at work or by ensuring the earliest possible return to work. Reinforce any teaching received as to the normality of the reaction. Endeavor to analyze what happened with sensitivity and involving the individual(s) in order to learn “lessons” and then enshrine them in protocols and training.
Later As time passes, other people’s interest in those involved will wane in a similar way to grief. Despite this, the individuals concerned may still be suffering, and the main clue to this is a change in personality. If you note this in others (or in yourself) do not be afraid to ask the individual if they are all right and offer access to psychological help when and where appropriate. Traumatic incidents can alter our schemata for ourselves and our world view. They challenge our belief systems, but in most cases the initial psychological symptoms and distress settle within 6–12 weeks. If individuals fail to accommodate to the changes wrought by trauma, they are likely to involute to a greater or lesser degree, and guilt over sins of omission or commission is not uncommon. Encourage talk to prevent “avoidance” while allowing due cognizance to the individuals’ normal coping mechanisms. Aim to provide the “right” environment for the individual to feel able to talk and avoid coercion. It is important to give the individual a feeling that they are supported and that others are “there” for them. Wherever possible, encourage the group to “look after its own.”
Preventive Measures Before Deployment ● ●
Selection should be by high-quality, experienced staff Predeployment training should be realistic in order to build group cohesion
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Sort your problems out; unresolved problems play on your mind and will be there on your return adding to the difficulties of readjustment, especially after a stressful deployment Expectation vs. reality: obtain as much information as possible, but beware of the media
During Deployment ● ● ● ● ● ●
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Make sure you are well informed about the mission and your role Be aware of difficulties inherent in the work and specific to theater Make sure there is work to do Make sure there is time for recreation (and a few little luxuries) if possible Make sure there will be smooth communication with home, i.e., mail, phones, etc. Make sure that home issues are dealt with professionally, and by the NGO where appropriate Make sure that there is access to reasonable medical, dental, and psychological care where possible Discuss any difficulties encountered in your work by your actions or omissions
While posttrauma mental illness is uncommon, there is little evidence that it can be prevented as its genesis is multifactorial. The earlier that help is offered to those suffering, the better the chance of success.
Posttraumatic Stress Reactions and Grief It may be helpful to conceptualize PTSR in terms of a normal human response to unpleasant life events such as grief. It may also be managed in a similar way. ● ●
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Both are a ubiquitous human experience. Both have an idiosyncratic meaning for each individual despite similar symptoms for all. Both “settle” in most instances in 6–12 weeks. Both are helped best by those who shared the experience – family, friends, and colleagues. Some individuals go on to develop mental illness. All are changed by exposure to death and trauma. Both require an acceptance of reality for resolution. Psychological defence mechanisms are at play in both situations and require acknowledgment. In both, there is a “time to talk” which must be dictated by the individual concerned. Some individuals require professional help to overcome their difficulties. Anger is common to both, although it is generally less obvious in grief. In both, psychological “work” is required to accept, assimilate, and accommodate to new realities.
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Stress Management Given the fact that human reactions to stress are so varied and multifactorial in their genesis, it is surprising yet true that most cope much better than an onlooker would anticipate. It is easy to overestimate potential psychiatric difficulties. It is equally easy to forget the long-term psychological cost paid by some people who volunteer to help other people in the world who are less fortunate than themselves. Look after yourself. Seek help and advice if you need it, and accept that change is the only constancy since it is both inevitable and irrevocable.
Coping Mechanisms Cumulative Nature of Stress Exposure to gruelling work schedules, witnessing human misery, and being exposed to traumatic and unpleasant events will take its toll if you do not care for yourself. Learn to recognize when and what stresses you and seek help. You are not superhuman. Make sure you take breaks and holidays to recharge your batteries. Work at relationships and maintain strong friendships and family ties wherever possible. Listen to others who care about you and accept appropriate offers of help. Do not do “back to back” tours of duty. If you burn yourself out you will become useless to those you may wish to help. Beware of thinking you are indispensable – you are not.
“Addiction” to Aid Work You may find that humanitarian aid work is the “only” work for you. The only work that makes you feel worthwhile, challenged, and validated. There are people who need your expertise, so look after yourself, and keep yourself physically and mentally fit to continue. However, do not forget to be truthful to yourself when you ask yourself: Why am I doing this (again)?
Conclusion Take care of yourself. Why Am I Going? Be clear and honest in your mind as to your reason for going. Is it: to do something worthwhile; to utilize your skills; to “put something back”; to take a risk; to “escape” from something? (But do not forget that the something will generally be there on your return!!) Who Am I Going With? Organization – what are its goals; are they trustworthy? Others – what are their motives, ambitions, drives, and personalities? Do we share a common agenda?
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What Information Have I Sought? What sources? Media, nongovernmental organization (NGO), friends, workmates, etc. What ever you do, get as much information as possible in order to answer all your questions. What are My Expectations of the Mission? How different will the reality be? Generate a picture of reality. Physical
Psychological
Racing heart, difficult breathing, nausea Dry mouth Palpitations Tightness in chest Sweating Indigestion Nausea and vomiting Altered bowel habit Teeth grinding Easily distracted Social/behavioral Intolerance, irritability, and argumentativeness Emotional and social withdrawal, isolating self Emotionally demanding, “using” others The individual Previous psychiatric illness Child sexual abuse Previous, current, and unresolved medical and personal problems Poor coping skills
Agitation and irritability Fearfulness and worry Increasing obsessiveness and rigidity of thinking Mood swings Jumbled and racing thoughts Loss of sense of humor Little joy in life Worrying unduly
Thinking Self-doubt Boredom and loss of direction The trauma Predictability and controllability Type and frequency of trauma Involvement – direct or indirect Experienced alone or in a group Helplessness and loss of control engendered Existential meaning of event
The environment Before the event Cultural beliefs Psychosocial support Current life events Predeployment training During the event Support/response to incident After the event Human kindness and support – extending over time Normalization vs. medicalization of reaction Appropriate involvement of hierarchy Media attention Signs & Symptoms
1. Re-experiencing ● ●
Recurrent, unwanted, intrusive thoughts, images, sounds, and smells Triggered by places, people, and events leading to distress and physical arousal
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2. Avoidance ● ●
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Avoiding thoughts and things associated with the event – even amnesia Feeling cut off, emotionally isolated from others with a reduction in the normal range of feelings Loss of interest in things previously enjoyed A different view of the future – shortened life span
3. Arousal ● ● ● ● ● ●
“Jumpy”, “on edge” – unable to relax Irritability and aggression Difficult sleeping Poor concentration Forgetfulness Physical responses to reminders of the event
4. Associated Behaviors ● ● ● ● ● ●
Risk taking activities and impulsivity Increased accidental deaths – road accidents Substance abuse, especially drinking Depression Relationship problems Survivor guilt
5. Adaptive ● ● ● ● ● ●
Sit and ponder the situation constructively Express emotions with friends Get appropriately angry Talk to as many close friends as is reasonable Look for the good in the experience and what you can learn Get help – practical and supportive
6. Temporary ● ● ● ● ●
Keep busy, throw yourself into something Do something where you do not use your mind, e.g., physical activities Bottle things up, then “explode” Irritability and irascibility Distract yourself by treating yourself to something
7. Maladaptive ● ● ● ● ●
Trying not to think Social withdrawal Denying reality Hiding emotions Constant worry
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Losing sleep Drinking or smoking too much
8. Dealing with stress – accept reality ● ● ● ● ● ● ● ● ●
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Acknowledge what stresses you Keep a balance between work and leisure Find a safe confidant Keep a network of friends and acquaintances Look after yourself Ask for help if you need it Avoid excessive alcohol and smoking etc. Take regular exercise Eat a balanced diet – always eat meals as they break up the day and relieve strain Maintain or develop outside interests Holidays exist for your mental health Be flexible – the only certainty is change Let the past go Assess situations objectively and accurately Listen to others
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Part B – Psychosocial Resilience and Distress in the Face of Adversity, Conflict, Terrorism, or Catastrophe Richard Williams and David Alexander
Psychosocial Trauma The Nature of Psychosocial Trauma Major incidents and disasters challenge our beliefs about ourselves, our families and friends, and the world. Ordinarily, we make three fundamental assumptions: ● ● ●
The world is essentially a good place. Life and events have meaning and purpose. One’s own person is valuable and worthy (Janoff-Bulman 1992).
Psychological trauma occurs when events and/or circumstances challenge these assumptions and take a person beyond their tolerance. Occasionally, events or relationships are so hurtful to us that we question and alter our fundamental worldviews, “Traumatic events effect great damage not so much because of the immediate harm they cause but also because of the lingering need to re-evaluate one’s view of oneself and the world” (Condly 2006). Certainly, events of the nature of those that are covered in this book rank at that level of enormity. While some people appear from the outside to be relatively unaffected or resistant to the potential psychosocial impacts of the events or circumstances they face, many others become at least temporarily distressed until the circumstances improve or they are able to adapt. A smaller proportion of people becomes more substantially psychosocially impaired or mentally disordered in the medium or longer terms. The latter response is seen more frequently after people experience repeated traumatic events. This chapter examines how people cope psychosocially with disasters, and why some people adapt better than others. Later, we use the principles that fall out of our exploration to commend a framework for developing and sustaining the psychosocial resilience of people who respond to disasters. In so doing, it is important to distinguish distress from disorder.
Distress or Mental Disorder? There are fundamental differences between distress and mental disorder (Horwitz 2007). Confusion arises because our responses may appear similar, but, the distinction is important because it influences how we understand the reactions of people after
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disasters and conflict, including the responses of responders, and how we decide which services to provide, when, and for whom. Horwitz sees distress as initiated and maintained by social stressors and as persisting as long as these stressful conditions endure. It subsides “… if the stressor … [disappears] … or as people adapt to their circumstances. Distress is a normal human emotion, not a disorder, when it emerges and persists in proportion with external stressful situations.” By contrast, mental disorder implies a dysfunction in particular people and exists when there is something awry with the internal functioning of affected persons in which “… some psychological system of cognition, mood, emotion and the like is unable to function appropriately.” While most events that are the subject matter of this book are potentially traumatizing, most people cope reasonably and adapt surprisingly well; “… among residents of New York City living south of 110th Street after the terrorist attacks of September 11, 2001, the prevalence of probable PTSD fell from 7.5% at 1 month to 1.6% at 4 months and 0.6% at 6 months” (Bisson et al 2007). We argue that the term PTSD is unlikely to be justified to describe the reactions of all of the people who were so identified 1 month after the event. Nonetheless, this example makes the point that a month after major incidents a sizeable proportion of the population affected directly or indirectly may show strong emotional and psychological responses, but that this proportion declines with time. These figures also fit with other experiences by showing that a much larger number of people are distressed within the first month than develops a mental disorder. This highlights how and when we might best assess the impact of potentially traumatic events; it raises the importance of timelines and people’s personal experiences and narratives. Additionally, this example shows that, while most people recover from or adapt to distress, positive adaptation cannot be assumed and traumatic events can and do lead to mental disorders for a proportion of the people who are involved. Despite this caveat, how and why do so many humans cope effectively with conflict and disaster without most developing long-term psychopathology? While the answer is complicated, the mist that obscures our understanding is lifting as we acquire more knowledge; what we now know raises the concepts of resistance and resilience. Our knowledge emphasizes how important in the aftermath of major incidents are supportive families, communities, workplaces, schools, and colleagues. While less is known than we wish, there are pointers to appropriate actions for responders to emergencies and disasters to take. This chapter links with other chapters in this book on leadership, teamwork, and the psychosocial consequences of conflict and catastrophes.
Resilience, Hardiness, and Resistance Resilience has become a colloquial term in emergency planning. But, it should be distinguished from resistance, hardiness, and recovery from a disorder. Often, all of these responses are implied by policymakers’, planners’, and practitioners’ use of the
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word, but inexact use of terms is of no assistance to evidence-based service design and practice (Layne et al. 2007).
Resilience The concept of resilience stems from technology. It concerns the capacity of a material to return to its original shape after a force is removed or changed that had caused deformation that did not exceed the elastic limits of the material. The tires of a moving vehicle, for example, are subject to dynamically and continuously changing forces; they change their shape in response to deforming pressures from the vehicle’s weight and motion that are balanced by restorative forces that are inherent in the rubber composition used and the air under pressure that is contained within. Together, these forces return the tires to their natural shape. Just as materials deform and return to their previous shape, so do humans in the face of challenge, threat, and adversity. Provided circumstances do not take us beyond our limits of tolerance for too long, many people respond either by showing relatively few emotional reactions or by becoming temporarily distressed before returning to more ordinary functioning and relationships once the source of our concerns is modified, removed, or adjusted to. This is resilience. Resilience is NOT about avoiding short-term distress or deleterious responses, but about how people adapt to and recover from them and about the resources, including our social and personal capital, that we have developed and which sustain us in adversity. We define psychosocial resilience as “A person’s capacity for adapting psychologically, emotionally, and physically reasonably well and without lasting detriment to self, relationships, or personal development in the face of adversity, threat, or challenge” (Williams 2007). “Resilience can be thought of as an enduring characteristic of the person, a situational or temporal interaction between the person and the context, or a unitary or multifaceted construct, and it can be applied to social, academic, or other settings” (Condly 2006). An important feature of resilience is that it involves a dynamic array of interacting experiences, relationships, and personal characteristics and some, at least, are amenable to change or development. So far, we have presented resilience as relating to individual people. However, resilience is also used to describe the capabilities and capacities of groups of people, communities, workplaces, services, and societies to recover, adapt, and return to their previous circumstances and relationships after incidents, events, or circumstances that produce challenge, distress, and dislocation. The former is termed personal resilience while the second is collective resilience. Recent research on the London bombings of 7/7 2007, for example, has explored the oft reported observation that groups of survivors and witnesses panic or put their own safety first (Drury, et al. 2008). “This work has reported findings that are similar to those about many other disasters which show that widespread panic in the face of catastrophic events is substantially a myth. Only a tiny number of people trapped in the tube tunnels on 7/7 reported seeing anyone who engaged in selfish behaviors or panicking. There were much more frequent reports of mutual helping and cooperation with strangers and of people delaying their release from entrapment to make sure that others were looked after or accompanied. Sometimes, those behaviors raised
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the risks to the people who stayed behind. That research group has argued that the people involved redefined their notion of self to create a temporary common identity (i.e., moving from “me” to a shared identity of “us”) in the immediate aftermath and that this is evidence of collective resilience. Thus, collective resilience has features in common with what good leaders try to do in creating and sustaining teams and with morale and esprit de corps.
Hardiness and Sense of Coherence Hardiness is a term that comes from horticulture. It describes the ability of plants to survive adverse growing conditions. Thus, it is related to resilience and resistance. When applied to people, it consists of three components Commitment implies that hardy people view potentially stressful events as meaningful and interesting; control means that people see themselves as able to change events; and challenge means seeing change as normal and as providing opportunities (Maddi and Kobassa 1984). Ambulance staff, who are rated as hardy on a rating scale that measures commitment, control, and response to challenge, were less likely to have general psychopathology, burnout, and posttraumatic symptoms (Alexander and Klein 2001). Also, commitment is the component of hardiness that moderates the relationship between stress and depression (Pengilly and Dowd 2000). Hardiness, therefore, describes some of the features of personal resilience.
Resistance Resistance concerns the capacity of materials to respond to strain without changing shape. Evidently, some materials are resistant up to a limit, but not resilient while others are highly resilient but not necessarily resistant. Translated into situations faced by human beings, resistance describes their abilities to maintain adaptive functioning in demanding circumstances, whereas resilience describes their plasticity and adaptability and capacity to recover quickly once the pressure of events is relieved.
How People Respond to Disaster The curve in Fig. 22.1 is a hypothetical graph (i.e., it is not based on research data though it is informed by observation and by evidence of a variety of types) that has been drawn to provide a graphical representation of how a population of people, who have been affected by a major incident or disaster, might respond psychosocially to the threat over time. It portrays the high frequency of people who respond with proportionate distress very soon after a disaster or major incident. Most people who are exposed to situations that have the potential to evoke distress do not develop substantial psychopathology. Nonetheless, distress provoked by exposure to disaster may precipitate a minority of people into developing a mental disorder or exacerbate a pre-existing condition such that it continues after the traumatizing circumstances have been resolved or been, otherwise, dealt with. The literature suggests there are four overlapping
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100%
Distress and /or Disorder
75% Aproximate Proportion of Affected Persons
50%
25%
Impact
3 Days
30 Days
Time
6 Months
3+ years
Fig. 22.1. Psychosocial responses of a population to a disaster or major incident.
broad groups of people for whom services may be requested in the immediate, postimmediate, and longer terms. Overall, these groups combine to produce the curve of Fig. 22.1. They are as follows.
Group 1 Resistant people who experience minor and/or transient distress in the immediate circumstances of disasters or traumatic events. Resistant people show the least debilitating responses.
Group 2 Resilient people who experience more substantial distress, which usually only lasts 2–7 days or so after traumatic events and is not associated with any substantial level of dysfunction. It is a common finding that resilient people experience short-term adverse reactions to traumatic events followed by rapid recovery; brief human perturbation after traumatizing events does not imply that they are not resilient. Most of them are capable of being involved in rescue work. Indeed, most resilient people have temporary and, sometimes, strong reactions to traumatic events or processes, but they recover rapidly in the following days provided they are offered support and are able to return to their work with only a brief period for recovery given sufficient inner resources augmented by external support from family members, colleagues, and friends.
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Group 3 People who have more sustained or persistent distress associated with dysfunction and/or impairment. There are two subgroups within this group of people who, though they are similarly affected, may take longer to recover. They are: people who are likely to recover, but whose recovery takes more time; and people who may be in the course of developing a mental disorder. In this regard, the concept of recovery implies a short to medium-term response to trauma that may well have compromised a person’s ability to function or cope.
Group 4 People who develop a mental disorder. Some of the members of Group 3 may develop an acute stress disorder and require more substantial intervention while a smaller number of people go on to develop a longer term mental disorder such as an anxiety disorder. Depression, PTSD, and substance misuse. Some people may not develop these conditions until several years after the event. In general terms, the needs of people who have been involved in disasters and major incidents become greater and potentially more complex in passing from Group 1 to Group 4, while the numbers of people involved decreases. Accordingly, there is a progression in the level of expertise required to deliver responses. The picture of people’s responses over time may be, however, more complicated than this generalized pattern, which varies considerably with the nature of events and the circumstances in which they occur. As an example, psychosocial reactions after flooding may not follow the speed of development that has been set out so far; distress may be prolonged and develop more slowly and peak later (at around 9 months after the event and as community life begins to return to more usual patterns). Current knowledge about resilience, risk and protective factors shows that it is difficult to predict with precision who is likely to recover from their immediate reactions or from distress with support from families or provision of community and welfare services and who may have more sustained distress or develop a mental disorder. However, despite the variability of individual and group responses to major incidents, it is possible to plan for sufficient psychosocial services provided flexibility is built in to allow adjustments as the nature of events clarifies. For these reasons, the generalized picture, summarized here, of how people respond psychosocially to traumatic events is intended to underpin planning, preparing and strategic management of services rather than to suggest that there is a single orthodoxy of clinical provision. However, at clinical and operational management levels, there is an international consensus that how people progress during the first month provides the most helpful information and this is the basis for the approach adopted by the UK’s armed services’ Trauma Risk Management (TRiM) programme (Greenberg et al. 2005). If distress is diminishing within 4 weeks of exposure to a major incident, the people concerned are more likely to continue to recover. But if their distress is continuing, is increasing, or is causing substantial problems for them or other people, a full assessment of their mental health needs is required.
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In summary, it is possible, perhaps arbitrarily though helpfully for planning and preparatory purposes, to distinguish several broad patterns of human reaction to adversity, threat, or catastrophe in which distress is a feature. They include people who have: ●
●
●
●
Low levels of very mild and transient immediate distress that do not interfere with their actions, but which are consistent with resistance Immediate and short-term distress that is only temporarily debilitating, but consistent with resilience Short- and medium-term distress from which they may take longer time to recover. Some members of this group may have experiences that amount to an acute stress disorder, which is followed by more gradual and protracted recovery to positive adaptation Severe, persisting, longer term chronic distress or distress that develops months or years after the event that is associated with incomplete short- to medium-term recovery and more severely compromised functioning in the medium to longer terms and which amounts to a mental disorder.
Additionally, there is another possible outcome; that of enhanced psychosocial development. One research study of Israeli adolescents who had experienced terrorist incidents has, for example, reported that around 40% had posttraumatic symptoms, but, conversely, that 75% also reported feelings of emotional growth (Laufer and Solomon 2006). This raises the possibility of challenges that are well handled being associated with positive as well as negative psychosocial outcomes. Arguably, we require from responders to emergencies, conflicts, and catastrophes a balance of resistance, hardiness, and resilience such that they are not only able to cope and remain effective, but also able to empathize with the impacts and burdens borne by people who are directly and indirectly involved. There is some evidence that hospital staff who are more empathic are also more likely to be emotionally distressed (Firth-Cozens 1987). This implies that empathic people may not appear to be as resistant as others though, of course, this does not imply that they have any lack of resilience. Empathy is a highly desirable capability that enables people to carry out their roles sensitively and compassionately, but it also requires good support facilities to be in place to support the resilience of the responders. These inferences should inform how we select and support personnel for humanitarian interventions; arguably, teams of responders might be composed of people who have differing styles to achieve a range of capabilities and capacities.
