Conflict and Catastrophe Medicine A Practical Guide Compress

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 David G. Burris, MD, FACS, DMCC, COL,
Adriaan P.C.C. Hopperus Buma, MD, PhD, MC, USA
DMCC Uniformed Services University
Inspector General Military Health Care of the Health Sciences
Ministry of Defence (MOD NL) Department of Surgery
Hilversum, The Netherlands Bethesda, MD
USA
Alan Hawley, OBE
The Army Medical Directorate James M. Ryan, OStJ, FRCS, MCh, DMCC,
Former Army Staff College Hon FCEM
Camberley Emeritus Professor, Faculty of Conflict
Surrey, UK & Catastrophe Medicine
St George’s University of London
Peter F. Mahoney, OBE, TD Tooting, London, UK
Defence Professor Anaesthesia &
and Critical Care Uniformed University of the Health Sciences
DMA&CC Department of Surgery
Royal Centre for Defence Medicine Bethesda, MD, USA
Birmingham, UK
Associate Editors John-Joe Reilly, BSc (Hons), PhD, DIC, GI Biol,
Ravi Chauhan, MBChB, DipIMC, RCSED BMedSci (Hons), BM, BS, RN
Department of Anaesthetics Department of Emergency Medicine
Queens Hospital Burton RCDM, Birmingham City Hospital
Burton-Upon-Trent, Staffordshire, UK Birmingham, West Midlands, UK
ISBN 978-1-84800-351-4 2nd edition e-ISBN 978-1-84800-352-1 2nd edition

ISBN 978-1-85233-348-0 1st edition
DOI 10.1007/978-1-84800-352-1
British Library Cataloguing in Publication Data
A catalogue record for this book is available from the British Library
Library of Congress Control Number: 2008941005
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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 entry-
level 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 para-
medical staff undertaking work in a hostile environment.
It covers aid across a spectrum of hostile environments encompassing natural dis-
asters, 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 difficul-
ties 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 sub-
ject, 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, vol-
unteer to deploy into an environment of conflict or austerity.
Jim Ryan
Peter F. Mahoney
Ian Greaves
Gavin Bowyer
vii
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 chal-
lenges. Specifically, this will be the primary source for review for those being exam-
ined 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
ix
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. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
B – Military Medical Assistance to Civilian Health Sectors
Martin C.M. Bricknell . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
C – Private Security Companies and First-Line Care
T. Spicer and K. Morland . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
D – Oil and Gas: Industry in Remote and Volatile Areas
Bob Mark . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
6. Interfaces
A – Medical Ethics Is Never Easy
David R. Steinbruner . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
B – Village Medical Outreach or MEDCAP: A Policy Perspective
Martin C.M. Bricknell, Robin Cordell and David C. Mcloughlin . . . . . . . . 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 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
B – High Altitude
Sundeep Dhillon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114
SECTION TWO:
Disasters, Public Health, and Populations
9. Disasters: An Overview
Tony Redmond . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
A – The London Bombings 7th July 2005: Forward Medical Response
Steven A. Bland . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 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 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197
A – Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197
B – Health Surveillance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 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
Contents xiii
B – Getting Involved
Steve Mannion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 268
C – “R and R”: Moving Between Worlds
D – Team Building and Maintenance
Kenneth I. Roberts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 284
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 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 287
B – Thinking Ballistic: Aspects of Protection
C – Mines and Weapons Awareness
D – The Oil Camp
Bob Mark . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 306
20. Voices from the Field
A – Just a Word About Toilets
B – Conflict Medicine: A View from the Ground
Luke J. Staveley-Wadham. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 317
21. Applied Communications in Conflict and Catastrophe Medicine
John F. Navein and Simon J. O’Neill . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 323
22. Mental Health
A – Practical Psychological Aspects of Humanitarian Aid
Ian P. Palmer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 345
B – Psychosocial Resilience and Distress in the Face
of Adversity, Conflict, Terrorism, or Catastrophe
Richard Williams and David Alexander . . . . . . . . . . . . . . . . . . . . . . . . . . . . 360
C – Requiem: Going Home . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 374
David R. Steinbruner
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
xiv 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 . . . . . . . . . . . . . . . . . . . . . . . . 417
B – Trauma and Triage
Walter Henny and Adriaan Hopperus Buma . . . . . . . . . . . . . . . . . . . . . . . . 418
C – Soft Tissues and Skeleton
Ralph de Wit and James M. Ryan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 428
D – Ballistics and Blast
Ralph de Wit and David G. Burris . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 438
E – Abdominal Complaints and Acute Surgical Emergencies
Walter Henny and Adam Brooks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 446
F – Maxillofacial, Eye, and ENT
Jan Roodenburg and Peter Dyer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 462
G – Head Injury
Andrew Maas and Walter Henny . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 471
H – Anaesthesia and Analgesia
Chris Bleeker . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 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 . . . . . . . . . . . . . . . . . . . 571
A – Checklists, Suppliers, and Specialist Advice . . . . . . . . . . . . . . . . . . . . . . . . 571
B – Publications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 575
C – Internet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 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
David A. Alexander Daloni A. Carlisle

Director Aberdeen Centre for Trauma Research Sevenoaks
Professor of Mental Health at University Kent, UK
of Aberdeen
Aberdeen A. Christodoulides
Scotland, UK Senior Specialist in Accident and
Emergency Medicine
Steven A. Bland Larnaca General Hospital
Emergency Department Cyprus
Queen Alexandra Hospital
Portsmouth
Robin Cordell
UK
1st (UK) Armoured Division
Chris Bleeker Herford, Germany
Institute for Defence and Partnership Hospitals
University Hospital Nijmegen Charles W.F.M. Cox
The Netherlands Women’s Unit, New Cross Hospital
Wolverhampton
Martin C.M. Bricknell West Midlands
HQ Allied Rapid Reaction Corps UK
UK
Ralph J. de Wit
Adam Brooks Department of Surgery
Academic Department of Military Surgery & Medisch Spectrum Twente
Trauma Enschede, The Netherlands
RCDM
Edgbaston, Birmingham Sundeep Dhillon
UK Institute of Research and
Development, Edgbaston
Andrew S.W. Bruce
Birmingham, UK
Department of Orthopaedics
Doncaster Royal Infirmary
Doncaster, South Yorkshire Peter V. Dyer
UK Maxillofacial Unit
Royal Lancaster Infirmary
David G. Burris Lancaster, UK
Uniformed Services University of
the Health Sciences Manolis Gavalas
Department of Surgery Emergency Department
Bethesda, MD UCH, London
USA UK
xvii
xviii Contributors
Rowland Gill Maria E. Kett

Society of Apothecaries Leonard Cheshire Disability and Inclusive
London, UK Development Centre
University College London
Iain C. Grant London
British Antarctic Survey Medical Unit UK
Derriford Hospital
Andrew I.R. Maas
Plymouth, Devon,
Department of Neurosurgery
UK
University Hospital Antwerp
Antwerp, Belgium
Alan Hawley
The Army Medical Peter F. Mahoney
Directorate Defence Professor Anaesthesia
Former Army Staff College and Critical Care
Camberley, Surrey DMA&CC
UK Royal Centre for Defence Medicine
Birmingham, UK
Timothy Healing
Steve Mannion
Independent Consultant in
Blackpool Orthopaedic Department
Medical Humanitarian Aid
Blackpool Victoria Hospital
Oxford, Oxfordshire
Blackpool,
UK
UK
Roderick James Heatlie Bob Mark
SO1 Joint Medical, Development Frontier Medical Services
Concepts and Doctrine Centre Vantage Point Business Park
MOD Shrivenham Mitcheldean, Gloucestershire
Swindon, UK
UK
James I.D.M. Matheson
Walter Henny Faculty of Conflict and Catastrophe
Colonel, Royal Netherlands Army reserve Medicine and Health, St George’s
formerly University Hospital University of London
Rotterdam Tooting, London
The Netherlands UK
Maarten J.J. Hoejenbos David C. McLoughlin
Surgeon Captain ret. RAF Centre of Aviation Medicine
Royal Netherlands Navy RAF Henlow
Aerdenhout, The Netherlands Bedfordshire, UK
Adriaan P.C.C. Hopperus Buma Kenneth N.A. Millar

Inspector General Military Health Care HQ Land Command
Ministry of Defence (MOD NL) Wilton, Salisbury
Hilversum, The Netherlands UK
Hervinder Kaur Gareth Moore

Obstetrics & Gynaecology Combat Service Support Division
Royal Wolverhampton NHS Trust Headquarters Allied Rapid Reaction Corps
Wolverhampton, West Midlands Mönchengladbach
UK Germany
Contributors xix
Kenny Morland James M. Ryan

Aegis Defence Services Emeritus Professor, Faculty of Conflict &
London, UK Catastrophe Medicine
St George’s University of London
Aroop Mozumder Tooting, London, UK
COS Health (RAF) &
RAF High Wycombe Uniformed University of the Health Sciences
High Wycombe Department of Surgery
Buckinghamshire, UK Bethesda, MD, USA
Tim S. Spicer
John F. Navein Aegis Defence Services
Modernising Healthcare Partnership London, UK
Stratford-on-Avon, UK
Luke J. Staveley-Wadham
Shauket Nazeer Department of Medicine
University College Hospital Brighton and Sussex Medical School
Cecil Flemming Building Brighton, East Sussex
London, UK UK
Simon J. O’Neill Emergency Department
ICS Limited, Great Hampden Memorial Hospital, Colorado Springs
Buckinghamshire, UK CO, USA
Ian P. Palmer Donald F. Thompson

Head of the Medical Assessment Programme Biological Defense OSD/Combating WMD,
Ministry of Defence UK Washington, DC
Pensions, Compensation and Veterans’ Unit USA
Visiting Professor of Military Psychiatry
to the Institute of Psychiatry Alexander G. van Tulleken
London Centre for International
UK Health and Development
University College London
London, UK
Anthony D. Redmond
Emergency Medicine Garry Vardon-Smith
Manchester Medical School Department of Security and Risk Consultancy
Salford, Manchester Centreville, VA
UK USA
Kenneth I. Roberts Claire S. Walford

Army Health Unit University College London Hospitals NHS
Army Medical Directorate, Trust
Camberley, Surrey A&E Department
UK London, UK
Jan L.N. Roodenburg Richard Williams

Department of Maxillofacial Surgery Welsh Institute for Health and Social Care
University Medical Centre Groningen University of Glamorgan
Groningen Glamorgan, Wales
The Netherlands UK
xx Contributors
Chris Bleeker Maarten J.J. Hoejenbos

Institute for Defence and Partnership Surgeon Captain ret.
Hospitals Royal Netherlands Navy
University Hospital Nijmegen Aerdenhout, The Netherlands
The Netherlands
Walter Henny
Colonel, Royal Netherlands
Army reserve
formely University
Hospital Rotterdam
The Netherlands
SECTION
1
Introduction:
Players and Paradigms
Peter F. Mahoney and James M. Ryan
Associate Editor - Ravi Chauhan
2. New Paradigms: The Changed World Since 9/11
5. 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
8. 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.
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 juxtaposi-
tion 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 deploy-
ment 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 3
2. New Paradigms: The Changed
World Since 9/11
James M. Ryan
● To introduce the subject

Objectives ● 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 slaugh-
ter 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
6 Section One
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 interna-
tional governmental organizations (IGOs) and nongovernmental organizations
(NGOs) concerned with caring for the victims of war and disasters proliferated, par-
ticularly 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
Introduction: Players and Paradigms 7
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 result-
ing 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 disintegra-
tion, 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:
8 Section One
“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 influ-
ence – 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
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 appro-
priate 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 disas-
ters 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 wide-
spread 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
10 Section One
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
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 antici-
pating 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, organiza-
tions 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:
● 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
12 Section One
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 long-
standing 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.
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 bound-
ary, looms vividly in the US soldiers’ collective conscience. The once tragic but com-
fortably 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 perspec-
tive 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, situ-
ated northwest of Baghdad. Since we do not have a neurosurgeon at Ibn Sina, we trans-
port 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.
14 Section One
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 breath-
ing. 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 duti-
fully 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 direc-
tions, each neighborhood denser than the last as we sped toward the heart of the
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 famil-
iar 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.
Alan Hawley
● To define conflict
Objectives ● 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 uncer-
tainty, 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 neces-
sarily 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 circum-
stances, 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.
18 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 funda-
mental 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 impli-
cations. 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 declara-
tion 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 geno-
cide 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 com-
mon 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
indiscriminate killing in large numbers. It may occur in conflict as a result of tempo-

rary 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 peren-
nial 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 epi-
sodes 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 legisla-
tion is welcome. For the purposes of this chapter, the concepts of conflict, war, mas-
sacre, 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 post-
conflict 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 con-
siderations: 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 tradi-
tion 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 sanc-
tion or consideration. Hence, morally absolute ethical positions, while having the
20 Section One
advantages of clarity and simplicity, do not sit comfortably with the realities of com-
promise 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 considera-
tion 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 preoc-
cupation 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 descrip-
tion of just:
1. There must be a just cause.
2. There must be a right intention; the stated reason for war is the crucial determi-
nant, 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.
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 pos-
sible 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 intel-
lectual 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 experi-
ence, 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
22 Section One
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 anal-
ogy 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 geostra-
tegic 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 rela-
tionships 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
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 cen-
tral 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 wit-
nessed 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 politico-
military 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 contem-
porary world and is always a possible option open to opponents. It can be waged
either nationally or internationally, with varying degrees of discrimination and vio-
lence. 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, cul-
tural, and technological imperatives. Essentially, its basis is the realistic view of inter-
national 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
24 Section One
depends upon an understanding of and commitment to the rationality of force; mili-

tary power is cast in the Von Clausewitzian role of political action. For most devel-
oped 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 commonal-
ity 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 asym-
metry 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 popu-
lations by arbitrary acts of indiscriminate violence. Meanwhile, a whole raft of con-
siderations (political, ethical and military) may restrain the other side to a more
traditional engagement of opposing military forces only. Equally, substantial differ-
ences 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
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 bur-
geoning 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 com-
ponent. 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 psycho-
logical elements within it. In this philosophy, uncertainty is recognized as being una-
voidably 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 uncer-
tainty, while accepting that an irreducible minimum exists, and simultaneously
increase that of the enemy. Uncertainty can be most debilitating, especially to organi-
zations 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 bat-
tlespace 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 tem-
pered 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 compet-
ing issues of the utility of the military, the contexts in which development and deploy-
ment 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
26 Section One
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 sug-
gests 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 devel-
oped 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 tradi-
tional 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 secu-
rity interests. In addition, the nature of conflict is becoming less interstate and increas-
ingly 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 commer-
cial 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 sur-
veillance 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.
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 cer-
tainties 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 conse-
quence, 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 develop-
ing 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 disagree-
ments 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 condi-
tions. 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 fre-
quently being the most vulnerable. In such a society, there may be reversion to gun
28 Section One
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 particu-
lar challenge for humanitarian involvement because of the complex of security, politi-
cal, 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 con-
flict. 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
Military
assistance
Humanitarian
operations
Peace-support
operations
Low-intensity
operations
Mid-intensity
operations
High-intensity
operations
Fig. 4.1. Spectrum of conflict.

Post- Pre-
conflict conflict
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 con-
flicts 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 simultane-
ously, and demonstrates how they may meld from one to another. It is a useful con-
struct 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 cul-
tural, 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 usu-
ally 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
30 Section One
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 consid-
erable 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 pre-
mature given the state of the world political stage and the lack of an enforcing mecha-
nism. 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 maxi-
mally 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
● To describe the agencies and organizations that health care

Objectives 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 communica-
tion 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 contem-
porary 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, inequal-
ity, 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
32 Section One
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 com-
panies, 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 circum-
stances 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 independ-
ent 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.
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 Section One
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 coordi-
nation 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 secre-
tariat, 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 mem-
bership is currently composed of all operational UN organizations along with stand-
ing 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 encoun-
tered 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 devel-
oping 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).
recent failures in humanitarianism. However, the ability of the UN to respond to dis-

asters 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 organiza-
tion 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 addi-
tion, 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 coordina-
tion 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 gener-
ate 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 per-
sons who are not receiving any assistance, is invaluable. It allows effective prioritiza-
tion of tasks so that the populations with the greatest needs can be targeted first, and
36 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 recommenda-
tions for reform.2 The recommendations made in this document have become the
basis for Humanitarian Reform, a set of changes designed to improve response capac-
ity, predictability, and accountability; to streamline financing; to improve coordina-
tion 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 imple-
ment 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 recog-
nized as important in disaster response. There are sectors in which there has histori-
cally 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.
Table 5.1. Global cluster leads
Sector or area of activity Global cluster lead
Clusters associated with service provision

Emergency Telecommunications OCHA/UNICEF/WFP
Logistics WFP
Cluster dealing with relief and assistance to beneficiaries
Emergency Shelter
IDPs (from conflict) UNHCR
Disaster situations IFRC (convener)3
Education UNICEF Save The Children (UK)
Nutrition UNICEF
Water, Sanitation and Hygiene (WaSH) UNICEF
Health WHO
Agriculture FAO
Clusters dealing with cross-cutting issues
Early Recovery UNDP
Camp Coordination/Management
IDPs (from conflict) UNHCR
Disaster situations IOM
Protection UNHCR
IDPs (from conflict)
Disasters/civilians affected by conflict (other than IDPs)4 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 humani-
tarian 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 clus-
ters 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 com-
mitted 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 interna-
tional 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 postgradu-
ate 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 gath-
ering 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 mal-
nutrition across the world, and its programs are divided into emergency programs,
relief and rehabilitation programs, development programs, and special operations.
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 logis-
tics 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 nutri-
tional 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 nonrefoule-
ment. 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.
40 Section One
UNHCR’s mandate has gradually been expanded to include those designated inter-
nally 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 protec-
tion 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 wors-
ened 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 bor-
ders 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).
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 migra-
tion problems and to provide humanitarian assistance to migrants in need,
including refugees and internally displaced people.
IOM works closely with governmental, intergovernmental, and nongovern-
mental partners. IOM activities include the promotion of international migra-
tion 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 funda-
mental principles of humanity, impartiality, neutrality, independence, voluntary
service, unity, and universality. Across the world the Movement works with govern-
ments, 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 vis-
its, 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 wit-
nessed. 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 gov-
ernments 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 promot-
ing 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
42 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, includ-
ing 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.
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 humanitar-
ian 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 estab-

lished 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 encoun-
tered during its work.
Though MSF has not publicly announced its position about the current human-
itarian 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 interna-
tional and local, is beyond the scope of the chapter; there are NGOs that operate in
10
www.icva.ch/ghp.html.
11
http://www.msf.org/msfinternational/invoke.cfm?component = article&objectid = 95542E25–5056-
AA77–6C6F0623221C3658&method = full_html.
12
Global Humanitarian Assistance, 2006. Available online at http://www.globalhumanitarianassist-
ance.org/pdfdownloads/GHA%202006.pdf.
44 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 coop-
eration 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 “humanitar-
ian” 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 high-
lighted 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 involve-
ment. The military usually only have very short-term mandates, especially in disas-
ters. 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 humani-
tarian 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.
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 sub-
clusters 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 clus-
ters as potential resources. The health cluster, for example, is responsible for,
amongst other things, providing databases of technical experts, health and nutri-
tion tracking service, global stockpiles of health supplies, and guidance for advo-
cacy 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 situ-
ations, 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 plan-
ning 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
46 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, advo-
cating the interests and mandates of the United Nations. In an emergency or humani-
tarian 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 quali-
fied 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
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 consoli-
dated 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 humani-
tarian 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 dis-
burses funds in consultations with Humanitarian Coordinators and other humanitar-
ian 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 por-
tion 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 ear-
marked 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,
48 Section One
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 par-
ties 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 activi-
ties. 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
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Hurst.
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displacement.org/8025708F004CE90B/(httpPages)/22FB1D4E2B196DAA802570BB005E787C?OpenDoc
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C802570F800518B64?OpenDocument, accessed 09 June 2007.
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Migration Review (29): 18–20. URL:
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basics/BASICS/3b028097c.html.
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protect/3c0762ea4.html.
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 humanitar-
ian 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 human-
itarian emergencies. It will consider some of the unique and complementary capabili-
ties 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 medi-
cal humanitarian operations included a response to aid the relief of famine in the west-
ern Netherlands in late 1944/early 1945 and the relief of former Nazi concentration
camps (Day 1984).
50 Section One
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 casual-
ties, care of homeless and destitute, disposal of the dead, epidemic prevention meas-
ures, provision of medical supplies, importation of fresh food, and restoration of
normal hospital and outpatient services. These tasks were achieved through coordi-
nating 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 interna-
tional 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 popu-
lation 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 humanitar-
ian 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 contribu-
tion was widely acknowledged to have been successful, principally because the medi-
cal 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
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 exter-
nal conflict and which requires an international response that goes beyond the man-
date 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 opera-
tions 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
52 Section One
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 main-
tain order in States and regions” (Department of Defense Directive 2005). It includes
stabilization, security, reconstruction, and transition operations, which lead to sus-
tainable 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 sup-
plementing the existing local health facilities and assisting with the regeneration or
development of local health systems coordinated with local authorities, local com-
munities, 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 short-
termism, very expensive, political rather than institutionally humanitarian, and tai-
lored 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 “humanitar-
ian 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 repre-
sented consensus in the reconciliation of these cultural conflicts in humanitarian
emergencies. UN General Assembly Resolution 46/182 states that humanitarian assist-
ance 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
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 under-
mine the perceived neutrality or impartiality of the humanitarian actors, nor jeopard-
ize 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 coher-
ent 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 ope-
rations 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 cam-
paign (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 inte-
gral 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.
54 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 Ownership

Humanitarian access to vulnerable populations Capacity building
Perception of humanitarian action Sustainability
Needs-based assistance free of discrimination Selectivity
Civil–military distinction in humanitarian action Assessment
Operational independence of humanitarian action Results
Security of humanitarian personnel Partnership
Do no harm Flexibility
Respect for international legal instruments Accountability
Respect for culture and custom
Consent of parties to the conflict
Option of last resort
Avoid reliance on the military
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 indi-
viduals, 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 com-
munity; in the event of life- or limb-threatening emergencies this group has access to
military medical care under humanitarian grounds. However, any extension of mili-
tary 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 dur-
ing 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 effec-
tiveness 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
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 over-
all 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 par-
ticularly 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 con-
sistent with their noncombatant status under the Geneva Convention. Although
under military command, tasks given to military medical services must be in accord-
ance 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 activi-
ties 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
56 Section One
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, envi-
ronmental 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 vul-
nerable 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 hand-
off to local medical providers or health-related IAs/NGOs. The definition of emer-
gency 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 treat-
ment 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
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 rec-
ognize that their primary duty remains to provide care for the military community.
58 Section One
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 rec-
ognized course and adds clinical credibility to the local doctors and also provides
a tangible way to reintegrate Iraqi medical staff into the international medical com-
munity (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 improve-
ment in the healthcare available to the local population. While the opening of medi-
cal 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, equip-
ment, consumables, and local community commitment. There are very few indica-
tions 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 popula-
tion 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 appro-
priate to the local circumstances. Specific technological solutions, such as solar-
powered refrigerators, may be better than conventional equipment. It should also
include a post-completion plan to include follow-up engagement with key stakehold-
ers, review of the use and maintenance of equipment, resolution of unforeseen prob-
lems 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.
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
60 Section One
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 mili-
tary 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
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Corps 1997;143:75–82.
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Natsios AS. Parameters, Autumn 2005 The Nine Principles of Reconstruction and Development.
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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.
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 combina-
tion 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 high-
risk 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 addi-
tion, it does teach how these phases of care affect definitive care.
62 Section One
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 pro-
gram 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 life-
saving 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 capa-
bility 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 develop-
ing “hearts and minds” projects and the project we run in support of the Italian
Government PRT.
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 train-
ing and implementation of medical support within PSCs is essential. It is also impor-
tant 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 com-
pany 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 thea-
tre 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 reflec-
tion 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 turn-
ing 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 envi-
ronment and civilian basic medical course, which were available to me at that time.
64 Section One
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 Army-
involved 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 step-
ping 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.
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 outlay-
ing 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 approxi-
mately 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
66 Section One
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 mili-
tary 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 usu-
ally 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” tour-
niquets, 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
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 resus-
citation in casualties here in Iraq. Although former British military personnel under-
stand 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 equip-
ment, 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 some-
times 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 situ-
ation. 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.
68 Section One
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 casu-
alties 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 tacti-
cal 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 air-
ways by the team members.
● Wound packing! In the past, the British have always been told to apply field dress-
ings to the outer section of any wound. After having experience in operating thea-
tres 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
disabled another. When I got to the vehicle that had born the brunt of the explo-
sion 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 regard-
less 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 dis-
turburing 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 train-
ing 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 aggres-
sively 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.
70 Section One
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 involve-
ment 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 dis-
continuously 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.
Reconnaissance and Planning

The military adage of “time spent on reconnaissance is never wasted” is readily applica-
ble 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 environmen-
tal 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 exam-
ple, 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 consum-
ers 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.
72 Section One
Security
The industry can be subject to security risks for a number of reasons other than con-
ventional 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 pris-
oner 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 dam-
age. 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 extin-
guished 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
community at large. Companies involved in this project are required to put in place-
approved 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
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.
76 Section One
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 frus-
tration 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
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, with-
out 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
78 Section One
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 inva-
sion 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%, immuniza-
tion 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 statis-
tics will take time, and at a local level, visible direct patient care to the local popula-
tion 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.
Fig. 6.1. Structure of Afghan health system.
Vietnam War and Onward

The term MEDCAP originates from the Vietnam War (Neel 1991). US military assist-
ance 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 mili-
tary 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
80 Section One
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 arrange-
ment 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
(immunizations), and health promotion but the exact role must be tailored to specific
circumstances. The ICRC guidance emphasizes the importance of referral arrange-
ment 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 con-
fidence 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 secu-
rity on which development of such services depends (Wilensky 2001).
Health activities within VMOs should be consistent with the national health strat-
egy 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 inter-
ventions (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.