The Origins and Nature of Personal Resilience The components that make up human resilience relate to particular people’s inherent characteristics, their experiences in life, and their relationships with family members, peers, and school and workplace colleagues. Personal resilience is a developmental concept. There is much research on the impacts on children’s development and their responses to chronic stressors that are associated with persisting poverty, poor familial relationships and, increasingly, on the effects of acute and potentially overwhelming single incidents. The two patterns interweave through particular people’s narratives of life, but it remains a moot point
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as to how far the research on developmental psychopathology is translatable into acute scenarios and vice versa. Research on 9/11 and other scenarios suggests to us that there are strong and practically important crossovers. Recently, it has examined why “… the long-term impact of the attack (on the World Trade Center on September 11, 2001) was less pervasive than anticipated for most survivors” (Fraley et al. 2006). The findings point to attachment capacity as an important factor; “… securely attached individuals exhibited fewer symptoms of PTSD and depression than insecurely attached individuals …”. These point to resilience having dynamic, developmental and relational characteristics. Additionally, we can distinguish between comparatively static attributes in people and their social and physical environments and dynamic mechanisms, processes, and pathways of influence that, together influence resilience. More is known about the attributes and relatively less about the latter three features. A summary is provided by Fig. 22.2. A recent literature review of the factors that influence children’s development in the face of chronic, and often, repeated challenges is summarized in Fig. 22.3. In all probability, different people’s differing responses to challenging events are determined by a variety of interlocking genetic, biological, neurochemical, psychoPersonal skills: 1 The capacity to receive social support; 2 Good cognitive skills ● 3 Good communication skills ● 4 Active problem-solving skills ● 5 Flexibility - the ability to adapt to change ● 6 Ability to cope with stress (seeing stress as a challenge) Personal beliefs and attitudes: ● ●
1 Self-efficacy (general expectation of competence) 2 Self-esteem ● 3 Hope ● 4 A sense of purpose ● 5 Religion or the feeling of belonging somewhere ● 6 Positive emotion and humour ● 7 The belief that stress can have a strengthening affect ● 8 Acceptance of negative feelings Interactive skills, relationships and achievements: ● ●
● ● ● ● ● ●
1 2 3 4 5 6
Good relationships with other people Contributions to community life Talents or accomplishments that one values oneself or which are appreciated by others Access to and use of protective processes Adaptive ways of coping that suit the situation and the person Growth through negative experiences
Fig. 22.2. Resilience factors. Reproduced from Williams (2008), developed from Schaap et al. (2006). With kind permission of Pavilion Publishing.
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Resilience is: Dynamic
Resilience changes over time and may be of differing strength in differing situations
Developmental
Resilience is affected profoundly by a person’s experience in childhood and beyond
Interactive
Passiveincreasing a person’s ability to withstand trauma
Resilience may be thought of as related to each person’s ability to withstand trauma. So, one approach is to help people to develop their ability to cope well when faced with trauma.
Active - shaping the environment to minimise trauma
A second approach to developing resilience is based on the observation that more resilient people express agency in doing what they can to organise the world around them to minimise the risks of being exposed to situations that are traumatic. At the same time, most people also wish to experience some risks and each one of us has our own setting on our ‘risk thermostat’. Actively coping well may, therefore, be related to knowing what is our own comfort with risk and adjusting the risks one faces when this is an option.
Related to attachment capabilities
Research has shown strong relationships between people’s capacities for secure attachments and their resilience.
Gender related
Generally, women are more resilient than men though they are also more likely to develop longer-term psychiatric disorders too.
Fig. 22.3. The nature of resilience. Based on Condly (2006) and reproduced from Williams (2008). With kind permission of Pavilion Publishing.
logical, developmental, social, and circumstantial factors though we know less about how environmental factors interact with the biological influences (Ciccetti and Blender 2006; Curtis and Cicchetti 2003). Through research on children and how they deal with obstacles and hostile environments, Garmezy (1991) has identified factors that are found in all definitions of resilience. On the basis of Condly’s review of Garmezy’s work, the factors, as they relate to children, are: ●
Factor 1: Intelligence and temperament There is research evidence showing that resilient children “tend to possess an above average intelligence and a temperament that endears them to others”. In Condly’s opinion, the combination of these two features is particularly important.
●
Factor 2: Family relationships and level of support available from family There is support for the notion that the roles of families in the development of resilience are most important early in life and decline as children grow older.
●
Factor 3: External support from other persons and institutions Support of specific types for families is a major discriminating factor in resilient urban children who have experienced life stresses. These positive social supports must actively include the children at risk and are best when whole families are supported.
The availability of social support and people’s abilities to accept it emerge from research recurrently and strongly as two of the most important components
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of resilience. Research by Brewin et al. (2000) and Layne et al. (2007) has shown that: ●
●
●
Absence of social support and occurrence of life stressors have greater effect sizes than do the risks presented by gender, abuse as a child, intelligence, socioeconomic status, poor education. The effect sizes of social support and contemporary life stressors are similar to or greater than the dose effect of degree of exposure to potentially traumatizing situations. Social support and optimism are associated with positive outcomes after trauma.
In summary, personal resilience has a number of hallmark characteristics. 1. It is an ordinary characteristic of ordinary people. 2. It is a concept that means a great amount more than a person not having been exposed to circumstances that produce risk of mental disorder. 3. It has contributions that stem from genetic and acquired personal features. 4. It means that people have transactional capacities for being able to make and sustain relationships, and receive and have available to them sufficient, effective social support. 5. It is a dynamic quality in which personal factors, such as attachment capacity and temperament, interact with relationships with other people and the changing external circumstances.
Planning Service Responses In this final section, we bring together information about resilience to offer a model for developing and sustaining people who respond to major incidents by considering core principles. Similar principles could be applied to working with communities that are at risk of major incidents or afterwards. Experience and research concur in showing that people are generally resilient and, perhaps, more so than we might consider to be the case. In favorable situations and, given adequate preparation and family and social support, resilience and resistance tend to be many human’s default settings. However, this should not lead to any complacency because: ● ●
●
●
There is a sizeable minority of people in which this is not the case. There are risks of a sizeable minority of people developing mental disorders that, sometimes, become chronic. There are imperatives to respond effectively to human suffering whether it is of short-, medium- or longer term duration. Our predictive science is just not good enough yet to forecast who is likely to do well and who is not.
Taken together, these findings are particularly important when people are designing the kinds of interventions that are intended to enhance people’s resistance and resilience and, thereby, reduce the deleterious psychosocial impacts on people who are involved in major incidents including responders.
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Strategic Considerations A key question is how we can and should use what we know to plan services that achieve the best for survivors but also promote their staff’s personal resilience, and the collective psychosocial resilience of families, groups, and teams that constitute services, communities, and societies and their recovery during and after emergencies, conflicts, and catastrophes. This implies questions about the actions that can and should be taken preventatively to create hardy people and systems by promoting greater resistance and resilience prior to major incidents. It also raises further questions about what actions we might take, as events unfold, to aid the resilience and reduce the prospects for protracted or impaired recovery of the affected populations and the responders. There are three levels for intervention: ● ● ●
Individuals Families Communities including workplaces
We also believe that our approach should stem from actions that are taken to improve the collective resilience of populations including, particularly in the context of this book, the workforce that is likely to be exposed by responding to events. These interventions include actions that should be put in hand through preparation and planning before any event, actions taken during an event and actions taken afterwards. Following Masten’s approach (Masten 2001), we think that a framework for promoting and sustaining staff resilience should: ●
●
●
●
Activate fundamental protective systems by making responders aware of them, increasing their self-confidence as they learn and, thereby, increasing their feelings of self-control (i.e., enhance sense of person worth, effectiveness, agency, and hardiness) Increase the quantity, accessibility, and quality of resources, including, particularly, the social support that they require in order to develop competence and retain it Reduce the exposure of responders to hazards or the chances of risks impacting on them so far as is possible Recognize that responders may become distressed and require additional support with the possibility of more specialized intervention for a very small minority.
This requires good planning and rehearsal of services that respond to disasters before deployment to ensure that: ● There is good and credible strategic leadership and management through which the vision, values, reason, and purpose of intervening is communicated, refreshed, and kept clearly in mind. ● Appropriate and realistic guidance, standards, and expectations are set and communicated before the event. ● Realist preparation and training is provided. ● Supervision and mentoring are available. ● Effective and responsive day-to-day operational leadership and service management are provided that supports group cohesion, builds self-efficacy, and provides social support. ● Information about events and impacts is made available, which is of high quality and credibility as is possible.
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Each team member has continuing contact with their family. Services are made available to the responders who may require them.
Thus, broadly, there are four types or levels of intervention that are required to achieve the aims of improving and sustaining the psychological resilience of responders individually and collectively. We recommend a stepped program that begins with work to develop the collective resilience of the staff involved and progresses through operational levels, at which individual responders are sustained on a day-today basis, and also that the system should allow responders who require personal assistance to receive it. The steps are: 1. Strategic leadership and management that enables planning and development for staff well before an incident such that teams are able to sustain psychological wellbeing and respond to the psychosocial needs of their members in the event of an incident. 2. Effective service leadership, management, and organization of services that sets clear standards and expectations of team members not only at the time of the acute phase of an incident but also throughout its duration as well as in the service regeneration phase. 3. Operational leadership and management that provides opportunities for teams to meet and exchange experiences and feelings and which ensures sustained follow through of effective self and team care. 4. Provision of basic psychosocial assessment and interventions immediately after the incident and throughout its duration for the people who require them with access to more comprehensive psychosocial facilities for a minority. These four levels of intervention are depicted in Fig. 22.4. LEVEL 1 Strategic Leadership & Management
Management of Expectations
Planning
Leadership and Management
Develop Models of Care
Education & Training
Competencies & Ethical Guidelines
Rest, Recuperation and Adherence to Duty Rotas
Monitoring Practice & Clinical Supervision
LEVEL 2 Service Leadership & Management that Sets Clear Expectations and Standards for Practice
LEVEL 3 Day-to-day Leadership and Management Practice
Clarity of Practice Expectations
Provision of accurate, up-todate and relevant information about the situation
Triage System
Discussion, Operational & Technical Debriefing
LEVEL 4 Psychosocial and Healthcare Responses
Psychological First Aid Mental Health Service Assessment & Intervention conducted in Primary Care
Specialist Mental Health Services
Fig. 22.4. A framework for promoting the psychosocial well-being and effectiveness of staff.
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Operational Considerations There is a spectrum of how humans respond to powerful psychological trauma. At one end, there is resistance, resilience, and growth, but, at the other end, there can be gross and identifiable psychopathology. Some, particularly the more extended emergency situations and challenges, may not appear so demanding on the surface, but the demands may be cumulative and exhaust the coping resources of the staff involved. Other major incidents, on the other hand, may be characterized by long and drawn out strain, due, for example, to the nature of the circumstances, and represent a deleterious threat to the effective coping of responders. Leaders should be aware that it can be difficult to distinguish the reactions of people who are resilient but who are experiencing temporary distress from those who have acute stress disorders and from the reactions of the lesser number of people who are developing longer term problems. Dealing with major incidents and disasters is emotionally draining and potentially traumatizing. On the other hand, critical incident debriefing is not recommended (Bisson et al. 2007). Nonetheless, teams should have available to them the knowledge and skills to: ●
● ● ● ●
Provide opportunities for teams members to meet each other to share their experiences Sustain credible information flow Assess responders’ needs Implement the principles of psychological first aid in caring for each other Provide basic psychosocial assessment
We advocate adoption of the 4 week rule when deciding how to manage responders who appear to be showing sign of distress (National Collaborating Centre for Mental Health 2005). We are not recommending that they do not receive help in those 4 weeks but that they are provided with additional social support that follows the principles of Psychological First Aid as described elsewhere in this book (National Child Traumatic Stress Network and National Center for PTSD 2005). A key question is how we should conduct assessments of people who appear to be distressed shortly after a major incident or while they are providing relief and recovery services because the consensus of advice is not to raise emotion through formal debriefing. There are several schemes. One of those is the Trauma Risk Management program that is in use in the UK’s armed forces and which is based on making assessments of affected persons three days and, again, 28 days later. TRiM practitioners are trained to assess ten aspects of interviewees, experiences and they are summarized in Fig. 22.5. Acute stress, which we prefer to call distress, at the day three assessment, is assessed on the basis of the ten items in Fig. 22.6.
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Thought that they were out of control during the event Thought that their life was threatened during the event Blames others for some aspect(s) of the event Expresses shame about their behaviour relating to the event Experienced acute stress following the event Has experienced substantial general stress since the event such as problems with work, home and health Is having problems with day-to-day activities Talks about problems relating to previous traumatic incidents Has problems in gaining access to social support (from family, friends or at work) Has been drinking excessively to cope with their distress Fig. 22.5. Risk factors. (from TriM) (reproduced with permission from the authors of TriM).
1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
Has upsetting thoughts or memories about the event that come into mind against the person’s will Has upsetting dreams about the event Acts or feels as though the event is happening again Feels upset by reminders of the event Has bodily reactions when reminded of the event Has difficulty falling or staying asleep Is irritable or has outbursts of anger Has difficulty concentrating Is overly aware of potential dangers to self or others Is jumpy or is startled at something unexpected Fig. 22.6. Indicators of acute stress (from TriM) (reproduced with permission from the authors of TriM).
References Alexander DA, Klein S. Impact of accident and emergency work on emotional health and well-being. British Journal of Psychiatry, 2001, 178, 76–81. Bisson JI, Brayne M, Ochberg FM, and Everly GS. Early psychosocial intervention following traumatic events. American Journal of Psychiatry, 2007, 164(7), 1016–1019. Brewin C, Andrews B, and Valentine J. Meta-analysis of risk factors for posttraumatic stress disorder in trauma-exposed adults. Journal of Consulting and Clinical Psychology, 2000, 68, 748–766. Cicchetti D, Blender JA. A multiple-levels-of-analysis perspective on resilience. Annals of the New York Academy of Sciences, 2006, 1094, 248–258. Condly SJ. Resilience in children: a review of the literature with implications for education. Urban Education, 2006; 41(3), 211–236. Curtis WJ, Cicchetti D. Moving research on resilience into the 21st century: theoretical and methodological considerations in examining the biological contributors to resilience. Developmental Psychopathology, 2003, 15, 773–810.
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Drury J, Cocking C, and Reicher S. (in press). Everyone for themselves? A comparative study of crowd solidarity among emergency survivors. British Journal of Social Psychology. DOI:10.1348/014466608x357893. Firth-Cozens J. Emotional distress in junior house officers. British Medical Journal, 1987, 295, 533–536. Fraley RC, Fazzari DA, Bonanno GA, and Dekel S. Attachment and psychological adaption in high exposure survivors of the September 11 attack on the World Trade Center. Personality and Social Psychology Bulletin, 2006, 32(4), 538–551. Garmezy N. Resilience in children’s adaptation to negative life events and stressed environments. Pediatric Annals, 1991, 20(9), 459–466. Greenberg N, Cawkill P, March C, Sharpley J. How to TRiM away at post traumatic stress reactions: traumatic risk management – now and the future. J R Nav Med Serv 2005, 91:26–31. Horwitz AV. Distinguishing distress from disorder as psychological outcomes of stressful social arrangements. Health, 2007, 11(3), 273–289. Janoff-Bulman R. Shattered Assumptions: Towards a New Psychology of Trauma. New York, NY: Free Press, 1992. Laufer A, Solomon Z. Posttraumatic symptoms and posttraumatic growth among Israeli youth exposed to terror incidents. Journal of Social and Clinical Psychology, 2006, 25(4), 429–447. Layne CM, Warren J, Shalev A, and Watson P. Risk vulnerability resistance, and resilience: towards an integrative conceptualization of posttraumatic adaptation. In MJ Friedman, TM Kean, and PA Resick (eds). PTSD: Science and Practice – A Comprehensive Textbook. New York, NY: Guilford, 2007. Maddi SR, and Kobassa SC. The hardy executive: health under stress. Homewood, Illinois: Dow Jones-Irwin, 1984 Masten AS. Ordinary magic: resilience processes in development. American psychologist, 2001, 56(3), 227–238. National Child Traumatic Stress Network and National Center for PTSD. Psychological First Aid: Field Operations Guide. National Child Traumatic Stress Network and National Center for PTSD: 2005; 2005. http://www.nctsnet.org/nctsn_assets/pdfs/pfa/PFA9-6-05Final.pdf Site last verified on 5 March 2006. National Collaborating Centre for Mental Health. Post-traumatic stress disorder: the management of PTSD in adults and children in primary and secondary care. National Clinical Practice Guideline Number 26. Commissioned by the National Institute for Clinical Excellence. London/Leicester: Gaskell/British Psychological Society, 2005. Pengilly JW, and Dowd ET. Hardiness and social support as moderators of stress. Journal of Clinical Psychology, 2000, 56(6), 813–820. Schaap IA, de Ruijter AM, van Galen FM, and Smeets EC. Resilience: the article. Amsterdam: Impact, 2006. Impact-kenniscentrum.nl (accessed 20 December 2007). Williams R. The psychosocial consequences for children of mass violence, terrorism and disasters. International Review of Psychiatry, 2007, 19(3), 263–277. Williams R. Resilience. In C Jackson, K Hill, and P Lavis (eds). CAMHS Today. Brighton: Pavilion, 2008.
Part C – Requiem: Going Home David R. Steinbruner
As the day of my departure from Iraq draws near, I find myself filled with a mixture of overwhelming joy and a nagging sorrow. The joy is obvious, pushing out of my chest and making me laugh out loud at times: I am going home to my family, to reenter the world, to again caress my life, and that which matters most to me. The steady pace of work here makes each new day on the calendar pop up as a surprise and the time, which I thought would crawl by, has shown surprising bursts of speed. A message came by email, however, which stopped me cold. Over the past 17 months, my cousin Mike’s daughter, Annika, had been fighting a private war with cancer. He had somehow summoned the strength and the presence
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of mind through the onslaught to write to all of us, family and friends, and answer the questions which we so desperately wanted to know but were afraid to ask. Each email he sent would fill me with a volatile mix of hope and dread. The other night he wrote to tell us of her passing. I hesitate to write of her death, because the telling of it is his and her mother’s story. I will only say that on my brief trip home in March, my children visited with her and her sister. I remember the look which she gave me when I came to the door, (I suspect that she knew that I was a doctor and therefore not to be entirely trusted): “I know that life is unfair, for I have seen it. Do not try and tell me different. Come on, let’s play.” Annika is not bothered of her cancer and never was. And so she did, showing Ryan her room and toys and fighting with him when he got too pushy. For me she is the happy little girl in the photograph on my wall, hugging her sister Katrina with a look of joy and mischief. That is how I shall remember her. The news of her death brought up the images of the children I have seen. I now have an understanding of my sorrow. It is the stillness of the faces which seem so wrong, for a child’s face is never still but filled with an intense, living movement that suffuses it even in sleep. It is as if you can see them growing beneath the skin and the air around them is charged with possibility. In our trauma room, at the moment of a child’s death, the world pauses for a few seconds to readjust; God himself holds his breath and lets out a deep sigh at her passing. It is at the moment when I declare the time of death that I believe I can see the soul as it flickers out. No matter how violent the end, every child’s face takes on a look of intense peace and it is hard not to think that she is just asleep. But the stillness is too deep and the quiet too profound. Each moment, and there have been too many here, leaves us numb and angry. The rest of the shift is cloaked in an unnamed sadness and the questions of our purpose here refuse to be easily answered or go away. I suppose, after nearly 11 months in Iraq, I should have a better handle on the best course of action. I cannot really say that I have any better understanding of the whole affair than anyone else. In some ways, my view is the most skewed as I see the worst each day of what the conflict has to offer. Yet I only see a small amount of the violence which encompasses Baghdad and the towns around it, so perhaps I can, on balance, see it for what it is and give it a fair assessment. Failure here is not really an option. We have taken a country the size of California, with a population of nearly 24 million, and stripped it of its power structure. What we have left behind is still in flux and its future very uncertain. Despite the ever shifting rhetoric of why we are here, we are engaged and must remain so until some security prevails. I do not believe that we will achieve a democracy here as we enjoy it, but we must leave it with some stability. Ironically, the government we leave behind is likely to be representative, repressive, and very Islamic. It is likely to be closely aligned with Iran and in constant battle with the Sunni minority. The Kurds, who steadfastly refuse to fly the Iraqi flag, will jealously guard their autonomy and keep Turkey, Iran, and Syria in an uncomfortable alliance against their independence and efforts to combine into a separate state. I do not think that we will see a comfortable peace here for a long, long time. There have been, of late, increasingly dire pronouncements of the historical importance of the fight here. Comparisons have been drawn to previous wars and the opposition has been cloaked by some in the garb of democracies’ greatest enemies.
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The aim of this section is to focus down onto hospitals and health systems. The first chapter illustrates how health services undergo transition in the wake of conflict. Other chapters then illustrate this process with specific examples and offer planning methods when looking to assist health systems. Personal views provide a “real world” context.
SECTION
4
Introduction: Hospitals and Health Systems James M. Ryan and Peter F. Mahoney 23. 24. 25. 26. 27. 28.
Conflict recovery-health systems in transition Pristina 1999-eating an elephant Conflict Surgery: A Personal View Military Health Services Support In Conflict Military Medical Assistance To Security Sector Reform MCM Hospital Blues
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The aim of this section is to focus down onto hospitals and health systems. The first chapter illustrates how health services undergo transition in the wake of conflict. Other chapters then illustrate this process with specific examples and offer planning methods when looking to assist health systems. Personal views provide a “real world” context.
23. Conflict Recovery-Health Systems in Transition James M. Ryan
Objectives
● ●
● ●
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To introduce the concept of conflict recovery To describe the transition from the immediate response to medium and long-term recovery measures To describe the process using case examples To describe the principles underpinning mounting an effective response To summarize lessons and pitfalls
Introduction The essence of conflict is the actual or implied use of violence. Recovery implies a return to a previous state. Recovery may be rapid (measured in days or months) or may take many years. What may be called the onset of recovery varies – it may begin almost immediately during the acute phase of a conflict or a catastrophe. The immediate provision of humanitarian provision of food, water, sanitation, and shelter in the first days is an illustration of a very early manifestation of conflict recovery. However, the process typically begins in the postemergency phase, when a degree of stability and safety allows a more comprehensive approach.
Conflict Environment Provision of health care and healthcare promotion in the aftermath of conflict or disaster, while a universally agreed priority, is increasingly difficult and, in some areas of the world, positively dangerous Fig. 23.1 & 23.2. The reasons are many but one event stands out. The last quarter of the twentieth century saw a radical restructuring of the world political arena with the collapse of old alliances and power blocs. Collapse, followed by intrastate conflict, has occurred in the Balkans, Caucasus, North and Central Africa, and Asia. From this disintegration have emerged dozens of selfgoverning entities seeking recognition as sovereign independent states. Many of these lack the means to survive independently and have failed or are failing. The terms “failed,” “failing,” and “rogue” states have entered the literature of sociology, politics, journalism, and humanitarian assistance. A. Hopperus Buma et al. (eds.), Conflict and Catastrophe Medicine, Second ed., DOI 10.1007/978-1-84800-352-1_23, © Springer-Verlag London Limited 2009
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Fig. 23.1. Hospital on a conflict fault line Northern Sri Lanka 2005. (Photo PF Mahoney)
Fig. 23.2. Hospital ward - Hospital on conflict fault line.
These unstable regions are characterized by political and economic failure with the collapse of infrastructure and social norms. This has encouraged the emergence of armed militias, paramilitary groups and terrorists. Hand in hand with the collapse of these new entities is a rise in extreme nationalism, tribalism, transnational religious
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movements, and racial/ethnic intolerance resulting in lawlessness, forced migration, and even mass murder. These then are the new wars and conflicts of the twenty-first century. Wars between states have been replaced by war within states. Further, the environment following a natural disaster may be equally dangerous as increasing these occur in regions already beset by war and conflict. The recent tsunami involving Indonesia and Sri Lanka and the earthquake in the Kashmir region of Pakistan are striking examples. This then is the new platform for health professionals engaged in humanitarian health care. The historical safety and freedom of movement afforded the humanitarian volunteer in times past can no longer be guaranteed – indeed deliberate targeting of health professionals is increasingly seen in such diverse regions as Chechnya, Iraq, Afghanistan, and Central Africa.
Time Lines and Phases Emergency Response and Early Recovery Earlier chapters in this manual are concerned with activities during the acute phase in a conflict or disaster setting. These may range from the aftermath of a natural disaster, such as a Tsunami or an earthquake, or the dangerous environment caused by war and conflict. For many aid organizations the acute phase response is the most attractive and even glamorous. The acute phase is characterized by widespread media attention and television coverage, and a myriad of aid organizations deploy and begin work in the glare of international news cameras. The immediate aim of these agencies is to drive down morbidity and mortality. These activities are exciting and telegenic, and occur at a time of international interest and attention. This phase passes, and along with it goes media interest. Further, many of the aid agencies which specialize in acute-phase activities depart very quickly when the situation stabilizes. There follows the postemergency phase, which includes the transition to recovery. The postemergency phase begins with early recovery. Paradoxically, money, equipment, and skilled personnel, so abundant during the emergency response, become scarcer. Budgets are cut, volunteer numbers are scaled down, and equipment items are no longer supplied. The reasons for this are complex. The postemergency phase is difficult, of uncertain duration, has little media attention, may be dangerous and is usually open-ended and expensive. Yet this is a time that is at least as important as the emergency response period. It is this neglected aspect of medical care in hostile environments that this chapter attempts to examine. The transition from emergency response to recovery varies and no one model exists. It may be lengthy, difficult, dangerous, and multifaceted depending on the nature of the conflict or disaster. The author pragmatically divides the recovery period into four time lines. The time lines are: ● ● ● ●
Transition Early Medium term Late
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Recent history reveals abundant examples of each – for brevity a single country case will be chosen to illustrate each time line.
Transition: Falkland Islands 1982 It is a moot point when the emergency phase ends and recovery begins. The transition may be short and clear cut, or may be protracted and blurred. The Falkland Islands, a region in the South Atlantic with a population of 2000 is an example where the transition was short and urgent. The situation in the Falkland Islands in early June 1982 is summarized below: ●
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Argentine troops invaded the islands in April 1982, taking complete control of the territory. All public utilities, including medical, continued to function but under Argentine military control. The Governor and all officials were detained and then deported and a military government was installed. The only hospital was taken over by military medical personnel and then functioned as a military hospital for the duration of the war with civilians continuing to be allowed access for care. Some of the civilian staff were interned or deported, others were allowed to work. Control of estates, utilities, and resupply was vested in the Argentine military.
Following an invasion by a British Task Force and a number of ensuing battles, the Argentine force surrendered and returned to Argentina. With the cease fire, the territory quickly entered a transition to recovery phase with all the problems that might be expected. The situation during this period is summarized below: ●
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Security and safety. In the absence of a local police or military forces became the responsibility of the British invasion force. Public and community health. The provision of clean water, food, sanitation, and shelter for the locals became the responsibility of environmental health specialists from the British Defence Medical Services (DMS). Primary health care. This was provided by joint DMS and civil medical personnel working from the island’s only hospital. Medical advice to outlying settlements was provided by short-wave radios. Hospital utilities and health care. Provided by DMS uniformed surgeons, anaesthetists and physicians supported by professionals allied to medicine (PAMs) in pharmacy, physiotherapy, and environmental and public health. DMS nurses made good civilian shortages. Other services and utilities. As an interim arrangement, DMS personnel took responsibility for maintaining estates and utilities such as engineering, communication, policing, and education.
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Transition to civilian administration and peace time began within days and was largely uneventful. However, fundamental differences from the pre-war position were evident. Three of the more striking differences were: ● ●
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The islands were now garrisoned by a force exceeding the pre-existing population. The island’s sole hospital became a de facto joint civil and military facility with all secondary care provided by military medical teams. It was now no longer possible to refer patients to Buenos Aires for specialist medical opinion and treatment – a previous life line that had existed for decades.
These problems continue to beset healthcare professionals 25 years after the invasion.
Early: Balkans – Pristina/Kosovo 1999–2000 It is arguable whether Kosovo continues to fit the definition of Failed State. Prior to and for sometime after the NATO led invasion in 1999, it most certainly did. The region had suffered a protracted civil war with large-scale forced migration of one community – ethnic Albanians. Following occupation by NATO there was now a further migration, in part forced, of the remaining population – ethnic Serbs. The health consequences were near catastrophic. Returning refugees and internally displaced persons (IDPs) faced a region without a functioning government, largely destroyed housing stock, and failed infrastructure. One of the most pressing needs was health care. The health problems listed below is illustrative but far from comprehensive: ●
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Collapse of water, power, and sanitation. A particular problem was to dispose of large dumps of clinical waste in hospitals and health centers Fig. 23.3. Mortuaries were inundated with bodies dumped in corridors and entrances. Rehabilitation of the entire healthcare system including primary health care, transport, communications, and hospitals-based systems. A particular anxiety related to the collapse of public health surveillance and reporting.
Fig. 23.3. Disorganized donations Kosovo 1999 (Photo PF Mahoney).
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Fig. 23.4. Young mine victims - Pristina teaching hospital 1999. (Photo PF Mahoney)
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Total systems failure at the regions 2,400 bed tertiary referral, university teaching hospital in Pristina Fig. 23.4. This was compounded by a departure of the prewar hospital staff (Serbs) and an influx of Albanian medical staff, few of which had any proof of identity or qualification.
Such a near total failure of the instruments of government required a complete take over of the functions of the state. The UN Interim Administration became the de facto government with the World Health Organization (WHO) taking the health portfolio.
Medium: Caucasus – Azerbaijan 1997–2001 The background to the crisis in Azerbaijan can be summarized as: ● ●
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Seventy years of control by the former Soviet Union. A disastrous territorial war with neighboring Armenia which also involved hostilities with the Soviet Union. Twenty percent loss of the national territory with forced displacement and migration of one million people Devastation of the territory’s agricultural and industrial base. Breakdown of the national health system. Creation of dozens of refugee and IDP camps accommodating up to one million men, women, and children.
The author reviewed in-hospital health care and refugee/IDP health care in this region through 1997 and 1998. The mission findings are summarized below: ●
All major hospitals, although geographically distant from the conflict zone, suffered from the consequences of financial ruin and loss of social cohesion.
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Major teaching hospitals fared better retaining staff and supported by a growing private practice. The majority of refugee and IDP camps were situated great distances from urban centers and were unable to access secondary and tertiary hospital care. Care for those in the camps was provided by expatriate and national NGOs.
The country has avoided long-term failure by utilizing major oil and natural gas resources to rebuild the economy and to build a reformed healthcare system. Prehospital care, particularly for refugees and IDPs, is also improving but more slowly. Azerbaijan exemplified a point made earlier concerning the departure of the majority of international aid agencies once the emergency response phase was over but was fortunate to be rich in natural resources which in turn attracted new players to fill the gap caused by aid agency departure – namely multinational oil corporations. There remains the unresolved territorial dispute with Armenia which, until resolved, risks a resumption of conflict.
Late: Middle East – Iraq 2003 to the Present While the crisis in Iraq is on going it illustrates many of the problems of a failed state. The country’s healthcare system, once on a par with middle-income European states, had deteriorated due to the Gulf war of 1990/1991, 10 years of sanctions, which followed and finally by the invasion of 2003 by a US led Coalition. The author has visited Southern Iraq on three occasions since the invasion, concentrating on health needs assessment and health promotion. The health problems in the postconflict period (if it can termed post-conflict) are many and diverse. While there was no mass movement of people or forced migration there were serious and unforeseen health consequences, mainly caused by sanctions and, to a lesser extent, the recent war. The most pressing needs relate to a failure of the public health surveillance and health information systems. In short, it is still very difficult to quantify the health needs and agree priorities. Maternal and child health schemes have failed with catastrophic maternal and infant mortalities being reported but these are unverifiable. At the time of writing the situation is probably worsening with the failure of many hospitals. The consequences of failure of hospitals in Iraq can be summarized. ● ● ● ●
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Loss of physical infrastructure which is a combination of deliberate and accidental. Degradation of utilities, especially power, water and food supply, and sanitation. Progressive loss of staff through emigration, kidnap, and murder. Degradation of clinical services resulting in cancellation of planned procedures, failure of chronic care, cancer care, complex surgery, and supporting services. Failure of emergency medical services and referral system resulting in failure to access care, even in those hospitals with residual capacity. Shortage of consumables, drugs, and related materials. Breakdown in morale and motivation often associated with failure to pay salaries, inability to provide care, and continuing threat of kidnap and death. Forced closure and ejection of staff associated with ethnic cleansing.
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Until the security situation improves, it is too dangerous for local or expatriate health professionals to travel to the regions and re-establish accurate health information systems – a prerequisite if health care is to be effective.
Principles Underpinning an Effective Response Other chapters and sections of this manual describe in detail the principles and practices of the act of intervention in conflicts and intervention. The purpose here is reiterate and emphasize critical aspects in mounting an effective response. Planning and implementation of an effective response is a combination of art and science and is underpinned by the need for an early and comprehensive needs assessment. It requires too an understanding of the dynamics of conflict and disaster events. Much of this information is already in the public domain and is easily accessible. Two United Nations bodies play a central role. The United Nations Disaster Assessment and coordination Agency (UNDAC) have expert teams ready to deploy (typically 2–6 experts drawn from a range of disciplines) to a disaster area to assess and report on immediate needs. Their main task is to determine immediate threats to life and to assess availability of water, food, sanitation, and shelter which are recognized as the four immediate determinants of survival. They also check for evidence of emerging epidemic threats such as measles, cholera, and diarrheal diseases. Their findings have a critical impact on the size and the shape of the emergency response. The UN Office for the Coordination of Humanitarian Affairs (OCHA) also plays a pivotal role. OCHA can provide detailed epidemiological data for disasters which have occurred over the last decade. This information allows risk analysis for future events and may also allow crude predictions on the nature and the number of expected casualties of an emerging new disaster thus informing emergency teams before deployment. Other national and international government and nongovernment organizations (GOs and NGOs) also perform assessment functions and historically this has lead to duplication of effort and competition. A new climate of cooperation and coordination is emerging and was particularly evident during the Pakistan earthquake which resulted in an unprecedented efficiency in the relief effort.
Preparation and Deployment of Teams It should be obvious that the objective in deploying aid teams should be to get the right experts and their equipment to the right place at the right time. This requires a good intelligence assessment as outlined above. Most expatriate team experts, particularly doctors, will have been trained in a developed European or North American healthcare system and as a consequence will have to undergone specialty and subspecialty training and practice in increasingly subspecialty niches. This aspect mainly affects health professionals working in hospitals. Few, if any, general physicians, surgeons, or pediatricians remain. Yet the overwhelming need in conflict and disaster settings is for competent generalists. If specialists are to be deployed planners must deploy larger teams and this has lead to the expression “hunting in teams.” Training beyond medical care is also vital. Deployed personnel will typically work in unfamiliar
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Table 23.1. Required verifiable competencies for deployed surgical and trauma team Life support qualification (ATLS® or equivalent) Triage training and skills (MMIMS©) Trauma team resuscitation skills Field craft proficiency Surgical care of the trauma victim (DSTS© or DSTC©) Critical care competence (CCrISP©) Leadership and organizational skills/experience
and austere environments and will have to care for themselves and each other. A spirit of collaboration, team play, and multitasking must prevail. All will have to share in activities such as driving, watch keeping, map reading, food preparation and, on occasion, manual labor. Predeployment preparation is also critical and covers professional and personal elements. High motivation, physical and mental fitness, and leadership skills are vital. Most reputable aid agencies deploying teams will insist on some form of predeployment assessment, training, and skill verification. Table 23.1 gives a typical “shopping list” of skills and competencies required of a surgical/trauma team deploying. Other skills and competencies will be required depending on specialty – pediatrics, obstetrics, and public health are examples.
Traps and Pitfalls Expatriate volunteers experience unique and character building opportunities but face many traps and pitfalls. What follows are rules of engagement learnt (sometimes the hard way) by the author and his colleagues on a variety of deployments.
Have Good Intelligence, Clear Aims, and Sound Planning The above underpin military deployment doctrine and are just as vital for nonmilitary agencies. Failure to obey this rule may result in inappropriate deployment with ensuing embarrassment and possible danger.
Deploy Personnel Trained and Fit for Task A conflict or disaster area is NOT a training ground for junior trainees to cut their teeth. The widely accepted rule is to deploy accredited specialists or senior trainees under supervision. All reputable aid agencies have high standards when choosing teams to deploy and increasingly apply governance standards, evidence of an audit process, and morbidity and mortality returns. This is being driven by donor bodies who demand value for donated money.
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Donation of Medical and Related Equipment It is wise to avoid giving equipment and consumable early in the deployment as your team may need them to perform their allotted tasks. By all means do so prior to departure but ensure medicines and consumables are in date and undamaged. Donated equipment items must be appropriate, well maintained, and capable of being repaired locally.
Do Not Become a Casualty Yourself A clean bill of health is a basic requirement for deployment to austere and dangerous environments. Beware deploying personnel with a history of chronic diseases such as diabetes mellitus, hypertension, and other history of cardiovascular disease or peptic ulcer disease. Chronic diseases are prone to relapse under conditions of stress.
Do Not Get Out of Your Depth “Stay in your lane” is an old adage. One well-known pitfall which may take you out of your lane is getting involved in hospital assistance. Hospitals in these settings are a bottomless well of need. Once involved it is very hard to withdraw. Few aid agencies can afford involvement in aid to hospitals – it is better to run limited primary care projects, which are cheaper and less open ended.
Have an Exit Strategy Decide before deployment how when and when you will withdraw. Withdrawal is often a stressful period for both team members and local people. Make a clean break and try to leave a lasting legacy. A good way to achieve this is to have a teaching and training side to your mission. An old hand in this business states “Teach, then teach again, then teach some more.”
Development Before concluding, a word about development. This is a vast topic and deserves a book in its own right. There is a pretty well-universal agreement within the humanitarian aid community that transition from emergency aid and recovery programs to longterm development is fraught with difficulty. Part of the problem is reaching consensus on meaning and definition. So far in this chapter discussion has been on early, medium, and late phases of conflict and disaster recovery. Where does development fit into this construct? Are recovery and development the same thing? The United Nations Declaration on the Right to Development, resolution 41/128, 4 December 1986, provides a definition of development
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Development is a comprehensive, social, cultural, and political process, which aims at the constant improvement of the well-being of the entire population and of all individuals on the basis of their active, free and meaningful participation in development and in the fair distribution of benefits resulting there from. It follows therefore for development to commence, a high degree of stability must exist, and the restoration of institutions and instruments of government must have occurred. There is a risk that development will be attempted before is sufficiently complete. This was well illustrated in Kosovo during 1999 and is evident again at the time of writing in Iraq and Afghanistan. In Kosovo, the medical development program had to be delayed because insufficient recovery had taken place and instability persisted. This is the situation now in Iraq, Afghanistan, and many parts of Africa. It is interesting to note that Donors and Western Governments are keen to move to development programs as soon as possible, and long term may be cheaper than acute recovery programs. However, if begun too soon they are doomed to failure.
Summary International aid agency interventions during the recovery phases following conflict and disaster are typically diffuse, complex, and long term. In the opening decade of the twenty-first century they have also became dangerous and non-permissive. New strategies will be needed which may involve a developing relationship between military medical personnel and those from the aid agencies. This will provide doubtless result in strife and hostility but the nettle must be grasped. These new environments are hostile and dangerous making it increasingly difficult for unarmed and vulnerable aid agency personnel to function effectively. The coming decades will demand a new mind set and a new spirit of collaboration and trust. The omens are good – civil/military collaboration was notable in two of the world’s most recent calamitous natural disasters, the Tsunami in South East Asia and the earthquake in Pakistan.
Further Reading Birch M, Miller S. Humanitarian assistance: standards, skills, training and experience. Br Med J, 2005;330:1199–1201 Boyarsky I, Shneiderman A. Natural and hybrid disasters – causes, effects and management. Top Emerg Med, 2002;24(3):1–25 Bricknell MCM, MacCormack P. Military approach to medical planning in humanitarian operations. Br Med J, 2005;330:1437–1439 http://www.Ochaonline.un.org Medicins Sans Frontiers. Hanquet G, Editor. Refugee health. An approach to emergency situations. MacMillan: London, 1997 Redmond AD. Needs assessment of humanitarian crises. Br Med J, 2005;330:1320–1322 Ryan JM. Mass casualties and the surgeon. Scand J Surg, 2005;94(4):311–318 Ryan JM, Mahoney PF, Macnab C. Conflict recovery and intervening in hospitals. Br Med J, 2005;331:278–280
24. Eating an Elephant: Intervening in Hospitals, Pristina 1
Tony Redmond
How Do You Eat an Elephant? There is little doubt that the hospital was damaged when the Serbs departed, but this was but a last parting shot at an institution that had been run down for years and particularly since 1990. It was about then that Milosovic redeployed Serb staff from Belgrade to replace local ethnic Albanian staff and the slide to the present situation really began. I was here in 1992. All the senior staff whom I met were Serbs and unhappy at their forced exile from Belgrade. They told me that the Albanians had walked out and set up their own parallel medical school. Those Albanian professors are now back, and while some jumped before they were pushed, and others left in protest at the failure of the Serbs to recognize the Albanian language, they certainly describe a grave injustice. When NATO arrived, many Serbs left, but not all, and the hospital still had many Serb staff – particularly doctors. The mass return of Albanian staff to the hospital led to a very unstable situation, culminating in the wounding of Serb staff and the disappearance of the previous (Serb) occupant of the office where I now work. It was the intervention of the British army that ultimately sounded the call to order. However, the exodus has continued, with only a handful of Serb patients remaining and the last two Serb doctors leaving last week. The hospital I first saw had dogs running wild, eating the waste, clinical and domestic, which was strewn around the hospital. The mortuary was littered with rotting corpses and the kitchens were filthy and unstocked. The drains were overflowing and discovered to have been blocked with the stock of the hospital pharmacy. The dogs have now been removed, and the British army has cleaned the stinking mortuary and buried the dead. The World Food Program feeds the sick; Pharmaciens Sans Frontières runs the pharmacy, and Oxfam has cleared the drains and will improve the supply of clean water. There are many nongovernment organizations from around the world working in the hospital, and together we are helping the local doctors and nurses to provide care to the people of Pristina.
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Reproduced from the BMJ with permission. BMJ 1999;319:1652 (18 December)
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I am here as part of an advisory team, funded by the Department for International Development. An international and therefore neutral medical director was thought the best option by all sides and my appointment has been greeted by cooperation and support. This now predominantly Albanian institution is staffed largely by doctors who have not practiced in the hospital for nearly 10 years or trained in the parallel Albanian medical school. Lessons were taken in private houses, and exposure to inpatient hospital experience was gained by pretending to be hospital visitors and stealing on to the wards to take histories. The effort required to complete this training was considerable, but the doctors are well aware of their lack of hands-on clinical experience. We have to identify training needs urgently while supporting clinicians in their daily activities. External advisers in all the major specialties have begun arriving to work alongside local doctors. An NHS management team has already visited and partnership with the NHS is being developed. A management board has been established and decisions about the future role and direction of the hospital are beginning to be addressed. The semiautonomous clinic system prevalent throughout hospitals in the former Yugoslavia is about to yield a little to the development of a central admissions and emergency center. This British-funded program will supply a single point of entry to the hospital and a focus for the development of clinical training. The future will not be easy. The only Serb members of the hospital management board were the last two Serbs to leave, and any prospect of reconciliation between the two communities still looks very far away. Yet in spite of, but perhaps because of, the suffering that has brought us to this position, there is around me, at least in the hospital, a palpable air of optimism. The staffs remain unpaid but patients get treated and the hospital looks cleaner every day. The army is still present but in much smaller numbers. A man with severe complications from a gunshot wound had surgery by a local doctor operating with colleagues from Britain and the Lebanon, with anesthesia and intensive care provided by an Albanian with two French colleagues. The type of operation he required was agreed among all after his details, including digital clinical photographs, were e-mailed to a surgeon in Salford. The immediate crisis is, I hope, easing, although the situation remains far from stable and the future is still unclear. The mortuary fills up but now gets emptied, and the fridge is still working. There is still rubbish around the hospital but not as it was before. The trickle of Serb patients has never actually stopped and I meet regularly with Serb doctors outside the hospital. They remain fearful, but I am told that one will rejoin the hospital board next week. So how do you eat an elephant? One bite at a time.