82 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 unhin-
dered without coercion or any implication that there is an obligation to support mili-
tary 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.
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 arrange-
ments in place for the MEDCAP.
At the tactical level, normal military practice of predeployment preparation includ-
ing 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 provi-
sion 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 prac-
tice 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 collec-
tive “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 treat-
ment 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.
84 Section One
Table 6.2. Predeployment and preparation
Identification and requesting 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
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.
86 Section One
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 fol-
lowing 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 Qalat (US) Provincial Including ANA male physician; 200
Reconstruction Team only a few women attended
23–29 June Helmand SBK Afghan National Army (ANA) First ANA VMO 100
mentored by US medical troops
27 June Zabul Qalat Qalat (US) Provincial Reconstruction Male and female US doctors 300
Team with ANA staff supported clinic
7 July Kandahar Arghestan US and Polish troops US, Romanian, and Polish doctors 605
13 July Kandahar Kandahar UK Force Protection 48 patients in Aliza Kalay 48
20–27 July Helmand Sangin US medical troops US medical teams including 800
female medics
25–27 July Zabul Daychupan Qalat (US) Provincial Undertaken in a Forward 160
Reconstruction Team Operating Base
2–5 Aug Helmand Sangin US medical troops US medical, dental, veterinary teams 857
including female staff
6–9 Aug Helmand USV ANA mentored by US medical troops US sponsored 400
7–8 Aug Heimand Nahr-e Saraj ANA mentored by US medical troops In support of UK troops 150
(Task Force Helmand)
village development plan
7–8 Aug Helmand Sangin ANA mentored by US medical troops In support of UK troops 200
(Task Force Helmand) 3,820
village development plan
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 submit-
ted through the chain of command to Regional CJ3, CJ9/CIMIC, and MEDADs.
Medical and other stocks should be replenished. Any hand-off or referral arrange-
ments 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 profes-
sionals are meager and so many doctors supplement their income by ownership of
pharmacies. The unstructured donation of pharmaceutical supplies may, inadvert-
ently, 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.
Acknowledgements
Elements of the work have appeared in the journal of the Royal army medical corps
and are used with permission.
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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 will-
ing 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 short-
hand, “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.
90 Section One
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 interna-
tional 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.
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 agen-
das 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 humanitar-
ians. 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
92 Section One
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, aca-
demics, 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 view-
ing figures. Another is providing information and analysis. A third is holding govern-
ments 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 circu-
lation 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 interna-
tional 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 Communi-
cations Act laid down specific obligations on public service broadcasters, including
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 out-
side 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 al-
Yarmourk 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).
94 Section One
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 pub-
lications. 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 con-
tinue 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 cover-
age 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
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 organisa-
tions 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 talk-
ing 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 pro-
viding 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 govern-
ment 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 deterio-
rating situation in Dafur.
96 Section One
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 trust-
worthy; 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 distri-
butions, 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.
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 kill-
ers 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 usu-
ally 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 immuniza-
tion 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
98 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 govern-
ments 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 invi-
tations 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 danger-
ous 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.
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 nerv-
ous 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 prin-
ciples: “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?
100 Section One
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 increas-
ingly 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 mis-
sion. 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, dis-
tances 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 loca-
tion 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
102 Section One
vary with seasons (Antarctica) as well as areas with less predictable weather pat-
terns (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 mis-
sion 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 subma-
rine 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
Table 8.1. Summary of environmental considerations and mission profiles
UK SSBN International
Factors Submarine Space Station ANARE Antarctic Station
General Conventional Conventional injuries Conventional injuries
injuries
Conventional medical Conventional medical Conventional medical
conditions conditions conditions
Isolation Isolation Isolation
Environmental Intrinsic Air purification Microgravity Nutritional deficiencies
Radiation Air purification
Noise Noise
Nutritional deficiencies Nutritional deficiencies
Extrinsic Hyperbaric Vacuum Hypothermia
Hypothermia Radiation
Hypothermia
Mission profile Mission length 2–3 months 6 months 6–9 months
Activity risks (Low risk) (Low risk, but in microgravity) (May be arduous)
Ladders, electrical Extravehicular activities Construction, trekking
hazards, hydraulic (EVA), minor injuries due to into polar region, heavy
systems microgravity environment machinery
Personnel 150 6 450 (summer), 100 (winter)
Medical staff One doctor and two Two crew medical officers One doctor per station plus
medical assistants (nonphysician) “assistants”
Onsite medical Sickbay and limited CHeCS Sickbay, operation theater,
facilities surgical facility laboratory, and X-ray
Radiation medicine Yes Yes No
Communications Constant one way Constant with video c Constant, ANARESAT with
(surface to onferencing and telemedicine
submarine), none telemedicine
from submarine
Catastrophe Catastrophic failure Collision Collision Fire
scenarios
Hull breech – flooding Hull breech – Epidemic
decompression
Fire – atmospheric Fire – atmospheric Transportation accident
contamination contamination
Epidemic Epidemic
Radiation accident Solar flare, increase in
cosmic radiation
Casevac (indi- (if operationally Space shuttle (Not during winter)
vidual) options acceptable)
Helicopter, subject
to range
Surface vessel Crew return vehicle Fixed wing aircraft (+/− ship)
(Soyuz/other)
Crew evacuation Controlled escape with Space shuttle crew (Not during winter)
options recovery support in return vehicle Weather-dependent (air)
Mk10 submarine (Soyuz/other)
escape suit (SEIS)
Rush escape in SEIS
Rescue submersible
(DSRV)
104 Section One
Table 8.2. Summary of perceived medical risks
US Navy SM US Navy SM Polaris SM

NASA perception Officers Enlisted Crew patrols
Disease category of risk survey 1997–2000 1997–2000 1968–1973
Mental disorders 2 9 7 7
Sensory 6 5 5–6 6
Circulatory 9 7 9
Respiratory 4 1 2 2
Gastrointestinal 8 6 5–6 3
Genitourinary 7 8 8 5
Skin 1 4 3–4 4
Musculoskeletal 5 3 3–4
Injury/poisoning 3 2 1 1
Table 8.3. Risk assessments of elements for autonomous medical care (NASA).
Risk/event ISS MOON MARS
19 Major illness or trauma Y R R

20 Pharmacology of space medicine delivery Y Y R
21 Ambulatory care G G Y
22 Return to gravity/rehabilitation G Y R
26 Palliative, mortem, and postmortem care 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: pre-
vention, monitoring, diagnosis, treatment, and informatics. These factors can also be
applied to all types of remote medicine. In some cases, prevention may include coun-
termeasures against environmental exposures and hazards such as radiation, mal-
nourishment, 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 casu-
alty 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.
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, possi-
bly 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 appendi-
citis 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
106 Section One
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 serv-
ices. 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 opti-
mal 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 sta-
tion, 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 signifi-
cant 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 evacua-
tion 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.
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, how-
ever, 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 sur-
rounded 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 medi-
cal 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, second-
ary, and tertiary services. In the Antarctic, however, the population is transient. There
108 Section One
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 tour-
ism 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 medi-
cine 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 tem-
pered 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 thera-
peutic 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 informa-
tion 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.medicalantarc-
tica.org), but it remains impossible to physically evacuate patients, or provide special-
ist 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 doc-
tors 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 emer-
gency 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
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 tempera-
ture 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 tempera-
tures 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).

110 Section One
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 reli-
ance 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 availa-
ble. 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 inactiv-
ity 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 pro-
moting 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 under-
stood. 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 dis-
turbances 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 environ-
ment 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.
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 lei-
sure 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 circum-
stances. 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 them-
selves 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 medicole-
gal 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 second-
ary 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 adjust-
ment 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 anti-
social 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.
112 Section One
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 medi-
cine 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 indi-
vidual 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 “civi-
lization” 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 isola-
tion 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 diffi-
cult. 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.
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114 Section One
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 popu-
lations 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 earth-
quake 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 esti-
mated 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 vil-
lages 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.
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 indi-
vidual 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 <1,500 No effect on healthy individuals

Intermediate altitude 1,500–2,500 Arterial oxygen saturation remains above 90%. Altitude illness possible2
High Altitude 2,500–3,500 Altitude illness common with rapid ascent above 2,500 m
Very high altitude 3,500–5,800 Arterial oxygen saturation falls below 90%, especially with exertion/exercise.
Altitude illness is common even with gradual ascent
Extreme altitude >5,800 Limit of permanent human habitation, progressive deterioration with
increased length of stay eventually outstrips acclimatisation, marked dif-
ficulty 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 under-
standing of the factors involved is essential in planning sensible strategies for mis-
sions 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.
116 Section One
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, reduc-
ing 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 tempera-
ture. 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).
Air Temperature (Celsius)

0 −1 −2 −3 −4 −5 −10 −15 −20 −25 −30 −35 −40 −45 −50 −55 −60
6 −2 −3 −4 −5 −7 −8 −14 −19 −25 −31 −37 −42 −48 −54 −60 −65 −71
8 −3 −4 −5 −6 −7 −9 −14 −20 −26 −32 −38 −44 −50 −56 −61 −67 −73
10 −3 −5 −6 −7 −8 −9 −15 −21 −27 −33 −39 −45 −51 −57 −63 −69 −75
15 −4 −6 −7 −8 −9 −11 −17 −23 −29 −35 −41 −48 −54 −60 −66 −72 −78
20 −5 −7 −8 −9 −10 −12 −18 −24 −30 −37 −43 −49 −56 −62 −68 −75 −81
25 −6 −7 −8 −10 −11 −12 −19 −25 −32 −38 −44 −51 −57 −64 −70 −77 −83
30 −6 −8 −9 −10 −12 −13 −20 −26 −33 −39 −46 −52 −59 −65 −72 −78 −85
Wind speed (km/hr)
35 −7 −8 −10 −11 −12 −14 −20 −27 −33 −40 −47 −53 −60 −66 −73 −80 −86
40 −7 −9 −10 −11 −13 −14 −21 −27 −34 −41 −48 −54 −61 −68 −74 −81 −88
45 −8 −9 −10 −12 −13 −15 −21 −28 −35 −42 −48 −55 −62 −69 −75 −82 −89
50 −8 −10 −11 −12 −14 −15 −22 −29 −35 −42 −49 −56 −63 −69 −76 −83 −90
55 −8 −10 −11 −13 −14 −15 −22 −29 −36 −43 −50 −57 −63 −70 −77 −84 −91
60 −9 −10 −12 −13 −14 −16 −23 −30 −36 −43 −50 −57 −64 −71 −78 −85 −92
65 −9 −10 −12 −13 −15 −16 −23 −30 −37 −44 −51 −58 −65 −72 −79 −86 −93
70 −9 −11 −12 −14 −15 −16 −23 −30 −37 −44 −51 −58 −65 −72 −80 −87 −94
75 −10 −11 −12 −14 −15 −17 −24 −31 −38 −45 −52 −59 −66 −73 −80 −87 −94
80 −10 −11 −13 −14 −15 −17 −24 −31 −38 −45 −52 −60 −67 −74 −81 −88 −95
85 −10 −11 −13 −14 −16 −17 −24 −31 −39 −46 −53 −60 −67 −74 −81 −89 −96
90 −10 −12 −13 −15 −16 −17 −25 −32 −39 −46 −53 −61 −68 −75 −82 −89 −96
95 −10 −12 −13 −15 −16 −18 −25 −32 −39 −47 −54 −61 −68 −75 −83 −90 −97
100 −11 −12 −14 −15 −16 −18 −25 −32 −40 −47 −54 −61 −69 −76 −83 −90 −98
105 −11 −12 −14 −15 −17 −18 −25 −33 −40 −47 −55 −62 −69 −76 −84 −91 −98
110 −11 −12 −14 −15 −17 −18 −26 −33 −40 −48 −55 −62 −70 −77 −84 −91 −99
0 to −10 Low −10 to −25 Moderate −25 to −45 Cold −45 to −59 Extreme −60 Plus very Extreme
Fig. 8.2. Windchill Index (copyright from Wikipedia: http://upload.wikimedia.org/

wikipedia/en/0/02/Windchill_chart.GIF).
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 success-
fully reached the summit.
118 Section One
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 ves-
sels 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, sim-
ple 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 mountain-
eers 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 ques-
tions. 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 mak-
ing 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
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, disori-
entation, 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 immedi-
ately (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 ill-
nesses commonly occur along with HACE and both acetazolamide and nifedipine
may be considered.
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 respira-
tory 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 dis-
charged 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 dis-
tress (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 (pink-
or red-stained). A dry cough is common at altitude due to the dry air and if not symp-
tomatic 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.
120 Section One
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 defini-
tive 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 baro-
metric 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 diox-
ide 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 mili-
tary operations. Previous performance at altitude is the most reliable, but not infalli-
ble 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 expe-
rienced 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.
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. Responding To Acute Humanitarian Crise
11. The Military Approach To Medical Planning
12. Health Risk Management Matrix-A Medical Planning Tool
13. Surveillance and control of communicable disease in conflicts
and disasters
14. Health Planning in action
15. Health Planning in action Op Phoenix
16. Health Care Of Prisoners And Detainees
17. Populations and people
124 Section Two
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 popula-
tion, 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 1
Tony Redmond
● To explain the terminology used in disaster and complex

Objectives 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 accu-
racy and widespread applicability.
However, whatever definition is chosen it always reveals a small number of key ele-
ments. Something happens, usually quite suddenly, but sometimes over time, that
overwhelms the capacity of local agencies to cope. This failure to cope may be rela-
tively 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 displace-
ment. 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 fur-
ther 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 vulnerabil-
ity 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.
126 Section Two
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 recogni-
tion 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, usu-
ally 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 emer-
gency 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 under-
stand that planning for the next disaster purely on the experience of the last disaster
Disasters, Public Health, and Populations 127
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 rec-
ognise 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 imme-
diately to hand, although of course replaced by more senior and appropriate person-
nel 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 over-
all 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 dis-
asters 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. HIV/AIDS
2. Ischaemic heart disease
3. Tuberculosis
4. Road traffic accident
5. Cerobrovascular disease
6. Self-inflicted injuries
7. Violence
8. Cirrhosis of the liver
128 Section Two
The eight leading causes of global disease burden (15–59 years):

1. HIV/AIDS
2. Unipolar depressive disorders
3. Tuberculosis
4. Road traffic accident
5. Ischaemic heart disease
6. Alcohol use disorders
7. Adult onset hearing loss
8. 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 popula-
tion 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 urbaniza-
tion 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).
Natural Disasters
Introduction
This phrase is commonly used but is often not helpful. We have now taken to remov-
ing 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 eco-
nomic 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 neighbor-
ing 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 num-
bers of injured very much greater than those in the developed world and sometimes
by a factor of tens of thousands.
130 Section Two
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 earth-
quake 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 sig-
nificant 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 restora-
tion 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 inter-
national 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 sig-
nificantly 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 addi-
tional rural population of 143,000. The climate is extremely changeable, and the district
experiences very warm summers (especially on the plains) and very cold winters
(especially in the mountains). In addition to being a significant population and admin-
istrative 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 rep-
resents 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 health-
care 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 (sun-
dried 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 facili-
ties were destroyed, and approximately 50% of the local health care workers were
killed. Survivors were exposed to near-freezing night temperatures, with no immedi-
ate 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:
● Patients requiring hospitalization would not be treated in Bam (using field hospi-
tals) 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 neighbor-
ing 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 reu-
nited 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
132 Section Two
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, col-
lected 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
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 engi-
neers and electricians.
People and equipment had to arrive in Southern Sri Lanka then travel up coun-
try 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 acci-
dents 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 sud-
den 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.
134 Section Two
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 vil-
lages 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 inhala-
tion burns but only the most superficial of these are likely to lead to survival. Acute respira-
tory 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 pro-
duces 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 con-
siderable 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 dem-
onstrated 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
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 sudden-
impact 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 fed-
eral public health officials, the American Red Cross, and the military established
temporary medical facilities. In the four weeks after the hurricane, officials estab-
lished 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 data-
collection 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
136 Section Two
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 sup-
plies 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 medi-
cal aid, and public health. These are not mutually exclusive. Obviously there are limi-
tations 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 pro-
duce the greatest health intervention of all that is prevention. One must also not
underestimate the impact of simple resuscitative/first aid measures and the philo-
sophical 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
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 traf-
fic 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 environ-
ment. 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 inju-
ries 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
138 Section Two
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 respond-
ing 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 cer-
tainly 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 unfa-
miliar or unable to be maintained locally will have a very limited lifespan.
Although specific types of incidents such as earthquakes and landslides will pre-
dictably 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 require-
ment 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
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 stor-
age 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 agen-
cies 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, accommoda-
tion 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
140 Section Two
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 under-
standing 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 immedi-
ate, 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.
On Site Operations Coordination Center (OSOCC)

In the early phases when international aid is arriving, it is important that a coordina-
tion 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 popu-
lation 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 medi-
cal 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 organi-
zations 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 separa-
tion. 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?
142 Section Two
Closing Remarks
The issues covered in this chapter will be explored further. Some final thoughts are
given in the following bullet points:
● 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 commu-
nity 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.
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 double-
decker 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 doc-
tor 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, addi-
tional 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,
144 Section Two
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 geographi-
cal 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 deploy-
ing 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 assess-
ment (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 radio-
logical 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 sugges-
tion 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 Active combustion/fire
Heat
Electrical (traction) current
Sharps/debris
Chemical Combustion products Specific chemical agents
Particulate (dust) debris
Biological Biological debris, including needlestick risks (bone fragments)
Radiological Low dose debris/dust
High dose fragments/debris/dust
Other Secondary devices (bus bomb) Armed perpetrators
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 inter-
ventions by the forward team, now joined by the second HEMS paramedic, were the
following:
● 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 com-
mands 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 sum-
mary of the incident command structures is shown in Fig. 9.2.
2
Command, Safety, Communications, Assessment, Triage, Treatment and Transport
146 Section Two
Civil Contingencies Act

(CCA) 2004
LAS
NHS Emergency Planning Local / Regional Multi-agency Police

Guidance 2005 Contingency Plans Fire Service
Local
Major Incident Medical Other
Provider courses
Local Ambulance Service

Medical Incident Major Incident & other
Commander Training Contingencies Plan
SOPs
STRATEGIC
OPERATIONAL
PRE-HOSPITAL
Operational Major Incident Plan:
PRE-HOSPITAL MAJOR INCIDENT
SOPs Action Cards
COMPETENCY RESPONSE
FRAMEWORK
-
INCIDENT
CORPORATE
MEMORY
-
Clinical
TRAINING 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 com-
munications 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, com-
manders 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 impro-
vised Joint Services Emergency Control (JSEC) point, until their arrival.
Safety
Safety must remain paramount at all times. For any incident where there is a deliber-
ate 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 cor-
don and at potential rendezvous points and marshalling areas.
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 intoxica-
tion. 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 assump-
tion 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 com-
munication 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 per-
sons will extricate themselves from the scene. Once away from the inner cordon, the
differentiation of walking wounded (T3) casualties and uninjured survivors is some-
times 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
148 Section Two
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 logis-
tic 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 par-
tial). Some patients did receive advanced procedures including rapid sequence induc-
tion and fluid resuscitation. This was dependent on clinical need, number and type of
casualties, and medical resources available. Some lifesaving interventions were pro-
vided 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 intramus-
cular 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 achieve-
ment, 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 contin-
gency plans, this is summarised in Fig. 9.3.
KINGS CROSS
EDGWARE RD
TAVISTOCK SQUARE
NORTH (incl. BMA House)
TAVISTOCK SQUARE
SOUTH
Kings Cross Tube (Piccadilly Line) Bomb

1 Kings Cross Underground / BR Station Complex
2 Russell Square Underground Station
Aldgate Tube (Circle Line) Bomb
1 Aldgate Underground Station RUSSELL SQUARE
Edgware Road Tube (Hammersmith and City Line) Bomb
1 Edgware Road area
Tavistock Square Bus Bomb
1 Tavistock Square North (incl. BMA House)
2 Tavistock Square South
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).
● To understand how health interventions in humanitarian

Objectives emergencies have evolved in the past three decades
● To understand how minimum standards in performance
and their linkage to human rights and humanitarian princi-
ples 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 humani-
tarian 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.
152 Section Two
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 collec-
tion 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 “humani-
tarian 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 coher-
ence, lack of coordination between UN and humanitarian agencies as well as govern-
ment 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 interven-
tions 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 beneficiar-
ies, 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.
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 account-
ability in humanitarian operations, to gather, to analyze, and to disseminate informa-
tion, 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 deliv-
ery. 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 princi-
ples that should inform all humanitarian action. Through the Humanitarian
Charter and Minimum Standards in Disaster Response, defined levels of serv-
ice 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 compe-
tence. 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, how-
ever (SPHERE Project 2004) has addressed some of these issues, with more techni-
cal advice and detail; becoming more of an instructional manual than the first
154 Section Two
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 data-
base (http://www.reliefweb.int), established in 1996 by the UN. However, some author-
ities 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 con-
flict 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.
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 opera-
tional 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 popu-
lation (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; informa-
tion 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 dif-
ferences, 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.
156 Section Two
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 debilitat-
ing 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 resi-
dent population. Shelter availability, population density per shelter, diurnal variation
in temperature, water availability and quality, and sanitation facilities are fundamen-
tal 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, par-
ticularly 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 mini-
mum, 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, gen-
eral 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.

Shelter quality compared to the current environment, spacing, and level of over-
crowding 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 promo-
tion, 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 vehi-
cles, size of truck that can gain access, and proximity to ports and airports, are also
health determinants, albeit indirectly. Personnel resources and logistic considera-
tions, 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 distribu-
tion, 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 con-
siderable 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
158 Section Two
Fig. 10.2. Food distribution – Ethiopia.
Fig. 10.3. Outpatients’ clinic – Sudan.

4. Food and nutrition

5. Shelter and site planning
6. Health care in the emergency phase
7. Communicable disease control
8. Public health surveillance
9. Human resources and training
10. 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 fun-
damental 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 tech-
niques. 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 situa-
tion. 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 repro-
ductive health were often considered less important in a rapidly developing emer-
gency 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.
160 Section Two
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 con-
ducting such an initial assessment:
SPHERE Health Services Assessment Checklist
Preparation:
● 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:
● 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:
● 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/influ-
ence and the role of women
Background health information:
● 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:
● Calculate the CMR
● Calculate the under-5 mortality rate (U5MR: age-specific mortality rate for chil-
dren under 5 years of age)
● Calculate cause-specific mortality rates
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
Available resources:
● 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, classifi-
cation 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 dis-
placed 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 inter-
vention 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 particu-
larly 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.
162 Section Two
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 human-
itarian 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.

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 contami-
nated, 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,
164 Section Two
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 pro-
tected 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 meas-
ure, 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 nutri-
tional 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 avail-
able, 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
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 indica-
tors are poor, such as a high CMR (greater than 1/10,000 per day) or severe environ-
mental 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
166 Section Two
and collection by heads of households on a regular basis. Every system must be pre-
pared 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 chil-
dren 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 para-
sites. 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, por-
ridges 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 mem-
bers of the family may benefit. Finally, there needs to be an awareness of micro-
nutrient 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 mea-
sles 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 tradi-
tional village structures should be replicated as far as possible, and that access to
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 refu-
gees 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, respira-
tory infections, malaria, and measles, normally complicated by underlying malnutrition
168 Section Two
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
large demand, where many may have self-limiting disease. The importance of ade-
quate 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, work-
ing 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 labora-
tory 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 num-
bers 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.
170 Section Two
Communicable Disease Control

The major causes of death in many mass displaced persons following a natural disas-
ter or complex humanitarian emergency are made up of malaria, measles, ARI (lobar
pneumonia), and diarrheal diseases, particularly when there is a background of mal-
nutrition. Some studies attribute 60–90% of all deaths due to these illnesses. In addi-
tion, 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, ill-
nesses 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 sur-
veillance 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, identify-
ing sources and the logistic implications of mass vaccination campaigns, and identi-
fying 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, tar-
geting 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 protec-
tion of susceptible groups; the classic example being measles vaccination of all chil-
dren. 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 situ-
ations. Shigella, rotavirus, cholera, and E. coli are significant pathogens. Bloody
diarrhea with fever is a strong indication that Shigella is present, which needs labora-
tory confirmation. Adequate oral rehydration therapy (ORT) networks and trained
workers, attention to camp and personal hygiene, clean water supply, adequate food
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 con-
vinced 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 sig-
nificant 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 signifi-
cant 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 dan-
gerous 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 defi-
nitions, 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 preg-
nant 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 systemati-
cally 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
172 Section Two
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 consist-
ency 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 popu-
lation, 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 consid-
ered, 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 expatri-
ates 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
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, nego-
tiations 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 con-
sultations 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 emer-
gency. 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 inter-
national community following the genocide in Rwanda being one example. There
have, however, been some recent improvements in interagency cooperation. A well-
coordinated 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 intera-
gency 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).
174 Section Two
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 coop-
eration 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 appre-
ciation of how an aid effort is coordinated and delivered are key skills, which when
effective can significantly improve health care of displaced persons and therefore
reduce their morbidity and mortality.
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11. The Military Approach to Medical Planning
Introduction
This chapter will discuss the military approach to medical planning within the con-
text of supporting both military and nonmilitary populations. In addition to providing
support for military operations, military medical services have a long history in pro-
viding 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 promo-
tion 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.
178 Section Two
Table 11.1. Examples of recent globally or regionally significant public health

emergencies
Event Date
Attack on the World Trade Center 11 Sept. 2001
Dissemination of anthrax in the US postal system Autumn/winter 2001
Severe acute respiratory syndrome 2003
Hurricane Katrina 29 Aug. 2005
Indian Ocean Tsunami 26 Dec. 2005
Regional conflict in Darfur Since 2003
Terrorist attacks – Bali, Spain, London, Mumbai, etc. Enduring threat
Pandemic influenza Enduring threat
The profile of medical planning within the wider context of civilian emergency plan-
ning 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 struc-
tured 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 treat-
ment 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 diag-
nostic label that fulfils the doctor’s concept of disease. In military planning, a com-
mander 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 sub-
ordinate missions are not clear then the commander may seek further information
from his staff, intelligence reports, or reconnaissance. Thus the critical problem-
solving 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 subordi-
nates. 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 con-
sidered. 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.
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 infor-
mation 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 organiza-
tions 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 mis-
sion 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,
180 Section Two
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 indig-
enous 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 iden-
tified from local knowledge or from information sources such as the WHO, UK Health
Protection Agency, or the US Center for Disease Control.
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 mili-
tary 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 humanitar-
ian response and those who will be recipients of this response. It is vital that the medi-
cal 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 con-
firmed 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 employ-
ment 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-
182 Section Two
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 infec-
tious 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.
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, equip-
ment 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 fac-
tors 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 previ-
ously 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 rap-
idly establish a common system so that all agencies can contribute to the data collec-
tion 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 com-
mon 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 informa-
tion for the humanitarian agencies.
184 Section Two
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 dis-
placed 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.
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.
186 Section Two
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 writ-
ing 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 exer-
cises 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/
US Centers for Disease Control and Prevention. http://www.cdc.gov/

UK Department of Health Emergency Planning. http://www.dh.gov.uk/en/Policyand-
guidance/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, dur-
ing 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.
190 Section Two
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 descrip-
tion 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 moni-
tor their risk management plan concurrently with their interventions, thus introduc-
ing 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.

Population At Risk Risk Assessment

HAZARD
Op & Activity Dependent Theatre, Op & Activity Dependent
MALARIA (Humanitarian Op)
ASSESSMENT
Refs: All Own Tps/Pers Very High −1
SGPL 10 /10. C2 / C3 & Specialist Very High −1
RISK
JSP 371. Friendly Forces/NGOs Very High −1
Theatre MIA Locally Employed Civilians Medium −3
Med Wng Notice Displaced Persons / Refugees Medium −4
Displaced Persons/Refugee Children High −2
MONITORING ACTIVITIES
CONTROL ACTIVITIES
(Audit and Surveillance)
Communal Vector Control
• Local Med Int.
Physical • Case Identification/Reporting.
• Avoidance or removal of breeding sites: • Breeding site surveys.
- Drainage or removal of mosquito breeding sites. • Bite rates / reports.
- Camp/unit dry day – once a week. • Camp /site inspections.
- Camp siting & segregation. o Op Sanitation & Camp
• Use nets on windows and doors of accommodation / tents Hygiene
Chemical o Screening/Netting
• Residual insecticide on structures, harbourage or resting o Knockdown insecticide use
GENERAL CONTROLS
areas. • Hygiene Diary / Vector Control

• Knockdown insecticides: Log entries:
- Swing fog dawn & dusk o Unit dry days.
- Knockdown aerosols in accommodation. o Swingfog routines.
• Larvicidal treatment of mosquito breeding sites (Abate). o Site inspections.
• Vector control carried out as per JSP 371. o Peripel issue / treatment:
- Clothing
Individual Bite Avoidance - Nets
o Abate dosing.
Physical o Residual spraying.
• Bite prevention : • Use and serviceability of bed-
- Use of bed nets. nets.
- Clothing - long sleeves and trousers at dawn and dusk. • Pesticide application recorded
RISK MANAGEMENT
Chemical and effectiveness assessed.

• Peripel for clothing and nets (JSP 371 – Chap 46B) . • Check dress states/SOPs.
• Insect repellent on exposed skin.
• Health Intelligence & Med Recce. • Local Med Int.

• Health Education (MHIT Pre-deployment). • Arrival/Induction Trg.
INFORMATION,
•
TRAINING &
o Bite avoidance Vector control operatives.

POLICY
o Communal measures • Examples of reinforcing

o Chemo-prophylaxis regimes information sources, SOPs and
• Vector & Hygiene control specialist trained personnel. orders.
• Divisional SOP’s to be prepared, according to health • Warning Cards carried.
intelligence.
• In-theatre reinforcement of Health ed/trg.
• Appropriate Chemo-prophylaxis for own tps. (MWN or DCI
MEASURES
COUNTER-
•
MEDICAL
JS172 / 2001), incl alternative regimes. Chemo-prophylaxis issue /

• Removal of individual from theatre if severe reaction occurs to parades.
C-P. • Monitoring of drug related
• Warning cards. adverse effects.
• Warning Cards carried.
• Case Notifications - FMed 85
• Early identification of suspect cases. • UNHCR/NGO/HN case reports.
• Appropriate symptomatic treatment/care. • Lab IDs / reports.
TREATMENT
• Diagnostic sample and analysis to confirm parasite . • Morbidity returns (J97).

• Definitive treatment/care. • Adherence to treatment
• Treatment arrangements for DPs. protocols.
• Evac of cases.
• Post deployment - case ID and
tracking.
Fig. 12.2. Health risk management matrix completed for malaria.