25. Conflict Surgery: A Personal View I am Lt. Col. Andrew Bruce and am 39 years of age, married with four children. I have been a Territorial Army Medical Officer since 1992 and currently hold an NHS Consultant appointment in Trauma and Orthopedics in the North of England. I have been trained in Sheffield, Durham, and Whitehaven, and on the Leicester Orthopedic Training Rotation. My special areas of interest are complex primary and revision hip arthroplasty and trauma. I have spent my TA career with 212 Field Hospital but have worked fairly regularly with the Regular Army. In preparation for deployment I attended a number of workshops (Mangled Extremity, Maxillo-Facial, Neurosurgery) – an Update to Battlefield Advanced Trauma Life Support (currently on the instructor cadre) – and spent time operating with the neurosurgeons in Sheffield to gain craniotomy and burr hole experience, having previously attended the Definitive Surgical Trauma Skills course at the Royal College of Surgeons. Military skills were worked on as was fitness in preparation for working in an austere and climatically hostile environment. Predeployment training consisted of an operational situational update, then training at the Army Medical Services training center in York culminating with a 3-day Hospital Exercise prior to deployment. This deployment in 2007 in Afghanistan was a busy deployment, averaging 9 h per day in the operating theatre, including many through the night operation sessions. Occasionally (2 days in 3 months) there was no operating. Routine second look and closure cases were not what I expected on a regular basis. All British casualties were evacuated to the UK, mostly before their second look was scheduled. The intensity of work was far greater than anyone expected, including those veterans of more than one deployment. Nothing can prepare you for your first multiply injured patient apart from speaking to those who have “been there and done it.” That only partially prepares you. The rule book goes out of the window as does the idea of a surgical “comfort zone.” The fact that military injuries do not respect anatomical body regions very quickly became very apparent. Multiple limb injuries rather than isolated limb injuries was the norm. The first trauma call sets the pulse racing as does the first multicasualty call. The interface with other health systems can be very frustrating. Two patients, one following debridement and external fixation of an open fracture of the forearm and the other with fragmentation wounds, were transferred out of the UK hospital before their “second look” and delayed closure surgery. This was due to the fact that the hospital was at capacity and operations were ongoing. The understanding was A. Hopperus Buma et al. (eds.), Conflict and Catastrophe Medicine, Second ed., DOI 10.1007/978-1-84800-352-1_25, © Springer-Verlag London Limited 2009
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that both of these patients were being transferred to host nation facilities for their secondary procedures to be performed. As it happened, they were both returned to the UK hospital 10 days later having had nothing further done. On questioning they had been transferred first to Kandahar where they spent 2 days with nothing done, and they were then subsequently transferred to Kabul where again nothing was done for them. After 8 days they were sent to another camp having had no further treatment. The doctor at this camp then contacted me asking for advice. The patients were reviewed by me at the UK hospital. At this stage there was no possibility for closure of the wounds and they were left to heal by secondary intent. Although there was no untoward outcome it concerns me that patients transferred for very simple secondary surgery went round the houses for 10 days having nothing done and ended up back where they started, still needing care. You also have to think outside the box. Figures 25.1 and 25.2 show an unusual method of fracture fixation in a little girl. Her arm was badly broken in a road accident; I was determined that she would keep her arm and she did. There are things that could be improved in preparation for deployment. It is vital that personnel leave behind the NHS mentality and switch to the military mentality of working when there is work to do, continuing until it is done, and resting when it is finished, but being prepared to start again at short notice when required. There was no preparation, for, or indication as to the possible intensity of operations. This could have been easily rectified by running seminars, with recently returned clinical counterparts, rather than participating in a Hospex up until 48 h before departure. The Directing staff at Hospex seem to be working in a different zone to that which was encountered on operations having experience of previous operations rather than Afghanistan. It would be beneficial to attend an update to the Definitive Surgical Trauma Skills course in the 6 months, or so, prior to deployment
Fig. 25.1. Ingenious external fixation method.
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Fig. 25.2. Ingenious external fixation in situ.
as significant numbers of vascular injuries were encountered without the presence of a vascular consultant. This deployment has been professionally challenging, thoroughly rewarding, and enjoyable, and it has been an honor to work with such a group of dedicated professional people, both regular and reservist, in an austere and challenging environment, while keeping our mission and goal of providing high-quality care, at all costs, to the forefront. Overall, my lasting impression is the sheer intensity of operating the long sessions but also feeling that you are doing some good, both for the soldiers, British, NATO, and Afghan, fighting on the ground, but also for the local civilians caught up in the conflict.
26. Military Health Services Support in Conflict Martin C.M. Bricknell and Roderick J. Heatlie
Introduction This chapter summaries the principles and practice of military health service support in conflict. It is based upon the key doctrine publications from both the North Atlantic Treaty Organization (NATO Standardization Agency 2006) and the UK Ministry of Defence (Ministry of Defence 2007). The language for this chapter is chosen for a nonmilitary audience but is consistent with more detailed descriptions contained in military publications and procedures. The chapter covers the breadth of military health services and includes the practice of medicine, nursing, dentistry, and those of allied health professions in the relief of suffering in multinational and Joint military operations. This links to Chap. 11, Chap. 12, Part B of Chap. 5, and Chap. 27. The chapter will start by placing health in the context of the military environment. It will then describe the organization and resources required to provide military health services and the military-specific issues associated with the planning, preparation, and deployment of health service support to operations. It will conclude by describing the command and control arrangements for the conduct of military health services support operations.
Healthcare in the Military Environment Health is a key element of an Armed Forces military capability: only a healthy force can function at, and sustain, maximum effort. In the context of military operations, health is the ability to carry out duties unimpeded by physical, psychological, or social problems. The health services have a substantial role in the prevention of disease, rapid evacuation and treatment of the sick and injured, and the return to duty of as many individuals as possible. However, creating and maintaining a healthy force is also the responsibility of commanders at all levels of the Armed Forces. The scope of health services support to military forces is summarized in Fig. 26.1. While many nations utilize military medical personnel for the provision of health services for military personnel in a wider context, military medical organizations exist for the relief of suffering on the battlefield through the provision of deployed military health services. Although nations have a moral and legal duty to provide A. Hopperus Buma et al. (eds.), Conflict and Catastrophe Medicine, Second ed., DOI 10.1007/978-1-84800-352-1_26, © Springer-Verlag London Limited 2009
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SCOPE OF HEALTH SERVICE SUPPORT TO MILITARY FORCES Military Operations
Infrastructure military health services
Deployed military health services
International military health services National civilian health services
International civilian health services
Fig. 26.1. Scope of health service support to military forces.
health services support for their own troops, not all nations can provide the full capability themselves and so there may be substantial multinational collaboration to ensure sufficient deployed medical capability and capacity for a military force (possibly including the military forces of the destination country). The deployed military health services may also need to collaborate with national and international civilian health agencies in the destination country. These issues are covered in more detail in Part B of Chap. 5 and Chap. 27. A residual military medical organization is required in the home nation in order to generate both a healthy military force and the military health services for deployment. The clinical personnel and medical organizations require both individual and organizational training in order to be prepared for deployment. Clinical training is best achieved through direct patient care, and so military clinical staff are frequently employed in the provision of clinical care to military personnel as part of a military infrastructure health service. This also ensures the delivery of health service support during the pre- and post-deployment phases of operations. In many countries there is cooperation between the military health service and civilian health services in order to achieve economic efficiencies between the Ministries of Defence and Health. During the recruiting process there will be a handover of clinical responsibility for members of the Armed Forces from civilian to military health services. The range of beneficiaries for military health services varies from country to country with some nations providing full health services to family members and retirees and even civil servants using military resources.
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Military health services personnel and organizations are bound by military law, international law, and professional ethics and codes of conduct. These separate military health services from combat and combat supporting forces. There is a general obligation to treat the wounded and sick solely on the basis of clinical need to the extent that it is practicable to do so. There is a specific obligation to treat prisoners of war, internees, and detainees and not to engage in any aspect of obtaining information from these individuals. Under the Geneva Conventions, medical personnel and units are to be protected from armed conflict and are only allowed to utilize armed force for the protection of themselves or their patients. Time is a fundamental factor in patient survival and recovery. Indeed the history of combat casualty care is the story of getting medical care closer to the casualty in time (evolution of medical evacuation from horses to helicopters) and space (moving surgery closer to the front line). Medical planning is driven by the 1–2–4 hour principle. Ideally a medical treatment facility (MTF) offering primary surgery1 will be located within 1 h of evacuation for casualties. Where this is not achievable, critically injured casualties should be able to undergo Damage Control Surgery2 (DCS) within 2 h and primary surgery within 4 h. The 1–2–4 hour principle is a pragmatic planning tool that simplifies clinical imperatives to enable synchronization of the medical plan with the wider military plan. It is not a justification for delaying evacuation but provides a benchmark against which the effectiveness of the military medical support arrangements can be measured. Military health services support is a specialist area of medical practice because of the environment and conditions in which it is delivered. The aim is to provide a standard of medical care to achieve outcomes of treatment equating to best medical practice delivered using the principles of evidence-based medicine and clinical governance. Clinical care in the military environment differs from civilian practice in that the individual patient may receive care from multiple clinical teams during the course of a single clinical single episode. Single clinicians or clinical teams are unlikely to generate the personal experience and case-series that usually drive clinical knowledge transfer. Thus, effective clinical governance in a military environment requires the generation of a robust evidence base for clinical practice through medical research, the dissemination of clinical protocols and procedures, and an assurance process to measure outcomes.
Military Health Service Support Organizations and Resources The principal components of operational health service support are Medical Force Protection, Emergency Medicine, Primary Health Care, Secondary Health Care (hospital services), and Medical Evacuation (MEDEVAC). Casualties passing through the medical system must be provided clinical support that is continuous and appropriate.
1 Primary surgery describes the first surgery to repair local damage caused by wounding and implies the capability to provide DCS as well. 2 Damage control surgery describes emergency surgical procedures and treatment by a surgical team in order to save life, limb, or function. DCS techniques are applied when the magnitude of tissue and organ damage is such that primary surgery is likely to exceed the casualty’s physiological limits.
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Medical Force Protection (MFP) is “the conservation of the fighting potential of a force so that it is healthy, fully combat capable, and can be applied at the decisive time and space. It consists of actions taken to counter the debilitating effects of environment, disease, and selected special weapon systems through preventive measures for personnel, systems and operational formations.” MFP is based upon four principles: measured assessment of the threat, risk assessment, health risk management, audit and surveillance. General medical staff and specialists in occupational medicine, public health, environmental health, and veterinary medicine conduct the MFP analysis. MFP is implemented through a combination of individual predeployment medical preparation, personnel policies, and medical supervision and surveillance. The roles and organizations that provide health service support on military operations have evolved to reflect developments in clinical technologies and changes in the military operational environment (Bricknell 2002a, b; Bricknella–c). Medical Treatment Facilities (MTF) are defined by their capability and capacity into one of the four “Roles”. The minimum capability of each Role is intrinsic to each higher Role. Under battlefield conditions, patients generally flow from a lower to a higher medical facility but they can be discharged at any level and do not have to be evacuated if the clinical capability of the receiving facility is no better than the current holding MTF. As medical capabilities increase so does their demand for support, thus increasing the medical and logistic footprint and diminishing their mobility. Definitions of Roles and Tasks are shown in Box 26.1.
Box 26.1. Definitions of roles and tasks Role 1. Task: “provides primary healthcare (PHC), specialised first aid, triage, resuscitation and stabilization.” This includes the provision of basic occupational and preventative medical advice to the Chain of Command, routine “sick call” and the management of minor sick and injured personnel for immediate return to duty, casualty collection from the point of wounding and preparation of casualties to the next MTF, primary dental care. Additional capabilities may include minimal patient holding capability, basic laboratory testing, and initial stress management. Role 2. Light Manoeuvre. Task “provides triage and advanced resuscitation procedures up to damage control surgery (DCS).” It will usually evacuate its postsurgical cases to Role 3 (or Role 2 E) for stabilization and possible primary surgery (PS) prior to evacuation to Role 4. This includes DCS with postoperative care, field laboratory, basic imaging, reception, regulation, and evacuation of patients and a limited holding capacity. Role 2. Enhanced MTF. Task: “provides basic secondary care facility built around PS, intensive care (ICU), and beds with nursing support.” A Role 2 E facility is able to stabilize postsurgical cases for evacuation to Role 4 without the need to put them through Role 3 MTF first. This includes surgical and medical ICU capability, beds with nursing support, enhanced field laboratory including blood provision, casualty decontamination facilities (dependent on operational risk assessment). (continued)
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Box 26.1. (continued) Role 3. MTF. Task: “provides theatre secondary health care within the restrictions of the Theatre Holding Policy (THP).” This includes primary surgery, intensive care, surgical and medical beds with nursing and diagnostic support. A Role 3 MTF can include mission-tailored clinical specialities [specialist surgery (neurosurgery, burns, opthalmology, etc.), advanced and specialist diagnostic capabilities to support clinical specialists (CT scan, sophisticated laboratory tests, etc.), and major medical and nursing specialities (internal medicine, neurology, etc.)] Role 4. MTF. Task: “provides the full spectrum of definitive medical care that cannot be deployed to theatre or is too time consuming to be conducted there.” This includes definitive specialist surgical and medical procedures, reconstructive surgery, and rehabilitation. This care is highly specialized, time consuming, and usually provided in the casualties’ home country either in military or civilian facilities. Medical Evacuation (MEDEVAC) is the process of moving a casualty to and between MTFs under clinical supervision. It forms part of the continuum of a casualty’s treatment and care and should be managed under medical oversight though often requires close coordination with other military functions such as ground and air operations staff. An effective MEDEVAC system includes the following: ●
●
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A 24-h all-weather transport capability able to operate over all terrain and in any operational environment. These should have the same mobility and protection as the military forces that they are supporting. Appropriately trained clinical staff equipped for in-transit medical care to enable rapid and safe transfer between aircraft, ambulances, and MTFs. A system of command and control, patient regulation, and patient tracking so that the flow and types of patients can be managed throughout the medical system.
Planning and Mounting Medical Support to Military Operations Medical planning is about achieving the optimum efficiency and effectiveness between capability, capacity, and evacuation to support the military mission to achieve the best outcome for the patient. Chapter 11 describes the military approach to medical planning. In the military context, the medical function exists to support the military operation, and so medical staff must be fully embedded in the military planning process. There should be medical representation on any reconnaissance visit to the potential area of operations, and the timing for deployment of medical capabilities should be matched to the increase of the deployed population at risk. Military doctrine describes four levels of military activity. The highest level is the Grand Strategic and is concerned with interministerial coordination to implement national policy in a comprehensive approach integrating all of the instruments of state (diplomatic, economic, and military activities). The Military Strategic Level is
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Table 26.1. Medical activities at each level of military activity Level
Activities
Remarks
Grand Strategic
Balancing health resources between civil and defense requirements Generating healthy manpower to support national requirements Integrating military and civilian resources to care for military casualties at Role 4
National health service resources are finite. In WW2 a national committee managed mobilization of civilian medical staff in the Armed Forces to ensure balance between military and civilian requirements
Strategic
Allocation of resources to the medical function Determining the medical support capabilities and capacities required to support campaigns Balancing medical resources between active duty and reserve forces Predicting the casualty load for campaigns
The medical function has to compete will all other military functions for defense resources
Operational
Determining the medical resources required for specific operations Balancing medical resources between nations and between Army, Navy, and Air Force medical services on operations Establishing and monitoring the medical evacuation chain from point of wounding to Role 4
This requires an understanding of the medical implications of operational design and balancing economy with risk. This is about allocation of medical resources (especially Role 2E and Role 3, and MEDEVAC airframes) for a particular operation
Tactical
Assigning missions and tasks to individual medical units Planning for and managing casualty. evacuation and care during and after battles Responding to medical emergencies
This requires an understanding of military and medical tactics and the potential casualty flows. This is about siting of Role 2E, Role 2LM units, and managing MEDEVAC from point of wounding to Role 4
concerned with the allocation of military resources to support the Grand Strategic plan. The Operational Level is about the employment of military forces to achieve strategic goals through the design, organization, integration, and conduct of campaigns. The lowest level, the Tactical Level is the level at which actual combat is orchestrated and battles are fought. Table 26.1 summarizes key medical planning and execution activities for each level.
Conducting Military Health Services Support Operations There will be a formal military command and control (C2) structure on any military operation (Table 26.2). This defines the responsibilities, authorities, and communications support for the military commander at each level of military activity. There will be military medical staff embedded into the C2 structure who will be responsible for the planning and execution of the health services support arrangements for the operation. These medical staff have a combination of military functions for medical units and specialist medical functions for both medical units and the whole force. This multiagency approach is very similar to the arrangements for the management of major incidents in civilian practice involving command and coordination arrangements between health, police, fire and rescue, civil government, and other agencies.
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Table 26.2. Military medical command and clinical functions Medical command and staff functions
Clinical functions
Supporting casualty tracking and casualty notification
Developing and communicating clinical policies specific to the operation Clinical governance of medical system Conducting health intelligence assessments and producing medical force protection advice Epidemiological health surveillance Coordination of the management of specific clinical cases
Managing MEDEVAC and patient regulation Oversight of medical logistics Developing and communicating the medical plan Oversight of medical information systems Managing military medical contribution to humanitarian relief and civilian reconstruction and development Medical contribution to crisis management
Commanders of medical units and medical personnel embedded with military units will be responsible for the execution of the health service support plan. These units and individuals need to be able to operate in the military environment (including personal survival skills and organizational skills such as camouflage and protection) and also deliver their medical skills (both generic professional skills and also military specific clinical skills such as the management of chemical casualties).
Summary This chapter has summarized the principles and practice of military health service support in conflict. The chapter links to Chap. 11, Part B of Chap. 5, and Chap. 27. This chapter considered the context of health in the military environment, discussed the organization and resources required to provide military health services, and examined the planning and mounting of health service support to operations. The chapter concluded by describing the command and control arrangements for the conduct of military health services support operations. This chapter contains material previously published in the Journal of the Royal Army Medical Corps (www.ramcjournal.com) and is used with permission.
References Bricknell MCM, The Evolution of Casualty Evacuation in the 20th Century in the British Army (Part 1) – Boer War – 1918. J Royal Army Med Corps 2002a;148:200–07 Bricknell MCM, The Evolution of Casualty Evacuation in the 20th Century in the British Army (Part 2) – 1918–1945. J Royal Army Med Corps 2002b;148:314–22 Bricknell MCM, The Evolution of Casualty Evacuation in the 20th Century in the British Army (Part 3) – 1945 – Present. J Royal Army Med Corps 2003a;148:33–7 Bricknell MCM, The Evolution of Casualty Evacuation in the 20th Century (Part 4) – An International Perspective. J Royal Army Med Corps 2003b;149:166–74 Bricknell MCM, The Evolution of Casualty Evacuation in the British Army (Part 5) – Into the future. J Royal Army Med Corps 2003c;143:357–63 Ministry of Defence, Medical Support to Joint Operations. 2nd Edition Joint Doctrine Publication 4–03. January 2007. Defence Development, Concepts and Doctrine Centre. Shrivenham NATO Standardization Agency, Allied Joint Medical Support Doctrine. Allied Joint Publication 4.10(A). March 2006
27. Military Medical Assistance to Security Sector Reform Martin C.M. Bricknell and D.F. Thompson
Introduction Recent military operations in Iraq and Afghanistan have widened the role of military forces to include “stability operations.” The US Department of Defense defines “stability operations” as “military and civilian activities conducted across the spectrum from peace to conflict to establish or maintain order in States and regions” (Department of Defense 2005). This operational task includes helping to develop or rebuild indigenous institutions including various types of security forces, correctional facilities, and judicial systems necessary to secure and stabilize the environment – so called “security sector reform.” The international community provides this help through a combination of governmental or international organizations and military forces. The chapter will examine the contribution and challenges involved in supporting security sector reform, both in terms of supporting the local security services to develop their own healthcare system and also in terms of providing medical support for the personnel of international military forces who may be involved in supporting the wider development of the local security services.
The Context of Security Sector Reform The need to restore and develop a robust security sector to support emerging governments in a postconflict environment is not new. The OECD defines the overall objective of security system reform (SSR) as “to create a secure environment that is conducive to development, poverty reduction and democracy” (OECD 2005). This secure environment rests upon two essential pillars: the ability of the state, through its development policy and programs, to generate conditions that mitigate the vulnerabilities to which its people are exposed, and the ability of the state to use the range of policy instruments at its disposal to prevent or address security threats that affect society’s well-being. A functional security system will enable the government to execute its responsibility for the security for its people and will enable the withdrawal of international military forces. The United Kingdom emphasizes the need for “joinedup” partnering between the departments of foreign affairs, interior, and defense when providing external support to SSR (Department for International Development 2005). A. Hopperus Buma et al. (eds.), Conflict and Catastrophe Medicine, Second ed., DOI 10.1007/978-1-84800-352-1_27, © Springer-Verlag London Limited 2009
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Ideally the activities of these agencies in an overseas country should be synchronized and mutually supporting. This function in Stability Operations is not new and formed a significant element of the military plan in other counterinsurgency campaigns in places such as Malaya, Oman, and Northern Ireland. In military terms, the local army (and supporting arms) will be employed in a counterinsurgency (COIN) role, operating on “internal lines” with easy access to base facilities. This is different to the employment of international military forces that will be conducting expeditionary operations some substantial distance from their home base. The common model SSR is based on “embedded training teams” (ETTs) from international military forces that provide training and mentoring to the local security forces. This is complemented by the attachment of mentors and liaison officers to support the chain of command in the local security forces and by the provision of training support in the central training centers (particularly the recruit training center and the officer training school). Finally the international community may offer out-of-country training to individuals or groups from the supported country. These factors influence the development of the medical services supporting security sector reform. Each agency (e.g., Army, Navy, Air Force, Police) may recognize the needs for access to medical support of its personnel and may establish its own medical system. There is little need for a large, deployable military health system because the security forces are operating within their own country and thus the balance of investment should be toward fixed facilities supporting garrisons, regional organizations, and the central requirements of the sponsoring ministries. The field medical system should be focused on prehospital care (including role 1) and medical evacuation to fixed facilities. While it is important for the medical services of the local security forces to meet the specific needs of each agency, it is clearly inefficient for each to establish its own healthcare infrastructure in competition with public health services as each will be competing in the same pool for healthcare professionals produced by the education system. It is interesting to note that this overlap does exist in many international health economies, and is often sustained by the variation in investment for medical services achievable because of the substantial difference in political power between the defense and interior ministries compared with the ministry of health. This imbalance is perpetuated by extending entitlements to the military healthcare system to political dignitaries and dependants of military personnel and thus providing a multitier health system. There is international evidence to suggest that these arrangements become unsustainable when the cost of meeting the demand from the dependant population (particularly when this includes retirees and elderly relatives) starts to distort the allocation of funds for operational health services. Eventually the ministry of defense is forced to transfer the responsibility for nonuniformed beneficiaries to the civilian sector such as the ministry of public health or private providers. The most important element of the military medical task in supporting security sector reform is to establish the “right” central structure and relationships within ministries and between ministries. Investment and development needs to achieve the right balance between the infrastructure health system, the operational health system, and individual clinical services while ensuring that medical procurement, training and education, preventive medicine (including selection and screening of recruits),
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and research are also enabled. It is vital that the most appropriate relationship between the medical function, the personnel function, and the logistic function in support of security sector forces is established from the outset. There are a variety of models including establishing the medical command as an entity in its own right or subordinating it to personnel or logistics; each has its own benefits. It is vital, during live operations, that medical staffs are empowered to engage with operational planning in the timeframe for good clinical care and not in logistic timeframes. Senior commanders involved in the transformation process must understand and support the role of health services in order to ensure that it is resourced to provide the patient treatment, evacuation, preventive medicine, and medical logistic services required to care for security force casualties from the point of injury to definitive care.