192 Section Two
1. Conventional battle hazards, e.g., bullet, bomb, blast

2. Nonbattle traumatic hazards, e.g., road accidents, training accidents
3. Infective hazards
4. Chemical hazards
5. Radioactive hazards
6. Environmental hazards
7. Psychological hazards
8. Ergonomic hazards
The medical planner should generate a HRM matrix for each of the hazards identi-
fied. 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, acclima-
tized/unacclimatized, occupational or trade groupings (e.g., catering staff, staff in
special protective equipment, medical staff), specific operational tasks (recon-
naissance, 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
Table 12.1. Matrix for assessment of operational risk

Probability
Frequent Likely Occasional Seldom Unlikely
Severity
Catastrophic Extreme Extreme High High Moderate
Critical Extreme High High Moderate Low
Marginal High Moderate Moderate Low Low
Negligible Moderate Low Low Low Low
Chronic Differed
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 imple-
mented 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 con-
trol 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 train-
ing 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
194 Section Two
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 opera-
tional 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) out-
of-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 consid-
ered 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 inves-
tigation 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.
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 case-
reporting 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’ abili-
ties to produce a MFP plan.
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
● To describe the principles of health surveillance in conflict

Objectives and disaster situations
● To assist in organizing a health surveillance system in con-
flict and disaster situations
● To describe the principles of control of communicable dis-
eases in conflict and disaster situations
● To assist in organizing a response to outbreaks and
epidemics
● To introduce the challenges associated with health surveil-
lance 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 popula-
tion 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
198 Section Two
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 popula-
tions, generally lead to increased rates of disease. Outbreaks and epidemics are not
inevitable in these situations and are relatively rare after rapid-onset natural disas-
ters, 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 popula-
tions 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 infra-
structure 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.
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 popula-
tion 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 system-
atic 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 consist-
ent, 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 surveil-
lance 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 estab-
lishing a system if one already exists, unless the existing one is inadequate or inap-
propriate or has broken down irretrievably.
200 Section Two
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
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 devel-
oped 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 mini-
mal 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.
202 Section Two
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 continu-
ous 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 popu-
lation 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.
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 assess-
ing 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 popu-
lation 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 defin-
ing 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, disa-
bled 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
204 Section Two
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 sur-
veillance 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 diag-
noses. 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
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 large-
scale 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 mortal-
ity 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 inci-
dence proportion or cumulative incidence) – number of new cases within a speci-
fied 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 popu-
lation 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 emergency-
affected population deemed to be representative of the whole (or from a particu-
lar group for a specific purpose)
● Outbreak investigations – which entail in-depth investigations designed to iden-
tify the cause of deaths or diseases and identify control measures
206 Section Two
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 occur-
ring 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 chil-
dren) 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 effec-
tiveness 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 authori-
ties 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 malnutri-
tion) 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)
● 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 devia-
tions 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 follow-
ing disasters. For example, measles vaccination is one of the most important health activi-
ties 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
208 Section Two
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 defini-
tions 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 labora-
tory for confirmation. Once samples have been examined and the causative organ-
ism 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 dis-
ease 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 infec-
tion, whether or not clinical signs or symptoms
are or have been present
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 prob-
lematical 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 respon-
sible 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 some-
times 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 neces-
sarily a large additional burden. Surveillance systems that cover larger areas and
bigger and more diffuse populations usually rely on a central data collection point
210 Section Two
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.
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 leish-
maniasis), 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, ade-
quate 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.
212 Section Two
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 publi-
cations 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 organ-
isms 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:
● 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
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 great-
est 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 vac-
cinated 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 vaccina-
tions 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 consid-
ered 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:
214 Section Two
– A supervisor.
– Logistics staff.
– Staff to prepare and administer vaccines.
– Record keepers.
– Security staff (to maintain order and control crowds) may also be needed.
The Cold Chain

Maintenance of the cold chain is particularly important. This is the system of trans-
porting 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 stor-
age 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 +2 to +8°C +2 to +8°C +2 to +8°C
fever, Hib freeze dried)
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
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.
216 Section Two
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 vaccina-
tion 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 assess-
ment 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 reex-
amined. 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, chil-
dren 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 neces-
sity 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:
● 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
● appropriate laboratories (microbiological, parasitological, hematological, bio-
chemical) 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 microorgan-
isms 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
218 Section Two
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
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:
● 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 defin-
ing 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 man-
agement, 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 vaccina-
tion supplies (needles, syringes, etc.) are adequate. Make sure the cold chain can
be maintained.
● Identifying sources for other supplies, including antimicrobials, and make arrange-
ments 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.
220 Section Two
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 con-
tact 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:
● 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 pre-
vent 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., loca-
tion 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.
● Formulate hypotheses for the pathogen about the possible source and routes of
transmission.
● Conduct detailed epidemiological investigations to identify modes of transmis-
sion, 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:
● Case–control studies in which the frequency of an attribute of the disease in indi-
viduals 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.
Control Activities
● 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
Evaluation
● 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
222 Section Two
– 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; how-
ever, 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.
● To examine the concept of medical intervention in conflict

Objectives 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 neces-
sarily 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 simi-
larities. First, both events are likely to produce the same mixture of shock, bewilder-
ment, 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
224 Section Two
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 expedi-
tions 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 mili-
tary 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:
● 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.
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 assess-
ment 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
226 Section Two
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 tech-
niques to be tried. These include hazard elimination, containment of the exposure,
limiting the duration and concentration of exposures to individuals, and finally com-
plete 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 conven-
iently 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 unex-
pected 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 maxi-
mally 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
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 deploy-
ment, 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 chan-
nels 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
228 Section Two
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 ques-
tionnaire, 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 impor-
tant, 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
refugees living at Goma Camp just over the border in Zaire, and with sporadic con-
tinuing 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 over-
whelmingly 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 occupa-
tion 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 guar-
antee 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 north-
west 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 loca-
tion 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
230 Section Two
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 inter-
ventions 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 simi-
lar 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 acknowl-
edged 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 corre-
sponding instruments of law and order. In such a time of human despair and short-
age, 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 accompa-
nying a conflict. In such circumstances, humanitarian assistance may make the differ-
ence 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
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 accept-
ance 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 relation-
ship. 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 pres-
ence, 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 fulfill-
ment. 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 over-
throw 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.
232 Section Two
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 demand-
ing 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 vulnerabil-
ity 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 infra-
structure 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, invest-
ment, 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 situa-
tion 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 refu-
gee 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
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, addi-
tional 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 proc-
ess of improvisation lends itself to both these requirements. Indeed, the act of build-
ing 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 responsi-
bility 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 simi-
larly dispossessed people much harder to endure than would people from a back-
ground 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 unsustain-
able 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, height-
ened violent action, and heightened counteraction is the pernicious and tragic out-
come 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
234 Section Two
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 sanita-
tion. 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 popula-
tions. 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 addi-
tion, 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 estab-
lished. 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 semiper-
manent 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,
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 popula-
tion movement. Thus, evidence of malnutrition is frequently found in such circum-
stances, 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 under-
pins such programs. As with many such humanitarian ventures, a hard-nosed assess-
ment of need and the matching of resources provide the basis of success.
Some assessment of need is a vital initial step. Widespread protein-calorie deficien-
cies 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 refer-
ence 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 assess-
ment, followed by a specialized logistic effort and augmented by a medical supervi-
sory 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) feed-
ing 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.
236 Section Two
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 indica-
tors of disease incidence and prevalence in particular regions. According to circum-
stances, 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 offi-
cial 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 underre-
sourcing 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 epidemio-
logical 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 avail-
able 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
and realistic approach to disaster planning and action. Nevertheless, the key to effec-
tive 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 situ-
ations 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 recog-
nized 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 particu-
larly 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 psycho-
logical reaction. Thus, genocide and expulsion are generally likely to cause more psy-
chological 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 therapeu-
tic interventions, it is particularly apposite to psychiatry, given the cultural determi-
nants of many behavior types and coping mechanisms. This transcultural dimension
238 Section Two
of psychiatric care in refugee situations is particularly demanding. A mixture of inpa-

tient 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, psychologi-
cal 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 destitu-
tion 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 refu-
gee situation. Equally, the difficulties of confidentiality, contact tracing, and continu-
ity 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 possibil-
ity 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 accepta-
bility, 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 imple-
mented. At all times the plan for disaster relief must be culturally appropriate.
Another aspect that needs early recognition is the disaster–development contin-
uum. 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 tech-
niques and no possibility of imminent acquisition of them. The commitment of
resources in the acute relief stage must recognize the realities of subsequent develop-
ment potential. This is aided by using the disaster–development continuum as a
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 revul-
sion 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 substan-
tial 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 concern-
ing 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,
242 Section Two
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 chil-
dren’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 coordi-
nate 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).
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 envi-
ronment 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 enthusias-
tically 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 treat-
ment. 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 inju-
ries, 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
244 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 profes-
sional 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 technol-
ogy. Clinical Centre Koševo was a modern high-tech hospital, relying on a high turno-
ver of sterile disposable items and equipment that needed regular and sophisticated
maintenance. The medieval siege of the city made anesthetic and monitoring equip-
ment 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 manufac-
turers 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 prob-
lem. 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
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 break-
down 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 vocifer-
ously 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 demonstra-
tion 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.
246 Section Two
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 accept-
ing 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 princi-
ples 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 steal-
ing 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 even-
tually 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 dis-
patched 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 confis-
cated. 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 depart-
ment, 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.
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 pres-
sure 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 ophthalmo-
logical 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
248 Section Two
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, sophisti-
cated 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 vehi-
cle 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 poten-
tially 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
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 prob-
lems 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 there-
fore 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, reunit-
ing old friends and colleagues, and letting others witness for the first time the impact
250 Section Two
of emergency aid. The next phase of the mission completed the ophthalmology pro-
gram. 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 estab-
lishing 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 pro-
tection of UNPROFOR and IFOR.
Special thanks to: M.V. Prescott, M.J. Timmons, M.E. Ward, F. Konjhodzic, B. Nakas.
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Jones L. On a front line. BMJ 1995; 310:1052–4
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and the Lockerbie Air Diasaster. BMJ 1989; 299:611–12
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Iran. BMJ 1990; 302:1521–3
16. Health Care of Prisoners and Detainees
Maarten Hoejenbos and Adriaan Hopperus
Buma
● To realize which specific problems doctors can encounter in

Objectives 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 mili-
tary 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 con-
flict and emergency situations as this status influences their “rights” under interna-
tional 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.
252 Section Two
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 dur-
ing 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 classi-
fied 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 serv-
ice 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 multilat-
eral 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 free-
dom of speech. In many cases, political prisoners are imprisoned with no legal veneer
directly through extrajudicial processes. However, it also happens that political prison-
ers are arrested and tried with a veneer of legality, where false criminal charges, manu-
factured 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 nation-
ally and internationally as a human rights violation and suppression of a political
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 rela-
tive, 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 convic-
tion 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. No punishment (no or not enough evidence, no proven guilt)
2. Punishment
3. Measurements to protect the society
4. 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 prison-
ers, 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 infor-
mation about the cause of death. This could well lead to serious ethical dilemmas.
254 Section Two
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 com-
ply 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 funda-
mental freedoms for all without distinction as to race, sex, language, or religion.”
United Nations Human Rights Council is involved with the investigation into viola-
tions 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 them-
selves and protesting.
Due process rights that protect against abuses of the legal system such as imprison-
ment 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
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 pre-
vent 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 indi-
viduals 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 inten-
tionally 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 intimidat-
ing or coercing him or a third person, or for any reason based on discrimina-
tion of any kind, when such pain or suffering is inflicted by or at the instigation
(continued)
256 Section Two
of or with the consent or acquiescence of a public official or other person act-

ing 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 dan-
ger 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 tor-
ture 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 sub-
stance abuse programs while in prison. Federal prisons echo this trend with reports
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 com-
mon in many prisons worldwide, and treatment is often ill-informed and inade-
quate. 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 spe-
cific physical and psycho-social environment has great influence on the health sta-
tus of many prisoners.
These special problems require healthcare personnel who understand the situa-
tion of prisoners and know the routes to give them the optimal care. In many coun-
tries, 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 data-
sets 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 men-
tal 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
258 Section Two
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 psychi-
atric 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 incarcera-
tion 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 under-
used. 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 deliv-
ery 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 educa-
tion 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,
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 situ-
ations. 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 (publications@ohchr.org)].
Practical Guidelines
1. Treat the prisoner as a normal patient. Use the normal professional skills to diag-
nose and to propose treatment.
2. Keep in mind what the background problems of prisoners are, and what the epi-
demiological 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 proc-
ess 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.
260 Section Two
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 (publications@ohchr.org)
17. Populations and People
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
262 Section Two
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 intri-
cate 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 trans-
gression, 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, coo-
ing 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 self-
ish 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
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.
SECTION
3
Introduction: Living
and Working
Adriaan Hopperus Buma, James
M. Ryan and Peter F. Mahoney
Associate Editor - JJ Reilly

A – Hello folks
B – Getting involved
C – R&R: Moving between Worlds
C – Team building and maintenance
A – Staying safe
B – Thinking ballistic
C – Mines and ordnance
D – The oil camp
A – Just a word about toilets
B – Conflict Medicine – a view from the ground
21. Applied Communications in Conflict and Catastrophe Medicine
22. 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
266 Section Three
This section is looking at the deployed experience from the perspective of the indi-
vidual aid worker. The section considers how to get involved and the potential impli-
cations 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 hope-
fully a lesson emphasized here will mean an error avoided out in the field.
Part A – Hello Folks
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 des-
perate 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 har-
bor. Each brings to the anticipation of violence a fatalistic humor that defuses the great-
est 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 strug-
gled 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
268 Section Three
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 fir-
ing 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.
Introduction: Living and Working 269
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 prac-
tice. Only a small proportion of expatriate health professionals will find their true
long-term vocation in aid work (Banatvala and Macklow-Smith 1997a); the remu-
neration is often poor, living conditions are difficult, and there is no security of ten-
ure. 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 part-
ner 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, qualifica-
tion, 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
270 Section Three
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, interna-
tional community health and epidemiology. (Further details of courses and institu-
tions 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 criti-
cised for making it more difficult for UK doctors in training to work in the developing
world (Cooper 2007).
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 suit-
able 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 negotia-
tions 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 speciali-
ties 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
272 Section Three
● 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 multi-
skilled 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.
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:
● Contact names, addresses, and telephone numbers for the employing organiza-
tion (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) regis-
tration 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 inde-
pendent 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.
● 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.
274 Section Three
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.
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 check-
points. Rucksacks can be protected by lockable covers or metal meshes.
A small day sack is useful for hand baggage and day trips in-country.
276 Section Three
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
those for leisure. In the Resources section there is a list of medical books that contribu-
tors 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-denom-
ination notes for taxis, tips, and other expenses (see section on arriving). Most
278 Section Three
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.
General Advice
● 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 docu-
mentation 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 expe-
riences 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 interna-
tional healthcare. Although no defined career path exists, this may involve further
missions with the same or other nongovernmental organizations, progressing to
280 Section Three
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 Macklow-
Smith 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 sup-
plement 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.
Part C – “R and R”: Moving Between Worlds

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 unencum-
bered 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 respon-
sibility. Good luck.
I make it in time for the party. In a time-zone hopping induced haze, my father-in-
law 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
282 Section Three
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 look-
ing 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 can-
not 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
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 over-
whelming 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
284 Section Three
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 rela-
tively 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 rela-
tively 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
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, Little visible output
disagreeing, questioning of goals
Members are confronting others within
the group
Norming Resolution of internal conflicts, division Little visible output
of responsibilities within group being
resolved, emergence of group norms
Nature of the group beginning to emerge
Performing Collaboration, commitment, Group productivity increases. Group has
self-regulation evolved into a team
Dissolving Sense of loss and lack of worth When tight-knit groups/teams dissolve
Little visible output
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 inappro-
priate 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 mis-
sion, 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
286 Section Three
the seemingly menial chores, irrespective of who they are). Regular progress discus-
sions (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 atten-
tion 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 sub-
ject 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.
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
● Personal Safety
Objectives ● 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
288 Section Three
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 merce-
nary 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
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 obvi-
ous 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
290 Section Three
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 circum-
stances; 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 expe-
rienced 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 famil-
ial 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 dimen-
sion 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
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 cre-
dentials, 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 inter-
preter 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:
292 Section Three
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 prov-
enance 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 recommenda-
tion 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 heli-
copters and aircraft!
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 over-
looked 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 cultur-
ally 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!
294 Section Three
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 consid-
ered 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 simi-
lar 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 posses-
sion 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 pho-
tos 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
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 compro-
mised 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 commu-
nicate 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 check-
points and some legal ones will be an opportunity for the locals to assert their influ-
ence 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 immigra-
tion 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.
296 Section Three
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 ciga-
rettes 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 before-
hand about what you can and should not do and what other “influencing” strate-
gies 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 caus-
ing 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 some-
thing 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.
Hostage Taking and Ambush

For most westerners this causes the most fear and panic; sometimes this is with good rea-
son 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 attack-
ers 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 kid-
napped 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 rocket-
propelled 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.
298 Section Three
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 dis-
courage 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 chas-
tise 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 transporta-
tion) 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 guar-
anteed 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 person-
ally 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 contin-
gency 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
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 coun-
tries 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 inevi-
tably 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 princi-
ples and procedures can be applied provided you adopt a principle of constant check-
ing, 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 expen-
sive) training and checking with your parent organization, and experienced profes-
sionals 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, work-
ing 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.
300 Section Three
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 your-
self 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:
● 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.
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 ele-
ments, 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:
● Proximity to vehicle access routes: Consider if these could be affected by adverse
weather conditions, and/or by conflicting parties. Also identify potential evacua-
tion 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
● 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 car-
ried out to make it fit for purpose?
● Can the building provide appropriate protection from the threat of locally avail-
able weapons?
302 Section Three
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 pos-
sible (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
Part C – Mines and Weapons Awareness

Kenneth I. Roberts
● To give an introduction to the threats of mines and other

Objectives other explosive weapons.
The Threat
The inherently indiscriminate nature of the widespread use of mines is well recog-
nized, 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, antiper-
sonnel types) remain in 68 countries. Although attempts are being made by a combi-
nation 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 foresee-
able 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
1
The 1997 Convention on the prohibition of the use, stockpiling, production, and transfer of antiper-
sonnel mines and on their destruction.
2
Strictly Protocols II and V.
3
Sometimes referred to as “butterfly mines.”
304 Section Three
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 approxi-
mately (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 typi-
cally 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 perpen-
dicular 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°.
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:
● 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:
● 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.”
306 Section Three
Part D – The Oil Camp

Bob Mark
● To describe the practicalities of running a camp or secure

Objectives 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 rub-
bish including kitchen leftovers. Arrange for the safe disposal of clinical waste includ-
ing “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.
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 indi-
vidual 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 treat-
ment, 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).
308 Section Three
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 unneces-
sary 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 good-
quality 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 condi-
tions 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.
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 defen-
sive 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 depart-
ing 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 pro-
vided, 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 proc-
esses, 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
310 Section Three
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 every-
thing 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.
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 occu-
pies 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 respon-
sible 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 accus-
tomed 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 land-
based 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
312 Section Three
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 communica-
tion 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 neces-
sary 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 multi-
purpose “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 responsibili-
ties, 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 mul-
tiple 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.
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 member-
ship 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 instruc-
tions in writing by fax or e-mail. Reliable international communications and the avail-
ability 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 in-
country. 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 profes-
sional 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.
314 Section Three
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.
Part A – Just a Word About Toilets
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 “collabo-
rators.” 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.
316 Section Three
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.
…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 rede-
ployed 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 deploy-
ments 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 mov-
ing 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
318 Section Three
in that it introduced combat medicine from a slightly different perspective than train-
ing I had received from British Army. Generally, the concept involved aggressive and
decisive provision of first aid. The American ethos also included returning the casu-
alty 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 opera-
tors 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 environ-
ments 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 con-
voy 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
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 essen-
tial 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 exam-
ple, treating casualties in the prone position during an attack will require an impro-
vised 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
320 Section Three
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 for-
ceps 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 imme-
diately 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 thor-
ough 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 equip-
ment 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.
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 imme-
diate 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
322 Section Three
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 medi-
cal 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
● The aim of this chapter is to provide an introduction to

Objectives different types of communication systems that the humani-
tarian 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 sophis-
ticated 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 disci-
plines to the prevention, immediate response, and rehabilitation of the health prob-
lems 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 con-
flict and disaster medicine. It will take a problem orientated approach to communi-
cations 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 defi-
nition 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
324 Section Three
telemedicine, provide guidelines by which to judge the applicability of emerging tech-

nologies 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 informa-
tion 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 informa-
tion 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 pic-
ture 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 environ-
ment 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 catas-
trophe 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
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 trans-
mission line. An useful analogy is to regard bandwidth as the size of your communi-
cations 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.
● 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 band-
width 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.
326 Section Three
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 communicat-
ing 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 stand-
ard 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., chat-
rooms) and hence asynchronous clinical email is called “store and forward” to dif-
ferentiate 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 elimi-
nates 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.
Wireless communication can be either via GSM (Global System for Mobile commu-
nications) 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 simon@icomms.com
or +44 (0)1494 489111.
328 Section Three
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 rene-
gotiate. 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 satel-
lite 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 emer-
gence 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
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 installa-
tion (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 tel-
ecoms 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 destina-
tions. 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.
330 Section Three
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 videoconfer-
encing 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 arrange-
ments 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
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 sophisti-
cated 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 emer-
gency 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 tele-
phones (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
332 Section Three
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 trave-
lers. 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
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.
334 Section Three
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 appli-
cations 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.
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 com-
petitively 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.
336 Section Three
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 communi-
cations 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
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 tele-
phone 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 enhance-
ments in voice encryption and frequency hopping which guarantee secure communi-
cations. 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 com-
municating around the world.
Table 21.2. The relative merits of the various options available for communicating around the World
Cost per Time (s) to

minute transmit Needs intact Building
London– Bandwidtha one page local infrastruc- penetra- Geographical
Cost of kit Lagos (kbit/s) Capability of A4 ture tion coverage
POTS Very low $0.50 15 V, D b 12 Y N/A ++++

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 $250 N/A 9.6 V, D 32 N Y ++
radio
HF radio $3,000 Free 9.6 V, D 32 N Y +++
Inmarsat $1,700 $2.00 2.8 V, D 89 N N ++++
MiniM
Inmarsat $500 N/A 144 D 2 N N ++++
RBGAN
Inmarsat $2,500 $0.80 464 MV, D, VTC 1 N N ++++
BGAN
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
b
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
338 Section Three
The Spectrum of Capability

The range of communications modalities described above enable a range of capabili-
ties 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 read-
ing 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 broad-
cast 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 surround-
ing 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 some-
times 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 situ-
ation 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
teleconferencing utilizes a multipoint bridge into which participants can call on the
same number at the same time and teleconference. Audioconferencing feels uncomfort-
able 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 calm-
ing 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 tele-
medicine consults and takes less specialist time and resources than traditional prac-
tice. 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 prac-
ticed 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 engineer-
ing 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.
340 Section Three
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 high-
light 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 serv-
ices 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 obvi-
ating 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 catastro-
phe 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 capabil-
ity 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.
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 technol-
ogy 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) peo-
ple 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 Equipment and networks must be appropriate to a resource constrained environment. Equipment should be able to
constrained 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 regu-
lar 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
342 Section Three
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 indi-
viduals or smaller agencies should develop a relationship with a specialist communi-
cations 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 inter-
est 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 tech-
nique 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 net-
work 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 chan-
nels to be carried over a single pair of copper wires. Through the
use of bonding techniques the 64 kbit/s channels can be aggre-
gated to create more bandwidth
Broadband A term describing any network that can multiplex several, inde-
pendent 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 Section Three
PSTN 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
● To raise issues about the predeployment phase

Objectives ● To discuss psychological problems arising during
deployment
● To heighten awareness of problems arising in the postde-
ployment phase
Introduction
The psychological aspects involved in the provision of medical aid in hostile environ-
ments 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.
346 Section Three
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 human-
ity, the workings of the world and your place within it, yet for a minority the experi-
ence 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 bore-
dom 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
problems, and the deaths of family members. The possibility of you being taken hos-
tage 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 deci-
sions 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 need-
less 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 individu-
ally. 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 rou-
tines, 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
348 Section Three
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 under-
stand 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 impos-
sible 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.
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 prob-
lems within the group. An unexpected intensity of emotions may be forged by prox-
imity, 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 specula-
tion 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 situa-
tions, 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 person-
alities 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 expa-
triate 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 deal-
ing 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 day-
time 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 rumina-
tions and lead to anxiety, worry, and distress, especially if there are problems
in-country, poor communications with home, isolation, and boredom. It is therefore
350 Section Three
important to take time away from the work. Organize group support wherever pos-
sible 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 explo-
ration 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 prob-
lematic the deployment, the more problematic the readjustment is.
Just as you had expectations when you deployed in-country, you will have expecta-
tions 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 under-
estimate your achievements. Write a report and keep a copy.
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 experi-
ence. 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 experi-
ences 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”
352 Section Three
– Avoiding friends and social situations – becoming socially “withdrawn”

– Relationship problems, especially if related to irritability and anger
– Disturbed sleep and poor concentration
– Becoming over anxious, always “on edge”
– Becoming depressed and miserable
– Drinking too much and misusing drugs
– Acting “out of character” and impulsively
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, psy-
chological 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 every-
one 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.
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 post-
traumatic 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 indi-
vidual, 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 phenom-
ena. 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
354 Section Three
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 nor-
malize 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 indi-
viduals’ 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
● 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 stress-
ful deployment
● Expectation vs. reality: obtain as much information as possible, but beware of the
media
During Deployment
● 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 suf-
fering, 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.
● 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.
356 Section Three
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 superhu-
man. 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?
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 Agitation and irritability
Dry mouth Fearfulness and worry
Palpitations Increasing obsessiveness and rigidity of thinking
Tightness in chest
Sweating Mood swings
Indigestion Jumbled and racing thoughts
Nausea and vomiting Loss of sense of humor
Altered bowel habit Little joy in life
Teeth grinding Worrying unduly
Easily distracted
Social/behavioral
Intolerance, irritability, and argumentativeness Thinking
Emotional and social withdrawal, isolating self Self-doubt
Emotionally demanding, “using” others Boredom and loss of direction
The individual The trauma
Previous psychiatric illness Predictability and controllability
Child sexual abuse Type and frequency of trauma
Previous, current, and unresolved medical and personal problems Involvement – direct or indirect
Experienced alone or in a group
Poor coping skills 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
358 Section Three
● Nightmares and “daymares” – “as if ” phenomena or flashbacks

2. Avoidance
● Avoiding thoughts and things associated with the event – even amnesia
● Feeling cut off, emotionally isolated from others with a reduction in the nor-
mal 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
● Losing sleep
● Drinking or smoking too much
8. Dealing with stress – accept reality
● 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
360 Section Three
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 distin-
guish 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
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 … [disap-
pears] … 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, emo-
tion and the like is unable to function appropriately.”
While most events that are the subject matter of this book are potentially trauma-
tizing, 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 iden-
tified 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 dis-
order. 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 experi-
ences and narratives. Additionally, this example shows that, while most people
recover from or adapt to distress, positive adaptation cannot be assumed and trau-
matic 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 sup-
portive 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 chap-
ters 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
362 Section Three
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 mate-
rial 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 mov-
ing 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 rela-
tively few emotional reactions or by becoming temporarily distressed before return-
ing 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 avoid-
ing 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 psychologi-
cally, 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 resil-
ience 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 coopera-
tion with strangers and of people delaying their release from entrapment to make
sure that others were looked after or accompanied. Sometimes, those behaviors raised
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 see-
ing change as normal and as providing opportunities (Maddi and Kobassa 1984).
Ambulance staff, who are rated as hardy on a rating scale that measures commit-
ment, control, and response to challenge, were less likely to have general psychopa-
thology, 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 func-
tioning 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 dis-
tress 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 psycho-
pathology. 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
364 Section Three
100%
75% Distress and /or Disorder

Aproximate
Proportion
of
Affected
Persons
50%
25%
3 30 6 3+
Impact Days Days
Time
Months 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 debili-
tating 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 aug-
mented by external support from family members, colleagues, and friends.
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.
366 Section Three
In summary, it is possible, perhaps arbitrarily though helpfully for planning and

preparatory purposes, to distinguish several broad patterns of human reaction to adver-
sity, 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 consist-
ent 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 devel-
opment. 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 hos-
pital 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
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 inse-
curely attached individuals …”. These point to resilience having dynamic, develop-
mental 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, psycho-
Personal 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 Good relationships with other people
● 2 Contributions to community life
● 3 Talents or accomplishments that one values oneself or which are appreciated by others
● 4 Access to and use of protective processes
● 5 Adaptive ways of coping that suit the situation and the person
● 6 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.
368 Section Three
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 Passive- Resilience may be thought of as related to each person’s ability to

increasing a withstand trauma. So, one approach is to help people to develop
person’s ability to their ability to cope well when faced with trauma.
withstand trauma
Active - shaping A second approach to developing resilience is based on the

the environment observation that more resilient people express agency in doing
to minimise what they can to organise the world around them to minimise the
trauma 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 Research has shown strong relationships between people’s

attachment capacities for secure attachments and their resilience.
capabilities
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
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, socioeco-
nomic 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.
370 Section Three
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 interven-
tions 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 pro-
moting 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 com-
municated before the event.
● Realist preparation and training is provided.
● Supervision and mentoring are available.
● Effective and responsive day-to-day operational leadership and service manage-
ment 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.
● 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 respond-
ers 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 Management of Leadership and Develop Models of
Planning
Leadership Expectations Management Care
& Management
LEVEL 2
Service Leadership Education Competencies
& Management Clarity of Practice Triage
& &
that Sets Clear Expectations System
Training Ethical Guidelines
Expectations and
Standards for Practice
LEVEL 3 Provision of Discussion, Rest, Recuperation Monitoring Practice

Day-to-day accurate, up-to- Operational & and Adherence to &
Leadership and date and relevant Technical Duty Rotas Clinical Supervision
Management
Practice
information about Debriefing
the situation
LEVEL 4
Psychosocial
and Healthcare Psychological First Aid
Responses
Mental Health Service
Assessment & Intervention
Specialist Mental Health
conducted in Primary Care
Services
Fig. 22.4. A framework for promoting the psychosocial well-being and effectiveness of staff.
372 Section Three
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 inci-
dent 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.
1 Thought that they were out of control during the event

2. Thought that their life was threatened during the event
3. Blames others for some aspect(s) of the event
4. Expresses shame about their behaviour relating to the event
5. Experienced acute stress following the event
6. Has experienced substantial general stress since the event such as problems with work, home and health
7. Is having problems with day-to-day activities
8. Talks about problems relating to previous traumatic incidents
9. Has problems in gaining access to social support (from family, friends or at work)
10. 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. Has upsetting thoughts or memories about the event that come into mind against the person’s will
2. Has upsetting dreams about the event
3. Acts or feels as though the event is happening again
4. Feels upset by reminders of the event
5. Has bodily reactions when reminded of the event
6. Has difficulty falling or staying asleep
7. Is irritable or has outbursts of anger
8. Has difficulty concentrating
9. Is overly aware of potential dangers to self or others
10. 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).
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Part C – Requiem: Going Home

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
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 chil-
dren 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 impor-
tance 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.
378 Section Four
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. Conflict recovery-health systems in transition

24. Pristina 1999-eating an elephant
26. Military Health Services Support In Conflict
27. Military Medical Assistance To Security Sector Reform MCM
28. Hospital Blues
378 Section Four
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
● To introduce the concept of conflict recovery

Objectives ● 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 effec-
tive 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 imme-
diate 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 self-
governing 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.
380 Section Four
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
Introduction: Hospitals and Health Systems 381
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 delib-
erate 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, equip-
ment, 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 atten-
tion, 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
382 Section Four
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 transi-
tion was short and urgent.
The situation in the Falkland Islands in early June 1982 is summarized below:
● 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 func-
tioned 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 terri-
tory quickly entered a transition to recovery phase with all the problems that might
be expected.
The situation during this period is summarized below:
● 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, anaes-
thetists 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, communi-
cation, policing, and education.
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:
● 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 medi-
cal 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 prob-
lems listed below is illustrative but far from comprehensive:
● 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).

384 Section Four
Fig. 23.4. Young mine victims - Pristina teaching hospital 1999. (Photo PF Mahoney)
● 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:
● Seventy years of control by the former Soviet Union.
● A disastrous territorial war with neighboring Armenia which also involved hos-
tilities with the Soviet Union.
● Twenty percent loss of the national territory with forced displacement and migra-
tion 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, suf-
fered from the consequences of financial ruin and loss of social cohesion.
● 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, con-
centrating 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 quan-
tify 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 fail-
ure of many hospitals. The consequences of failure of hospitals in Iraq can be
summarized.
● 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.
386 Section Four
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 prac-
tices 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 assess-
ment. 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, par-
ticularly doctors, will have been trained in a developed European or North American
healthcare system and as a consequence will have to undergone specialty and subspe-
cialty training and practice in increasingly subspecialty niches. This aspect mainly
affects health professionals working in hospitals. Few, if any, general physicians, sur-
geons, 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
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 occa-
sion, 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 predeploy-
ment 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, obstet-
rics, 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 nonmili-
tary 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.
388 Section Four
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 depar-
ture but ensure medicines and consumables are in date and undamaged. Donated equip-
ment 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 long-
term 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
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 pro-
gram 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 mili-
tary 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 vulnera-
ble 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 disap-
pearance 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 discov-
ered 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.
1
Reproduced from the BMJ with permission. BMJ 1999;319:1652 (18 December)
392 Section Four
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 inpa-
tient 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 experi-
ence. 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 hos-
pital, 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.
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 pre-
viously 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 train-
ing 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
394 Section Four
that both of these patients were being transferred to host nation facilities for their sec-
ondary 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 trans-
ferred 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 con-
tacted 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 acci-
dent; 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 opera-
tions. 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 opera-
tions 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.

Introduction : Hospitals and Health Systems 395
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 profes-
sional 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, prepara-
tion, 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
398 Section Four
SCOPE OF HEALTH SERVICE

SUPPORT TO MILITARY FORCES
Military Operations
Infrastructure Deployed
military health services military health services
International
military health services
International
National
civilian health services
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 capa-
bility themselves and so there may be substantial multinational collaboration to
ensure sufficient deployed medical capability and capacity for a military force (pos-
sibly 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 organi-
zational 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.
Military health services personnel and organizations are bound by military law,
international law, and professional ethics and codes of conduct. These separate mili-
tary 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 informa-
tion 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 indi-
vidual 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 (hospi-
tal 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.
400 Section Four
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 environ-
ment, 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 opera-
tions 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 medi-
cal capabilities increase so does their demand for support, thus increasing the medi-
cal 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, resus-
citation 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 proce-
dures 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 hold-
ing 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, casu-
alty decontamination facilities (dependent on operational risk assessment).
(continued)
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 sup-
port 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 treat-
ment 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:
● 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 capabili-
ties 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
402 Section Four
Table 26.1. Medical activities at each level of military activity
Level Activities Remarks
Grand Strategic Balancing health resources between civil and defense requirements National health service resources are finite.
Generating healthy manpower to support national requirements In WW2 a national committee managed
Integrating military and civilian resources to care for military casual- mobilization of civilian medical staff
ties at Role 4 in the Armed Forces to ensure balance
between military and civilian require-
ments
Strategic Allocation of resources to the medical function The medical function has to compete will
Determining the medical support capabilities and capacities required all other military functions for defense
to support campaigns resources
Balancing medical resources between active duty and reserve forces
Predicting the casualty load for campaigns
Operational Determining the medical resources required for specific operations This requires an understanding of the
Balancing medical resources between nations and between Army, medical implications of operational
Navy, and Air Force medical services on operations design and balancing economy with
Establishing and monitoring the medical evacuation chain from point risk. This is about allocation of medical
of wounding to Role 4 resources (especially Role 2E and Role 3,
and MEDEVAC airframes) for a particular
operation
Tactical Assigning missions and tasks to individual medical units This requires an understanding of military
Planning for and managing casualty. evacuation and care during and and medical tactics and the potential
after battles casualty flows. This is about siting of
Responding to medical emergencies 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 cam-
paigns. 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 communica-
tions 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 arrange-
ments between health, police, fire and rescue, civil government, and other agencies.
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
Managing MEDEVAC and patient regulation Clinical governance of medical system
Oversight of medical logistics Conducting health intelligence assessments and producing medical
force protection advice
Developing and communicating the medical plan Epidemiological health surveillance
Oversight of medical information systems Coordination of the management of specific clinical cases
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 (includ-
ing personal survival skills and organizational skills such as camouflage and protec-
tion) 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 exam-
ined 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.
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
1918–1945. J Royal Army Med Corps 2002b;148:314–22
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 indige-
nous institutions including various types of security forces, correctional facilities, and
judicial systems necessary to secure and stabilize the environment – so called “secu-
rity sector reform.” The international community provides this help through a com-
bination 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 person-
nel 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 govern-
ments in a postconflict environment is not new. The OECD defines the overall objec-
tive 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 vulner-
abilities 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 exe-
cute its responsibility for the security for its people and will enable the withdrawal of
international military forces. The United Kingdom emphasizes the need for “joined-
up” partnering between the departments of foreign affairs, interior, and defense when
providing external support to SSR (Department for International Development 2005).
406 Section Four
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, operat-
ing 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 secu-
rity 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 medi-
cal 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 organiza-
tions, and the central requirements of the sponsoring ministries. The field medical
system should be focused on prehospital care (including role 1) and medical evacua-
tion 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 allo-
cation of funds for operational health services. Eventually the ministry of defense is
forced to transfer the responsibility for nonuniformed beneficiaries to the civilian sec-
tor 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),
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 plan-
ning 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 capac-
ity 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 casu-
alties 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 hos-
pital 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 out-
patients 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 teach-
ing patients and their immediate carers how to provide simple wound care for the
(continued)
408 Section Four
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 employ-
ment might make the security sector the most attractive source of work. The recruit-
ing 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 coun-
try. 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 sys-
tem. 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 profes-
sional 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 syl-
labus 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 sig-
nificant 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 gradu-
ates 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.
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 inter-
national 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)
410 Section Four
trauma care, incident management, military medical ethics, and war surgery. The
international military medical services will be keen to reduce the level of “in-
extremis” support provided to the local security forces, and therefore the postop-
erative 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 physiother-
apy, and follow-up care of the amputated limb (and simple prosthetic manage-
ment). 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 representa-
tives 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 repre-
sentatives of the international military medical community to act as mentors and
conduits for external investment. These mentors can also facilitate the develop-
ment 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 encour-
aging 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 expe-
rience 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 pro-
vides personal mentorship to the Afghan Army Surgeon General and a team of tech-
nical 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)
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 impor-
tant 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 prox-
imity 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 impor-
tant to clarify the arrangements to enable them to access “western standards” of mili-
tary 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 understand-
ing 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 preex-
isting 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 predeploy-
ment orientation and training for EETs, sharing of training resources and good prac-
tice, transparent funding arrangements for all parties, and communication of plans
and policies so that all parties understand the intent.
412 Section Four
Conclusion
This chapter describes the potential roles of international military medical forces
within the context of security sector reform in stability operations. The chapter high-
lights 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 “in-
extremis” 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.
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 92-64-00786-
5). 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
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 wan-
dering 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 calm-
ness 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 sup-
posed to be. Hope all is well at home.
SECTION
5
Introduction: Clinical Care
David G. Burris, Adriaan Hopperus Buma,
and James M. Ryan

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
33. Conflict, Terrorism And Disasters
416 Section Five
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.
● To indicate the range of common injuries and illnesses likely
Objectives 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 deploy-
ment 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
418 Section Five
● 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
● This section emphasizes the importance of managing

Objectives 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 pro-
fessionals 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
Introduction: Clinical Care 419
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 profes-
sional 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 life-
saving 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 spe-
cific 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.
420 Section Five
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 pro-
fessional (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 predict-
able 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, how-
ever, deteriorate if constant delivery of oxygen and nutrients to the brain is not main-
tained. 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.
● 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 prehos-
pital 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, usu-
ally: 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 insidi-
ous!) 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.
422 Section Five
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 (cricothyroidot-
omy) 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 intu-
bation, 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.
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)
424 Section Five
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:
● Hypovolemic (loss of blood and/or fluids)
● Cardiogenic (loss of contractile strength as in myocardial infarction and conges-
tive 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 replenish-
ing 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)
Listen
● 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)
– 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 move-
ment 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 investiga-
tion 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”.
426 Section Five
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-cavi-
tary 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,” dilu-
tion 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.
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 deci-
sion 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 sec-
ondary 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
428 Section Five
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 trau-
matic 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.
● 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 (chemi-
cal 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.
430 Section Five
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 man-
agement 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 envi-
ronment, 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:
● 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 rec-
ommended; especially when the patient needs to be transported.
● For associated fractures, external fixators are mostly safer than internal fixation
devices.
● When available Vacuum Assisted Closure techniques can provide excellent pro-
tective and draining wound dressing.
Postoperative Care
The wounded area should be rested and mildly elevated if possible. Repeated observa-
tion 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 consid-
erable quantities of blood and serum, even to the extent of requiring blood transfu-
sion. 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 distur-
bance 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
432 Section Five
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 tailor-
made; 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.
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 neurov-
ascular 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 hospi-
talization is required. External hemorrhage should be dealt with by external compres-
sion 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 indi-
cations 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 analge-
sic 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
434 Section Five
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 injec-
tion. 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.
● 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 swell-
ing 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.
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 encoun-
tered 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 support-
ive treatment with fluid resuscitation, hemodynamic stabilization, and broad spec-
trum 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
436 Section Five
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 anaes-
thesia 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 per-
formed, 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 inju-
ries 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 peri-
neal muscles and around the rectum.
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 impor-
tant 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 spec-
trum 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 nee-
dle 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
438 Section Five
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
● This section is concerned with unique injury mechanisms –

Objectives 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 dis-
ruption 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 charac-
teristics 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,
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-energy-
transfer 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
440 Section Five
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 tis-
sue 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 abdom-
inal 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. Low-
energy-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.
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.
442 Section Five
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 pres-
sure 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 environ-
ment. 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 pri-
mary 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
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.
444 Section Five
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 trau-
matically 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 vas-
cular 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 dam-
age 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
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 pulmo-
nary 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 hem-
orrhages. 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.
446 Section Five
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 prac-
tise 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
● This section deals with surgical, (mainly) nontraumatic,

Objectives 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?
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:
● Abdominal complaints may be caused by disease processes located outside the
abdomen: myocardial infarction and pneumonia. Also the chest should be exam-
ined 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 present-
ing 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
● 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
● Internal examination (rectal, vaginal)
Laboratory Tests and Imaging

● 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 aspi-
ration and angiographic embolization will not be discussed, as they are rarely avail-
able in an austere environment.
In all instances, it is extremely important that the patient be stabilized hemo-
dynamically, as much as possible. Recording the fluid balance, especially urine
output, is vital, and nasogastric aspiration should be commenced where vomiting
continues.
450 Section Five
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 involve-
ment 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
● 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 exami-
nation. 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).
452 Section Five
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 = irre-
ducible 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.
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 usu-
ally 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”)

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
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
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
454 Section Five
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
Percussion: normal
Palpation: normal; sometimes some tenderness in the flank
Internal examination: normal
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

Percussion: dullness in the lower abdomen
Palpation: tender mass in the lower abdomen
Internal examination: occasionally enlarged prostate; otherwise normal
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 aneu-
rysm. 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 aneu-
rysm may be felt as a pulsating mass
Internal examination: some tenderness
Tests are initially normal. A drop in hemoglobin is a late sign.

456 Section Five
Sonography will show free abdominal fluid and if an aneurysm is the cause of intra-
peritoneal 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.
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.
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 well-
established 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
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
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 reason-
able time span.
458 Section Five
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.
Palpation: unremarkable; there may be upper abdominal tenderness
Internal examination: unremarkable
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
Palpation: unremarkable
Internal examination: unremarkable
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 (one-
sided), with occasional radiation to the lower abdomen. No fever.
Examination
Swollen testis; extremely painful on examination

460 Section Five
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

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 throm-
bosis 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.
462 Section Five
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 sup-
port 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 air-
way obstruction and spread to the neck and finally to the mediastinum.
Maxillofacial
Introduction
Those conditions involving the mouth and oral structures may be divided into two
groups:
● Hard tissues (including the teeth and bony anatomy of the face)
● Soft tissues
Nomenclature
The mouth is divided into four quadrants to identify the teeth and the site of intraoral
lesions. Both the upper and lower arches are divided into the patient’s left and right
as viewed from looking directly into the mouth. The teeth are named as follows, start-
ing at the midline:
● Incisors
● Canines
● Premolars (only found in adults)
● Molars
There are 20 primary teeth (deciduous teeth) in children. When looking into the
mouth, the teeth are sequentially lettered 1–5 starting from the midline. The quad-
rants are numbered 5 = upper-right, 6 = upper-left, 7 = lower left, and 8 = lower-right.
The 64, called “six four,” is the upper left first deciduous molar.
In adults, there are 32 permanent teeth, which are sequentially numbered from 1 to 8
starting from the midline. The quadrants are numbered 1 = upper-right, 2 = upper-left,
3 = lower left, and 4 = lower-right. The 43, called “four three” is the lower right canine.
Examination of the Mouth

The mouth should be examined with a good light (headlight), suction, and with the
aid of a dental mirror or spatula. The patient will normally be able to point to the
affected side of the mouth and may be able to identify the exact location of the
prob1em.
Tapping a tooth with the handle of the mirror may elicit a painful response if there
is a significant problem like an inflammation of the dental pulp or a traumatic injury
of the tooth or the jaw. If in doubt, apply a cold stimulus such as ethyl chloride on a
pledget of cotton wool to the tooth. A short reaction that disappears after removal of
the stimulus indicates a vital dental pulp. Increase of pain intensity or duration is a
sign of pulpitis.
Hard Tissues
Toothache
1. Pulpitis (inflammation of the pulp) is the commonest cause of dental pain. The
main causes are:
● Dental caries
● Fracture of the tooth
● Dental treatment (exposure of the nerve)
The symptoms of pulpitis are:
● Pain (sharp and stabbing in nature)
● Hypersensitivity to hot and cold stimuli
● Patient kept awake at night because of pain.
Examination of the mouth may reveal a carious (decayed) tooth. The main treatment
is either to remove the pulp (nerve) from the tooth or to extract the tooth. Dental
cement containing oil of cloves can be applied to the tooth as a temporary analgesic
measure.
2. Periapical periodontitis is inflammation of the periodontal membrane around the
apex of a tooth. It is due to spread infection following the death of the pulp. The
symptoms are as follows:
● Pain on biting on the tooth (which can be extruded out of the socket)
● Worsening pain (throbbing in nature)
● Hot and cold stimuli have no effect
Treatment is again aimed at either saving the tooth or extracting it.
3. A dental abscess occurs when infection persists around the apex of the tooth
following periapical periodontitis. Pus may spread directly into the surrounding
soft tissues and emerge into the mouth or onto the face. The patient may complain
of pain swelling in the mouth or on the face. Examination may reveal an unwell
patient with pyrexia. They may not have eaten or drunk recently due to trismus
464 Section Five
(difficulty in opening the mouth). The position of the swelling will indicate the
tooth that is source of infection. This is illustrated below.
Name of tooth and position of swelling
Upper Teeth
Central incisor Upper labial sulcus
Lateral incisor Anterior palate
Canine inner Canthus of eye
Premolars upper Buccal sulcus
Molars upper Buccal sulcus
Lower Teeth
Central incisor Lower labial sulcus
Lateral incisor Lower labial sulcus
Canine lower Buccal sulcus
Premolars lower Buccal sulcus
Molars lower Buccal sulcus
2nd and 3rd molars Submandibular space
The intra oral abscesses need drainage.
Abscesses in the submandibular space, the floor of the mouth, and the parapharyngeal
area can extent to the neck and finally the mediastinum and be life threatening.
Drainage of all abscesses under general anaesthesia is mandatory within a few hours!
These patients need intravenous fluid replacement and antibiotics. The antibiotic
currently suggested is a broad-spectrum penicillin, although metronidazole is also
effective. The source of the infection should be extracted after reduction of the acute
signs of the inflammation.
Postextraction Hemorrhage
The causes of bleeding following the extraction of a tooth are listed below.
● Trauma to the bone socket
● Soft-tissue trauma
● Bleeding disorder
● Anticoagulant therapy
● Infection
● Failure to follow postoperative instructions
The patient should be examined in a good light and preferably with an assistant to
suck away any blood. The tooth socket should be examined for signs of excessive
trauma. The treatment is described below:
● Reassure the patient and instruct them to sit down quietly.
● Ask them to bite on a rolled-up piece of gauze placed over the socket for half an-hour.
● I the bleeding persists, the socket should be sutured using a local anaesthetic
(2–4 mL 1 in 80,000 adrenaline and 2% lignocaine) infiltrated around the area. If
that is not effective, the socket can be plugged with a gauze soaked with Vaseline
or with a clot-stimulating product.
● The patient should avoid rinsing or hot drinks for 12 h.
● Lay in bed with an elevated head.
Injury to the Teeth

Teeth may be avulsed (completely lost from the socket), extruded (partially lost from
the socket), intruded into the socket or subluxed (displaced in a forward, backward,
or sideways direction).
Injuries to the tooth may be confined to the enamel, the dentine and the enamel, or extend
below the level of the gum. A fracture of the tooth may involve the pulp and be painful.
A tooth which has been completely avulsed (usually a front tooth) should be managed
in the following way:
● Instruct the patient to reinsert the tooth into the socket immediately and hold it
in place until seen.
● Alternatively, advise the patient to place the tooth into a container of milk and to
bring it to the carer as soon as possible.
● Under local anaesthetic, wash the socket using saline and reimplant the tooth
within 2 h after transport in an adequate medium.
● Temporarily hold the tooth in place using wire from a paper clip and a dental
adhesive.
● Antibiotics should be prescribed and tetanus profylaxis should be given.
If a tooth or a fragment of a tooth is missing, a chest radiograph is necessary to
exclude the possibility of inhalation.
Fractured teeth involving the pulp may be dressed using a calcium hydroxide paste
on the exposed surface.
Injuries to the Bones of the Face

Injuries to the face are usually assessed during the secondary survey. However, some
injuries may be life-threatening and should be managed during the primary survey
and resuscitation phases.
1. Mandibular Fractures
● Mobile fragments of jaw
● Teeth not meeting properly (malocclusion)
● Sublingual hematoma
● Step deformity along the line of the jaw.
● Anaesthesia of the mental nerves (lower lip and chin)
● Reduced mouth opening
2. Zygomatic Fractures
466 Section Five
● Depression of the cheek

● Infra orbital swelling
● Periorbital hematoma
● Unilateral bleeding from the nose
● Anaesthesia of the infra orbital nerve
● Redness of the eyeball
● Diplopia
● Steps lateral and/or inferior rim of the orbit
● Step at the zygomatic-maxillary rim (intra oral, lateral of the first molar)
3. Maxillary Fractures
● Mobile maxilla (Le Fort I), including nose (Le Fort II) and orbits (Le Fort III). Can
be absent due to impaction of the fragments.
● Teeth not meeting properly (malocclusion)
● Bilateral facial swelling
● Bilateral periorbital hematoma
● Bilateral bleeding from the nose
● Bilateral steps at the zygomatic-maxillary rim (intra oral, lateral of the first molar.
Le Fort I and II)
4. Nasal Fractures
● Bleeding from the nose
● Asymmetry
● Movable at the frontal bone
● Hematoma of the septum
Beware, nose-bleeding can be a symptom of a skull base fracture!
Life-threatening injuries in the face which may compromise the airway, particularly
in a patient with an associated head injury, are listed below.
● Displacement of the fractured maxilla
● Loss of tongue control (occurs with a bilateral fracture of the mandible or chin
area)
● Foreign bodies, e.g., teeth, dentures, bone fragments, vomitus, or hematoma.
● Hemorrhage
● Soft-tissue swelling and edema
● Direct trauma to the larynx and trachea
Cervical spine injury occurs in 2% of facial trauma cases and must always be consid-
ered. The spine should be protected with a cervical collar and appropriate radio-
graphs obtained.
5. Dislocation of the Jaw
This may follow trauma to the jaw or be caused by simply yawning widely. The symp-
toms are the following:
● The mouth is fixed open
● The patient is unable to speak
● Drooling saliva
● Considerable pain
The jaw can be relocated by laying the patient with the clinician standing in at the side
of the patient. The fingers of both hands, wrapped with gauzes, are placed over the
posterior lower teeth and both thumbs are placed under the chin. With the fingers
traction is applied in a downward direction and by pressure of the thumbs the joint
is repossitioned. The clinician can feel the jaw move back into the correct position
and the patient has immediate relief. Occasionally sedation (10 mg of diazepam iv)
may be required, particularly if the patient is anxious or if the dislocation happened
some time before.
Soft Tissues
There are a number of conditions that commonly affect the soft tissues of the mouth.
The gingivae (gums) may be affected by:
● Chronic periodontal disease
● Acute necrotising ulcerative gingivitis (ANUG)
● Acute pericoronitis
● Ludwig’s angina
● Trauma
1. Chronic periodontal disease is very common and is caused by plaque or calculus
(tartar) building up around the teeth. This can be a local or a generalized problem.
The main reason for this is inadequate brushing of the teeth. The patient usually
complains of halitosis and bleeding from the gums on brushing. The dental sulcus
depth is increased over 3 mm. Treatment is professional cleaning of the teeth and
oral hygiene instruction.
2. Acute necrotising ulcerative gingivitis (ANUG) (trench mouth) may occur in epidemic
form especially in institutions. It is often preceded by immune suppression by:
● Viral respiratory infection
● Fatigue
● Immune defects
The symptoms are the following:
● Widespread soreness of the gums
● Spontaneous bleeding of the gums
● Characteristic halitosis
● Pyrexia and malaise
● Cervical lymphadenopathy
The appearance of the gums is diagnostic. The papillae (between the teeth) are ulcerated,
tender, and bleed to the touch. ANUG is managed by gentle cleansing with a toothbrush
and diluted hydrogen peroxide. Metronidazole is the appropriate antibiotic. The patient
must be considered infectious. Use of cutlery and toothbrush by others should be
avoided. The patient must not be involved in preparation of food for others.
468 Section Five
3. Acute pericoronitis is an infection of the gum around a partially erupted lower

wisdom tooth (third molar). The symptoms are:
● Pain ranging from mild to severe
● Bad taste in the mouth
● Halitosis
● Difficulty in opening the mouth
● Occasionally pyrexia and malaise
The immediate treatment is antibiotic therapy with penicillin or metronidazole. Hot
salt mouthwashes are helpful. If the patient is unwell, intravenous fluids should be
commenced. There is a potential risk for abscesses (see earlier) and the airway.
Extraction of the tooth, after treatment of the acute symptoms, will prevent further
episodes of infection.
4. Ludwig’s angina is a rare but life-threatening spreading infection usually from a
lower molar tooth. Both sides of the floor of the mouth become swollen, and the
tongue is raised up against the roof of the mouth. Swelling spreads below the
lower jaw on both sides to compromise the airway. This must be treated
immediately with high-dose antibiotics and drainage of all the infected tissue
spaces. Occasionally tracheostomy is needed.
5. Trauma: Bleeding from the soft tissues of the mouth, face and scalp may be profuse
due to the good blood supply in that the area. Fractures of the facial bones can also
produce considerable hemorrhage. Life-threatening bleeding due to airway
obstruction or hypovolaemic shock must be managed in the primary survey.
● Open wounds should be assessed for blood loss
● Open wounds should be cleaned using chlorhexidine solution (0.05% chlorhexi-
dine gluconate) and covered with a sterile dressing
● Simple nose bleed (epistaxis) may be controlled by direct digital pressure the
lower nose
● Closed wounds may produce bleeding from the nose and mouth. The nose may be
packed using ribbon gauze anteriorly and a 12/14 G Foley catheter and balloon
posteriorly
Eye Injuries
● Periorbital hematoma (black eye) may be due to soft-tissue injury or an underlying
fracture of the cheek bone (zygoma) or maxilla.
● The eye must be examined and the visual acuity (ability to see) tested.
● Foreign bodies should be left in situ and the eye covered with a noncompressive pad.
● Penetrating foreign bodies must not be removed.
● If the globe is disrupted, the eye should be covered with a noncompressive pad.
● If chemicals enter the eye, copious amounts (500–1,000 mL) of normal saline,
sterile water, or Hartiman’s solution should be used to wash the eye.
N.B. Patients with foreign-body injuries should be referred to an appropriate surgical
team if one is available.
Ear, Nose, and Throat

Examination of the patient should be in a good light, preferably using a mirror.
Common problems include:
● Infections
● Foreign bodies
● Trauma (see above)
Infections
1. Acute otitis externa is inflammation of the ear canal and may be due to trauma or
eczematous ear canal skin. The symptoms are as follows:
● Mild irritation to severe pain and discharge from the ear canal
● Hearing loss
Treatment consists of gentle removal of ear canal debris and application of antibiotic/
steroid drops, ointment, or spray.
2. Acute otitis media is inflammation of the middle ear and is common in children.
Symptoms include:
● Recent upper respiratory tract infection
● Severe earache, which may be bilateral
● Rupture of eardrum produces relief of pain
Treatment consists of bed-rest, antibiotics, painkillers, and nosedrops to reduce
mucosal swelling.
3. Acute mastoiditis may occur if acute otitis media is inadequately treated. It is often
seen in young children and the symptoms are:
● Severe pain
● Pyrexia and tachycardia
● Swelling and redness behind the ear
Intravenous antibiotics and surgical intervention asap are necessary.
4. Acute pharyngitis commonly occurs following a viral infection. The patient will
complain of:
● Difficulty in swallowing
● Feeling unwell
Treatment is aimed at relieving the symptoms and includes fluids and pain killers.
5. Acute tonsillitis is seen in children and the symptoms include:
● Sore throat
● Difficulty in swallowing
470 Section Five