International Military Medical Tasks in Security Sector Reform Field Medical System The first, and most immediate, task for international military forces is to facilitate “in extremis” medical support for security sector forces. It is highly unlikely that the medical system for indigenous security forces will be functioning effectively in the immediate aftermath of conflict or instability, and thus the international military medical system may be the only source of casualty care. The provision of visible and effective combat casualty care is as much an important moral and morale component of motivation for local security forces as it is for the international military forces. Troop-contributing nations may be concerned that providing access to international military medical facilities has the potential to conflict with the capabilities and capacity available for international forces. However, as local security forces become more involved in security operations, international military casualties should reduce. The key challenge is the “hand-off ” of local security force casualties once they have received their immediate clinical care. It is vital that the clinical care provided to casualties is appropriate to the technology and clinical care available locally and is not just a replication of “western” trauma surgery. The local infrastructure health system may not be able to provide the necessary clinical care, or the security situation may make these patients vulnerable to attack if treated outside the security cordon. This can be ameliorated if the international military medical forces assist the security forces hospital system to provide access to nursing and rehabilitation services.
Example 1. Teaching Nursing Care of External Fixators In Afghanistan, the US Combat Support Hospital in Bagram wanted to manage local security force casualties who had had fractures treated by external fixation as outpatients in order to reduce inpatient bed occupancy. The “rate-limiting” factor was the provision of local wound care for external fixators. This was addressed by teaching patients and their immediate carers how to provide simple wound care for the (continued)
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Example 1. (continued) external fixator wound sites and by providing a stock of dressings. This enabled the patients to be discharged from inpatient care and to be followed as outpatients. The development of the security sector will require an expansion in recruiting and the basic training system. Furthermore the limited opportunity for other employment might make the security sector the most attractive source of work. The recruiting process should include a simple system for the medical screening of recruits, particularly as there is likely to be a high prevalence of chronic disease in the country. This medical screening should also form the start point for a basic medical record system for security personnel. This might be based on a patient-held record in view of the limited central control and communications within the medical system. The basic training system should include training in the maintenance of health and hygiene in communal conditions and elementary first aid. Finally there should be medical oversight of the physical training environment for recruits to ensure that the need for demanding a realistic training is balanced with the risk of injury.
Example 2. Teaching in Basic Hygiene to Iraqi Army Recruits NATO has a small military training team supporting the training of recruits to the Iraqi Army. It was found that there was a high incidence of gastroenteritis amongst recruits in the training camp. The local NATO medical officer developed a teaching package in basic field hygiene that was culturally appropriate but emphasized the importance of personal hygiene. This was taught to the local Iraqi instructors who then taught this package to their recruits. The development of the operational medical system should be designed around a holistic package of training, equipment, and manpower. A “field medic” training program might be considered to be the “pump-primer.” The paucity of professional medical staff means that this program is the best mechanism to provide good quality casualty care. The “field medic” can also provide limited primary care, and maintain health and hygiene standards in the field. The literacy, culture, and religious experience of young people in the local country will require the syllabus and methods of delivery for all medical subjects to be adjusted from that taught to standard “western” military forces. This should be very simple, practical, and deliverable with the minimum of training aids. The assessment process should also be culturally appropriate as, in some countries, failure is associated with significant stigmatization. The “field medic” syllabus and teaching materials should be standardized and shared between international military medical ETTs so as to minimize the likelihood of discrepancy due to variation between national “field medic” training. A good syllabus is the First Aid in Armed Conflict and other Situation of Violence published by the International Committee of the Red Cross (International Committee of the Red Cross 2006). The employment of the graduates of the “field medic” training should be carefully monitored as the intellectual ability of these students might make them attractive as candidates for other employment in the expanding security sector.
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Example 3. The Introduction of the Combat Lifesaver Course to the Afghan National Military Medical Training Centre The US Combat Lifesaver Course was introduced into the Afghan Military Medical Training Centre as part of the US support to the Afghan National Army. This course was translated into Pashtun. This included both the course handbook and the Powerpoint® slides. The US instructional staff rehearsed the delivery of the course with translators and then taught it to a cohort of potential instructors. This then formed the basis of the medical training given to selected soldiers in the Afghan National Army. This same training package was then shared with all other NATO medical staff so that continuation of training could be run for Afghan Combat Lifesavers by all of the NATO military medical community.
Infrastructure Health System The development of infrastructure health services for the security sector should be aligned to the development of public health services. While there may be very good reasons for a separation between both health sectors, if this occurs, this must be a positive choice and not the result of lack of awareness of the issues. The international community will be supporting the country in order to establish a stable, governable society. This effort may be undermined if the disparity in support (not only medical) between the security sector and the general population causes discontent.
Example 4. Development of Afghan National Military Hospital and Regional Medical System In Afghanistan the US has invested considerable sums in the development of the Afghan National Army medical infrastructure. This is based on a central, National Military Hospital located in Kabul with regional medical centers located in the regional military headquarters for each region. The investment provides for the infrastructure. It has been much more challenging to recruit medical staff, both doctors and paramedical staff, to man these facilities as many health professionals are employed by the international community as interpreters and this pays much better wages than the local health economy. As stated earlier, the infrastructure health system for the security sector will be based on fixed medical facilities in garrisons, regions, and at a national level. The capability of these facilities should reflect the prevalence of disease in the country and also the need to provide trauma care to injured security forces personnel. It is likely that the distribution of these facilities will align to the distribution of international military medical units, and so there is scope for partnership between the two medical communities. In addition to general medical topics and education programs for security force, medical staff should cover subjects such as advanced (continued)
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Example 4. (continued) trauma care, incident management, military medical ethics, and war surgery. The international military medical services will be keen to reduce the level of “inextremis” support provided to the local security forces, and therefore the postoperative care and rehabilitation of war injured is a particularly important subject to share, especially the role of nonmedical staff. Training for this clinical capability might include basic wound care, care of external fixators, elementary physiotherapy, and follow-up care of the amputated limb (and simple prosthetic management). This might merit the development of training course at a national level that can be cascaded down to all security force medical facilities. Finally we need to consider the mentoring and support required at ministry of defense level. It is likely that politically senior members of the local community will be holding appointments at this level, which may or may not align with their technical competence and experience. Organizations providing external financial assistance for security sector development may wish to have their own representatives inside the relevant ministries in order to ensure probity in the expenditure of their money. Thus, there will almost certainly be a requirement for senior representatives of the international military medical community to act as mentors and conduits for external investment. These mentors can also facilitate the development of local medical policies and procedures by sharing information on these arrangements from their own nations. Finally senior mentorship can include sponsorship for out-of-country visits and attendance at conferences, thus encouraging the senior local military medical leadership to become engaged with the international community. While it is naturally assumed that Western military medical personnel have the competence to provide this advice, it may be more appropriate to invite nations from the international coalition with practical experience of developing military medical services during a period of economic and political transition to provide this mentorship function (e.g., former Soviet Union countries or Middle Eastern countries).
Example 5. OSC(A)/ISAF Engagement at MOD level In Afghanistan, both the USA through the Organisation for Security Cooperation (Afghanistan) (OSC(A) ) and ISAF through the Medical Branches have liaison with the Afghan Military Medical Services in the Ministry of Defence. The USA also provides personal mentorship to the Afghan Army Surgeon General and a team of technical advisers for medical operations, medical logistics, and preventive medicine. These teams provide technical advice, make submissions for financial support, and examine options for direct support from USA and other multinational forces. An important, intangible, aspect of the engagement of the international military medical community is the sharing and monitoring of ethical standards. Medicine (continued)
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Example 5. (continued) plays an important role in observing and reporting the behavior of security forces toward the population they serve. While local policing and judicial frameworks will reflect the local cultural and security situation, it is important that the security forces medical services align to internationally agreed standards of behavior and do not become accessories in the maltreatment of detainees or members of the security forces.
Not to be Forgotten This paper has focused on the role of international military forces in assisting the development of the medical services of the local security sector. However, it is important not to forget their role in the medical support of EETs providing mentoring and training support in other areas. EETs are likely to be living and working in close proximity to the local security forces and are thus vulnerable to the same risks. They will require additional training in preventive medicine and advanced first aid as they will be more isolated than usual from conventional military medical care. It is also important to clarify the arrangements to enable them to access “western standards” of military medical care.
Who and How to Do It? My final section will consider how these tasks should be delivered. It is unlikely that any single nation is able to provide the resources to meet the full range of tasks that I have outlined earlier. Thus, the international military medical community will be working within a coalition or existing international framework. This framework may have challenging arrangements for the generation of military forces and financial support for security sector reform. Success requires shared and mutual understanding of the intent and mechanisms for delivery of the task. While some assets such as mentors or ETTs will be dedicated to the tasks described, others assets such as preexisting international military medical treatment facilities will have to balance their role in security sector reform with their main function of providing medical support to international military forces. There may be scope for other innovative methods of delivery such as the use of external civilian agencies or contractors in addition to using conventional military forces. This pluralistic model requires a significant investment in coordination and sharing of resources in order to achieve unity of effort even if the arrangements preclude unity of command. This includes predeployment orientation and training for EETs, sharing of training resources and good practice, transparent funding arrangements for all parties, and communication of plans and policies so that all parties understand the intent.
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Conclusion This chapter describes the potential roles of international military medical forces within the context of security sector reform in stability operations. The chapter highlights a number of challenges and practical examples where international military medical forces can make a significant contribution to the development of local national military medical services. The most immediate task is in the facilitation of “inextremis” medical care for local national casualties. However, it is also important to take a long-term view and to create the managerial structures and processes that will deliver a capable and effective infrastructure local medical system so as to reduce the potential dependency on international military medical facilities. At the tactical level this might include teaching basic field hygiene, running first aid training courses for instructors, and mentoring the further education of local military medical staff. Overall, we need to establish a basic framework for these roles so that international military medical forces can be properly prepared for this task prior to deployment. This chapter contains material previously published in the Journal of the Royal Army Medical Corps (www.ramcjournal.com) and is used with permission.
References Department of Defense Directive Number 3000.05. Military Support for Stability, Security, Transition, and Reconstruction (SSTR) Operations. 28 November 2005. OECD. Security System Reform and Governance. DAC Guidelines and Reference Series (ISBN 92-64-007865). OECD, Paris, 2005. Department for International Development. Understanding and Supporting Security Sector. DFID, London. 2005. www.difd.gov.uk (accessed on 19 Jul 2006). International Committee of the Red Cross. First Aid in Armed Conflict and Other Situations of Violence. ICRD, Geneva, April 2006. www.icrc.org (accessed on 19 Jul 2006).
28. Hospital Blues David R. Steinbruner
Baghdad January 10, 2006 Hello folks, It poured down rain in the IZ several days ago. Given that the total average rainfall for this area is just shy of 7 in., we may have had our quota for the month. It filled up the walkways and dusty corners of the hospital grounds, leaving a rancid pool just outside the ER. There were hopes that behind the rain would be a clean, fresh Baghdad, with crisp cool skies. No luck, as the following was cool, humid, and dirty. It reminds me of Colorado after the snow melts away: everything covered in a layer of fine, wet dirt. The strange world of the IZ continues without a great deal of change. It is a place where Iraqi women in western dress and high heels walk beside soldiers in full “battle rattle”: kevlar helmet, ballistic vest, and M-16 with several magazines strapped to one’s body. Crossing the street can be an adventure. The general principle of driving in Iraq is not to stop under any circumstances, never mind the clueless doctor wandering in the middle of the road. Mix in a couple of Bradleys and up-armored Humvees and you have some legitimate excitement. Once in a while we have a little run around one of the compounds. It is good to get out without all the gear and just run for a bit. I call it the 5k race and mortar dodge. The ambiance is further enhanced with occasional crack of AK-47’s and the return fire of M-16 or heavier weapon. Mix in the call of songbirds in the date palms lining the streets and you have a sense of the wonderful dissonance of this place. The dissonance is echoed by the rhythm of our day. Several hours of no business can come to a crashing end within several minutes. There is very little of the general background business, which keeps ERs across America so busy. Today I am sitting around writing e-mails and listening to a little Led Zepplin (the young lieutenants and enlisted have only vague notions of who they are… sigh). Several days ago the calmness was broken by a deluge of casualties: Iraqi and American. The insurgents, busy during the cover of cold and rain, had laid down lethal shaped charges and waited. A convoy was hit hard and 28 men in various stages of pain and suffering descended upon us in the space of 2 h. The ER filled, the wounded treated and then sent to various parts of the hospital, then filled again, treated and filled again. It was a deluge of blood instead of rain this time. We are getting very good at channeling it and cleaning up. I would like to pick this hospital up, intact, at the end of this deployment and take it with me. Strange that one has to go to Baghdad to remember the way medicine is supposed to be. Hope all is well at home. A. Hopperus Buma et al. (eds.), Conflict and Catastrophe Medicine, Second ed., DOI 10.1007/978-1-84800-352-1_28, © Springer-Verlag London Limited 2009
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Introduction: Clinical Care David G. Burris, Adriaan Hopperus Buma, and James M. Ryan 29.
Trauma and Surgery A – Scene setting B – Trauma and Triage C – Soft tissue and skeleton D – Ballistics and blast E – Abdominal Complaints and Acute Surgical Emergencies F – Maxillofacial, Eye and ENT G – Head Injury H – Anaesthesia and Analgesia
30. 31. 32. 33.
Acute Medical Problems Women’s Health Children’s Health Conflict, Terrorism And Disasters
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This section considers clinical care of the individual and special groups. It is not intended as a comprehensive medical textbook but rather a distillation of practical advice on deployed medicine.
29. Trauma and Surgery ●
Objectives ●
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To indicate the range of common injuries and illnesses likely to be encountered across the spectrum of surgical disciplines. To describe a rational approach to the management of these conditions. To introduce the problems associated with ballistic and blast injury. To detail common surgical emergencies To describe the principles of analgesia and anaesthesia in hostile environments.
Part A – Introduction: Scene-Setting Walter Henny and Adriaan Hopperus Buma
The authors of this chapter include specialists, many of whom have extensive deployment experience. The aim of this chapter, however, is not their fellow-specialists; but the “junior” health professionals trying to help them find their way in the difficulties posed by an “adverse” environment. They will be confronted by all imaginable ailments and injuries, and should be a true generalist. As we are all aware, even in medical school nowadays there is a tendency to make students choose the direction of their future work at an ever earlier stage; the opposite of what’s needed for a generalist. The chapter aims to impart (basic) surgical knowledge, placed against the background of the constraints posed by conflict or catastrophe. Self-evidently, it is not a text-book but it covers the entire body (including maxillofacial, eyes, and ENT), indicating what might be treated by the junior health professionals themselves and what should be referred. Referral in an adverse environment is usually difficult and occasionally impossible; careful planning is required. If a patient should, but cannot be referred, the consequences are most often very serious. All health professionals have an obligation to provide assistance to those in need, commensurate with their training and skill. The topics covered in this chapter are the following: ● ●
Trauma and triage Soft tissues and skeleton
A. Hopperus Buma et al. (eds.), Conflict and Catastrophe Medicine, Second ed., DOI 10.1007/978-1-84800-352-1_29, © Springer-Verlag London Limited 2009
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Ballistic and blast injury Nontraumatic surgical emergencies Maxillofacial problems Head and spinal cord injuries Anaesthesia and analgesia
Part B – Trauma and Triage Walter Henny and Adriaan Hopperus Buma
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This section emphasizes the importance of managing trauma victims effectively and expeditiously, by using a systematic approach. The management of a variety of injuries including soft-tissue wounds and fractures, and injuries to body regions, is described in Parts C–G.
Introduction Worldwide, trauma is the leading cause of morbidity and mortality during the first four decades of life and is the third most common cause of death overall. During catastrophe or conflict, much attention is, rightly, paid to overwhelming public and environmental health risks. However, trauma is an inseparable part of conflict and catastrophe; not only in the populations involved but also in health professionals who travel from abroad to give humanitarian support.
Mechanisms By convention injuries resulting from physical trauma are classified as follows: ● ● ● ● ● ●
Penetrating Blunt Blast Thermal Chemical Miscellaneous (e.g., crush and barotrauma)
Basically, trauma is a transfer of energy, leading to damage of tissues. Depending on the characteristics of that tissue and the amount of energy transferred, the resulting damage will be repaired by a number of processes; occasionally that damage is
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irrecoverable. A good local oxygen supply is necessary for the repair processes to evolve effectively. “Macroscopic” damage can be differentiated by mechanism: ● ● ● ● ●
Compression Stretching Tearing Laceration Incision
In dealing with trauma victims, it is most important to realize that the threat to life is not always immediately obvious. The problem is compounded when a health professional is called upon to care for more than one victim at the same time. This calls for a very systematic approach. Those who have little experience with these subjects are most strongly advised to follow one or more life support courses (as mentioned in the Resources section) or, as a minimum, study the manuals.
Multiple and Mass Casualties In conflict and catastrophe, patient numbers may be large, temporarily exceeding the capacity to deliver optimal medical care. Be aware that this may also be the case when a single health professional, without back-up, has to care for two or more victims of, e.g., a road traffic accident. Under these conditions, one must do “the most for the most”. Attempting to deliver optimal care to one victim will deprive others of much-needed and potentially lifesaving care. This calls for “triage”; the process by which victims are quickly assessed in order to assign a priority for further care. Triage should take many factors into account: the patients’/victims’ condition, the severity of their injuries and the availability (or lack thereof) of “assets” (the number of health professionals, resources for treatment “on the spot” and “at a distance,” etc.), distances to cover in transportation, means for transportation, time required for specific treatments, survivability of the injuries sustained, and external threats. There are many triage systems. Those of the readers who have experienced should use the system they are used to, as long as the actual circumstances are taken into account. We think that the best system now available for use in the field and at the entrance of the first treatment facility is “triage sieve,” which assigns an order of priority to each victim on the basis of simple criteria; taking into account that victim’s characteristics only. T1 are those victims who have an abnormality in their airway, and/or an abnormal respiration, and/or shock. T2 have normal vital signs, but are unable to walk. T3 are the walking victims. T4 Definitive care (details are described in part C,D,E, F,G) Please note that an unconscious victim is categorized as T1, until the airway has been secured.
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Be aware that a victim’s condition may change over time and that triage should therefore be repeated, using either Triage Sieve or Triage Sort, depending on the circumstances. Triage Sort assigns priorities based on the revised trauma score. At this time, a victim may be up or down triaged depending on factors such as time requirements of specific treatments, survivability, etc. Clearly, this is a judgement call; for that reason triage, sort but also sieve, should be performed by the most experienced health professional (who, ideally, has been trained in performing triage). Triage Sort has four categories: T1: Victims who require immediate care (ABC unstable: problems in airway and/ or breathing and/or circulation) T2: Victims who are ABC stable, but who require treatment (usually: surgical) within 4–6 h T3: Victims whose treatment can be postponed; if needed, for days T4: Victims who have been categorized T1, but whose survival is considered to be unlikely (given the circumstances). Use of this category should be “avoided” as long as possible Please note that both management of an individual casualty (see below) and triage of multiple casualties use the same systematic approach. We refer to the current (B)ATLS and MIMMS manuals for further study on triage.
The Individual Casualty It has become generally accepted that one should “treat first what kills first”; this principle is valid “everywhere” and for all patients/victims, trauma and non-trauma. The description below is confined to injured people. As threats to life are not always immediately obvious, the systematic approach now entails: 1. Assessing the general condition of the victim and a quick search for obvious life threats (abnormalities of airway, breathing, circulation, and consciousness) 2. Elimination or alleviation of those threats and reassessment 3. Preparing an inventory of all injuries (in themselves not life threatening) 4. Definitive care (details are described in Part C,D,E,F,G) This systematic approach has first been described in the American College of Surgeon’s Advanced Trauma Life Support Programme©. Although the programme was designed to be used by doctors working in the emergency room of a modern hospital, the approach holds good even in the austere setting of a refugee camp or in a conflict setting. The background is that death following injury occurs in a predictable and time-dependent manner. An obstructed airway will kill before a lethal chest injury, while a lethal chest injury will kill before a fatal circulatory problem, and abnormalities should be looked for and treated in that order. Serious brain injury is only occasionally treatable by surgical intervention; the victim’s condition will, however, deteriorate if constant delivery of oxygen and nutrients to the brain is not maintained. That flow depends on an unobstructed airway, effective gas exchange, and circulation. Local injuries are usually not life-threatening. This recognition leads to the approach, listed below.
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Primary survey: what is killing the victim? Resuscitation: treat what is killing the victim Secondary survey: identify all other injuries Definitive care: develop a definitive care plan
Resuscitation includes frequent reassessment. Primary survey and Resuscitation together are also called is Initial Assessment. In the prehospital or field setting, the emphasis should be on Initial Assessment; secondary survey and definitive-care are best conducted in a static health centre where the patient can be fully undressed and assessed in an appropriate environment. The elements of the primary survey are described below, using the mnemonic ABCDE. ● ● ● ● ●
A: Airway assessment, with protection of the cervical spine B: Breathing and ventilation assessment C: Circulation assessment and control of bleeding D: Dysfunction of the central nervous system E: Environment considerations and exposure (and, if appropriate, evacuation/ transfer of the victim)
In the military medical services, this sequence is preceded by a small “c”: management of catastrophic (exsanguinating) bleeding. In an austere environment, this “c” may very well be important also for the civilian health professional.
Scope of the Initial Assessment In all circumstances, the aim of the health professional who is working in the prehospital environment is to get the victim in the best achievable condition to an appropriate hospital in the shortest possible time. In peace-time in an ordered society, this usually means that after a brief assessment the victim is transported to a well-equipped hospital, with resuscitation on-going en route. This is known as “scope and run”. When transportation times are longer (e.g., in rural areas of that same ordered society), it may be advisable to perform a more lengthy assessment and institute resuscitative measures on-site (“stay and play”). The latter is all the more to the point in an austere environment, where “scoop and run” is simply not possible, usually: long distances, lack of transportation, destruction of physical infrastructure, and so on. When physical danger is present, it is best to “try and get out” after a minimum of resuscitative measures, aimed at securing the airway and dealing with the small “c”.