Treatment includes bed-rest, painkillers, antibiotics, and fluid replacement.
6. Quinsy (peritonsillar abscess) occurs as a complication of acute tonsillitis and is
more common in adults. An abscess forms around the tonsil causing the patient
to complain of:
● Sore throat on the affected side
● Difficulty in swallowing and dribbling saliva
● Change in the voice (hot-potato quality)
● Malaise
● Difficulty in opening the mouth (trismus)
● Earache
● Cervical lymphadenopathy.
Intravenous antibiotics and drainage of the abscess are essential for treatment.
Beware of airway problems and spreading to the neck or even the mediastinum.
7. Supraglossitis affects children between 3 and 7 years of age and requires urgent
management. It is characterized as follows:
● Stridor (noisy breathing resulting from an upper airway obstruction)
● Sore throat
● Mouth breathing and dribbling
Immediate treatment with intravenous antibiotics (chloramphenicol) is essential.
Beware of the airway. In case of edema corticosteroids can be considered. In doubt, a
cricothyroidectomy must be performed.
Foreign Bodies
1. Ears
● Commonly occurs in children
● Earache may be the presenting complaint
● Can be removed either by grasping the foreign body with forceps or gentle syringing
(providing that the item is not vegetable matter which may swell)
● General anaesthetic may be required for children
2. Nose
● Commonly found in children
● Foul discharge from a nostril may be the presenting symptom
● Can be removed by visualising the object and grasping it with forceps
● General anaesthetic may be required for children
3. Throat
● An object may lodge anywhere in the pharynx or laryngo-tracheo bronchial tree
● May cause scratching, tearing, or perforation of the mucosa
● Differentiation must be made between inhaling and swallowing the foreign body
● Inhalation may be suggested by a sudden onset of coughing. Chest infection may
be the presenting symptom
● If the airway is compromised, a sharp blow to the back may dislodge the item
● A general anaesthetic may be needed to remove a foreign body
● In case of a high airway obstruction, a cricothyroidectomy must be performed.
Further Reading
Andreasen JO, Andreasen FM. Essentials of traumatic injuries to the teeth. Copenhagen: Blackwell Publ,
2007.
Dhillon RS, East CA. Ear, nose and throat, and head and neck surgery. New York: Churchill Livingstone,
1999.
Hupp JR, Tucker MR, Ellis E. Contemporary oral and maxillofacial surgery. Philadelphia: Elsevier, 2003.
Part G – Head Injury

Andrew Maas and Walter Henny
Introduction
Head injury constitutes a major health and socioeconomic problem throughout the
world, and forms an important aspect of combat-related injuries. The type of brain
injury sustained in the military situation may be different from those more commonly
observed in the civilian population. In the military situation, penetrating injuries are
more frequent and commonly result from shell and shrapnel injuries. These are
generally low velocity injuries, frequently causing a depressed skull fracture and cortical
contusions with a very similar pathophysiology compared with closed civilian head
injury. Gunshot injuries may be perforating (through and through), penetrating (missile
lodged within the head), or tangential (glancing off the skull). Penetrating injuries due
to higher velocity projectiles result in a complex wounding pattern with extensive
damage both produced by an impact shock wave preceding the projectile and more
specifically by a temporary cavitation effect in the wake of the projectile following its
passing. The resulting tract of injury is often 10–20 times the size of the passing
projectile. More recently blast injuries have been identified as a novel entity within
Traumatic Brain Injury (TBI). Blast injuries mainly result from Improvised Explosive
Devices, both in the military and unfortunately also in the civilian situation due to
terrorist activities. The pathomechanism of blast injuries is unknown, but they are
characterized by severe early brain swelling, prominent vasospasm, subarachnoid
hemorrhage, and despite an initially very severe condition may have a surprisingly
good outcome following intensive management including a decompressive crainiectomy.
With regard to the specific features identified in blast injuries, the term “a new beast”
has been used to characterize this entity (Gean 2007).
472 Section Five
Despite the recognition of specific characteristics particular to penetrating head injury,

the general therapeutic goals remain very similar to those for closed head injury:
1. Prompt diagnosis and timely evacuation of an intracranial hematoma. Most feared
are cases where a seemingly minor injury leads to intracranial hemorrhage, with rapid
neurological deterioration. Immediate operative treatment can be life saving with
patients obtaining a full recovery, while any delay may cause the death of the patient.
2. Prevent and limit secondary brain damage. An important concept in traumatic
brain injury is that the primary damage initiates a complex sequence of events
leading to secondary damage, potentially amenable to treatment. Secondary damage
can result from intrinsic pathophysiologic mechanisms occurring within the
brain and in particular due to systemic events such as hypoxia and hypotension.
A major focus in the management of head injury is therefore to ensure adequate
perfusion and oxygenation of the brain. General approaches to management have
become standardized and are summarized in generally accepted international
guidelines, covering different aspects of TBI management (Table 29.1).
Medical personnel operating in an austere environment, however, have to constantly
ask themselves which of these guidelines is applicable in their actual situation.
The following recommendations are aimed at nonspecialist medical personnel
Prehospital Care
● All casualties with head injury and/or traumatic loss of consciousness should be
ABC stabilized, as far as possible given the circumstances.
● Hypotension and hypoxia should be prevented, with a target blood pressure of at
least 90 mm Hg and a target SaO2 of at least 90% (if pulse oxymetry is used).
● In the event of (relative) hypovolemia, fluid resuscitation is essential; administra-
tion of hypertonic saline has the benefit of reducing raised intracranial pressure.
If used, volume administered should not exceed 500 mL.
● If clear neurological deterioration develops, hyperosmolar fluids should be
administered.
Table 29.1. TBI guidelines relevant to combat-related injuries
Guidelines Reference
Guidelines for prehospital management of TBI http://www.braintrauma.org

J. Neurotrauma 2002; 19:111–174
Guidelines for the management of severe TBI http://www.braintrauma.org
J. Neurotrauma 2007, 24:S1–S106
Guidelines for the field management of combat-related head injury http://www.braintrauma.org
Guidelines for the surgical management of traumatic brain injury http://www.braintrauma.org
Neurosurgery 2006, 58:S21–S262
Management and Prognosis of penetrating brain injury Journal of Trauma 2001, 51:S1–S86
NICE guidelines
● In penetrating head injury, intravenous antibiotics are indicated, if available.

● Cervical spine immobilization is recommended in casualties with:
○ GCS < 15
○ Neck pain or tenderness
○ Focal neurological deficit
○ Paraesthesia in the limbs
Care at a Medical Treatment Facility

The extent depends to a high degree on the availability of diagnostic facilities (CT
scan) and therapeutic facilities (neurosurgery and intensive care including the
availability of mechanical ventilation). In the absence of appropriate facilities for
treating severely injured patients, all such casualties should be immediately transferred
to a tertiary care facility following initial stabilization. All casualties should be
approached according to ATLS standards.
ABCDE (Primary Survey): Important Items for Head-Injured Casualties

○ Intubation and ventilation should be considered in casualties with:
■ GCS < 9
■ Bradypnea (<10), spontaneous hyperventilation (exclude hypoxia first)
■ Bilateral fractured mandible
■ Copious bleeding into mouth (e.g., from skull base fracture)
■ Seizures, not responding immediately to medication
○ ICP directed management (hyperventilation, hyperosmolar fluids) is indicated
when signs of herniation are present.
○ In the absence of signs of herniation, hyperventilation should be avoided during
the first 24 h after injury.
○ Maintain adequate ventilation and circulation.
○ Immediate CT scanning is indicated, if neurological deterioration occurs, sign of
herniation develop or the patient is unconscious.
○ Cervical spine immobilization should be maintained until the spine can be
cleared, following the ATLS guidelines
Secondary Survey: Important Items for Head-Injured Casualties

History
The following should be addressed:
– Initial level of consciousness and any changes thereof as measured by GCS
– Mechanism of injury (shell/shrapnel, gunshot, blast, accident)
– Neurological deficits (weakness; paresis of arm/leg)
474 Section Five
– Persistent headache, vomiting, seizure

– Altered behavior
– Medication (anticoagulants in particular); drugs, alcohol
Physical Examination
This consists of:
○ The level of consciousness (GCS)
The values for E(yes), M(otor) and V(erbal) should be determined separately; ideally
in and ABC stabilized patient, before paralytics or opiates are administered.
○ Pupils: size and reactivity
■ The development of pupillary a symmetry or unresponsive pupil is a warning
sign of impending herniation, possibly caused by an enlarging intracranial
hematoma requiring prompt diagnosis and intervention.
○ Focal deficits
○ Signs of a penetrating head injury (the entry wound may be small)
○ Signs of a skullbase fracture
■ Clear fluid running from the ears or nose
■ Black eye with no associated damage around the eyes
■ Bleeding from the ears
■ Bruising behind the ears
A skull base fracture does not require any immediate therapy, but can increase the
risk of meningitis occurring.
Laboratory
– Glucose
○ In all patients with a decreased level of consciousness hypoglycemia should
be excluded: hyperglycemia is related to poorer prognosis and should be
avoided.
– Electrolytes (hyponatraemia may aggravate the development of cerebral edema)
– Coagulation parameters (the presence of coagulopathy carries a substantially
increased risk for the development of a progressive intracranial hematoma and is
related to poorer outcome).
Imaging
– Immediate CT scanning following initial stabilization is indicated in all patients
with a GCS ≤ 8 and in all patients with neurological deterioration.
– Ideally, CT scanning should be performed in all patients with GCS ≤ 14 at any point
since the injury and in patients with a GCS of 15 in the presence of risk factors:
○ Suspected open or depressed skull fracture
○ Any sign of basal skull fracture
○ Post traumatic seizure(s)
○ More than one episode of vomiting
○ Retrograde amnesia > than 30 min
○ Age over 65 years
○ Warfarin use
– In the absence of CT facilities, all patients with a GCS ≤ 12 should be transferred
to a tertiary care facility as soon as possible. In patients with a GCS of 13–15, care-
ful neurologic observation may be acceptable.
– X-rays of the cervical spine should be performed in patients with:
○ GCS ≤ 15 at the time of assessment
○ Paraesthesia in the extremities
○ Contraindication for functional examination of the spine (pain in the neck,
midline tenderness on palpation)
○ Inability to actively rotate neck to 45° to the left and right
○ Age over 65 years
– Specialist workup including CT angiography is recommended in TBI when a vas-
cular injury is suspected. An increased risk of vascular injury is present if:
○ The wound trajectory passes through or near a major vessel trajectory, either arte-
rial or venous, and in the presence of an intracranial hematoma. Awareness should
exist of the increased risk for developing a traumatic intracranial aneurysm.
Treatment
As mentioned in the introduction, this text has been written primarily for nonspecial-
ists personnel. Here we limit a summary to the most important aspects, without
describing the specialist care in detail.
Surgical Management
Surgical indications include intracranial hematoma (epidural, acute subdural, or intrac-
erebral), elevation of a depressed skull fracture, management of penetrating injury and
performing a decompressive craniectomy for treatment of raised intracranial pressure.
Generally these operative procedures should be performed by a neurosurgeon. However,
a general surgeon may be the only one with operative skills who is available or who can
be reached. In those circumstances, we recommend the following approaches:
476 Section Five
– Patients with an epidural hematoma and loss of consciousness should be operated

immediately without any delay. The preferred procedure is to perform a small
craniectomy to release the pressure of the hematoma. As long as this pressure is
successfully released, the patient can be transferred for secondary final operation
at a tertiary center.
– Patients with an acute subdural or intracerebral hematoma should be referred for
neurosurgical care without delay.
– Patients with a blast injury and raised intracranial pressure should be referred for
neurosurgical care immediately.
– The entry opening of a penetrating head injury may be managed by simple wound
closure and the patient secondarily transferred.
– A closed, depressed skull fracture can be managed conservatively.
Conservative Treatment
– Careful, clinical monitoring (GCS and pupillary reactivity) is the most important
element of conservative management.
– Patients in need of specialist treatment for raised intracranial pressure should be
transferred for tertiary care.
– Prophylactic antibiotic treatment is indicated in patients with penetrating brain
injury. Antibiotics are not indicated in other cases.
– Prophylactic antiseizure medication is only indicated in patients with penetrating
head injury.
– There is no place for the administration of steroids.
Observation
Any patient who has suffered an objectively confirmed diagnosis of TBI will not be fit
to return to combat duty at short notice. All such patients should, therefore, be trans-
ferred outside the combat area. Indications for consultation and rapid transfer include:
– Definite or suspected penetrating injury
– Cerebrospinal fluid leak
– Unexplained confusion which does not clear quickly
– GCS of 13 or less
– Persisting coma (GCS less than or equal to 8) after initial resuscitation
– Progressive focal neurological signs
– Seizure without full recovery
– Relevant abnormalities on imaging
– Need for imaging (see above), in the absence of a CT scanner
– Deterioration during observation (see above)
If transfer is impossible (because of weather, tactical/political situation, etc.) consulta-
tion should be sought, and the patient observed.
Patients are admitted for observation
– If they have no indication for referral but their GCS is below 15

– If an indication for referral exists, but transfer is not possible
The latter category is at a distinct risk.
Items to be documented during observation:
– GCS
– Pupil size and reactivity
– Limb movements
– Respiratory rate
– Heart rate and blood pressure
– Temperature
– Blood oxygen saturation
Frequency of observations
– Half-hourly until GCS 15 has been achieved
– Thereafter: half-hourly for 2 h
then one hourly for 4 h
then two hourly
When deteriorating: half-hourly
Consultation should be sought and transfer considered if during observation:
– Agitation or abnormal behavior develops
– There’s a sustained (>30 min) drop of one point in motor level or any drop of
greater than two points in GCS level regardless of duration
– Severe or increasing headache or persisting vomiting occurs
– New or evolving symptoms or signs (pupils/lateralization) are seen
Further Reading
ATLS Manual 7th Edition, American College of Surgeons, Chicago, 2004
Geans, A.D. 2007. Scientists: brain injuries from war worse than thought. (Greg Zoroya) USA Today, November
05, 2007, [http://www.usatoday.com/news/world/iraq/2007–09–23-traumatic-brain-injuries_N.htm]
Guidelines for Prehospital Management of Traumatic Brain Injury, Brain Trauma Foundation, New York,
2000. [http://www.braintrauma.org] J. Neurotrauma 2002; 19:111–174
Guidelines for the Management of Severe Traumatic Brain Injury, Brain Trauma Foundation, New York,
2007. [http://www.braintrauma.org] J. Neurotrauma 2007; 24:S1–S106
Guidelines for field Management of Combat-related Head Injury, Brain Trauma Foundation, New York,
2005. [http://www.braintrauma.org]
Guidelines for surgical management of Traumatic Brain Injury. [http://www.braintrauma.org] Neurosurgery
2006; 58:S21–S262
Guidelines for the management of penetrating head injury, Journal of Trauma 2001; 51:S1–S86
Head Injury: Triage, Assessment, Investigation and Early Management, National Institute for Clinical
Excellence (NICE), London, 2003
Management and Prognosis of penetrating brain injury, Journal of Trauma 2001; 51:S1–S86
478 Section Five
Part H – Anaesthesia and Analgesia

Chris Bleeker
● To discuss pain relief in an austere environment
● To discuss the principles of pain treatment
● To describe the range of agents and techniques available
● To discuss local and general anaesthesia in an austere
environment
Objectives ● To discuss the options and to describe techniques
Introduction
If not the first word then certainly the second word a doctor will learn in Afghanistan
is: “dard ky,” meaning: it hurts. A doctor is expected to be able to deal with this
complaint. It describes the main issue and is meant as an appeal to the doctor for help.
A doctor will encounter pain under different circumstances such as operational
circumstances in the field, a rural clinic call, or humanitarian situations. This chapter
means to describe how you can provide aid in a confident and responsible fashion.
Definitions
Throughout this chapter, the term analgesia is used to mean relieving pain, whereas
anaesthesia is used to mean the absence of sensation. Anaesthesia may involve gen-
eral anaesthesia (the patient is put to sleep, usually to allow a surgical procedure to be
performed) or local anaesthesia (where a body part is deprived of sensation). Some
anaesthetic drugs provide analgesia (e.g., ketamine) and some analgesic drugs (e.g.,
certain opioids), if given in large doses, will cause unconsciousness and general
anaesthesia. All of these drugs have side effects. Depending on the drug and the dose
given, this can include decrease in blood pressure, stopping a casualty breathing, and
other toxic effects.
Analgesia
General
It is a well known fact that the doctor will underestimate the pain and family will
overestimate the pain. This often leads to under treatment of the patient. Remember
the pain sensation belongs to the patient.
There are different types of pain, which respond differently to different medica-
tions. Acute pain is treated easiest and provides grateful patients. For chronic pain,
you should be wary of starting a treatment. Do you have the right medications, the
supplies to sustain the treatment and is follow-up guaranteed? Certain pains, such as
ischemic pain or cancer infiltration into nerve tracts, cannot be treated with every day
medications and may lead to overdosing with opioids. So know your limitations – We
cannot treat everybody.
The choice of analgesia method may also depend on the operational circumstances.
Should the casualty be able to continue the fight, should he stop shouting right now?
Principles of Pain Treatment

● Resuscitation comes before attempts at pain relief. Treating pain before resuscita-
tion may remove pain and the sympathetic stimulation this causes as compensa-
tory mechanism to shock.
● Verbal anaesthesia/analgesia is a valuable adjunct to other analgesia methods. Calm
the patient, explain what is happening, and promise only what can be guaranteed.
Never lie to the patient especially children as they will never trust you again.
● Simple physical measures to relieve pain should be tried first. This includes
splinting limb fractures and cooling burns.
● Start with the WHO analgesia ladder.
● Then switch to specific analgesic techniques.
● Know what is available in the doctor’s kit and in the personal kits and know how
to use it.
● Consider the number of casualties involved, their clinical condition and the circum-
stances of injury (including threats to the safety of both casualties and helpers).
Clinical Assessment
Your clinical assessment will be modified in the light of the situation and the number
of casualties. Where practical, it is valuable to find out about the past and present his-
tory. Before giving a drug, contraindications (such as pregnancy or allergy) should be
ruled out.
Clinical assessment relies on clinical observation and regular measurement of con-
sciousness level, blood pressure, pulse rate, and respiratory rate (these findings should
be charted in a manner that will be understandable to personnel both in the field and
the receiving hospital).
Routes of Administration of Medication

Orally
Oral analgesics are effective after minor surgery and in the less seriously injured. After
serious injury or major surgery, gastric emptying and gut motility are likely to be
delayed, and patients may vomit so alternative routes for giving drugs are needed.
480 Section Five
Intramuscular Injection
Intramusculair (IM) injection of drugs may be necessary when carers lack cannula-
tion skills, resources are limited, and the casualties are inaccessible or presenting in
large numbers with minor injuries. IM injection has a number of limitations. Onset
of drug action is unpredictable and will be delayed in the shocked and cold patient.
Subsequent fluid resuscitation and rewarming following an IM injection can result in
the drug being rapidly “washed” out of the muscle into the circulation. This may in
turn produce cardiovascular and respiratory depression.
Subcutaneous injection, infiltration

See IM injection. An i.v. cannula can be inserted subcutaneously and left for subse-
quent injections making it easier and less painful than an injection every 4–6 h.
Precautions must be taken to assure nobody attaches an i.v. line to the cannula.
Rectal application
Another easy route of applying medication is rectally. In warm climates without
refrigerator suppositories may be a little too fluid to use, and they are not easily trans-
ported in a warm backpack. However, many medications can be applied rectally in
their native fluid form. Ketamine, morphine, midazolam, or diazepam can be inserted
using a bit of tubing, grease, and a syringe. Make sure you have enough volume to fill
the tubing and still reach the rectum by adding saline or flushing the tube. For chil-
dren sat on their mothers lap, it may prove to be a friendly method. Dosage will need
to be adjusted, but can be titrated to effect just by keeping the cannula in place and
adding shot after shot of medicine.
Intravenous Injection
Intravenous (i.v.) injection provides a faster onset of analgesia and is best done by
giving small amounts of the drug slowly into an intravenous cannula and monitoring
the patient’s response. Remember to give the drug a chance to work before adding the
next dose. Morphine only starts to work after 10 min to peak at 20 min. Do not make
the patients urgency your own.
Infiltration and Nerve Blockade

This will be discussed under “local anaesthetics” later in this part of the chapter.
Inhalation
The drug is absorbed across the large surface area of the lung. An advantage is the
rapid onset of drug action. Auto inhalation is a controlled manner of providing pain
relief and sedation.
Choice of Drugs for Medical Kits

If you are in a position to compile your own selection of drugs for pain relief take the
following into account when choosing: The medication should be
● Familiar to the people who will be giving them
● Nonaddictive
● Legal in the country or area of work and importing the drugs must be arranged
with all the paperwork necessary
● If possible available locally
● Able to withstand the temperature and conditions likely to be encountered
● Have a predictable action and minimal side effects
● Have effects that can be reversed in the event of an accidental overdose
Pharmacology and Use

WHO’s Pain Ladder
The WHO has developed a three-step “ladder” (Fig. 29.1) for cancer pain relief. The
escalation in therapy can be used in other pain settings as well. The WHO internet site
states:
If pain occurs, there should be prompt oral administration of drugs in the following
order: nonopioids (aspirin and paracetamol); then, as necessary, mild opioids
(codeine); then strong opioids such as morphine, until the patient is free of pain. To
calm fears and anxiety, additional drugs – “adjuvants” – should be used. To maintain
freedom from pain, drugs should be given “by the clock”, that is every 3–6 h, rather
than “on demand.” This three-step approach of administering the right drug in the
right dose at the right time is inexpensive and 80–90% effective. Surgical intervention
on appropriate nerves may provide further pain relief if drugs are not wholly
effective.
Oral Analgesics
A normal pain schedule will almost always start with paracetamol, and then an
NSAID should be added. If this is not adequate, a mild or strong opioid can be added.
This multi pronged approach constitutes a broad attack on pain (Table 29.1).
482 Section Five
Paracetamol
This drug has a good analgesic action and unlike aspirin causes minimal gastric irri-
tation. For adults, 500 mg to 1 g is taken up to four times a day. In the correct dosage,
other side effects are rare. Paediatric dose ranges from 10 mg/kg to 15 mg/kg four
times per day. Paracetamol is available in an i.v. formulation as proparacetamol.
Paracetamol is dangerous in overdose and can cause fatal liver damage.
Nonsteroidal Antiinflammatory Drugs (NSAIDs)

This group of drugs is used in hospital to treat musculoskeletal and postoperative
pain. They have been shown to have opioid-sparing effects. A range of drugs is avail-
able, but they differ in terms of recommended dosage, dosage interval, and licensed
route of administration, and severity of side effects. They have been used effectively
in a variety of circumstances. Intramuscular ketaprofen has been used successfully in
battle casualties with minor fragment wounds, while in emergency department prac-
tice, oral ibuprofen and intramuscular ketolorac have supplied comparable analgesia
for musculoskeletal injuries. In the authors’ experience, diclofenac and naproxen are
the most effective analgesics of this group when used in trauma patients. Diclofenac
is also very effective in treating pain from colics. It is registered only for i.m use, how-
ever, 75 mg i.v. in a single dose has proven very effective in stopping a renal colic.
At present, out-of-hospital injectable use of NSAIDs may be restricted by the condi-
tions of a particular drug’s license.
There are also a number of disadvantages and limitations to the use of NSAIDs:
● They can inhibit platelet aggregation and prolong bleeding time, resulting in an
increase in bleeding during surgery.
● Postoperative hemorrhage has been reported.
● They have been implicated in acute renal failure, particularly in patients with
diminished renal function.
● They may exacerbate asthma.
● They may cause gastric irritation and should not be used in aspirin-sensitive people.
This means that their use may be limited in cases of major injury associated with
hemorrhage and shock.
Opioid Analgesics
These drugs remain the gold standard by which other analgesic agents are judged,
particularly for treating severe visceral pain. Many synthetic and semisynthetic drugs
are available but certain comments are relevant to all opioids:
● In severe pain, small incremental doses should be administered by the intrave-
nous route where possible, and patient response should be observed closely both
Fig. 29.1. WHO’s pain relief ladder. Reproduced from http://www.who.int/cancer/palliative/painladder/en/.