Catastrophic Hemorrhage This type of bleeding is usually immediately visible: a spurting artery or (very insidious!) a quickly spreading stain or pool of blood. Local compression often suffices to stop the bleeding; occasionally a tourniquet is warranted. In the last couple of years, particularly in the military, hemostatic bandages (QuickClot, Hemcon, Celox) have come to the forefront.
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Airway and Cervical Spine Protection Always talk to the victim: if you get an effortless and coherent answer, the airway is unobstructed (and breathing, circulation, and perfusion of the brain are adequate also; at that moment). Further assessment is by “LLF”: look for movement of the chest and signs of obstruction (“effort”), listen for abnormal sounds, feel for air passage. The scope and extent of interventions will vary with skill, training, and available equipment. Chin lift/jaw thrust and cleaning of the mouth are the most simple ones and are always possible; airway adjuncts such as naso- and oropharyngeal airways have their indications and risks; intubation and the surgical airway (cricothyroidotomy) require considerable skill. Refer to one of the trauma manuals listed in the Resources section for a full description of the options. Only do what you are familiar with and have trained for (and for which the equipment is available). If the victim is unconscious and the airway cannot be definitively secured by intubation, it is best to either leave that victim supine with somebody maintaining a chin lift or jaw thrust, or (if no additional personnel is available) put the victim in the recovery position (the adage still holds: “if an unconscious victim can look at Heaven, he’ll soon be there”). The latter always raises questions about immobilizing the spine. Cervical spine control should be addressed sagely. In peacetime almost every trauma victim will be immobilized with a cervical collar and a backboard. Be aware that further airway measures are very difficult when the collar is in place. When such measures are necessary, it is advisable to have someone immobilizing the head manually and to remove the collar temporarily. In an austere environment, collars and the like may not be available; then consider alternative ways of immobilization (or put an unconscious victim in the recovery position). In the latter case, maintaining the airway takes precedence over protecting the spine. Moreover, recent experience has shown that in a victim with penetrating neck injuries immobilization is not necessary.
Breathing and Ventilation There are five “intra-thoracic killers,” which should be systematically looked for, and immediately dealt with when found. They are: ● ● ● ● ●
Tension pneumothorax Open pneumothorax Massive hematothorax Flail chest and pulmonary contusion Cardiac tamponade
The first four kill by impairing gas exchange; cardiac tamponade by circulatory standstill (the latter is a “C” problem but will be discussed here). Assessment is again by “LLF” (and in this case, percussion), after baring the neck and the anterior chest.
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Look ● Distended neck veins (think of tension pneumothorax/cardiac tamponade) ● Breathing rate (below 10/min: think of brain injury; above 29/min; think of “hypoxemia”) ● Excess respiratory effort (think of airway obstruction) ● Chest asymmetry (think of pneumothorax/tension pneumothorax) Listen ● Listen for the quality of breath sounds, comparing left to right (if diminished/ absent on one side: think of pneumothorax/hemothorax) Feel (palpate; include the back!) ● The position of the trachea in the jugulum sterni (if deviated: think of tension pneumothorax on the opposite side) ● Crepitus (think of subcutaneous emphysema) ● Tenderness (think of rib fractures) Percuss (apices and axillae) ● Resonance (air; think of pneumothorax) ● Dullness (fluid; think of hemothorax, hydrothorax) ● Equal (may differentiate cardiac tamponade from tension pneumothorax in a deeply shocked patient with engorged neck veins) Please note: at first inspection bruises and wounds on the anterior trunk will also be noted. In a treatment facility the chest X ray is of help. For a full description of all possible interventions you are referred again to one of the trauma manuals listed in the Resources section. Below they are mentioned for each of the “killers”: ● Tension pneumothorax In the field: needle thoracostomy In a treatment facility: needle thoracostomy, tube thoracostomy ● Open pneumothorax In the field: airtight dressing, taped on three sides; Asherman valve In a treatment facility: closure (see above), operation ● Massive hematothorax In the field: none In a treatment facility: tube thoracostomy after inserting i.v. lines; occasionally thoracotomy ● Flail chest and pulmonary contusion In the field: none In a treatment facility: pain relief; occasionally mechanical ventilation ● Cardiac tamponade In the field: none In a treatment facility: ideally thoracotomy (pericardiocentesis often is ineffective)
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Circulation and Hemorrhage Control When the circulation no longer perfuses organs and oxygenates tissues, we consider the patient to be in shock. Shock is not a disease entity, but a clinical state with many causes. There are four groups of causes: ● ●
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Hypovolemic (loss of blood and/or fluids) Cardiogenic (loss of contractile strength as in myocardial infarction and congestive failure, dysrythmia) Distributive (neurogenic as in high spinal injury, anaphylactic as in acute allergic reaction, septic) Obstructive (tension pneumothorax, cardiac tamponade, acute aortic dissection, massive pulmonary embolus)
Although most mechanisms may occur in trauma patients, the main cause of shock in this group is blood loss, resulting in hypovolemia. The earlier (impending) shock (and its cause) is recognized, the better the results of treatment are. Treatment rests on two pillars: eliminating the cause and replenishing the volume lost. Shock is diagnosed by “LLF”: Look ● ● ●
External blood loss Paleness of the skin (particularly in Caucasian individuals) Duration of capillary refill time (CTR: after 5 s of compressing a nail, the normal color should return within 2 s)
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How the conscious patient reacts to being addressed (loss of consciousness, however, is a late occurrence!) By stethoscope for the blood pressure (decreased pressure is a late sign!)
Feel ● Temperature of the skin ● Heart rate by palpating an artery (tachycardia is a very early sign!) ● Presence/absence of pulsations in the radial artery bilaterally (absence usually means that the patient is in shock!) The extent of blood loss can be roughly gauged by a combination of symptoms and signs. Please note that the blood pressure remains unchanged until blood loss exceeds 1,500 mL. As soon as the patient is considered to be in shock, a search for its cause should begin and measures be taken. Catastrophic hemorrhage (the small “c”) should already have been excluded, or diagnosed and treated; likewise tension pneumothorax. For the remainder of the search the check list is: ● ●
Blood on the floor (other external bleeding sites), the so-called compressible bleeding Four places more (incompressible bleeding)
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– Chest (hemothorax) (see under Breathing and Ventilation) – Abdomen (pain on palpation, and by excluding the other sites; in a treatment facility sonography is a very effective diagnostic modality) – Retroperitoneum and pelvis (instability of the pelvis on gentle compression; a pelvic X ray is of help in a treatment facility) – Fractures of long bones, in particular the femur (pain and abnormal movement on palpation; in a treatment facility X rays are useful) Measures to eliminate the cause are: ● External blood loss In the field: compression; occasionally tourniquet A treatment facility: occasionally surgery ● Hemothorax In the field: none A treatment facility: tube thoracostomy after inserting i.v. lines; occasionally thoracotomy ● Abdominal bleeding In the field: none In a treatment facility: often surgery ● Retroperitoneal bleeding/pelvic fracture In the field: immobilizing the legs In a treatment facility: compression with a sheet”; occasionally surgery ● Fractures of long bones In the field: splinting of the involved limbs In a treatment facility: often surgery Please note: the measures mentioned under “in a treatment facility” depend on your personal skills and the availability of equipment. “Never” attempt treatment you are not familiar with! Measures to restore the circulating volume are infusion and transfusion. In the field oral fluid replacement should be considered, provided the victim is not vomiting. Ideally access to the circulation should be gained, at this moment either by a short, large bore cannula in a peripheral vein or by the intra-osseous route (adults and children). Both are feasible in the field. Central venous lines carry considerable risks and should be reserved for usage in a treatment facility (if ever). The intra-rectal route is not advised; particularly not when abdominal injury may be present. Infusion should begin with a crystalloid solution (Ringer’s or normal saline ideally at body temperature), and be followed up (when available) with blood (which should be ordered early). Hypertonic saline, dextrans, and starches are still under investigation and have not (yet) replaced isotonic crystalloids. The same is valid for blood substitutes such as perfluorocarbons and bovine hemoglobin solutions. When to start an infusion obvious depends on where the victim is; on the availability of fluids (remember: in the field every unit will have to be carried on someone’s back!). In the field the end-point of i.v. therapy should not be a normal blood pressure: 90 mm Hg is entirely acceptable, and possibly, as long as a victim remains coherent, “any” blood pressure will do. Striving for normal values may “pop the clot”.
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In a treatment facility i.v. therapy should be used sagely: if vital signs normalize after 1 bolus of 2 L of Ringer’s solutions, the victim will probably not need surgery for bleeding control. However, if there is no or only temporary improvement, the victim should be expeditiously transferred to surgery in order to stop the (often intra-cavitary or retroperitoneal) blood loss. It is “no use” to go on giving large amounts of fluids; that would be a waste of resources and the result is “yo-yo resuscitation,” dilution of the circulating volume and loss of clotting factors. The resulting acidosis and clotting abnormalities, together with hypothermia, are known as the “terrible triangle of death.” As much as possible, the victim should, therefore, be protected from hypothermia; beginning in the field, even in a hot climate. When the need for surgical control becomes apparent, steps should immediately be taken to transfer the victim to a facility where that surgery is possible. If no evacuation is possible, common sense and realism should prevail: some of these patients will die. This group of patients is not abandoned: they are entitled to care and pain relief.
Dysfunction of the Central Nervous System In the field setting, this component can be assessed quickly. There are three tasks: ● ● ●
Assessment of the level of consciousness using “AVPU” Assessment of the size and reactivity of the pupils Assessment of “lateralization”: looking for differences in sensibility and motor function of the limbs, comparing the left to the right side and the upper to the lower limbs. This can only be done in conscious victims
The elements of AVPU are: ● ● ● ●
A – Alert and orientated to the surroundings and the eyes are opened spontaneously V – Responds to Voice P – Responds to a Painful stimulus (by applying pressure an eyebrow) U – Unresponsive to any stimulus
The pupils are examined to assess equality and to check their response to light. In the field these tests can (and should) be performed only cursorily. In a treatment facility, the same tests are performed, but more elaborately. To asses the level of consciousness usually the Glasgow Coma Scale is used. If any abnormality of the central nervous system is detected, there is very little that can be done in a prehospital, hostile environment. Pending evacuation/transfer, secondary brain injury due to hypoxia should be prevented, as described under Airway. At the completion of the “D” assessment, the victim’s back should be inspected. As a “log roll” is required, this is formally done in a treatment facility only. In the field, health care professionals should swipe their hands under the body (e.g., during the “B” assessment) to see whether there is blood on the gloves.
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Reassessment During the Initial Assessment, the victim should be regularly reassessed, to see how the situation is developing. If a victim suddenly deteriorates, the health professional should return to “A,” and assess again. During Primary Survey and Resuscitation, a brief history should be obtained. Essentials are covered by the mnemonic AMPLE: ● ● ● ● ●
A – Allergies M – Medications P – Previous illnesses and operations L – Last meal E – Event
The victim’s condition at the end of the Initial Assessment, the injuries present, and the local situation (level of danger, available resources, possibility of evacuation, and distance to the next treatment facility) “decide” what happens next. This critical decision making may precede the Secondary Survey. A patient who has no life-threatening lesion, or one who successfully resuscitates, may be moved if that is possible. Others with more severe injury who fail to respond pose unique problems. If evacuation is possible, then this must be achieved safely and promptly. Where no evacuation is possible, reassurance and optimal nursing care, including pain control, is the minimum. Never move an unstable, dying patient when no destination is known. Have the moral courage to hold such people and care for them until they die.
Secondary Survey A secondary survey is a full, head-to-toe assessment of the patient and takes place following a successful initial assessment. Ideally the patient is fully undressed, which implies a stable, warm, safe environment. In the field, the secondary survey can only be performed cursorily; the environment is often unstable and undressing a patient there is for many reasons contra-indicated. In a treatment facility, the question always is whether it is better to transfer the patient (e.g., to surgery, or to a facility with more resources). In those cases, the secondary survey will have to be postponed until the patient is fully stable. Additional diagnostic modalities (imaging, laboratory tests) can only be done in an appropriately equipped treatment facility.
Definitive Care This requires careful planning and can obviously only be done in a treatment facility with appropriate resources
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Part C – Soft Tissues and Skeleton Ralph de Wit and James M. Ryan
Wound Management This section is concerned with the time-honoured principles of open-wound management in a hostile environment. These are distilled from the many lessons learnt over the last 200 years, in situations of war and disaster, often by hard experience. The circumstances often dictate another approach to wound care, an approach that differs from what may be safely practised in a twenty-first century hospital in the developed world. This section aims at health professionals who specialize in the management of traumatic wounds in hostile environments but it should also help to inform all who may have to care for the injured. Effective and simple ways for primary treatment of these wounds are listed as well as indications for referral. The range of injury in austere environments is considerable. The main features are: ● ● ● ● ● ●
Multiple open wounds, involving multiple body cavities or systems Variable degree of soft-tissue injury Extent of the injury initially hidden to physical examination Wounds associated with delay and heavy contamination Initial management rendered by relatively inexperienced personnel Poor working conditions and less than optimal equipment and environment
General Statement on Wounds Prompt and appropriate initial management of all injury types reduces suffering and prevents unnecessary loss of life and limb. Local circumstances largely determine what types of injury are to be expected. In remote areas, especially when means of transport are limited, serious multiple injured patients will not reach health care facilities in time. The majority of patients will present with nonimmediate life threatening conditions. Nonetheless, improperly treated soft-tissue injuries, wounds, and other septic conditions can lead to prolonged or even permanent disability. Whenever possible one should document the history including circumstances, time, and mechanism of injury (how, where, and when). This documentation must also be made available to other health professionals who care for the patient at that time or in the future. A wound is any break in the continuity of the skin. The extent of tissue damage and therefore treatment required is related to the mechanism of injury. Most soft tissues react similarly to mechanical forces; five types of wound can usually be identified. ● ●
Abrasion: A breach in the skin caused by friction, usually only superficial damage. Contusion: Damage to the skin and deep structures caused by blunt force. Associated with bruising but no defect in the skin, loss of skin later might occur.
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Laceration: A breach in the integrity of the skin caused by the tearing effect of a blunt injury. This includes degloving injuries where skin with the local layer of subcutaneous fat is stripped of the underlying muscular fascia. Incision: Damage caused by a sharp object. Puncture: A penetrating injury involving deep structures.
Contusions and lacerations are often associated with similar internal injuries. In puncture or penetrating wounds, external evidence of serious internal damage may be minimal. The mechanism and history of the injury contain essential information for estimating the extent of any damage, the likelihood of any contamination (chemical or infective), or the presence of foreign bodies. Minor wounds should be gently cleaned with antiseptic or sterile solutions and then covered with sterile dressings. Foreign bodies should only be removed if not adherent or penetrating, this to prevent further tissue damage or hemorrhage. Large wounds, damage to special areas such as the eyes, hands, or head or wounds involving bones or internal organs need to be covered and reviewed by medically trained personnel.
Principles Open, penetrating wounds are usually obvious. What often may be less obvious is the extent of concealed injury. Little can be determined from the wound’s appearance and no assumptions can be made on the basis of appearance. Initial management when faced with patients with open wounds is as described in the preceding section. It is important that apart from controlling compressible hemorrhage, nothing further is appropriate until the primary survey has been completed and the patient is stable.
Management Strategy A suggested working management strategy is described below.
Early Priorities Take a history and examine the patient using the time-honoured ABCDE approach according to the Advanced Trauma Live Support directives. Life-saving measures take priority to attending to a wound unless this is necessary to control the bleeding. Note any delays or contamination that points to the likelihood of impending sepsis. Cover the wound with a field dressing, wound pad, or bandage. Record your findings and draw a diagram if possible.
Pain Relief If pain is a feature, small incremental doses of intravenous opiates are best. This will also allay anxiety. Beware of overdose. See also the section on Anaesthesia and Analgesia.
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Control of Infection While never a substitute for early and adequate surgery, systemic, preferably intravenous, broad-spectrum antibiotics will control bacterial growth and colonization for a time, if started as soon as possible (ideally within an hour of wounding). There is little to no evidence that the use of local antibiotic powders is helpful. It may even be detrimental to the process of wound healing, and it interferes with repeated wound inspections. The following sections are for surgeons who may be unfamiliar with wound management in hostile and austere environments.
Preoperative Assessment Surgery should not be delayed for laboratory and radiological investigations, if there is an immediate risk to life or limb. If time permits, some tests are appropriate, X-rays of the chest, pelvis in search for significant hemorrhage, and X-ray of the cervical spine are helpful in the multiply injured. When available (portable) sonography can rapidly confirm or rule out most of the immediate life threatening injuries in the chest or abdominal cavity. In the case of ballistic injury, biplanar X-rays are helpful in determining wound tracks and in locating metallic fragments. Some baseline laboratory tests are appropriate. These include a full blood count, blood for bacterial cultures, and serum for group and a cross-match of whole blood or erythrocyte concentrate for transfusion.
Surgical Technique Most surgeons will be familiar with current techniques used in wound excision in the stable environment of a hospital in the developed world. In a hostile and austere environment, some modifications are appropriate. Wounds in these environments are often old, neglected, and contaminated. Furthermore, many surgeons may not be familiar with injury caused by bullets, shell fragments, or mines (blast injury). An aggressive and, if necessary, repeated approach with generous skin incision, wide fasciotomy, and meticulous excision of all devitalised tissue holds the key to success. In the field, neurovascular structures must be directly inspected for injury that maybe subtle. At the end of the procedure, it is often appropriate to leave the soft tissues open for a delayed primary closure at 4/5 days, a time-honoured lesson in these situations. Wounds should be carefully dressed as follows: ●
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Lay on (do not pack) fine, fluffed gauze layers with overlying synthetic or cotton wool. Wound edges may adapt but allow for drainage of wound secretions into the gauze. Hold in place with a broad (6-in.), conforming or elastic crepe bandage Formal drainage is not required unless infective secretions already exist or the amount of secretion exceeds the absorbent capacity of the dressing. For major limb wounds, splinting with plaster of Paris slabs or split casts is recommended; especially when the patient needs to be transported. For associated fractures, external fixators are mostly safer than internal fixation devices.
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When available Vacuum Assisted Closure techniques can provide excellent protective and draining wound dressing.
Postoperative Care The wounded area should be rested and mildly elevated if possible. Repeated observation for impending vascular compromise and wound sepsis is mandatory. Soft tissue swelling may require the readjustment of outer dressings. The inner wound dressings should be left undisturbed unless they are felt to be causing vascular compromise or are masking serious underlying bleeding or infection. Antibiotics should be continued depending on the severity of the contamination or infection already present. When the wound is intended to remain open and heal by secondary intention (by formation of granulating tissue, with or without subsequent skin grafting), antibiotic treatment can be stopped when signs of infection disappear. In case of ongoing infection, the treatment must be continued and changed if cultures indicate a resistant organism. Open wounds do not require antibiotic treatment when there are no signs of infection. Wounds under these circumstances often leak considerable quantities of blood and serum, even to the extent of requiring blood transfusion. When striving for delayed closure in noninfected wounds, a 5-day course of antibiotics may be started at the time of the closure.
Delayed Closure If wounds have been left open, the optimal time for inspection and closure is between the third and fourth postoperative days. This usually requires a return to theatre and a general anaesthetic. If the wound is clean and shows no signs of infection, it may be closed, but this must be done by suture without tension and with minimal disturbance to the wound edges. In case of doubt concerning the condition of the wound, it is prudent to insert a subcutaneous drain for 2–3 days when the skin is closed. When there is tension on the wound edges during closure, a combination of direct suture and split-skin grafting may be appropriate.
Fractures and Dislocations This section is aimed at health professionals with little or no exposure to treating fractures or dislocations, but who may encounter such patients during a deployment. It is not intended to be an exhaustive discourse on management, but rather an outline of the principles of early management. Experts in the field should manage such patients where possible.
General Statement A fracture is any crack or break in a bone. It can be associated with an open wound, and complicated by injury to adjoining muscle groups, blood vessels, nerves, and organs. A dislocation is a displacement of a bone at a joint; there will always be associated
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sprains and tearing of ligaments around the affected joint. Deformed limbs should be gently returned to as normal a position as the patient will allow, certainly in case of neurological or vascular deficit. Any further movement should then be restricted by splinting, since it may cause additional injury or pain. Splint devices need not be tailormade; blankets or belts for example can be used to restrict unnecessary movement. The definitive treatment of any fracture or dislocation requires specialist medical input.
Biomechanics and Pathophysiology Fractures and dislocations occur when the bony skeleton fails, when a load or force is applied. The skeleton rarely fails in isolation – surrounding structures such as soft tissue and neurovascular structures may also suffer injury. The principle that should apply is not to manage bones and joints in isolation. The affected limb or limbs should be assessed as a whole. In managing these injuries, the approach outlined earlier should be applied. Start with the primary survey and work through it in the usual way. Injuries to bones and joints will normally be encountered either as part of the “C” of the ABCDE paradigm in case of life threatening hemorrhage, or during a detailed secondary survey (limb-threatening).
Management Strategy The recommended approach is outlined below.
Primary Survey and Resuscitation Check for and manage any life-threatening injury. In the context of limb injury, this will be recognition and control of external hemorrhage and placing the injured limb in rough alignment and length. Doing this is a very effective measure in controlling bleeding and reducing the risk of further injury. It also reduces pain. Do not do this against resistance!
History The history (road traffic accident or gunshot wound, for example) gives important information on the extent of injury. Road traffic accidents are typically associated with multiple and multisystem injuries. Ambulance paramedics refer to this as “reading the wreckage.” Falls from a height suggest foot, ankle, leg, pelvic, and spinal injury. Gunshot wounds inevitably mean injury to multiple structures and wound contamination. The history may also give an indication of the delay between injury and management.
Limb Examination A systematic approach is necessary. The time-honoured way is known as look, feel, move, stabilise.
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Look at the skin, soft tissues, and bone and note swelling, bruising, or deformity. Feel the skin, surrounding tissues and over the bone (gently!) and also assess neurovascular integrity. Movement: first ask the patient to move the limb, and then move it yourself (gently) as far as the patient allows. Stability: gently check the stability of the affected joint. In a field setting, there is much that can be learnt by this simple approach. The general vascular state of the limb can be ascertained, and the extent of swelling or deformity will be noted. The range of movement will also be noted actively and passively. Location and severity of the pain as well as loss of function may indicate the presence of a fracture. The complete examination will not only give an indication of the extent of injury, but also a guide to the necessity of urgent intervention and the need to get the patient to a hospital or higher level of care.
Treatment Treatment should be divided into immediate and early.
Immediate This means save life, then limb. For example, if the patient is unconscious, clear the airway and then attend to the limb. If there is vascular compromise, pulling the limb out to length and roughly realigning it may restore circulation. If not, urgent hospitalization is required. External hemorrhage should be dealt with by external compression over a wound pad or with a pressure bandage. Depending on the situation, for example under fire, a tourniquet might be the best option to control the bleeding. The person performing this technique should be trained and educated on the proper indications and use. The time of application should be noted and the patient moved to hospital as soon as possible.
Early In the field, there should be no attempt to perform definitive reduction. Returning the limb to length and alignment should now be attempted if this was not done earlier. It is usually possible to do this with fractures but only seldom with dislocations. Do only use minor force! An expert may perform reductions of dislocations to shoulder and ankle in the field. One may try distraction of a dislocated joint once but when not successful the attempt should be stopped. As a rule, some form of intravenous analgesic and anxiolytic agent are required. Do not attempt reduction if you are not trained in these procedures unless there is neurovascular compromise. Having achieved length and alignment and attended to wound dressing, some form of splint is required. In the field, setting ingenuity may be required. Use any materials in the immediate surroundings such as pieces of wood or tree branches. No matter
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what your discipline or area of expertise, you should acquire some basic knowledge in the management of wounds, fractures, and joint injuries. Many humanitarian agencies will insist on such training. If not, approach organizations such as St. John Ambulance or the Red Cross societies. Many of these injuries are very painful and frightening. If available, opiate analgesia is best given in small intravenous boluses rather than a single dose by intramuscular injection. Repeated small intravenous increments maintain a plateau of pain relief and overall less analgesia may be required. See also the section on Anaesthesia and Analgesia
Other Injuries Sprains and Strains Sprains are stretching injuries of joint-related structures, whereas strains involve damage to muscular tissue. The acronym PRICE summarises the initial treatment priorities for both problems. ●
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Protection and pain relief: The injury and the individual should be protected from further harm; simple analgesia should be given if available. Rest: The initial injury may be exacerbated by any undue exertion. Pain and swelling will also restrict the amount of activity possible. Ice: A cold compress made from crushed ice, bags of frozen peas, etc. should be wrapped in a towel to protect the skin from cold injury and placed next to the injured area for 20 min per hour for the first 3 h. Compression: Where possible, the injured area should be compressed by a layer of bandaging. Care needs to be taken not to constrict the circulation; an increase in pain may indicate a dressing that bas been applied too tightly. Elevation: Raising the injured area to the level of the heart can reduce swelling and pain.
After 2 days or when tolerated, gentle mobilization of the injured area can begin. A supportive elastic bandage may reduce pain and recurrence of swelling. In case of sprains, a tape bandage of the affected joint can promote mobilization when the swelling has come down. Continued pain or swelling may be an indication of a more serious underlying condition requiring more specialised medical help.
Burns Burns are injuries caused by heat, but by convention, and since the treatment is similar, damage caused by irradiation and chemicals are also included. The source of the injury is usually outside the individual and as a result the surface layers of body are commonly affected first. Exceptions to this are electrical burns where extensive damage can affect deep structures with little damage to the skin. Another exception is inhalation injury form of inhaled heat or smoke. The initial management of any burn is to remove the source of the injury; this may involve stripping the patient.
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The damaged area should then be flushed with lukewarm water (any water will do!), for 10 (fire) to 30 min (chemicals); this cools the burn, removes any residual chemical contaminant, and provides pain relief. Minor burns, as assessed by depth and area, can be treated by sterile dressing and observation. Larger, deeper burns or burns to a special area (face, hands, genitalia) need more intensive resuscitation or treatment and are best looked after in specialised medical facilities. Since burns are initially sterile, antiseptic preparations should only be used if the wounds have become infected, if sterile dressings are not available or if evacuation is likely to be lengthy. Reassessment of depth and area should be done after 24 h.; undue use of ointments might make this more difficult.
Injuries to Special Sites Certain injuries are beyond the scope of this manual. They require highly specialized training and expertise. Included here are serious head injuries and spinal injuries. Readers who are likely to encounter such injuries during their deployment should ensure a level of training appropriate to their seniority and field of work.
Surgical Infections Introduction This section will discuss different types of soft tissue infections that may be encountered in catastrophe and conflict situations. Soft tissue infections can lead to loss of limb and develop into life threatening conditions because of accompanying severe systemic toxicity (septic shock and multiple organ failure). The early recognition of these infections is crucial for successful treatment but initial clinical signs are often minor and delay correct diagnosis. Common characteristic in the treatment of these soft tissue infections is that early surgical intervention is indicated. Besides supportive treatment with fluid resuscitation, hemodynamic stabilization, and broad spectrum antimicrobial regimen, always expedient and radical surgical débridement must be performed. When clinical signs are present deep infections may mimic superficial pyodermas such as erysipelas, impetigo, ecthyma, furunculosis, or cabrunculosis; a “suspicious” attitude is warranted. Soft tissue infections of fingers or the hand can easily spread in the direction of deeper anatomical structures. Tendons and tendon sheets as well as fascia structures provide a route for fast progression of the infection to other parts of the hand and lower arm. Staphylococci and Streptococci are the main causative bacteria but sometimes saprophytes are also involved. Initial treatment includes broad spectrum antimicrobial regimen until results of bacterial cultures are available. Clinical signs are primarily severe pain and not necessarily markers of infection like erythema, swelling, and elevated skin temperature. Especially when the tendon sheets of the flexor muscles of the hand are involved (panaritium tendineum), pain and loss of function are the dominant signs. A superficial small wound with pus discharge on a
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finger can well be a sign of deeper infection of the underlying bone or pulpa. Even very small skin wounds (sometimes already healed) can allow access of bacteria to the deeper anatomical structures so the presence of a large or fresh wound is not a prerequisite for making the diagnosis. To determine the presence of deep infection, surgical inspection under local anaesthesia may be performed, i.e., local incision of the skin and exploration. But when deep infection is encountered an extended exploration is necessary, often into other parts of the hand and lower arm. Complete drainage and débridement must be performed, which is only possible with adequate anaesthetic care and surgical expertise. So preferably a surgical inspection should be performed in an adequate equipped surgical facility; otherwise a two-step procedure is needed: the explorative wound is left open for drainage, supportive treatment is started as needed including antibiotic treatment, and the patient must be referred to an appropriate facility.
Necrotizing Fasciitis This type of acute soft tissue infection involves the deep and superficial fascia as well as the local subcutaneous tissue. The underlying muscle is unaffected. In the early course of infection, the skin is not involved, only later showing blisters, hematoma like appearance, markers of infection, or necrosis. Also in necrotizing fasciitis, local pain (without evident cause) is an alarming first sign. Severe sepsis or septic shock may be present even before a deep infection is clinically suspected. Common initiating injuries leading to this infection are mostly minor trauma, less frequently operative wounds and decubitis ulcers. The onset can be slow (up to 14 days) or very sudden with septic shock and extensive necrosis within 24 h. Progression of the infection and necrosis in the affected fascia with one or more centimetres per hour is possible. In case of slow onset, the course of the disease may be more benign with less tissue necrosis and less systemic effects. Group A Streptococcus, (anaerobic) Clostridium perfingens, and/or a mixture of gram positive and gram negative bacilli lead to this type of infection. The clinical presentation is not typical to the causative bacilli, so broad spectrum antibiotic regimen must start immediately when this infective condition is suspected. To diagnose necrotizing fasciitis, a local puncture and aspiration can confirm the diagnosis, but a negative test does not rule out the diagnosis. Should the puncture be inconclusive local surgical exploration is indicated. When the diagnosis is confirmed, immediate and complete surgical débridement must follow. The patients often require extensive surgical exploration, frequently including limb amputation. Postoperative often large open wounds remain that need further surgical attention and supportive treatment in an Intensive Care Unit for most patients is necessary. Patients with (suspicion of) this condition should be referred to an appropriate medical facility. Fournier’s gangrene is a type of necrotizing fasciitis that affects the scrotum and genitalia. Cutaneous gangrene appears early in the course of the disease because of the lack of subcutaneous fat between the dartos fascia and the skin. The infection often spreads rapidly in the direction of the buttock and upper leg as well in the perineal muscles and around the rectum.
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Myonecrosis Bacterial myonecrosis syndromes include clostridial infections, also known as gas gangrene. But also non-clostridial myonecrotic infections can occur, presenting with the same clinical signs. Rapidly progressive necrosis of the affected muscles is the main characteristic. After some time also the overlying subcutaneous tissue and skin become necrotic. Penetrating trauma and arterial insufficiencies are the most important causes. Surgical management and supportive treatment are in accordance with the information in the previous section.
Cellulitis This group of more superficial infections initially only involve the skin and the local subcutaneous fat. Classic presentation is erythema, edema, pain, and local tenderness, sometimes lymphangitis. The course of the infection is mostly more benign than in the previous mentioned soft tissue infections but rapid progression to surrounding skin regions and entire extremity can occur, also with systemic toxicity (sepsis). Broad spectrum antibiotic regimen is indicated for Streptococci and Staphylococci infection. Local care includes immobilization and elevation of the affected extremity. Further analgesic drugs and cool compresses may be of help. Sometimes abscesses or necrosis develop that need surgical management. When the cellulites type of infection does not respond to appropriate treatment within 48 h or the systemic toxicity progresses, one should keep in mind the possibility of a more virulent deeper soft tissue infection and act accordingly.
Septic Arthritis Joint infection with pyogenic bacteria can result from penetrating trauma, adjacent osteomyelitis, or hematogeneous seeding. The onset is mostly acute and characterized by fever and pain. Physical examination shows swelling, erythema, and tenderness to palpation or movement of the affected joint. The diagnosis can be confirmed by needle aspiration, which should be performed under careful sterile conditions. Cloudy and turbid aspect of the synovial fluid and elevated cell count are indicative. Gram stain can help to guide the antibacterial treatment. Radiography does not contribute to the diagnosis in the early phase of the infection. Septic arthritis must be treated as an emergency condition. Intravenous antibiotic treatment and rest of the affected joint are primary measurements. Irrigation with sterile saline or surgical incision and drainage are needed when the joint aspiration reveals infection, certainly when the aspiration produces pus.
Further reading Sabiston D, editor. Textbook of Surgery; The biological Basis of Modern Surgical Practice (fourth edition). Philadelphia: W.B. Saunders Company, 1991 Hall J, Schmidt G, Wood L, editors. Principles of Critical Care (second edition). United States of America: McGraw-Hill Companies, 1998
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Fink M, Abraham E, Vincent JL, Kochanek P, editors. Textbook of Critical Care (fifth edition). Philadelphia: Elsevier (USA), 2005 Mattox K, Feliciano D, Moore E, editors. Trauma (fourth edition). United States of America: McGraw-Hill Companies, 2000 Rüter A, Trentz O, Wagner M, editors. Unfallchirurgie (language: German) (second edition). Munich: Elsevier GMBH, Urban & Fischer Verlag, 2004
Part D – Ballistics and Blast Ralph de Wit and David G. Burris
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Objectives
This section is concerned with unique injury mechanisms – ballistics and blast. Although not unique to the hostile environment, most aid workers will not have encountered injuries of this nature. This section serves to introduce and elucidate the topic.
Ballistic Injuries Ballistic wounds are produced by penetrating missiles. These cause injury by giving up their energy to the body, which results in laceration, contusion, crushing, and disruption of tissue: either by direct energy transfer or by cavitation and shock wave. Additional injury often also arises from heavy contamination.
Mechanism of Injury Energy Transfer When the body is struck by a missile, the damage inflicted depends upon the characteristics of the missile and the tissue through which it passes. The amount of damage caused is related to the amount of energy that the missile transfers to the tissues. Injuries can broadly be classified into low-energy-transfer and high-energy-transfer injuries, since kinetic energy equals ½ times mass multiplied by the square of the velocity of the object. The greatest amount of tissue damage is caused by high-energy transfer, which is related to the retardation of the missile and where the velocity of the missile is a more important factor than the size (mass). The retardation of the missile is an important factor in the creation of the wound, for the more rapidly a missile is retarded, the greater will be the energy release and consequent tissue damage. Retardation depends upon missile factors such as shape,
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stability, and composition, since this determines the way the missile passes through the tissues. It also depends on tissue factors such as density and elasticity.
Fragments and Bullets Penetrating missiles can be classified into two major groups: fragments and bullets. Fragments are the most common wounding agents in war, accounting for between 44% and 92% of all surgical cases, depending on the location and type of conflict situation. Antipersonnel fragments from military munitions tend to be small and numerous and are fairly regular in shape to ensure adequate range and consistent performance. Most military antipersonnel fragments have poor penetrating power and limited effective range. The energy available for wounding by the fragments is low and so a low-energy-transfer wound is created. However by direct force and blast military munitions can cause devastating injury. The current world wide trend is to prohibit the use of antipersonnel mines but in many (former) conflict areas these munitions will remain a burden for decades to come. In civilian practice, bullets are the predominant penetrating missiles, although fragmentation injuries can occur following terrorist bombings. The bomb can be designed to contain all kinds of fragments or the blast produces fragments of irregular shape and size. In general, bullets have a greater range and more penetrating power than fragments. Hand-gun bullets tend to have a lower velocity than rifle bullets, but both can produce a spectrum of high-energy-transfer and low-energy-transfer wounds, depending on the amount of energy transferred to the tissues (size of the bullet, range of the weapon used). Keep in mind to “treat the wound, not the weapon.”
Wound Track When a projectile hits the body, it produces a wound track. As already stated, the nature of the wound track will depend upon the amount of energy transfer. Low-energytransfer wounds are characterized by the injury being confined to the wound track. Injury results from a simple cutting mechanism, and the severity will be determined by the nature of the tissue penetrated, i.e., bone, muscle, nerve, or vascular structure.
Cavitation High-energy-transfer wounds are characterized by the formation of a temporary wound cavity, as well as by cutting and laceration in the path of the missile. This phenomenon is called (temporary) cavitation and occurs because the tissues surrounding the missile track are accelerated away. The velocity and momentum imparted causes tissues to continue to move after the passage of the missile and create a cavity that is 10–40 times the diameter of the missile. Because of the elasticity of the tissue, this cavity expands and contracts several times. These contractions are also
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very forceful and also contribute significantly to the amount of damage to the adjacent tissues. It is this cavitation effect which leads to the devastating injuries seen in high-energy-transfer wounds. A permanent cavitation results eventually.
Indirect Injuries As the effects of a missile are not confined to the missile track, indirect injuries can occur. For example, the spinal cord may be involved by the accompanying shock wave when the wound track passes close to the vertebral column, or a long bone may fracture in a limb even if it is not hit by the missile itself. Also pieces of a directly hit bone may spread through the body and act as additional fragments. Some bullets may fragment on impact.
Entry and Exit Wound Size The sizes of the missile entry and exit holes are governed by the size and shape of the penetrating missile and the degree of energy transfer at the site. Although a large tissue defect is the result of large energy transfers, the corollary that small entry and exit wounds imply low-energy transfer is not true, as high-energy transfer may have occurred internally. This is particularly true of long wound tracks, such as those occurring in abdominal wounds. Significant injury may have occurred within abdominal cavity due to a large amount of energy dissipation, although the projectile only retains a small amount of energy at the end of its track and so produces a small exit hole, or may even remain lodged within the tissues.
Wound Contamination Pattern of Spread Contaminants can enter the wound track from both entry and exit wounds. Lowenergy-transfer wounds have contamination that is limited to the wound track itself, whereas high-energy-transfer wounds have contamination spread throughout the boundaries of the temporary cavity. Contaminants include skin bacteria from the normal skin flora, pieces of clothing, fragments of the projectile, and material from the external environment (e.g., mud and dirt). This is especially valid at the entry side of the tract because a short-term high vacuum follows the missile.
Bacteria Clostridium welchii causes gas gangrene and has a rapid onset, which is quickly fatal. Staphylococcus aureus and Streptococcus pyogenes infections develop in the first 3 days, followed by gram-negative bacilli infections (e.g., Pseudomonas aeruginosa, Escherichia coli). See also the section on Surgical Infections.
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Principles of Treatment of Ballistic Injuries Basic principles Staged Surgery The surgical treatment of a ballistic wound is a two-stage operation. The first part is concerned with saving the life and when possible the limb. Also of concern is the prevention of serious sepsis by primary wound excision. In unstable patients, surgery should only address immediately life threatening injuries. Only after stabilization (in an Intensive Care Unit if available) wound excision should be performed. The second stage is the closure of the wound, which is carried out 3 or 4 days later. Intravenous antibiotic treatment should start upon arrival in the medical facility.
Timing of Surgery All wounds are contaminated by a mixture of organisms. Infection remains latent and superficial for about 6 h, after which time it becomes established and invasive. Therefore, providing the patient’s condition has been stabilized, surgery should be carried out as soon as possible after wounding.
Resuscitation Patients should receive adequate fluid resuscitation before surgery, although surgery maybe part of the resuscitation process.
Debridement It may be necessary to excise some viable soft tissue when there is extensive contamination. There should be generous surgical access with control of hemorrhage and extensive wound débridement (and decompressive fasciotomy for limb wounds). Subsequently, the wound should be dressed in preparation for delayed primary closure at 3–4 days or for more definitive surgery. When in doubt about the viability of the injured tissues or in an effort to save vital structures a second look may be required after 24 h.
Antibiotics Antibiotics are only an adjunct to, and not a replacement for, surgery. They should be used early in the treatment for maximum effect and should be discontinued as quickly as possible (5–7 days) to prevent the emergence of resistant strains of bacteria.
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Broad spectrum antibiotics should be used according to local or regional protocols. If available bacterial cultures should guide treatment.
Dressings Once dressed, wounds should be daily inspected, as appropriate, in the operating theatre or a special dressing area. Adequate analgesia must be provided to the patient.
Blast Injuries An explosive is a substance that undergoes chemical decomposition into gaseous products at high pressure and temperature.
Physics Blast Shock Wave The explosive substance, when detonated, is rapidly converted into large volumes of gas, which results in the formation of a blast shock wave. The blast shock wave rapidly expands as a sphere of hot gases with an instantaneous rise to peak pressure (the overpressure) that travels at supersonic speed. The overpressure falls as the speed of the shock wave declines, ending as a phase of negative pressure. This change in pressure results in blast winds, which blow alternately away from, and then back to the epicenter of the explosion. Blast waves may be reflected by buildings or other fixed structures, causing complex interactions of pressure changes. Additional injuries are caused by high speed fragments from the explosive device itself or from the environment. Blast wind and heat following an explosion (and/or fire) may add to the insult. Injuries following blast are traditionally divided into primary, secondary, and tertiary types, although a victim may exhibit components of all three.
Injuries Due to Blast Primary The overpressure associated with the shock or blast wave is responsible for the primary blast injuries. The most vulnerable sites are the air-containing organs such as the ear, lungs, and bowel.
Ear The ear is the most sensitive organ, with rupture occurring at modest pressures. Blast damage may result in tympanic membrane rupture, disruption of the ossicles, and
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inner-ear damage. The usual symptoms are tinnitus and deafness. The orientation of the ear relative to the shock wave is important in determining whether ear damage will occur. When approaching a victim of a blast assault, one should keep this injury in mind: the person may not respond as expected and the diagnostic process may be misdirected.
Blast Lung Lung contusion (blast lung) is rare, and occurs in less than 10% of survivors. Damage occurs at the alveolar membrane, resulting in hemorrhagic contamination of the alveoli and pulmonary oedema. Although usually mild, it may take the form of rapidly progressive respiratory distress syndrome.
Bowel Injury Bowel injury is rarely a cause of clinically apparent injury when the blast occurs in air, but is an important mechanism of injury in underwater blast. The most usual injury is hemorrhage into the bowel wall, but there may also be visceral disruption.
Sudden Death Sudden death may occur with no apparent evidence of external injury. This is believed to be due to occult cerebral or cardiac injury (coronary embolism), although fatal dysrithmias have also been suggested.
Secondary Fragment Injuries Secondary blast injury is caused by the impact of missiles from the explosive device or from other debris generated and propelled by the explosion. There are primary fragments from the explosive device itself and secondary fragments from surrounding objects. Casualties will have multiple penetrating wounds, most of which will be relatively superficial, widespread bruises, abrasions and lacerations, and severe bacterial contamination of wounds. In fatalities, the principle cause of death is from head injury arising from penetrating missiles and blunt impacts. Thoracic and abdominal wounds account for the majority of the remainder, and the pattern can extend from multiple very high-energy-transfer wounds, to injury in a vital organ from a small, low-energy-transfer projectile with good penetrating power. In modern combat situations, military personnel are often equipped with protective garments leading to a reduction of lethal injury to head and torso. Main cause of death in this situation is severe hemorrhage from injured extremities. First aid and live saving procedure, especially under hostile fire, is the application of a tourniquet.
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Tertiary Blast Wind Tertiary blast injuries are caused by the blast wind. Victims may be thrown through the air, sustaining impact injuries particularly to solid organs. Such injuries have been estimated to occur in 25% of the victims in a confined space. Traumatic amputation can occur as parts of the body are torn off and long-bone fractures and head injuries can occur. The bodies of victims very close to the explosion may be completely disrupted. Traumatic amputation of limbs by blast occurs only very close to explosions.
Antipersonnel Mines The most common explosive wounds of limbs in modern conflicts are those inflicted by antipersonnel mines, which cause a typical pattern of injury. There is traumatic amputation or disruption of the foot with mud, grass, and fragments of the mine, shoe, and foot being driven upwards into the patient’s genitals, buttocks and arms. The other leg is normally severely injured. Massive contamination occurs throughout the limb, even though only the foot has been amputated. Similarly, if a hand is traumatically amputated, tissue damage extends beyond the forearm, especially along tendon sheaths.
Crush Injuries Tertiary injuries may also result from building collapse. Crush injuries can result from falling masonry. In prolonged entrapment, amputation at the scene may very occasionally be required. In case of prolonged entrapment of an extremity with vascular compromise application of a tourniquet should be considered when trying to free the victim after more than 2 h of entrapment. With reperfusion of the extremity, dangerous amounts of potassium, lactate, and other toxic substances may enter the systemic circulation (Crush syndrome).