With kind permission of WHO Press.
Table 29.2. The figures given for maximum safe doses

are approximations, and in practice they may need to be
reduced depending on the condition of the patient and the
techniques being used
Maximum safe Duration of

Drug dose (mg/kg) effect (h)
Procaine 7 0.5–1
Tetracaine 1–2 1–2.5
Prilocaine 6–9 1–2
Lidocaine 4–7 1–2
Mepivacaine 4–7 1–2
Etidocaine 4–5 2–6
Bupivacaine 2–3 2–5
Ropivacaine 2–3 2–4
to assess pain relief and to check for adverse effects (particularly for signs of res-
piratory depression).
● The opiate antagonist naloxone must always be available, as should facilities for
advanced airway management.
● Anti-emetics will frequently be necessary when opioids have been used.
484 Section Five
● Certain of these drugs are controlled and subject to the Misuse of Drugs Regulations.
The respiratory depression may be deleterious in brain injury casualties where an
insidious increase in CO2 may increase intra cranial pressure of the patient.
Morphine
This is the standard narcotic analgesic against which all other opioids should be
assessed. Its classic actions of analgesia with euphoria (and ultimately physical
dependence) and respiratory depression depend upon an agonist (positive) action at
central nervous system opioid receptors. These effects are reversible with the opiate
antagonist naloxone.
In the field, a 1 mg/mL solution can be used to provide an adult bolus injection
between 2 and 5 mg followed by l-mg increments according to patient response.
Analgesia may be expected to start after some 5–10 min. Cardiovascular effects
include a lowering of blood pressure from systemic vasodilatation following hista-
mine release. Morphine is generally avoided in head injuries as hypercapnia may
occur and pupillary assessment during neurological examination may become more
difficult.
Nalbuphine
This is an injectable (subcutaneous, intramuscular, or intravenous) synthetic opioid
characterized by its minimal abuse potential. A dose of 10–20 mg is given every 3–6 h
as necessary. Its analgesic effect and degree of respiratory depression are stated to be
similar to those of morphine, while nausea and vomiting may be less. Reports of its
clinical effect in hospital are varied, but prehospital use is reported to be safe and
effective.
Codeine Phosphate
This is an opioid with good analgesic activity; 30–60 mg is given orally or intramus-
cularly every 4–6 h up to a maximum of 240 mg per day. Constipation and drowsiness
may occasionally be problems.
Pentazocine
This is a morphinomimetic with mixed agonist–antagonist characteristics. It comes
in ampoules of 30 mg/mL or capsules of 50 mg.
Side effects are less than Morphine but include nausea and vomiting. The dose is
15–30 mg i.v. or 30–45 mg i.m or s.c. It is antagonised with naloxone.
Tramadol
Tramadol is a centrally acting synthetic opioid analgesic. Although its mode of action
is not completely understood, at least two complementary mechanisms appear appli-
cable: binding of parent and M1 metabolite to μ-opioid receptors and weak inhibition
of reuptake of norepinephrine and serotonin. Tramadol has the same side effects as
morphine such as pruritis, constipation, nausea, and vomiting. It does, however, not
have the histamine release effects of Morphine. Tramadol is partly antagonised by
naloxone. Doses range from 50 to 100 mg four times daily.
Fentanyl lollipops
Fentanyl lozenges are a solid formulation of fentanyl citrate on a stick in the form of
a lollipop that dissolves slowly in the mouth for transmucosal absorption. These loz-
enges are intended for opioid-tolerant individuals and are effective in treating break-
through cancer pain. It is also useful for breakthrough pain for those suffering bone
injuries, severe back pain, neuropathy, arthritis, and some other examples of chronic
nonmalignant pain. The unit is a lozenge on a stick, which is swabbed on the mucosal
surfaces inside the mouth – inside of the cheeks, under and on the tongue and gums
– to release the fentanyl quickly into the system. It is most effective when the lozenge
is consumed in 15 min. The drug is less effective if swallowed, as despite good absorb-
ance from the small intestine. Fentanyl lozenges are available in six dosages, from 200
to 1,600 μg in 200 μg increments (excluding 1,000 and 1,400 μg).
Most patients find it takes 10–15 min to use all of one lozenge, and those with a dry
mouth cannot use this route. In addition, nurses are unable to document how much
of a lozenge has been used by a patient, making drug records inaccurate. Also as any
opioid this formulation is particularly susceptible to misuse and abuse.
Inhalational Analgesia
Both Entonox and Methoxflurane present an easy method of providing analgesia.
Both are prone to misuse as a party drug.
Entonox
Premixed 50:50 nitrous oxide and oxygen (Entonox) has been a traditional analgesic
in UK prehospital care for some 30 years. Its popularity is owing to its ease of admin-
istration and safety. The mixture is provided from on-demand valve cylinders and
administered via a mask or mouthpiece. Overdose is unlikely as once a patient becomes
drowsy, they release the mouthpiece and their level of consciousness recovers.
Analgesia will peak some 2–5 min after inhalation, and this fact needs to be
respected when Entenox is used to assist procedures such as patient extraction. Size
D cylinders allow 20–30 min continuous use, the efficiency of which is improved by
locating the demand valve at the patient’s mouthpiece.
486 Section Five
During storage, care must be taken to ensure that the temperature of the gas is not
allowed to fall below −7°C because at this point separation of the gases can permit
delivery of a hypoxic mixture.
When necessary, a cylinder can be re-warmed at 10°C for 2 h and then completely
inverted three times (to mix the gases), or rapidly rewarmed by immersion in water
at 37°C for 5 min and then inverted three times.
Entonox is contraindicated in decompression illness. It should also not be used in
the presence of a pneumothorax unless there is a functioning chest drain in situ.
Nitrous oxide diffuses out of the blood stream into gas-filled cavities (and bubbles)
faster than nitrogen can be removed, causing an increase in pressure and volume
within these spaces. Theoretically similar considerations apply to air collections
within the cranial cavity of head-injured patients. In practice, Entenox should be safe,
for a casualty with mild concussion and pain from other injuries, particularly since it
is likely to be given for a short time period.
Methoxyflurane
This is an old fashioned anaesthetic vapour, which is a weak anaesthetic and strong
analgesic. It is currently used by ambulance services delivered via an inhaler with or
without oxygen. Onset of action is 1–3 min and the duration is 5–10 min. The dose
should be self administered. If patient is unable to self administer then the attendant
should observe consciousness of the patient en remove the inhaler when patient
starts to lose consciousness. Care should be taken in patients with an already altered
level of consciousness, e.g., after a head trauma, that airway patency is maintained.
The dose is 3 mL inserted on the wick of the inhaler. This may be repeated to 6 mL
per day and 15 mL per week.
Anaesthesia
Anaesthesia uses medication to induce a controlled state of depressed consciousness
or unconsciousness in which the patient may experience partial or complete loss of
protective reflexes including the ability to independently and continuously maintain
a patent airway. This is the reason why the provision of full anaesthesia is undertaken
by specially trained individuals with the ability to maintain oxygenation in spite of
the airway being at risk. So do not try this at home.
Even so events may call upon the available doctor to provide for a more cooperative
patient. He can choose to provide help without full loss of consciousness. This is
called conscious sedation. Conscious sedation is defined as the use of medication to
minimally depress the level of consciousness in a patient while allowing the patient
to continuously and independently maintain a patent airway and respond
appropriately to verbal commands and/or gentle stimulation. It is still a form of
anaesthesia and on the continuum to full unconsciousness. Therefore, the monitoring,
observation, preparation, and execution remain essentially the same as for full blown
anaesthesia.
Preparation: during this, the patient is assessed as to his suitability for the sedation.
The elderly will crossover to full anaesthesia easily and have little physiological
reserve to compensate for the side effects of the medications. So essentially patients
should be healthy and reasonably strong (ASA classifications 1 and 2 and some 3).
Beware especially of patients with symptomatic heart disease and symptomatic dia-
betes mellitus. Pre-existing airway problems will exacerbate when you sedate. You
should ask about allergies, medications use, last meal, and other diseases. The patient
should be fasted just as for full anaesthesia.
After the sedation the patient should not be allowed to drive, operate equipment, or
cook until next day.
Personnel
There should be one competent person available to watch the patient during the seda-
tion. This person should have no other duties to perform during the sedation. The
condition of the patient during the sedation should be charted. The sedation is not
finished once the procedure is completed but only once the patient is fully conversant
and clear headed.
Equipment and Supplies

Oxygen: System capable of delivering 100% at 10 L/min
Suction: Apparatus capable of producing continuous negative pressure of 150 torr
Airway Management:
Face masks (all sizes)
Oral and Nasal airways
Endotracheal Tubes
Laryngoscopes
Monitors:
Pulseoximeter
Cardiac Monitor in a cardiac patient
Blood Pressure Device
Resuscitative Equipment/Medications:
Ambu-Bag
Defibrillator
Emergency Drugs including Naloxone (Narcan), Flumazenil, Ephedrine, and
Epinephrine
Emergency Drug Card and ACLS Protocols
Principles of Providing Conscious Sedation

Conscious sedation is achieved using the same medications and delivery methods
used for anaesthesia. The object is to titrate the medication to slowly reduce con-
488 Section Five
sciousness to a level of slurred speech. The medication is slowly injected and the
result checked after waiting for the effect time, then another small bolus is added.
Medication used
Midazolam
Midazolam is a short acting water soluble benzodiazepine. It has anti-anxiety, anti-
convulsant, sedation, muscle relaxation, and antegrade amnesic properties.
Side effects include decrease in blood pressure, some depression of ventilation, and
the muscle relaxation may lead to airway obstruction.
Sedation dose: titrate 0.05–0.15 mg/kg. Dilute the solution to 1 mg/mL and slowly
start with 1 mg and then add 1 mL per bolus.
Ketamine
Ketamine is an anaesthetic drug with a profound analgesic effect. It has little or no
ventilatory depression, and it does not depress the pharyngeal reflexes as much as
other agents but the airway should not be presumed safe. It causes little cardiovascular
depression. It produces a dissociative anaesthesia, which looks like a catatonic state. It
is often accompanied by unpleasant dreams and hallucinations. It produces hyperten-
sion and tachycardia. Also there may be a disturbing hyper salivation. Because of the
side effects, ketamine is usually combined with low dose midazolam and with
atropine.
Ketamine is very useful for short painful procedures such as bandage changes
(burn cases).
Fentanyl
Fentanyl is a potent synthetic short acting opioid. It will work for 20–30 min. As it is
so potent, it should be used with extreme care. A central ventilatory depression will
provide decreased sensitivity for CO2. Fentanyl may increase intracranial pressure due
to the CO2 rise. It may produce a bradycarda and thoracic rigidity.
Fentanyl should be titrated very slowly to a good effect. Titrate with 25 μg per bolus.
A normal dose is 50–100 μg in a grownup with a maximum effect after 5 min. When
combined with other medication should be even more careful.
Local Anaesthesia
Local anaesthetic techniques can provide safe and effective analgesia in acute trauma.
Regional anaesthesia is a local anaesthetic technique that removes sensation from a
particular body region, e.g. using a nerve block for a limb or using spinal or epidural
injections to numb the abdomen and legs. Table 29.2 gives a guide on safe dosage.
There are a number of limitations to local anaesthesia in prehospital and field

conditions:
● Personnel with the appropriate anatomical knowledge and training may not be
available
● Preparation of the patient (resuscitation, positioning, and access) is difficult
● There may be insufficient time to perform the technique and wait for it to work
● Inadvertent toxic problems may be difficult to manage
In practice, local anaesthesia will be used for certain specific purposes:
● Infiltration: Direct injection of local anaesthetic into the skin and subcutaneous
tissues for wound exploration and suturing, or to assist practical procedures such
as chest drain insertion.
● Nerve blocks: Certain blocks such as femoral nerve block (which can be per-
formed quickly and safely in some instances even during transport to hospital) or
intercostal block to assist with chest drain placement or moving a casualty with
fractured ribs.
● Hematoma blocks: Direct injection of a fracture hematoma is useful for certain
limb fractures, particularly at the wrist.
● Specialised blocks: Less common and more specialized techniques such as caudal,
epidural, and spinal anaesthesia.
Local Anaesthetic Safety

Local anaesthetic safety is a complex subject. The potential danger will vary according
to the technique proposed, the patient’s condition and the local anaesthetic selected.
Safety is maximized by careful preparation and execution of the local anaesthesia.
You have to ensure that:
● The patient has an intravenous cannula (to allow fluid resuscitation and treatment
of allergic and toxic reactions to the local anaesthetic).
● The local anaesthetic is never injected as one bolus. Once the needle for the local
anaesthetic is in place, first you should aspirate and make sure the needle is not in
a vessel. If you aspirate blood do not inject but reposition the needle. Once a good
position of the needle is achieved and no blood aspirated, you inject the local
anaesthetic ml after ml aspirating in between each increment until the full dose is
inserted thus guarantying it is not intravascular.
● The recommended maximum safety doses (MSD) relevant to nerve block and infil-
tration techniques should be calculated beforehand and not exceeded Table 29.2.
Adrenaline is often added to local anaesthetics. It prolongs the action of the local
anaesthetic. The adrenaline containing mixtures should not be used in body parts
that are fed by end arterioles. Traditionally, these are the digits, nose, ears, and penis.
On accidental intravascular injection, there will be an immediate rise in pulse rate on
the pulseoximeter, warning you of impending danger.
490 Section Five
Pharmacology of Local Anaesthetics

Toxic reactions from local anaesthetics are usually the result of technique failure or
incorrect doses. They may well be fatal. The smaller the individual the more at risk the
patient is of being intoxicated. Never just infiltrate a skin area of a baby or paste with
local anaesthetic cream or spray so many squirts from a nebulizer, without calculating
the total dose allowed.
Toxic reactions:
Cardiac: Decreased stimulus conduction, prolonged PQ time, suppression of ectopic
pacemakers, negative inotropic effects, and fibrillation. Resuscitation of a patient
intoxicated with bupivacaine is hardly ever successful.
CNS: sedation up to a coma, dizziness, fasciculations, paraesthesias around the
mouth and fingers, hypersalivation.
Selected Local Anaesthetic Procedures

Exact details of anatomy and technique should be studied from any of the standard
texts on nerve blocks and regional anaesthesia.
Femoral Nerve Block
This technique may be used to assist splinting or movement of an injured during leg
extrication. A 3-cm 23-gauge needle will be sufficient for nonobese patients. The
nerve is frequently more superficial (1–1.5 cm deep) than is taught in some trauma
skill courses. As quick-onset analgesia is required, lignocaine is a suitable anaesthetic,
and bilateral blocks are permissible within the MSD.
First, identify the point of injection, using the surface landmarks. For the femoral
nerve, this is just below (distal to) the inguinal ligament. Palpate both the anterior
superior iliac spine and the pubic tubercle. The line between these two overlies the
inguinal ligament. It is often helpful to draw the lines that are described on the skin.
The femoral artery should lie at the midpoint of the inguinal ligament, and it is neces-
sary to locate this by feeling for the pulse at this point. The site for injection is 1 cm
lateral to (outside of) the pulsations of the femoral artery and 1–2 cm below (distal to)
the line of the inguinal ligament. After skin and subcutaneous tissue infiltration of
local anaesthetic agent, the needle is inserted aiming approximately 45° cranial. The
point of needle entry is just inferior to the inguinal crease. Two definite “pops” should
be felt when the needle penetrates first the fascia lata and then the iliaca fascia. It is
very important to penetrate both these layers of fascia, because the local anaesthetics
agent will not cross the fascia layer if deposited superficial to it. This is a common
mistake when performing femoral nerve blocks.
The local anaesthetic should be deposited in a fan-shaped distribution to accom-
modate the variable distances of the nerve lateral to the femoral artery.
Peripheral Hand Blocks for the Hand
Ring blocks of digits or single nerve blocks at the wrist or ankle may occasionally be
of value for individuals whose limbs are trapped in machinery. A digital block will
allow a finger operation or amputation of a mangled digit. Do not use adrenaline.
Hematoma Block for Reduction of Closed Fractures
This may be useful when dealing with large numbers of casualties. You should, how-
ever, be aware of the risks of converting a closed fracture to a potentially infected
fracture. How clean are your circumstances, how clean can you get the patient, is it
your only option, can you improve circumstances after postponing?
Intercostal Nerve Block
This technique can be used to treat pain from fractured ribs. The practical danger is
the risk of pneumothorax, and short small-gauge needles must be employed.
Remember to insert the needle onto the rib and then walk the needle down till it
slides under the rib insert 1/2 cm and inject 3–4 mL of local anaesthetic per rib. In this
location a lot of local anaesthetic is absorbed so extra attention should be given to the
MSD.
Preparation
1. Anaesthesia in the UK for doctors.
The Royal College of Anaesthetists, 48–49 Russell Square, London WC1B 4JY.
2. Training for anaesthetists in anaesthesia for difficult locations.
Courses run by the Departments of Anaesthesia at Frenchay Hospital, Bristol and the
Radcliffe Infirmary in Oxford.
3. The recommendation is for qualified medical and nursing staff, who are unfamil-
iar with pain management to arrange to spend time in a hospital postoperative
recovery unit.
Further Reading
British Medical Association and The Royal Pharmaceutical Society of Great Britain. British National
Formulary (BNF). Updated every 6 months.
Dobson MB. Anaesthesia in the district hospital. Geneva; World Health Organisation, 1988.
Eriksson E. Illustrated handbook in local anaesthesia. 2nd ed. Loudon: Lloyd-Luke. 1979.
Fenton PM, Africa anaesthesia, Malawi: Montford Press, 1993.
King M, editor. Primary anaesthesia, Oxford; Oxford University Press, 1986.
492 Section Five
Conclusion
In this multipart chapter, we have tried to cover the more important conditions likely
to be encountered during a deployment. A sense of realism has to be maintained. The
sheer diversity of volunteers in terms of their age, experience, and specialist field has
influenced the lay out and content. To reiterate, the chapter is an attempt to heighten
awareness and to act as a spur to further reading and study. A final word, field deploy-
ments in hostile environments are not places for the inexpert or inexperienced to
“give it a go.” If in doubt, always seek help – “first do no harm.”
Editor’s Note – See also the Resources Section at the end of this manual.
Trauma Life Support Training Courses:

Advanced Trauma Life Support (ATLS©) Courses – These courses are for physicians
working in an Emergency Room (ER) environment.
Pre-hospital Trauma Life Support Courses (PHTLS) – These courses are for
Paramedics working in the pre-hospital or field environment.
Battlefield Advanced Trauma Life Support Courses (BATLS©) – These courses, run
by many NATO countries, are for military medical officers deploying on humanitarian
and conflict missions.
Pre-hospital Emergency Care (PHEC) Course – A course combining training in
medical and trauma emergencies in the pre-hospital setting. For medical and non-
medically qualified personnel.
Advanced Trauma Nursing Course (ATNC) – Specifically for qualified nursing staff
engaged in trauma care.
There are a myriad of other advanced life support concerned with care of children,
burn victims, and care of the injury in pregnancy.
David G. Burris, Manolis Gavalas, Claire Walford
and Shautek Nazeer
● To heighten awareness of the range of conditions which

Objectives might be encountered
● To highlight risks to locals and expatriate care givers
● To discuss general principles of prevention and mitigation
● To discuss principles of recognition and management of
important conditions
Introduction
In the context of austere settings and after natural and man-made disasters, it is difficult
to draw a line between public health medicine and acute medical care. Thirst, starvation,
diarrhea, and communicable disease are all illnesses requiring management and are seen
as the responsibility of the acute care health professional as well as the public and
community health professional. This has lead to some overlap with other chapters and
sections in this manual. We see this as reinforcement, which allows, perhaps, an additional
viewpoint. This chapter attempts to deal with a wide array of medical problems in a wide
variety of conflict settings. It is intended to alert the care giver to the issues they may face
so they can prepare themselves.
To the experienced senior physician, seasoned by numerous deployments, it will be a
reminder and ready reference. The authors hope that readers of this manual who are
elective students in medicine and professions allied to medicine, junior doctors, nurses,
and a range of other health professionals will find these comments helpful. This chapter
is not an exhaustive treatise on medical therapeutics. Such specialist texts already exist
and are listed in the suggested reading section at the end of this chapter.
A variety of other impacting issues may confound and disrupt delivery of care and
need to be considered when reading this chapter. These include:
● The nature of the disaster – natural or manmade
● Climate – hot/cold – winter/summer
● Environment – urban or rural
● Infrastructure – intact/compromised/destroyed
● Political situation
● Transport and communications
494 Section Five
Medical Problems: Scope

Bearing in mind the sheer scale of potential medical problems, a structure or frame-
work is demanded. The following main headings are used:
● Mass gatherings
● Climate – hot and cold
● Preexisting disease
● Envenomation
● Miscellaneous
Mass Gathering
Mass gathering under normal circumstances is associated with large groups of
people gathering for sporting occasions or music festivals. The problems faced by
medical attendants in such gatherings are those associated with the disease and
illness profile of an otherwise healthy group. There may be anxieties concerning
trauma and mass casualties but communicable disease is rarely an issue. Mass
gathering due to displacement of individuals or groups following war or conflict is
a different matter.
This section is concerned with mass gatherings under conditions associated
with catastrophe and conflict. The medical conditions then are typically related to
overcrowding, inadequate water supply, deficient nutrition, poor sanitation,
adverse environments, and lack of shelter. The issues of water, nutrition, and
shelter will be dealt with in other chapters. This chapter will focus on the conditions
that will be more likely and need to be considered, planned for, and treated in these
conditions.
Many conditions are not specific to war or disaster and are encountered under
normal circumstances but become epidemic under conditions of mass gathering.
There is also a nonspecific group of conditions – acute diarrheal diseases are an obvi-
ous example. Other conditions are specific to certain geographic regions and climates
and while endemic under normal circumstances, become a problem both in terms of
numbers and severity in a mass gathering scenario: vector associated conditions such
as malaria or yellow fever are examples.
There are multiple classifications of the important conditions. Classification can be
by pathogenic agent, as is conventional in most medical texts, or by means of trans-
mission which is more appropriate in conflict and mass gathering settings. In this
chapter, conditions are classified according to means of transmission. The following
list gives a broad overview that emphasizes the principles. The provider will need to
anticipate the most likely conditions that will be encountered in the area where they
are to work, and broaden there study in those areas.
The World Health Organization (WHO) has published protocols for the treatment
of these conditions, as well as a suggested formulary of medications. In addition,
notices of expected diseases in various locations in the world are regularly updated.
These are available on “the web” at the references included at the end of the chapter.
Communicable Diseases Associated with Mass Gathering:

By Means of Transmission
1. Vector Transmission
● Malaria
● Yellow fever
● Typhus and related conditions
● Plague
● Human African Trypanosomiasis
● Schistosomiasis
● Onchocerciasis
2. Fecal Contamination
● Acute watery diarrhea (Vibrio cholera and related organisms)
● Acute bloody diarrhea (bacillary dysentery)
● Chronic diarrhea
● Amoebiasis and Giardiasis
● Enteric fevers (typhoid and related fevers)
● Viral hepatitis
● Ascariasis
● Hookworm disease
3. Air/droplet Transmission
● Measles
● Acute respiratory infections
● Tuberculosis
● Meningitis
4. Sexually Transmitted
● AIDS
● Syphilis
● Gonorrhea
5. Direct (contact) Transmission
● Scabies
● Impetigo
● Conjunctivitis
● Trachoma
● Fungal skin infections
Volunteer’s requirements in terms of depth of knowledge of the above conditions will
vary depending on training, qualifications, and assigned role. All of these conditions
are covered in depth in various texts, which are listed at the end of this chapter and in
the Resources Section. However, many of these conditions are of such importance that
they merit further discussion here. In discussing selected conditions, it is wise to
496 Section Five
remember that risks apply not only to the local community but also to volunteers in
whom the risks may be greater because of lack of prior exposure.
Vector Transmission
Malaria
Malaria is a vector borne disease. The vector is the female anopheline mosquito.
Disease results when an infected mosquito bites a human and injects malaria parasite
into the victims’ bloodstream. Four varieties of parasite give rise to disease in man:
● Plasmodium vivax
● Plasmodium falciparum
● Plasmodium ovale
● Plasmodium malariae
All present with fever, accompanied by headache, nausea, and muscular pains. These
paroxysms commence with chills, then shaking, followed by a febrile phase and end-
ing with drenching sweats, lasting in all about 10 h. The periodicity of paroxysms
varies with parasite type. In endemic areas, malaria must be considered by the sur-
geon when evaluating postoperative fevers. In vivax and ovale malaria, episodes occur
every 48 h. In malariae malarias, episodes occur every 72 h. Falciparum malaria has
no definite periodicity, and fevers may be continuous. Falciparum is also the most
dangerous type with the risk of complications and death. Established falciparum
malaria is a life threatening emergency demanding immediate management.
Chemotherapy will depend on local expert advice.
Malaria is a major health problem affecting refugee and displaced populations in
times of catastrophe and conflict. The disease is prevalent in tropical and subtropical
regions of the world. It is endemic throughout South and South-East Asia, Africa,
parts of the Middle East, and South and Central America. Epidemics may supervene
in endemic areas with the arrival of a displaced and vulnerable community.
The disease poses risks to refugees, internally displaced persons (IDPs), and aid
volunteers alike.
The best option is prevention which for the aid volunteer implies chemoprophylaxis
prior to deployment and use of repellents and nets in country. The regimen used will
depend on the area of deployment, prevalent parasites, and the level of resistance.
Expert advice must be sought. Mass prophylaxis for vulnerable communities is more
contentious. Programmes are expensive, difficult to implement and monitor, and may
result in adverse drug side effects and the emergence of resistant parasites. The deci-
sion to provide chemoprophylaxis for a particularly high risk group (for example
pregnant women at risk from drug resistant falciparum malaria) should be made at a
high level by aid officials well versed in managing the condition.
Whatever your role you should understand the principles underpinning preven-
tion. Predeployment prophylaxis has been discussed. The other measures are:
● Avoidance of proximity to water sources
● Application of larvacides to vital water sources
● Periodic residual insecticide spraying – check local guidelines

● Use of impregnated mosquito nets over sleeping accommodation
● Wearing long sleeved trousers and shirts at dusk and dawn.
Management of established malaria will depend on parasite species, severity of ill-
ness, risk factors (children, pregnancy, or the presence of P. falciparum are some
examples), local drug resistance, and available resources. There is no standard treat-
ment for malaria. Growing resistance and adverse drug reactions complicate matters.
Expert advice must be obtained before deployment.
Yellow Fever
This disease and a wide variety of related conditions are caused by Arboviruses
(arthropod-borne viruses). Yellow fever is fully preventable by vaccination, which
should be mandatory for expatriates traveling to at risk areas. Related diseases include
Marburg disease, Lassa fever, Ebola disease, Rift Valley fever, and Dengue fever.
You must check if any of these diseases are prevalent in your deployment area. If so,
take expert advice.
Epidemic Yellow fever occurs when the Aedes aegypti mosquito with an urban
breeding cycle transmits the virus to humans. The disease is characterized by fever,
jaundice, and a bleeding diathesis, which may cause fatal hemorrhage.
Confirmation of the disease requires serological testing. Management is by case
isolation, and symptomatic treatment of symptoms since no specific therapy is avail-
able (Lassa fever excepted). Prevention requires good vector control and immuniza-
tion if that is feasible.
Typhus and Related Conditions

These conditions are important vector borne diseases. They include are a range of
diseases caused by the Rickettsial group of microorganisms. Disease is transmitted by
lice, ticks, mites, and fleas. Displaced populations associated with overcrowding and
poor personal and community hygiene are particularly at risk. The diseases are
under-diagnosed and under-reported.
Louse borne typhus is the most important as it may occur as an explosive epidemic
in vulnerable communities. Severity varies, with case fatality rates from 10 to 50%.
The main reservoir of the disease is the convalescent typhus patient.
The classical features of the disease group are:
● An incubation period of 3–14 days
● Sudden onset of malaise, myalgia, headache, fever, and chills.
● Vomiting with diarrhea or constipation
● A maculopapular rash which may become confluent
● Photophobia
● Generalized lymphadenopathy and splenomegaly common
● Circulatory collapse and death in severe cases.
Diagnosis in early cases must be confirmed by serological techniques. Thereafter, a
clinical diagnosis may be made. Treatment is with antibiotics. Rickettsiae are very
498 Section Five
sensitive to tetracyclines and chloramphenicol. Doxycycline in a single dose is the

recommended regimen.
Prevention is by vector control and improving sanitation and personal living condi-
tions. In a risk setting, a surveillance programme aimed at monitoring lice infestation
is recommended.
Plague
In plague, the infecting organism is Yersinia pestis, which primarily affects wild
rodents and their fleas. Plague is transmitted to humans through flea bites.
There are three clinical varieties:
● Bubonic – marked by fever, and painful lymphadenopathy (bubos), which may
suppurate. Bubonic plague is the most common form, with a case fatality rate in
the region of 50%.
● Pneumonic – marked by extensive pneumonitis and mediastinitis, either alone or
with bubonic disease. This variant is highly contagious and lethal with a case
mortality approaching 100% if untreated.
Septicaemic – usually a progression from the varities above. This is rapidly fatal if
untreated.
Diagnosis and early treatment is vital. Serology and culture of the organism is needed
initially to confirm the diagnosis, thereafter, clinical diagnosis is acceptable. Blood culture
and gram stain identification may be used in a resource constrained environment.
Treatment demands isolation of pneumonic plague victims and administration of
either a tetracycline or chloramphenicol. In the presence of an epidemic, all expatriate
and other aid staff should receive prophylaxis.
Preventive measures include vector control, control of rodents, and education of
those at risk.
Human African Trypansomiasis

The incidence of this disease, also known as Sleeping Sickness, is rising sharply as a
consequence of war and conflict displacing communities into susceptible areas in
sub-Saharan Africa. The disease is caused by a parasite of the Trypansoma brucei
group. There are two clinically important species, Tb gambiense and Tb rhodesiense.
Transmission to man is by the bite of an infected tsetse fly. The condition is lethal if
untreated. The clinical picture is one of a progressive meningitis and encephalopathy
leading to dementia and inevitably ends in death if untreated.
The condition should be suspected if a vulnerable group arrives in an infected area.
Confirmation of the disease is by serological testing and the detection of the parasite
in blood, lymph nodes, or cerebro-spinal fluid.
Treatment should be only be commenced once the diagnosis is confirmed. It relies
on the administration of a range of expensive and toxic agents such as suramin, pen-
tamidine, and oral eflornithine. The decision regarding choice of therapy is an expert
one and advice must be sought in advance.
Preventive measures include education of the population at risk and control of the
tsetse fly.
Fecal Contamination
Acute Watery Diarrhea
Acute watery diarrhea is an increasing public health problem in developing countries
and among displaced communities. It is hard to overstate the importance of diarrhea as
a major cause of morbidity and death. The annual death toll from diarrhea of all
etiologies is 4,000,000 children under the age of 5 with 80% being under the age of 2.
Poor water and sanitation, overcrowding, and malnutrition are invariable
precipitating factors and these circumstances are best exemplified in refugee camps
and in areas where displaced people assemble. Figures quoted by the ICRC indicate
that diarrheal diseases account for up to 40% of all medical consultations among
displaced people.
Acute watery diarrhea is caused by a wide spectrum of organisms with Vibrio cholera
heading the list. The following organisms have all been implicated:
● Vibrio cholera
● Vibrio parahaemolyticus
● Non-typhoid Salmonellae
● Escherichia coli, enterotoxigenic (ETEC) and enteropathogenic (EPEC)
● Clostridium perfringens
● Crytosporidium parvum
● Rotavirus
● Enteric adenoviruses
NB Falciparum malaria may present with acute watery diarrhea.
Cholera
Cholera is a disease of poverty and malnutrition and is a constant threat in refugee
camps and among displaced communities, particularly if the community passes
through or settles in a cholera endemic area.
Clinical features – All age groups are susceptible. Infection results from ingestion of
contaminated food or water. The majority of patients have a mild, self-limiting dis-
ease, or are completely asymptomatic. In symptomatic cases, there is an acute onset
of watery diarrhea. The classic description is of “rice water stools” – white diarrhea
flecked with mucus. Fever may be a presenting feature in children. Mortality is vari-
able and is highest in locations where hygiene is poor and no trained personnel are
available to manage the outbreak. Mortality rates, or more accurately, case fatality
rates (CFR) in the last decade have varied between 2 and 25%. Good management
should result in CFR below 2%. In fatal cases, death results from profound dehydra-
tion, metabolic acidosis, and renal failure. Dehydration may be so severe as to cause
uncompensated hypovolaemic shock and death within hours.
500 Section Five
Managing an outbreak – The first aspect of management is preparation. Plans

should be in hand for populations at risk and should include systems for:
● Early detection and agreement on case definition
● Agreed protocols for case management
● Establishment of cholera treatment units with standardized equipment
● Measures to improve personal and food hygiene
● Health education
Case Definition
“any patient developing a rapid onset of severe watery diarrhea resulting in severe
dehydration”
Case management – The corner stone of management is oral rehydration with glucose-
electrolyte solution and this usually suffices in up to 80% of cases. There are established
preprepared solutions for mixing. When the standard solutions are unavailable, other
local fluids may be used, if verified as noncontaminated. “Home-made” solutions should
be made with attention to clean water and hygienic preparation. Such solutions
approximate 8 teaspoonfuls of sugar and one of salt in a liter of water. In shocked
patients, intravenous therapy is needed. One to two liters of WHO intravenous diarrhea
treatment solution or Ringer lactate solution should be infused rapidly and further
boluses given according to clinical findings. In austere circumstances, a return of a
strong, easily palpable radial pulse indicates a good response to therapy. The initial
bolus in children can be calculated by the formula 20 mL/kg/body weight. Boluses can
be repeated until clinical improvement is observed. Vascular access in children may be
difficult and the inter-osseous route may have to be used.
WHO recommends a single dosage of doxycyline (30 mgs/kg) for adults. For children
take expert advice
Prevention and control – Vaccination, even with current inactivated vaccines is not
recommended for displaced communities. The reasons are ineffectiveness, cost, and
logistic difficulties. The best control/preventive measures are health education, sur-
veillance, and preparedness.
Afternote – While cholera is a discrete disease, it is in most ways similar to other
watery diarrheal disease and management is much the same for all.
Enterotoxigenic E. coli (ETEC)