Burns Thermal injury may result from exposure to the fireball. These are usually flash burns affecting the exposed parts of the body. They are usually superficial, but airway damage and oedema may occur. If the interior of a building ignites, flame burns may also occur. An additional hazard in confined spaces is inhalation of hot air and/or smoke and toxic gases.
Psychological Problems Approximately, 40% of those involved in a bomb incident will develop psychological sequelae. As well as the victims of the bombing, health care workers will also be
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psychologically traumatised, but this appears to be less troublesome amongst trained rescue personnel, especially if their actions had a beneficial result.
Treatment of Blast Injuries Non-Limb Injuries All those suspected of having been exposed to a significant blast effect should be observed for 48 h. Patients with no injury other than a ruptured eardrum should be considered to have been exposed to a significant blast effect and should be observed accordingly.
Blast Lung Blast lung will usually occur within 6–12 h, but may take up to 48 h to develop and so the patient needs careful observation. Chest X-rays, if available, will reveal bilateral diffuse shadowing; early presentation (at admission) of these infiltrates suggests serious injury and rapid referral to a health care facility with artificial ventilation equipment is warranted. There will be hypoxia and hypercapnia on blood gas analysis. There is a risk of bilateral pneumothorax and so consideration should be given to the insertion of prophylactic bilateral chest drains, in particular when there is an indication (pulmonary support, neurological deficit) to intubate the patient. Vigorous chest physiotherapy is required during the severe phase of blast lung. The role of corticosteroids remains controversial. Nebulization of mucolytic and bronchodilatory medication may be supportive. Resuscitation should be with colloids or blood. Crystalloids may exacerbate pulmonary oedema as will over-infusion of fluids.
Tympanic Perforations The majority of uncomplicated tympanic perforations will recover with conservative management.
Abdominal Injuries Abdominal injuries may present as mild abdominal pain due to multiple small hemorrhages. Conservative treatment is appropriate, although should the patient develop signs of peritonitis, significant gastrointestinal hemorrhage, or radiographic evidence of free gas under the diaphragm (where X-ray facilities are available), a laparotomy should be performed. When abdominal lavage is available, sonography or CT-scan can aid in the diagnostic work-up for abdominal injuries. This additional information can provide safer guidance for operative or conservative treatment. Timely referral to a more appropriate health care facility should be considered in these situations.
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Limb Injuries Survivors with limb wounds from blast alone are amongst the most severely injured patients. The amputated limbs have been torn away from the torso, and nerves, blood vessels, and tendons are often avulsed at a proximal level. After resuscitation, in hemodynamically stable patients, surgery is confined to wound toilet with extensive débridement of dead and possibly infected tissue. There will be multiple fragment wounds, which will also need débriding. Initially wounds should left open; (too) early closure is a recipe for disaster.
Further Reading CoupIand RM, War wounds of limbs: surgical management Oxford: Butterworth-Heinemann, 1993. Greaves I, Porter K, editors. Blast and gunshot injuries. In: Pre-hospital medicine: the principles and practise of immediate care, London: Arnold, 1997. Greaves I, Dyer P, Porter K, editors. A handbook of immediate care. London: W B Saunders, 1995. Kirby NG, Blackburn G, editors, Field surgery pocket book. London; HMSO, 1981. Ryan J, Cooper G, editors. Ballistic trauma- London; Arnold, 1997. Skinner DV, Whimster F, editors. Trauma. A companion to Bailey and Love’s short practice of surgery. London: Arnold, 1999. Mattox K, Feliciano D, Moore E, editors. Trauma (fourth edition). United States of America: McGraw-Hill Companies, 2000. Rüter A, Trentz O, Wagner M, editors. Unfallchirurgie (language: German) (second edition). Munich: Elsevier GMBH, Urban & Fischer Verlag, 2004.
Part E – Abdominal Complaints and Acute Surgical Emergencies Walter Henny and Adam Brooks
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This section deals with surgical, (mainly) nontraumatic, emergencies. It describes the range of conditions that may present and suggests a management approach suitable both for the hostile and for the more secure environment.
Introduction Acute conditions should immediately make the responsible health professional ask: 1. Does this patient need operative treatment? 2. Can I provide that treatment or should the patient be transferred?
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If the former question has been answered negatively, the patient should be reassessed frequently: the patient may deteriorate in which case the treatment plan may have to be altered. The answer to the latter question depends in the first place on your own skills and the availability of transportation; in an austere environment other factors such as possibility of transportation, distance to and capabilities of the next treatment facility, and the tactical situation have to be taken into account as well. In this section, the following acute conditions will be discussed: ● ●
Abdominal complaints Other surgical emergencies – Superficial abscesses – Acute ischaemia of a limb
Abdominal Complaints In assessing patients with abdominal complaints, it should be realized that there are several cofounders: ●
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Abdominal complaints may be caused by disease processes located outside the abdomen: myocardial infarction and pneumonia. Also the chest should be examined in all patients with abdominal complaints. Systemic abnormalities may present as abdominal complaints: uremia, diabetes mellitus, acute porphyria, sickle cell crisis, lead intoxication. These possibilities should be addressed in the history. Medications such as morphine and corticosteroids will assuage the severity of complaints, and the findings at physical examination. Complaints and findings may be less clear-cut in young children and the elderly.
While assessing the patient, the essential question is: does this patient need surgery? You should be thinking in “processes”; the exact organ which gives rise to the presenting complaints is, with a few exceptions, less important. Assessment rests on three pillars: ● ● ●
History Physical examination Laboratory tests and imaging (in an austere environment often not or hardly available, which may necessitate transfer)
History This should cover: ● ●
Age and sex Complaints and their characteristics
448 – – – – – – – – – – – – – – –
Section Five Most important complaint Sudden or gradual onset Site and possible movement of pain Radiation of pain Constant or fluctuating pain Relieving and aggravating factors Appetite Vomiting: frequency and aspect of vomitus Flatus, constipation, diarrhea Micturition: frequency, pain Bleeding from orifices Menstrual cycle, vaginal discharge Fever Medications Allergies
Physical Examination This should cover: ●
General impression – Well/unwell – Pale, jaundiced – Lying still/agitated
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Vital signs Temperature Chest (lung base consolidation, cardiac dysrithmia) Abdomen – – – –
Inspection (including groins): scars; distension; movement on respiration; lumps Auscultation: tinkling/normal/diminished/silent Percussion: dull/tympanic; tenderness Palpation (including groins): tenderness; rebound tenderness; guarding/rigidity; masses; hernias Note: the quadrant of the abdomen where the complaints and findings are mainly localized may give some indication of the most likely involved organ – – – – – –
Right upper: gallbladder Right lower: appendix, Fallopian tube, ovary Left lower: large bowel (diverticulitis), Fallopian tube, ovary Flanks: kidney Middle upper: pancreas Middle lower: bladder
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Internal examination (rectal, vaginal)
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Laboratory Tests and Imaging ●
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Blood: hemoglobin, white cell count, CRP, sedimentation rate, electrolytes, urea, creatinin, glucose, amylase, liver function tests Urine: dipstick (blood, protein, ketones white cells, glucose, bilirubin); sediment Chest/abdominal X ray (basal pulmonary consolidation, free gas, distended bowel, fluid levels), sonography (calculi, aneurysm, gynaecological pathology) Contrast X ray, CT, endoscopy will often not be available
Differentiation and Management There are four main groups of causes of abdominal complaints. 1. Inflammation 2. Obstruction of a hollow viscus – – – –
Small bowel Large bowel Biliary tract Urinary tract
3. Bleeding – Intraperitoneal – Retroperitoneal – Intraluminal • Digestive tract • Urinary tract • Genital tract 4. Miscellaneous – – – – –
Bruising of the abdominal wall Acute pancreatitis Acute mesenteric ischaemia Urinary tract infection and acute pyelonephritis Testicular torsion and acute epididymo-orchitis
Not all these conditions warrant operative treatment, but many do. Newer treatment modalities, such as interventional endoscopy/laparascopy/sonography-guided aspiration and angiographic embolization will not be discussed, as they are rarely available in an austere environment. In all instances, it is extremely important that the patient be stabilized hemodynamically, as much as possible. Recording the fluid balance, especially urine output, is vital, and nasogastric aspiration should be commenced where vomiting continues.
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Inflammation Inflammation usually begins on the inside of a hollow viscus, tending to spread through the entire wall and leading to involvement of the adjacent peritoneum and/ or frank perforation. In both cases generalized peritonitis will result.
History Continuous pain, not severe and ill-defined at first (visceral pain); at a later stage severe and well-localized Some vomiting, not very productive Some constipation Little fever at first, at a later stage (much) higher
Examination Inspection: lying still, some guarding Auscultation: diminishing bowel sounds, silence at a later stage Percussion: at first normal, at a later stage ipsilateral, then also contralateral pain Palpation: tenderness, at a later stage rebound tenderness, then rigidity Internal examination: tenderness Note: in the case of frank perforation generalized peritonitis will develop (as described above under “at a later stage,” often in a short period of time (occasionally without the preceding complaints and findings).
Laboratory and Imaging WCC↑, CRP↑ Erect chest X ray: free abdominal gas under the diaphragm in cases of perforation
Treatment When the findings mentioned under “at a later stage” are present, this implies involvement of the peritoneum: operative treatment is warranted. Ideally inflamed structures are removed before peritoneal involvement has occurred. There are exceptions to this guideline. In some instances, conservative treatment is warranted because surgery does not lead to a better outcome. ●
Several abdominal diseases that have become rare in the developed world (e.g., tuberculosis, helminth infection of the biliary tract, splenic infarct). You a referred to textbooks on tropical medicine
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Diverticulitis coli
This may occur in middle-aged and elderly people, who will have all the signs of inflammation in the left lower quadrant, including peritoneal involvement. However, if conservative treatment (consisting of bedrest and nothing by mouth, no antibiotics) does not lead to resolution quickly, or if perforation occurs, surgery is indicated. ●
Salpingitis
This may occur in younger women, with a painful adnex on bimanual vaginal examination. Treatment is by antibiotics. Again surgery is indicated if this approach does not lead to resolution, or if perforation occurs ●
Crohn’s disease
This ailment should be considered if the history is positive. Treatment consists of antiinflammatory drugs and possibly steroids. Frank perforation (the signs of which may be obscured if steroids have been given!) should be treated operatively ●
Development of an “abdominal infiltrate”
The body tries to “isolate” an inflamed structure by enveloping it with omentum majus and loops of intestine. Usually this process takes a couple of days. This diagnosis becomes likely if you see a patient who has had abdominal pain for 2–3 days and now seems to be “on the mend.” If there are no signs of peritoneal involvement (the infiltrate can sometimes be palpated as a mass) and the patient has a considerably elevated sedimentation rate, conservative treatment (no antibiotics) is justified. However, an abscess that develops within the infiltrate (diagnosed by a see-saw fever pattern) should be drained surgically. Note: in cases of generalized peritonitis antibiotics should be begun preoperatively.
Obstruction of a Hollow Viscus Mechanical obstruction of the bowel arises from a number of causes: ● ● ●
Outside the wall: hernias, adhesions from previous operations, volvulus In the wall: tumors In the lumen: gallstones, corpora aliena, bezoars
If the blood supply to the bowel is compromised, it is a strangulating obstruction.
Small Bowel History Severe, intermittent, cramping pain; often with agitation during cramps. Frequent vomiting (in parallel with cramps), which remains productive and becomes eventually fecaloid (may lead to hypovolemia and shock). No constipation at first. No fever (if fever occurs it may be indicative of strangulation).
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Examination Inspection: agitation during cramps; abdomen may be distended; occasionally visible peristalsis; sometimes visible scars from previous operations. Note: also look for swelling in the groin and umbilical areas (incarcerated = irreducible hernia). Auscultation: hyperperistalsis, “tinkling” (during cramps). Note: if on auscultation the abdominal sounds seem to normalize, but the patient does not improve generally, the gut is becoming exhausted. Percussion: often tympanitic. Palpation: some tenderness; no signs of peritoneal involvement. Note: in cases of strangulation (ischaemia of the bowel wall) perforation will occur; the clinical picture then changes to one of generalized peritonitis. Internal examination: normal. Laboratory and Imaging No specific tests; in severe cases acid-base and electrolyte abnormalities. WCC ↑ may be indicative of strangulation. Erect abdominal X ray: distended loops of bowel and fluid levels. Treatment Depends to a degree on the underlying abnormality; An initial conservative regime of intravenous fluids, a nasogastric tube and close observation is justified, unless ● ● ●
The patient is very ill with signs of peritonitis There are signs of impending strangulation The picture fails to settle within 12 h
In those cases prompt operative intervention is indicated.
Large Bowel Obstruction of the large bowel is most often seen in elderly patients. The cause is usually a neoplasm; occasionally inspissated feces. History No defecation (sometimes with “false” diarrhea). Little pain. Sometimes vomiting (at a late stage). No fever. Examination Inspection: abdomen may be distended (“frog’s belly”)
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Auscultation: no abnormalities; at a late stage some hyperperistalsis Percussion: usually no abnormalities; occasionally a tympanitic area in the right lower quadrant Palpation: sometimes a “full” descending colon; no signs of peritoneal involvement Internal examination: a low rectal tumor may be palpable Laboratory and Imaging No specific tests Abdominal X ray: occasionally a distended caecum Treatment “Gentle enema” if inspissated feces likely Operation if caecum has a diameter >10–12 cm, and depending on general condition
Biliary Tract History Severe, intermittent, cramping pain in the right upper quadrant or flank; often with agitation during cramps. Infrequent vomiting. Sometimes jaundice. Normally no fever Examination Inspection: normal; sometimes jaundice Auscultation: normal Percussion: normal Palpation: some tenderness in the right upper quadrant Internal examination: normal Laboratory and Imaging Sometimes bilirubine ↑ and alkaline Phosphatase (UK/US Spelling) ↑ Sonography may show concrements in gallbladder Treatment Conservative with spasmolytics Note: if fever is present the diagnosis is obstructive cholangitis; because of the risk of septicaemia the biliary tract should be drained operatively
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Upper Urinary Tract History Severe, intermittent, cramping pain in one flank; often with agitation during cramps Infrequent vomiting. Sometimes hematuria. Normally no fever Examination Inspection: normal Auscultation: normal Percussion: normal Palpation: normal; sometimes some tenderness in the flank Internal examination: normal Laboratory and Imaging Sometimes hematuria Sonography may show a dilated renal pyelum Treatment Conservative with spasmolytics Note: if fever is present the diagnosis is obstructive pyelonephritis; because of the risk of septicaemia the urinary tract should be drained operatively
Lower Urinary Tract (Acute Urinary Retention) History Gradually increasing difficulties with passing urine (hypertrophy of the prostate), or sudden onset (concrement, clot) Patient may be quite ill, with hypotension Normally no fever Examination Inspection: distended lower abdomen Auscultation: normal Percussion: dullness in the lower abdomen Palpation: tender mass in the lower abdomen
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Internal examination: occasionally enlarged prostate; otherwise normal Laboratory and Imaging Sonography will show an enlarged bladder Treatment Introduction of a urinary catheter In case of prostatic hypertrophy definitive treatment of that condition at a later stage Note: if fever is present the diagnosis is obstructive urinary septicaemia. In that case antibiotic treatment is also warranted
Bleeding In bleeding, the most important guide for deciding what treatment to give is the hemodynamic status of the patient.
Intraperitoneal This is most often caused by trauma (liver, spleen); occasionally by a ruptured aneurysm. In the latter case, the patient has usually died before being seen by a health professional. History In trauma cases is usually is obvious (also see parts B and C of this chapter); There may be some pain A ruptured aneurysm leads to tearing pain in the back. Examination Inspection: In trauma cases there may be bruising or wounds of the abdominal wall. Distension of the abdomen is a late sign Auscultation: bowel sounds may be diminished Percussion: unremarkable Palpation: some tenderness. Rebound tenderness and rigidity are late signs. An aneurysm may be felt as a pulsating mass Internal examination: some tenderness Laboratory and Imaging Tests are initially normal. A drop in hemoglobin is a late sign.
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Sonography will show free abdominal fluid and if an aneurysm is the cause of intraperitoneal bleeding, sonography will confirm its presence Treatment A ruptured aneurysm should always be treated operatively; likewise the other causes of intraperitoneal bleeding if the patient is in shock. Nonshocked patients may be managed nonoperatively.
Retroperitoneal This is caused either by trauma (kidney, pelvis); or by a ruptured aneurysm. History In trauma cases is usually is obvious (also see parts B and C) There may be some pain. A ruptured aneurysm leads to tearing pain in the back. Examination Inspection: In trauma cases there may be bruising or wounds of the back and/or flanks. Auscultation: bowel sounds may be diminished. Percussion: unremarkable. Palpation: no obvious findings. An aneurysm may be felt as a pulsating mass. Internal examination: unremarkable. Laboratory and Imaging Tests are initially normal. A drop in hemoglobin is a late sign. Sonography will confirm injury to the kidney and the presence of an aneurysm. Treatment A ruptured aneurysm should always be treated operatively; other causes are treated conservatively unless the patient becomes hypotensive.
Intraluminal There is a variety of nontraumatic causes for bleeding from the digestive, urinary, and genital tracts.
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Hematemesis is associated with bleeding from the upper digestive tract (proximal of the pylorus); bleeding from the more distal digestive tract usually presents as hematoschezia. The color of blood lost rectally may give an indication about the localization of its source: the darker, the more proximal. Bleeding from the urinary tract presents as hematuria. A ruptured ectopic pregnancy should be considered in every women of childbearing age who is experiencing lower abdominal pain, with or without vaginal bleeding You are referred to obstetrical textbooks for information on bleeding in a wellestablished pregnancy and around the time of childbirth. Management of nontraumatic bleeding is highly influenced by the hemodynamical status of the patient.
History Bleeding is the main complaint, as described above. Sometimes pain (upper abdomen for upper digestive tract; flank for urinary tract; lower abdominal for genital tract). Examination Inspection: normal Auscultation: unremarkable. Peristalsis may be active in bleeding from the digestive tract Percussion: unremarkable Palpation: sometimes tenderness in the upper abdomen (upper digestive tract), flanks (urinary tract), lower abdomen (genital tract) Internal examination: an ectopic pregnancy may be felt in one of the adnexes on bimanual vaginal examination Laboratory and Imaging An ectopic pregnancy may be present with OR without a positive pregnancy test Bleeding from the digestive or urinary tracts requires finding the source (e.g. by endoscopy). Treatment An ectopic pregnancy should be treated operatively. Bleeding from the digestive and urinary tracts can be treated conservatively, as long as the patient remains hemodynamically stable and the bleeding stops within reasonable time span.
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Miscellaneous Acute Pancreatitis History Extreme pain in the upper abdomen and back May be a history of gallstones or alcohol abuse; is feeling very sick and looking very unwell Fever may be present Occasionally some vomiting Examination Inspection: normal. Cullen’s sign and a discoloration in the left flank are extremely rare Auscultation: unremarkable; from auscultation to palpation. Percussion: unremarkable Palpation: unremarkable; there may be upper abdominal tenderness Internal examination: unremarkable Laboratory and Imaging Amylase ↑↑↑ Sonography may show an enlarged pancreas Treatment Most cases of pancreatitis can be treated conservatively, with careful monitoring; If hypotension develops, operative treatment is warranted.
Acute Mesenteric Ischaemia History This is an ailment of the elderly; these patients have often been in bad shape for other reasons. Extreme pain in the abdomen; the patient is feeling very sick and looking very unwell Occasionally some vomiting, and/or bloody diarrhea. No fever Examination Inspection: unremarkable Auscultation: unremarkable
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Percussion: unremarkable Palpation: unremarkable Internal examination: unremarkable Laboratory and Imaging WCC ↑↑↑ and Base Excess ↓↓↓ (“pathognomonic”) Treatment This condition is almost always untreatable. Usually a laparotomy is performed to exclude other pathologies.
Urinary Tract Infection and Acute Pyelonephritis History UTI presents with burning pain on passing urine, with frequency and urgency. Acute pyelonephritis is associated with abdominal or loin pain, hematuria, and fever. Examination Tenderness in flank and/or loin Laboratory WCC ↑; positive dipstick and microscopy Treatment Antibiotics
Testicular Torsion and Acute Epididymo-orchitis History This occurs mainly in adolescents. Sudden onset of severe pain in the scrotum (onesided), with occasional radiation to the lower abdomen. No fever. Examination Swollen testis; extremely painful on examination
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Note: this condition should be differentiated from epididymo-orchitis (which presents with fever and pain on passing urine). When in doubt, it “is” testicular torsion! Treatment Operative derotation; fixation of both testes
Other Surgical Emergencies Abscesses Soft Tissue Abscess History Any infection of the soft tissues may give rise to formation of an abscess Pain, fever Examination Red, swollen area with fluctuation Treatment Incision (parallel to Langer’s lines) and drainage. Exploration for corpora aliena
Breast Abscess History Recent breast feeding; usually following acute mastitis Examination Red, tender swelling, which may become fluctuant Treatment Incision, following the edge of the areola, and drainage
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Anorectal Abscess History Throbbing pain in the peri-anal area. Sitting down is extremely painful. Fever Examination Tender mass in the peri-anal area Occasionally no visible abnormalities Very painful rectal examination Treatment Incision and drainage
Acute Ischaemia of a Limb Acute arterial occlusion may be the result of embolus from a distant source or thrombosis on underlying atherosclerotic disease.
History Acute onset of extreme pain Possibly recent myocardial infarction or atrial fibrillation (embolus); intermittent claudication (arterial thrombosis)
Examination Pale skin, absence of arterial pulsations, paraesthesia, paralysis Check for sources of emboli
Treatment To save the limb, perfusion must be restored as soon as possible: surgical removal of emboli and elimination (if possible) of the source; anticoagulation.
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Part F – Maxillofacial, Eye, and ENT Jan Roodenburg and Peter Dyer
Introduction Most of the pathology in this area needs treatment by specialist. This chapter is a support for the general practitioner to decide on starting a therapy or referral of a patient to a higher echelon. Especially in head and neck trauma cases, the principles of (Battlefield) Advanced Trauma Life Support (B), ATLS, should be followed. The “A” airway and cervical spine, “C” circulation, and “D” disability can be involved. In case of referral, the patient should be stabilized for (potential) A, B, and C problems. Advanced inflammations in this area can cause life threatening situations like airway obstruction and spread to the neck and finally to the mediastinum.
Maxillofacial Introduction Those conditions involving the mouth and oral structures may be d