This is the organism usually associated with Traveler’s diarrhea. It is also a common
cause of acute watery diarrhea in children. Rarely a cause of severe illness, manage-
ment is with oral rehydration salt solution.
Enteropathogenic E. coli (EPEC)

A cause of watery diarrhea in children aged 6–18 in the tropics. Treatment is as
described for other causes of acute watery diarrhea.
Non-Typhoid Salmonellae
These organisms may also result in acute watery diarrhea in children and adults.
Primary spread to man is from contaminated food – secondary spread follows the
usual fecal-oral route. A chronic carrier state can occur. The disease may progress to
involve the colon resulting in the onset of bloody diarrhea.
The following organisms have been implicated

Shigella dysenteria, flexneri, boydii, and sonnei
Entero-invasive E. coli (EIEC)
Entero hemorrhagic E. coli (EHEC)
Entamoeba histolytica
Salmonellosis
Campylobacter jejeni
Yersinia enterocolitis
Acute Bloody Diarrhea (Dysentery)

Acute bloody diarrhea or dysentery differs from acute watery diarrhea in a number
of important ways. Watery diarrhea is associated with enterotoxin-induced diarrhea,
whereas dysentery is associated with an inflammatory colitis following bacterial
invasion of the colonic epithelium and, in some cases, the production of cyto toxin
causing epithelial cell death. The result is bloody diarrhea.
In the context of displaced communities Shigella dysenteriae Type 1 is the most
virulent and in addition to colonic invasion produces a powerful cytotoxin. As with
so many lethal communicable diseases, it flourishes in a climate of poverty, over-
crowding, poor hygiene, inadequate water, and malnutrition.
Clinical features – The classic feature of dysentery is blood in the stool, but this may
take some time to develop. The condition typically presents with fever, lassitude, and
onset of watery diarrhea. Following colonic wall invasion, visible blood appears in the
stool. Anorexia, vomiting, and abdominal pain are common features. The disease is
highly contagious and requires a low infecting dose to cause clinical disease. Attack
rates vary from 5 to over 30% with case fatality rates (CFRs) fluctuating between 2 and
20%. Low rates are associated with good epidemic management – the higher rates are
associated with inadequate or no treatment. All age groups are susceptible but chil-
dren and vulnerable groups are particularly at risk. The disease has a “sting in the
tail.” Anorexia, coupled to a protein loss diarrhea, results in the early onset of malnu-
trition. In displaced communities, many will be malnourished for other reasons.
Dysentery may then lead to overt protein energy malnutrition. Dysentery is thus
inextricably linked to malnutrition among displaced and vulnerable populations.
Management of an outbreak – The advice given for acute watery diarrhea outbreaks
also holds good for dysentery. Case definition is different. A suggested definition is:
“any case of diarrhea with visible blood in the stools.” An outbreak of epidemic pro-
portions should be suspected if:
502 Section Five
● There is a sudden and consistent rise in number of new cases.

● An increased number of deaths from bloody diarrhea are reported.
● There is an increase in the proportion of cases of bloody diarrhea compared with
overall diarrhea cases
Bacteriological proof of an outbreak is vitally important but can be difficult due to the
fragility of the organism. Multiple media may have to be used. Expert advice should
be sought.
Case management – If possible, cases should be managed in hospital where consid-
erable control can be exerted. Oral rehydration therapy is used but dehydration is
usually severe. Adequate nutrition is essential and is another reason for hospital treat-
ment if this is feasible. The use of antibiotics is fraught with difficulty – resistant
strains are emerging and more and more antibiotic regimens are now useless. Expert
local advice is needed before embarking on mass use of antibiotics.
Prevention and control – The most effective measures are hand washing, adequate
disposal of feces, and care in food preparation.
Amoebiasis
Amoebiasis is a protozoal disease afflicting displaced and impoverished communi-
ties. It is caused by the protozoon Entamoeba histolytica. Infection follows the inges-
tion of cysts, passed in the stools of carriers, which contaminate food or water. Person
to person spread also occurs.
The disease presents with nausea, colicky abdominal pain, and bloody diarrhea,
which can lead to an incorrect diagnosis of Shigella dysentery. Conversely, cysts of
E. histolytica may be found while investigating an outbreak but may be an incidental
finding. The disease is characterized by remissions and exacerbations and may lead
ultimately to bowel perforation or hemorrhage. Amoebic abscesses may form in the
liver and brain. Investigation is complex and beyond the scope of this handbook.
Readers are referred to the reading list for detailed information. The condition should
be remembered as a cause of dysentery, and it may be appropriate to treat the condi-
tion pragmatically. The condition responds well to metronidazole. Alcohol should be
avoided when using this agent.
Enteric Fever
Enteric or typhoid fever is endemic worldwide and is a particular hazard for dis-
placed and vulnerable communities. It is caused by the following bacteria:
● Salmonella typhi
● Salmonella paratyphi A
● Salmonella paratyphi B
The organisms are transmitted to man by ingestion of food or water contaminated by
the feces or urine of infected patients or asymptomatic carriers. Healthy carriers con-
tribute significantly to the spread of the disease, especially if they are employed in
food preparation. Most cases are mild and never reported.
Clinical features – After infection, bacteraemia occurs and is followed by coloniza-

tion of the small intestine leading to enteritis, which manifests itself as a diarrheal
illness. Patients have fever, chills, headache, meningismus, and lassitude. A relative
bradycardia (lower than expected pulse rate) is described. A typical rash, described as
“rose spots” and affecting the trunk, appears after several days. A variety of psychiat-
ric and neurological signs have been described but are inconsistent. This, coupled
with under reporting of mild cases, makes case definition difficult.
Management – Suspected cases require serological confirmation or the identifica-
tion of organisms in blood or bone marrow. After the first week, organisms maybe
cultured from stool and urine. The presence of a leukopenia (low white cell count) is
supportive. Case treatment requires antibiotics but local expert advice on drug resist-
ance should be obtained.
Prevention and Control – There are no easy solutions. As with all communicable
diseases, great care must be taken regarding group and personal hygiene, storage and
use of water, and food preparation. Aid volunteers should be vaccinated but this is not
practical for entire displaced and at risk communities. Personnel involved in food
preparation may need screening and vaccination to prevent outbreaks under high
risk conditions.
Viral Hepatitis
Viral hepatitis is a worldwide infection posing health risks to displaced and impover-
ished communities, and to expatriate volunteers. Viral hepatitis incorporates several
distinct diseases.
Hepatitsis A (HAV) – Infection is caused by ingestion of water or food contaminated
by feces containing the virus. It is usually a mild self-limiting disease. Vaccination
is recommended for expatriate volunteers only. The disease is best prevented
by health education aimed at safe and secure water and food supply and by good
sanitation.
Hepatitis B (HBV) – This disease has a very different epidemiology. Transmission
is parenteral, sexual, and feto-maternal. There is some evidence that fecal-oral trans-
mission is possible. Vulnerable communities are at risk. Routes of transmission may
be perinatal, related to sexual activity, from contaminated blood transfusion or nee-
dles. Aid volunteers are at risk from needle stick incidents, unprotected sexual con-
tact, and occasionally from intravenous drug use. The disease is characterized by
chronicity, which may lead to cirrhosis and hepatocellular carcinoma of liver. There is
no specific therapy. Vaccination is mandatory for all health care workers. Immunization
is also recommended for infants in endemic areas.
Hepatitis C (HCV) – This is similar to hepatitis B in many respects. It is usually
transmitted by contaminated transfusion. There is no vaccine against HCV. Chronic
active HCV disease can be treated with alpha-interferon.
Hepatitis D (HDV) – Similar to, and transmitted with HBV. Combined B and D
infections are particularly prone to chronicity, cirrhosis, and liver cancer.
Hepatitis E (HEV) – Similar to HAV but poses a particular risk of fulminating hepa-
titis in pregnant women.
504 Section Five
Worm Infestations
Infestation by worms or Helminthiases is a worldwide problem but is of particular
significance for displaced and vulnerable communities. Many are asymptomatic or
cause minimal signs and symptoms. The purpose here is to provide a classification and
to highlight the few conditions of clinical significance to displaced communities.
Classification
Roundworm disease
– Ascariasis
– Hookworm disease
– Strongylodiasis
– Trichnosis
– Trichuriasis
Tapeworm disease
– Taenia saginata
– Taenia solium
– Echinoccus granulosus
Trematode faltworms and Flukes
– Schistosomiasis
– Liver Fluke disease
– Lung Fluke disease
– Intestinal Fluke disease
Filariasis and Onchocerciasis
– Lymphatic filariasis
– Loiasis
– Mansonella perstans
– Mansonella streptocera
– Onchocerciasis
– Dracunculiasis
It is worth elaborating on two important conditions:
Schistosomiasis
This disease, also called as Bilharziasis, is of increasing importance to displaced com-
munities and is being increasingly reported. The disease is caused by three varieties
of trematode flatworm, which, depending upon variety, cause liver, gastrointestinal, or
bladder disease. Spread of the disease requires a water source and an appropriate snail
to act as intermediate host to motile larvae, which subsequently, as motile cercarial
larvae, penetrate the skin of humans paddling in contaminated water. Volunteers as
well as displaced people are at risk. Prevention is by health education and locating
camps away from high risk areas. Water can be treated to destroy the eggs and larvae.
Effective treatment is now available but expert advice should be sought locally.
Drancunculiasis
This condition, also known as dracontiasis, is caused by the Guinea worm (Dracunculus
medinensis). It is exclusive to man. Infection occurs by ingestion of water containing
the water flea Cyclops containing Guinea worm larvae. Mature female worms later
migrate to skin overlying the legs and feet. Skin ulceration occurs with the tail of the
worm protruding through the skin. Immersion in water results in the exposed female
worm releasing larvae – thus the cycle continues.
It is a disease of refugees and displaced people in North, West, and East Africa, and
parts of the Middle and Far East. Ulceration and abscesses at multiple sites over the feet
and lower legs cause pain and disability. Treatment is by the age old method of removal,
namely by rolling the worm on a stick taking care not to break it as it is gradually
withdrawn through the skin. Prevention is best achieved by health education, boiling or
filtering drinking water, and using insecticide to eradicate the Guinea worm.
Air/Droplet Transmission
Measles
Measles is one of the great “Captains of Death” affecting refugees and displaced chil-
dren. Large scale epidemics among displaced and vulnerable communities have
caused millions of childhood deaths, particularly among the youngest, weakest, and
most malnourished. MSF lists measles as number two in its top ten priorities for
intervention in the acute phase of a relief programme.
A mass vaccination programme for children aged 6 months to 15 years is an abso-
lute priority during the first week. Detail on surveillance, immunization programmes,
case management, and prevention can be found in the selected reading list at then end
of this chapter.
Influenza
This world wide disease is important for refugees and displaced communities because
of the complications of the condition among the weak and vulnerable. Death is usu-
ally due to secondary bacterial chest infections. It is under reported but should be
considered if there is an outbreak of fevers of unknown origin leading to severe res-
piratory infections in vulnerable groups. There is promise of a cheap and universal
vaccine for the future.
Pertussis (Whooping cough)

Whooping cough is a leading cause of death in nonimmunized and vulnerable popu-
lations. It tends to present after an interval in well-established camps. In at-risk popu-
lations whooping cough can be prevented by immunization as part of an Expanded
Programme on Immunization (EPI) activity in the post emergency phase.
506 Section Five
Tuberculosis
This disease is a major public health problem in developing countries, and among
refugees and displaced people. The annual incidence of new cases of all forms of the
disease is between 7 and 10 million cases. It is estimated that the tubercle bacillus
infects one third of the world’s population and kills 2.5 million people every year.
Establishing and managing tuberculosis is a task for specialist NGOs and pro-
grammes are usually not established until after the acute emergency phase has been
completed.
From an expatriate health worker’s point of view, there are a number of key points:
● Protect yourself – check your BCG status before departure
● Be aware of the association between HIV and tuberculosis
● BCG vaccination should be part of the Expanded Programme of Immunizations
for refugees and displaced communities
Meningitis
Acute bacterial meningitis, caused by Neisseria meningitids, is endemic in parts of the
world associated with concentrations of refugees and displaced communities. The
disease thrives where there is overcrowding and poor sanitation and, not surprisingly,
large outbreaks and epidemics are frequent in refugee and IDP camps. Case fatality
rates in untreated cases reach 70%, so surveillance and early detection and treatment
are vital. Expatriate health workers working in high risk areas, or where an outbreak
is anticipated, should be vaccinated. The decision to vaccinate a community is difficult
and demands expert consultation. Current vaccines do not cover all serogroups, there
are logistic constraints, and protection is short lived. Treatment of established cases is
with a single IM dose of long acting chloramphenicol.
Sexually Transmitted Disease

HIV-AIDS
Transmission of HIV and subsequent development of AIDS is fraught with ethical,
legal, and moral difficulties at the best of times, but even more so when present
among refugee and displaced communities. These problems are beyond the scope of
this chapter. The emphasis here is protection of the expatriate and local health work-
ers. Workers should understand the main avenues of viral transmission. These are:
● Sexual intercourse
● Transfusion of contaminated blood
● Injection with contaminated needles
● Mother to child transmission
Prevention of infection is achieved by adopting safe practice in each of the above
areas. Management of AIDS patients is a specialized subject and readers are directed
to specialized publication on the topic and to the Resources Section at the end of this
Handbook.
Climate: Hot and Cold

Heat and cold-related illness is a potential hazard faced by both indigenous victims and
expatriate volunteers. However, the expatriate is likely to be more at hazard because of lack
of acclimatization. Illness rates even among acclimatized victims may be severe if there
has been loss of shelter. The preexisting ill, the young and the old are particularly at risk.
Heat Injury
A number of syndromes or conditions are recognized. These range from the benign
to the potentially lethal. Note that core temperature varies in a healthy individual.
Normal ranges are:
● At rest: 36.5–37.5°C
● During exercise: 36.5–38.5°C
The common conditions are:
Dehydration – This may affect displaced and exposed individuals or communities
who have limited or no access to drinking water. It may also affect expatriate volun-
teers engaged in vigorous (and unfamiliar) physical effort. Severity is related to extent
of body weight lost. The following is a good guide:
● 2% loss – severe thirst
● 2–5% loss – severe thirst, anorexia, headaches, and altered conscious level
● 5–10% – all of the above, plus dyspnea, cyanosis, and neurological signs
● >10% – the above plus visual disturbances and uncontrolled rise in core tempera-
ture (see heat exhaustion and heat stroke below)
Weight loss of 10% or greater signifies an immediate threat to life. As a general rule,
losses above 5% are best treated by intravenous fluids (interosseous access may be
best in babies and children <6 years). The initial bolus in an otherwise healthy adult
is 2 L of isotonic crystalloid. In a child, the initial volume is calculated by the formula
−20 mL/kg/body weight. These are initial challenges and may be repeated. Urinary
output is an excellent guide to clinical response. An output of greater than 30 mL/h in
the adult indicates effective volume replacement.
Sunburn – This is caused by excessive exposure to sunlight. Expatriate volunteers
should ensure liberal use of UV blocking creams and should avoid prolonged expo-
sure. Displaced people without shelter are vulnerable, with infants and small children
being particularly at risk. Prolonged exposure may lead to heat stroke. Management
is by protection under cover, nonadherent dressings to blistered areas, oral rehydra-
tion, and simple analgesics.
Heat cramp – The mildest in a range of hyperthermic conditions. This typically
occurs in a nonacclimatized individual engaging in vigorous physical activity. The
508 Section Five
characteristic muscle cramps are caused by a combination of salt and water

depletion.
Treatment is with oral fluids if tolerated. If vomiting is a symptom, replacement by
the intravenous route may be required.
Heat faint – Also known as heat syncope. It is associated with prolonged vigorous
exercise in a nonacclimatized expatriate volunteer. It is a more severe variant of heat
cramp. Dehydration and widespread peripheral vasodilation are major features.
Management is by resting in a shaded place and fluid replacement by oral or
intravenous routes.
Heat edema – Similar to the above conditions but with dependant oedema in addi-
tion. Associated with heavy manual labor and prolonged standing. Treatment is by
rest and elevation of affected limbs, in addition to the measures outlined above.
Heat exhaustation – A potentially lethal condition and a more severe variant of the
above. In addition to hypotension and fainting, there is an alteration in conscious level
and severe headache. This condition requires immediate management consisting of:
● Cessation of all physical activity
● Removal to a cool place
● Tepid sponging and fanning
● Intravenous fluid resuscitation using an isotonic solution until clinical improvement
Heat stroke – This is the most severe and immediately life threatening hyperther-
mic syndrome. It usually follows a failure to recognize the onset of less severe hyper-
thermic conditions. It includes all of the events outlined above plus a rapid rise in core
temperature and a failure to loose heat. At 41°C, organ failure commences. If untreated,
changes become irreversible and convulsions leading to coma follow. If suspected,
central temperature must be recorded using the rectal or esophageal route.
Prevention is better than cure. The following is advised:
● Avoidance of hard physical labor until acclimatized
● Appropriate clothing
● Head cover
● Drinking plenty before and during heavy manual labor
● Liberal use of sun screen creams
Central to effective management is rapid cooling. The following approach should be
adopted:
● Tepid bathing, but avoiding ice cold fluid, which results in vasoconstriction limit-
ing heat loss.
● Evaporative cooling of moistened skin by fanning. The skin must be moistened to
achieve heat loss.
● Administration of oral rehydration salts if tolerated.
● Administration of 1–2 L of electrolyte solution IV over one hour in an adult. In a
child, 20–40 mL/kg/body weight is used as a guide to volumes required.
Cooling should be stopped when rectal temperature falls to 38.5°C to avoid overshoot
and resultant hypothermia. A benzodiazepine administered intravenously or rectally
may be required to control convulsions.
In a catastrophe or conflict setting, it is unlikely that advanced laboratory or critical

facilities will be available and treatment must be based on clinical observation. Rapid
lowering of core temperature, rehydration with resulting improved urinary output,
and good control of convulsions are the keys to survival.
A final note. It is often the young, enthusiastic, and very fit expatriate who succumbs
to heat illness.
Cold Injury
Cold injury poses a particular problem for displaced communities in war and disas-
ters. Even in warm climates, it is often very cold after dusk. The risk factors may
include any or all of the following:
● Lack of shelter
● Inadequate clothing
● Presence of vulnerable groups (children and elderly)
● Open wounds
Classification
Local Injury – Three variants of local injury may be seen:
● Frostnip
● Frostbite
● Immersion (non-reezing) injury
Frostnip – the mildest form of injury characterized by pain, pallor, and numbness
of the affected part (fingers, toes, nose, and ears). If recognized before progression to
frostsbite, it is easy to treat by rewarming. Frostnip injury does appear to predispose
to subsequent injury.
Frostbite – This condition results from freezing of tissues with intracellular ice
crystal formation. The extent varies from superficial through partial skin thickness
injury to deep injury involving muscle and bone and can be graded in degrees of
injury similar to burn classification. The condition is characterized by hyperaemia,
edema, and vesicle formation in superficial injury to frank necrosis in deep injury.
Urgent management is needed either to prevent necrosis and gangrene or to limit its
extent. Rewarming is the key element in treatment but should not be undertaken if
refreezing is likely. If possible the injured part should be placed in warm circulating
water at 40°C until the part turns pink and reperfuses. Treatment may be painful
requiring analgesia. Following rewarming, the injured parts remain vulnerable and
need to be protected. Antibiotics should only be used if clinical signs of infection are
evident. It may take several weeks to determine the extent of tissue loss so early surgi-
cal intervention should be avoided. If refreezing is possible, the frozen part should be
left frozen until definitive rewarming can take place.
510 Section Five
Immersion Injury – This is nonfreezing variant of cold injury usually seen in vic-
tims who have had prolonged exposure to wet conditions in temperatures just above
freezing. It was endemic among soldiers during the Falkland Islands War in 1982. It
typically effects the feet but may affect hands. Injury tends to more superficial than
frostbite. The appearance varies from widespread superficial necrosis to an intensely
painful hyperaemia. Management is by gentle rewarming in circulating warm water
at 40°C and by protecting the injured part from further injury and infection.
Systemic Injury – The most clinically important condition is systemic hypothermia,
which may be life threatening. Accurate diagnosis requires measurement of core body
temperature using special thermometers capable of measuring low temperatures.
Health care workers in war and disaster settings may not have access to such equip-
ment and will have to use clinical judgement.
By convention the condition is classified as mild, moderate, or severe.
● Mild: 35–32°C
● Moderate: 32–30°C
● Severe: Below 30°C
Recognition – Awareness and a high index of suspicion is essential. Displaced com-
munities with many elderly, young, ill, and injured among their number are particu-
larly vulnerable. Provision of shelter and some form of energy source for heat is vital.
Key physical signs include:
● A drop in core temperature (low reading thermometer)
● Altered level of consciousness
● Cold peripheries (cold to touch)
● A grey appearance with central cyanosis (a blueness around the lips and in the
nail beds)
Alterations in vital signs such as pulse rate, respiratory rate, and blood pressure are
not helpful except in patients close to death.
Management – The best management is prevention by provision of shelter and heat.
Where the condition is suspected or proven by core temperature recording the follow-
ing steps are recommended:
● Removal from the cold environment
● Removal of wet, cold clothing, and covering in warm blankets or dry clothing
● Administration of high flow oxygen if available
● Cardiac monitoring if possible
Regular reassessment is essential. If the patient is improving, they should be protected
from exposure and given hot fluids and drinks. If there is no improvement, consider
administration of warm (body temperature) intravenous fluids – ideally an isotonic
electrolyte solution. Volumes administered will be determined by age and preexisting
disease. However, in a healthy adult, 2 L of warmed electrolyte is recommended. In a child,
a dose of 20 mL/kg body weight as an initial bolus and then repeated is a safe approach.
Under austere conditions, it is unlikely that anything further will be possible.
Techniques such as active core rewarming and the use of anti-arrhythmic agents
require a critical care environment.
Preexisting Disease
A displaced community reflects society in general and consequently preexisting, uni-
versal illnesses may be expected to be present. Further, some of these universal condi-
tions or illnesses are likely be more prevalent and severe because of general
vulnerability. These universal conditions cover the whole spectrum of disease. The
more important are listed.
● Upper and lower respiratory tract infections
● Nonspecific gastrointestinal tract infections, including inflammatory bowel disease
● Peptic ulcer disease
● Hepato biliary disease
● Peripheral vascular disease
● Cardiac illnesses including angina, congestive cardiac failure, and congenital
heart conditions
● Endocrine conditions, including diabetes mellitus
● All forms of malignancies (cancer)
The difficulty in the emergency phase is that patients with these preexisting and often
chronic diseases often pose insurmountable problems for carers. The emergency phase
is rightly focused on driving down overall mortality with attention to initial assessment,
provision of shelter food and water, and control of lethal communicable disease.
Inexperienced volunteers are often horrified at the apparent lack of attention given to
patients with preexisting disease. Lack of means to manage such patients in the
aftermath of a crisis or disaster may mean that no other approach is possible. Many will
be on complex drug regimens or require sophisticated investigation and monitoring of
their conditions. In other cases, in less well-developed societies, these conditions will
have been neglected prior to the crisis because of the absence of any form of health care.
Thus patients will present with florid and advanced disease, not seen in developed
practice outside the pages of a nineteenth century textbook of pathology. Even with the
transition to development at a later stage, it may be impossible to provide an adequate
service for many universal conditions, particularly those on longterm treatment
regimens – a sense of realism, coupled with compassion must prevail.
General Approach
This topic is covered superbly by Dr. Pierre Perrin in his “Handbook on War and
Public Health” listed in the Resources Section. Although the initial medical manage-
ment impetus is to treat life threatening conditions related to the crisis, establishment
of a long-term health-care facility is a priority.
Establishment of a “Chain of Care”

This concept of a “Chain of Care” works on the principle that a normal standard of
care, provided by health professionals, is not possible. It recognizes too that accessible
512 Section Five
facilities may not exist within striking distance of the crisis area. Care is provided at
various levels or echelons, described as primary, secondary, or tertiary. This has a
distinct relationship to military levels of care in war.
Primary Level – Provided by nonprofessional carers or community health workers.
These may include traditional healers utilizing traditional remedies, do not dismiss
this approach, it may have as much validity as so-called Western medicine. At this
level, therapies such as basic wound management, oral rehydration, and psychosocial
interventions should be encouraged. Primary facilities may be located in a health
room or within the affected community.
Secondary Level – The size, complexity, and staffing will vary depending on circum-
stances. The principle here is that care is provided by a health care professional.
Equipment scales for these facilities have been recommended by such organizations
as MSF and WHO – (see reading list in Resources Section).
Tertiary Level – This is care within hospital facilities, often located some distance
from the affected area. Within an affected area, it is rare to find total destruction of all
medical facilities, including hospitals. The need is to identify what remains and to
liase. Large organizations such as the ICRC have particular skills in taking over or
assisting in the functioning of affected hospitals. The Leonard Cheshire Centre for
Conflict Recovery, for example, has developed a “Fast Track” referral programme to
match refugees and IDPs to still functioning hospitals. A general rule concerning
Tertiary Level care is that it should take place within the borders of the affected area,
should, if possible, be provided by local medical staff and should be in keeping with
predisaster care for that region.
Access to Highly Specialized Care

One of the features of conflict and catastrophes is the breakdown of the more special-
ized and expensive care regimens. This particularly applies to cancer therapy pro-
grammes, renal dialysis services, and transplant programmes. Health care volunteers
must be careful not to make rash promises, for example, by referring patients to hos-
pitals for initiation or continuation of chemo or radiotherapy for cancers when facili-
ties no longer exist. WHO advice in these settings is to concentrate on palliative care,
particularly pain control.
Bites and Stings

Steve Bland
Introduction
The burden of health for cases following bites and stings, including envenomations
and rabies, involves greater than 200,000 deaths per year worldwide. Unlike some of the
illnesses with a greater burden of health on the global population (TB, malaria, and
HIV), there are treatments and prophylaxis with nearly 100% efficacy. However, with
poor medical infrastructures in the developing world and delays in presentation, many
of these avoidable deaths are not prevented. The incidence of lethal bites and stings
may also be under reported due to the lack of access to medical facilities and health
registries. Animal bites also have a significant nonlethal morbidity including deformity,
organ dysfunction, and chronic pain (Source: World Health Organization).
The effect of a bite or sting from any animal may have an adverse effect on human
health for a number of reasons:
● Mechanical trauma – Any bite usually requires some form of physical energy to
penetrate the skin. This energy may cause a range of injuries from minor irrita-
tion to major trauma and loss of function and even death (sting ray/dog bite).
● Envenomation – Some animal bites or stings contain potent biological toxins
(venom) that act in a number of ways to cause pain and/or death. The venom may
be for predation or for use as a defensive mechanism. Toxins within some arach-
nid species’ saliva or injected venom assist in early digestion of food but cause
local necrosis in humans.
● Zoonotic infections – Examples of zoonotic infections spread to humans from
animal bites with significant health implications include malaria, rabies, and
leishmaniasis.
● Opportunistic infections – Any penetration of the skin may allow for the inocula-
tion or introduction of bacteria into the wound. The probability of secondary
infection varies with each species. Secondary infection from snake fang penetra-
tion is relatively rare compared with bites from some mammal species.
● Hypersensitivity reactions – Most venom components are peptides and proteins.
They will, therefore, have the potential to cause immunological sensitization and
hypersensitivity reactions. The severity of these reactions may vary between indi-
vidual humans and are independent to the toxicity of the venom, not following a
dose/response relationship. A common example within the United Kingdom is the
hypersensitivity of individuals to arthropod stings such as the honeybee.
This chapter will concentrate on the toxic effects of envenomation.
Snake Bites
About 15% of snake species are venomous. There are two major families of snakes,
Elapidae (cobra, mamba, kraits, coral snakes) and Viperidae (vipers). There is a sub-
family of the viper, the Crotalinae (pit vipers, such as the rattlesnakes, puff adder).
The pit vipers have sensory organs that allow them to detect warm-blooded prey by
heat. Two minor families of venomous snakes are Hydrophidae (sea snakes) and
Colubridae (rear fanged snakes such as the boomslang). The distribution of species
and clinical effects is very region specific, and therefore interpretation of published
advice including journal articles should reflect this. For example, the North American
continent has a greater proportion of pit vipers (rattlesnakes), while Australia has a
greater Elapidae population.
Snake venom: This is a complex mixture of peptides and proteins of various sizes.
Although effects can be grouped into syndromes, it is important to understand that
the observed effects of envenomation may be complex with variation within a species
and an individual casualty. The main effects observed due to the action of the venom
components include:
514 Section Five
● Neurotoxic – These effects may be presynaptic, postsynaptic, or both. Symptoms

include neuropathic pain, nerve palsies (especially cranial nerve), convulsions,
coma, and respiratory paralysis.
● Hemotoxic – These effects can be complex due to procoagulation and anticoagula-
tion effects. The end result is a bleeding disorder often similar to disseminated
intravascular coagulopathy (DIC) due to a mixture of consumptive coagulopathy
and direct antagonism and disruption of the normal clotting cascade with
increased fibrinolysis. Additional causes for hemorrhagic presentations include
endothelial disruption.
● Myotoxic – Local breakdown of muscle and connective tissue often occurs even in
the more neurotoxic elapids. Local tissue swelling will lead to increase pain and
may result in compartment syndrome. Secondary toxicity is due to the breakdown
of muscle tissue (rhabdomyolysis) and the release of myoglobin, this causes acute
tubular necrosis and renal failure.
● Cytotoxic/hemolytic – Some components of venom cause disruption of cells,
including red blood cells, usually through disruption of the cell membrane.
● Cardiotoxic – Similar to the effects of neurotoxic agents, some toxins are more
specific for mechanisms involved in cardiac function, such as sodium channels.
These toxins often have a rapid onset and are more common in certain species of
snake (sea-snakes).
The most toxic snake: The title of the most toxic snake depends on definition and
toxicity can be defined in a number of ways. Some snakes have the ability to inject a
significant quantity of venom per bite, while other snakes achieve this with multiple
bites. The quantity of venom may also depend on the maturity of the snake and its
ability to control the quantity of venom it injects. For this reason, any bite from an
immature or smaller species of snake should be considered as significant. The potency
of the venom is important and this is defined by the LD50 or lethal dose, expressed as
weight of venom per kilogram of victim, needed to kill 50% of the sample. Some spe-
cies account for more human deaths than others, but the reason for this is multifacto-
ral. These factors include species population, cohabitation with humans, and
aggression.
A snakebite from a venomous species may not always cause envenomation, this is
commonly call a dry bite. This may be due to the snake’s ability to control to the bite
reflex when performing a defensive bite rather than a bite intended to kill prey. Fang
size is also important with some species such as the Gibbon Viper having significantly
large fangs compared with some of the Australasian elapid species with fangs that
may be more easily defended against with clothing and footwear. Better medical serv-
ices and rapid access to effective antivenom will also reduce the incident of snakebite
deaths despite significant envenomation.
Prevention: Many snakebites are preventable. A review of cases within more devel-
oped parts of the world suggest that snakebites tend to be associated with the younger
adult males with a high incidence of alcohol consumption. The location of the bite is
often the distal limb, including the arm. In certain parts of the world, snakebites are
an occupational hazard with a greater incidence in farming and fishing communities
that may encounter snakes when tending the fields or nets, respectively. Understanding
the importance of pest control is also important with an increase in the local rodent
population likely to attract natural predators such as snakes. Increasing human

migration into snake habitats is likely to result in increased snakebites (Southeast
Asia/Australia). Depending on the resilience of the snake species, the end result may
be the eventual reduction in the native snake population as seen in areas of Northeast
America.
First aid management: Safety is paramount and a number of rescuers/responders
have become victims while trying to catch the snake for identification. Decapitated
snakes may still be hazardous due to the presence of the bite reflex even minutes after
death. In many areas, first aid management maybe the most important intervention
because of the distance both geographically and in time from medical resources, if
any. Any inoculated substance such as venom is likely to be subcutaneous, intrader-
mal, or intramuscular, unless the fang breeched a vascular structure or penetrates a
bone, which is unlikely. Immediate effects are, therefore, likely to be local to the bite
and the tissue planes penetrated. Systemic effects depend on absorption via the lym-
phatic system that drains the compromised tissues. For this reason, there is an oppor-
tunity to reduce absorption by limiting the mechanisms that promote lymph drainage.
The patient should be removed from the immediate area, if the threat of further bites
remains. The patient should be calmed and reassured. Most first aid measures sug-
gested in the last few decades and in Hollywood (cutting the wound, sucking out
venom) have no proven efficacy, may cause more harm and should not be used. Where
venom is still present, it should be left in situ or wiped with a gauze or swab. The
sample should be taken to the medical facility with the patient. In some facilities,
especially in Australia where there are a number of species-specific antivenin, venom
can be used to identify the type of snake and therefore likely antivenom to be effec-
tive. In other countries, polyvalent antivenom may only be available.
The initial first aid measure is to reduce limb movements and rest the patient.
Splintage will improve compliance and, where self-extrication of the patient is required,
minimize absorption despite patient movement. The next intervention is the application
of pressure dressings to the effected limb. When combined with splintage, this is called
pressure-immobilization. The empirical use of this method is debatable as local
pressure and reduction in tissue fluid and blood flow may worsen local effects
especially of the myotoxic components in the venom. The advice may therefore vary
regionally depending on the prevalence to species with venom that have a greater local
effect than those with immediate life threatening effects (neurotoxins). This advice can
also be applied to arachnid bite/stings discussed later. Advice for bites in SE Asia is to
use pressure-immobilization only for elapid bites, while in Australia this method is
recommended for all snakebites because of the higher prevalence of elapid species.
Once a pressure dressing has been applied, it should not be removed until the casualty
has access to advanced resuscitation capability including ventilation and, ideally,
antivenin. Within a medical facility, access to the snakebite wound may be made by
windowing the dressing without reducing the pressure dressing to the whole limb. This
allows for the assessment of local toxic effects such as ecchymosis as well as the
sampling of any residual venom for identification. The removed dressing window may
also be used for venom sampling. The diagnosis of a species can sometime be difficult
in regions with several venomous and nonvenomous species. There may be significant
color variation even within a species (Fig. 30.1).
516 Section Five
Fig. 30.1. Two taipan from the Northern Territory, Australia. (note the different coloration
in the same species). Photo Steve Bland.
Investigation and initial patient management: On arrival in a medical facility, the

patient should be assessed for any obvious signs of envenomation. A history should
be taken from the patient or witness with a description of the snake or safe handover
of any snake samples. Symptoms should be asked for including wound pain and neu-
rological symptoms (parasthesia, weakness, and cranial nerve lesions). Any bruising
or bleeding tendencies should be noted as well as the color of urine, especially if dark
brown (rhabdomyolysis) or hematuria (hemotoxic).
Where available venom identification kits should be used (Australia) or a
herpetologist sought to assist in snake identification. The key question is whether the
snake was venomous or not. The next question is whether the bite was dry or
envenomation is likely. If envenomation occurred, the history, examination, and
investigations are vital to assess the risk benefit of antivenom use where available. In
the absence of antivenom, management is supportive. The observed syndromes that
the patient presents with may provide additional species identification or verification.
It should be noted, however, that the complex nature of the venom might result in
various syndromes. The most important medical intervention, with or without
antivenom, is respiratory support in patients with neurological impairment. Repeated
assessment is important and warning signs include increased anxiety, cranial nerve
lesions, diarrhea and vomiting, as well as deteriorating vital signs. Increasing local
pain may suggest a compartment syndrome and this will be discussed below. ECG
monitoring and serial 12 lead electrocardiograms should be carried out in view of the
risk of primary cardiotoxicity and secondary causes such as autonomic dysfunction
and hyperkalemia.
Laboratory investigations are useful especially for the early identification of
coagulopathy and deteriorating respiratory function. Tests should therefore include
renal function, clotting (INR, APTT, fibrinogen, and fibrin-degradation products such
as d-dimers) and, if not contraindicated, arterial blood gases. In resource-limited
facilities, a 20-min whole blood clotting test has been described as a rapid assay for
coagulopathy. This involves the use of a glass test tube and leaving a blood sample for
20 min. If it remains uncoagulated after this time, a hemotoxic syndrome should be
suspected.
Antivenom: This is derived usually from animal subjects such as horse or sheep. It
is a result of repeated sublethal exposures of the subject animal to specific venom. The
result is a host immunological response against the proteins and the increase in IgG
titers against the relevant antigens. The importance of understanding the mechanism
of the action of IgG and derived Fab fragments is that the dose required for an
effective treatment is dependent on the amount of circulating venom. There is a 1:1
interaction rather than a receptor antagonism mechanism of action for the antidote.
The antivenom should therefore be titrated to effect rather than given as a dose per
kilogram of patient. For this reason, pediatric patients may require “adult” doses.
Dose regimes may require a significant number of doses; in some cases over ten vials
depending upon total venom injected and efficacy of the antivenin formulation (IgG
vs. Fab fragments).
The presentation of the antivenom varies regionally. Some antivenoms are poly-
valent with broad species coverage. The disadvantage of empirical treatment with
polyvalent antivenom is that there is a significant antigen load both in number and
dose, if multiple doses are required. The reactions seen following antivenom
administration range from the acute anaphylactoid/anaphylaxis to the delayed
Serum sickness, a type III hypersensitivity. It is recommended that any administra-
tion of polyvalent antivenom should be supported with full resuscitation facilities
including the immediate access to adrenalin (for intramuscular use), histamine
antagonists, and corticosteroids. Some units advocate pretreatment with antihista-
mines and steroids before antivenom use. In some regions such as Australia, there
are a number of species-specific antivenoms. In these areas, it is advantageous to
identify the species of snake and as a result there are often venom identification
kits. In summary, the decision on the use of antivenin is dependent on severity of
symptoms, availability, and experience of a clinician with the use of antivenom and
its complications.
Other treatments: Surgical management – first aid, supportive management, and
antivenom are the mainstay of snakebite treatment. Other treatments may be neces-
sary, although their use in lieu of antivenom is not supported. The development of
compartment syndrome requires immediate intervention. However, unlike traumatic
compartment syndromes, the initial management should be antivenom due to the
underlying aetiology. Surgery, in the form of fasciotomies, may have a role but any
coagulopathy should be treated prior to surgery.
Fresh Frozen Plasma (FFP): The treatment of any coagulopathy depends on the
mechanism of action of the venom on the coagulation cascade. In some cases, FFP
may fan the flames of the coagulation fire. However, where there is a consumptive
disorder, there may be scope for judicious use of FFP especially if surgery is a possibil-
ity. In this circumstance, hematological investigations including fibrinogen levels
should be considered, where available.
518 Section Five
Scorpion Stings
Scorpions (Scorpiones) are an order of arachnid. Other orders include spiders
(Araneae), mites and ticks (Arcari), and sun/camel spiders (Solpugida). Scorpions are
found worldwide on most continents, and the majority of species pose little threat to
human life. Size is a poor predictor of the toxicity of the scorpion’s sting, and some of
the most venomous species are relatively small with small pincers. Stings are often a
result of human interaction with a scorpion using shoes or clothing for shelter.
Venom: Scorpion venom is primarily made up of neurotoxic peptides. These act
either on ion channels or interfere with synaptic conduction either by depolarizing or
nondepolarizing effects. The effects are a combination of pain, sympathetic simula-
tion (via noradrenalin release), cholinergic, and anticholinergic syndromes. Most
envenomations initially present with severe pain, usually without local tissue necro-
sis. Systemic toxicity is a combination of the above syndromes and depends upon the
timing and the dominant syndrome. Local pain may affect all casualties, while sys-
temic toxicity is more likely in the young and the elderly.
Treatment: This is mainly symptomatic with strong analgesia for the pain that can
persist for several days. Analgesia includes systemic (opiates, paracetamol) and local
(cold compresses, immobilization). Patients should be observed for up to 12 h for any
signs of systemic neurological signs or symptoms. ECG monitoring should be consid-
ered. Any hypertensive crisis should be treated by vasodilators (nitroprusside or
GTN) and anxiolytics.
Antivenom: Species-specific antivenom is available, but again subject to regional
variation. The evidence for the use of scorpion antivenom is not as strong as for snake
antivenom. Early use is also suggested (<1 h) and this is unlikely to be met in most
regions of the world and may reflect North American practice and EMS. Prevention
remains the most important factor in reduce morbidity and mortality.
Spider Bites
The order of spiders (Araneae) has over 34,000 named species. In general, the toxic
effects of a spider bite can be divided into two:
● Local effects due to the requirement for spiders to liquefy their prey to aide digestion
(necrotic arachnidism). Secondary infection may also occur either due to inoculated
bacteria from the spider fang or opportunistic infections. The initial presentation of
a spider bite may have a broad differential diagnosis if the causation is unknown; this
includes cellulitis, necrotising fasciitis, anthrax in endemic areas, and Lyme disease.
The brown recluse spider causes significant local effects. The lesion may initially look
ischaemic with a blanching circle around a bluish necrotic area.
● Systemic toxicity: Systemic effects vary between species and some may on occasion
be a result of the local effects. Unlike snakebites that may involve supralethal doses
of venom, spider bites are within an order of magnitude of the LD50 for humans. As
a result it is usually the larger members of the species or larger gender that are more
venomous. Again, children are at greater risk of death following envenomations.
Venom: The mechanism of action for the systemic toxicity of spider venom appears
to be mainly neurotoxic. For example, the Australian funnel web spider increases the
levels of acetylcholine in the synaptic cleft causing cholinergic type symptoms,

although a tachycardia is also described. The major concern is respiratory depression
and pulmonary oedema. The black widow spider also has a neurotoxic venom causing
presynaptic neurotransmitter release, this results in severe muscle contractions and
pain, especially in the abdominal wall resulting in severe abdominal pain.
Treatment: First aid includes pressure immobilization as tolerated and cold com-
presses. Further management is mainly supportive. Some antivenoms exist but the
risk:benefit of efficacy against the significant possibility of hypersensitivity means
the threshold for its use is high.
Marine Envenomations
In coastal areas, there are a number of animal species that have significant health
effects. Human interaction with these species is primarily through local fishing indus-
tries and recreation. Sea snakes may be caught in fishing nets and their management
is consistent with other life threatening snakes bites with pressure-immobilization
and rapid access to medical facilities.
Venomous fish: Most venomous fish use venomous spines for defence in addition
to either camouflage (weaver fish/stone fish (Fig. 30.2) ) or bright warning colors (lion
fish). The venom is very painful but in most fish species it is heat sensitive. Treatment
should include the immersion of the effected body part, usually a limb, into a water
bath as hot as tolerated (approx 45°C); pain usually subsides rapidly.
Jellyfish stings: Some areas of coastline in the world are annually inaccessible to
humans without protective suits due to the toxicity of some of its marine inhabitants.
The box jellyfish (chironex) across the Northern Australian coast is an example
(Fig. 30.3). Stings are extremely painful and lead to a very localized dermatonecrosis.
A large surface area of stings may lead to systemic toxicity including a rapid onset
Fig. 30.2. Two stone fish, the most venomous fish (camouflaged). Photo Steve Bland.
520 Section Five
Fig. 30.3. Box jelly fish (chironex). Photo Steve Bland.
cardiac arrest due to a number of dysrrhythmias. Initial management consists of

dowsing the sting in vinegar; this causes the sting mechanisms (nematocysts) to
retract. Supportive management is required and analgesia. Box jellyfish antivenom is
also available for systemic intoxication.
Other species of jellyfish can cause a late (~2 h) presentation of severe muscle
spasms, anxiety, some respiratory distress, and headache. The syndrome, known as
Irukandji Syndrome, is significant as the initial sting may go unnoticed. Symptoms are
usually self-limiting and resolve within 24 h with symptomatic treatment normally
only required.
Octopus bites: Some octopus species (blue-ringed octopus) are highly venomous.
The venom is a very potent neurotoxic leading to respiratory paralysis. There is no
antidote and supportive treatment including ventilation is required until the patient
recovers, usually within 24 h.
Cone shell: Cone shells may result in acute paralysis with similar duration to the
blue-ring octopus. The initial injury may go unnoticed or seem negligible but a rapid
paralysis with or without myalgia can occur. Cranial nerve palsies may be the first
signs of deterioration with visual disturbance, speech, and swallowing disorders.
Treatment is supportive.
Summary
Preparation for a medical mission must include an assessment of the local fauna and
flora. Medical literature may be very region-specific and as a result species-specific.
The most important factor in reducing deaths from any animal bite or sting is preven-
tion with an understanding of the local environment. For many species, the use of
venom in defence is wasteful especially in areas where food is often very scarce. It is
not surprising that the most potent venoms are found in regions of the world that are
barren, inhospitable, and remote from medical resources. Understanding the mecha-
nism of action of a specific venom allows a medical practitioner to predict and quan-
tify the severity of an envenomation. Supportive management, including ventilation,
may in many cases be the only treatment available. Most of the antidotes in the form
of antivenom have varying efficacy and all have the potential for life threatening side
effects. Predeployment preparation to areas with any venomous species should
include awareness training and resource allocation based on appropriate risk assess-
ments and access to medical facilities and antidotes (antivenom).
Further Reading
South East Asian Snakes
Warrell DA. Guidelines for the clinical management of snake bites in the South-East Asia region. World
Health Organisation, New Delhi. 2005. Accessed on WHO website. http://www.who.int
North American Snakes
Gold BS, Barish RA & Dart RC. North American snake envenomation: Diagnosis, treatment and manage-
ment. Em Med J N Am. 2004; 22: 423–43.
Australasian Envenomations
University of Melbourne: Australian Venom Research Unit website. http://www.avru.org
Sutherland SK. Australian animal toxins: The creatures, their toxins and care of the poisoned patient (2nd
Ed). Oxford University Press, Melbourne. 1983.
Arachnid Envenomations
Saucier JR. Arachnid envenomation. Em Med J N Am. 2004; 22: 405–22.
Miscellaneous
Included here are other conditions that are not easily classified.
Poliomyelitis
This condition is discussed here because it does not readily fit the classification used
in this chapter. For example, it may be spread by droplet infection or by contamina-
tion of food or water by infected feces. It is an acute viral infection in which most of
those infected remain asymptomatic. In a minority, disease is associated with acute
flaccid paralysis. Case fatality rates (CFR) are low and quoted between 2 and 10%.
Refugees and displaced communities are vulnerable to the spread of the disease,
and it should be considered as part of disease surveillance activity. The vaccine is
cheap, safe, and effective orally and should be part of the Extended Programme of
Immunizations (EPI).
Rabies
The Rabies virus is lethal in man, resulting in a progressive and untreatable meningitis
and encephalitis. The disease is transmitted by the bites, licks, or scratches of infected
mammals. These include dogs, foxes, wolves, cats, and bats. The most common cause
522 Section Five
of human rabies is the bite of a rabid domestic dog. The incubation period is usually
between 20 and 60 days, but may extend for up to 4 years. The shorter the distance
from the wound to the brain, the shorter the incubation as the virus spreads along
neurones to reach the central nervous system.
As the disease has no cure once symptoms have developed, the emphasis is on pre-
vention, particularly for expatriate volunteers. Preexposure or predeployment regi-
mens are widely available and effective. The most widely recommended regimen is
the Merieux human diploid cell vaccine (HDCV). 1 mL i.m. or 0.1 mL i.d. is given
thrice; day 0, day 7, and day 28.
Bites among refugees and IDPs (Internally displaced persons) require a post expo-
sure regimen, which consists of wound cleaning, debridement, anti-tetanus measures
and HDCV on days 0, 3, 7, 14, 28, and 90. Additionally passive immunization is
achieved with human rabies immunoglobulin – 30 IU/kg – half infiltrated around the
bite, the remainder by intramuscular injection.
The best preventive measure in camps is the destruction of stray dogs and health
education.
Myiasis
Myiasis is the presence of the maggots (more correctly larvae of tropical flies) in
human tissue. The maggots burrow into human tissue and typical sites are below
healthy skin, eyes, ears, and the nasal passages. They may also infect open wounds.
The condition is encountered in tropical Africa and South America, and in parts of
Asia. Burrowing below healthy skin produces papules or boils which may ulcerate.
Lesions may be multiple and resemble chicken pox, impetigo, or scabies.
Treatment is by applying water or an oily substance such as petroleum jelly over the
surface of the lesion. This causes suffocation and the maggots can then be “shelled out.”
Prevention is by use of fly screens, careful attention to laundry (drying clothes
indoors and ironing them), and by destroying any fly eggs which are encountered.
Bugs, Ticks, and Mites

Fleas and lice are associated with potentially lethal infections and have already been
discussed. This section covers a wide variety of small creatures, which, while largely
of nuisance value, may cause alarm and considerable discomfort.
Bed-Bugs – As their name implies these live in bedrooms, infesting bedding mate-
rial, including bed frames. They may also live under carpets and under wallpaper.
They are nocturnal feeders and cause irritating bites, which result in disrupted sleep
patterns. They do not carry disease. Control is difficult – cleaning of bedding, insec-
ticide sprays, moving bedding away from walls and leaving lights on at night are all
recommended.
Ticks and Mites – These become attached to skin while walking through under-
growth in prevalent areas. They are easily seen and can become large when engorged.
Removal is by grasping the head end and disengaging the teeth by rocking from side
to side followed by removal, or by touching with a lighted cigarette.
Ticks and mites are associated with a variety of diseases including scrub typhus
and Rocky Mountain spotted fever. Volunteers should be aware of diseases endemic to
their area of deployment. It is important to maintain a high index of suspicion and
seek advice.
On-Going Health Care

On-going medical care must include attention to the following:
● Health surveillance and reporting
● Continuing health needs assessment
● Establishment of a health clinic
● Acute medical care
● Preventive health measures
● Health education measures
● Maternal and child health measures
● Care of the elderly and other vulnerable groups
● Storing and dispensing medicines
● Resupply network
● Documentation and records
A health information or surveillance system needs to be established early. Careful moni-
toring of trends in health and nutritional status is essential if problems are to be identified
and preventative action taken. Mortality surveillance monitors changes in Crude Mortality
rate. Nutritional status, population movement, and provision of health clinics should
also be observed. The mortality caused by key illnesses can be studied using return forms.
The forms used by most relief agencies vary little in content, but one type should be
adopted by all organizations in the area to standardize the information collected.
Mobile and Transitional Care

The focus of this chapter so far has been on care of displaced people in established
and static camps. However, you may have to care for victims prior to the establish-
ment of a static camp.
This involves caring for individuals or a community on the move from their homes
to a perceived place of safety or at a transitional location prior to moving to a perma-
nent location. Ideally, international organizations will be providing or guaranteeing
safe passage. The safe passage may not be apparent or believed by the community on
the move so reassurance coupled with transport assistance may be a primary task. In
certain evacuations, there may be control of the movement of certain categories of
individuals, based on age, sex, or nationality. This was particularly evident in the
Balkans during the 1990s.
Depending on the transport available the terrain and the distances involved, a form
of sorting or triage may be needed to ensure that evacuees will survive the journey.
524 Section Five
For those prevented from traveling through illness or infirmity, medical care will have
to be arranged.
Most displaced people who have been on the move for prolonged periods will arrive at
their final destination in a highly vulnerable state. The measures outlined in the earlier
part of this chapter are particularly appropriate here. Travel will usually have involved
overcrowding, lack of sanitation, poor nutrition, thirst and exhaustion – the risk of
early onset communicable disease is very high.
You may be asked to advice on overcrowding or the suitability of transport. EU
regulations on animal transportation are a good guide to the lowest acceptable level
of provision. Generally, international law should be left to professionals. However,
there is one rule which those assisting a mobile community need to be aware of. This
is the principle of nonrefoulement:
No person (entitled to invoke article 14 of the Universal Declaration of Human

Rights) shall be subjected to measures such as rejection at the frontier or, if he
has already entered the territory in which he seek asylum, expulsion or com-
pulsory return to any State where he may be subjected to persecution.
Transition from Acute Care to Long-Term

Development and Repatriation
This is a highly specialized field and beyond the scope of this manual. However, it is
important to recognize the need to move toward long-term solutions when consider-
ing refugee care. As a rule, the post acute phase begins when the excess mortality of
the acute phase is controlled and basics needs met. The commonly accepted marker
which indicates transition is a Crude Mortality rate under one death/10,000/day.
Other Aspects
Use of Local Staff
A displaced population will have a rich range of skills and attributes. Use them. Early
utilization of local skills will ease administration and is vital for surveillance. Pay
scales must be standardized throughout if conflict is to be avoided. UNICEF may be a
useful source of funding and advice on pay matters. A certain tolerance toward cor-
ruption may be necessary to ensure good labor relations and to prevent conflict.
Relief Agency Rivalry

It is sad to note that competition and rivalry do occur among relief organizations. In
part this is a matter of reputation, but also there may be funding and financial issues.
Clear communication is vital to avoid misunderstanding and duplication of effort.
Regular meetings of representatives, established early, help to defuse tension. Finally,
each organization should have clearly defined areas of responsibility and an atmos-
phere of cooperation should be fostered. Many of the relief organizations have classi-
cally refused to be involved with any military organization from fear of being seen as
not neutral, and thus harming their ability to treat “all sides.” In the past such organi-
zations were treated as neutral by combatants, and this strategy was successful. More
recently, terrorist organizations have targeted aid organizations leading to a recogni-
tion that the security offered by a military organization – especially as part of a peace-
keeping force – is important to aid organizations.
Withdrawal and Return Home

This is discussed in various chapters in the manual. For most volunteers, withdrawal
should be considered once the acute phase is over. Long-term care is best left to pro-
fessionals. Withdrawal and handover should be planned and must avoid giving the
impression of abandonment. If a successor is present, formal handover is needed to
ensure a smooth transition.
Conclusion
This multipart chapter is merely an introduction to the myriad of medical and related
conditions, which may affect displaced populations. Readers are strongly recom-
mended to read widely. Consult related chapters and use the Resources Section in
addition to the reading list below.
Further Reading
Behrens RH, McAdam KPWJ, Scientific Editors. Travel Medicine – British Medical Bulletin, Volume 49.
Churchill Livingstone, 1993:Edinburgh.
Cook GC, Editor. Travel-Associated Disease. Royal College of Physcians, 1995:London.
Cowan GO, Heap BJ. Clinical Tropical Medicine. Chapman & Hall, 1993: London.
Dawood R, Editor. Travellers Health – How to stay healthy abroad. Oxford University Press, 2002: Oxford.
Immunisation against disease. HMSO:London. Updated annually.
Médecins Sans Frontiéres, Refugee Health – An Approach to Emergency Situations. Macmillan,
1997:London
Perrin P. Handbook on War and Public Health, English Edition. ICRC, 1996:Geneva.
Editors’ note – see also Resources Section at the end of this manual.
Websites
The following Websites are recommended. These can be used to search for current
information on specific diseases and for links to related sites. Some contain journal
articles and have question and answer sections.
AMERICAN SOCIETY OF TROPICAL MEDICINE and HYGIENE: http://www.astmh.org/
ENCARTA: http://encarta.msn.com/index/concise index
526 Section Five
ICRC (International Committee of the Red Cross): http://www.icrc.org/

Medicine Sans Frontieres: http://www.msf.org/
WHO (World Health Organization) Home Page: http://www.who.int/en/
WHO Formulary: http://www.who.int/medicines/publications/essentialmedicines/
en/index.html
WHO Treatment Protocols: http://search.who.int/search?ie = utf8&site = default_
collection&client = WHO&proxystylesheet = WHO&output = xml_no_dtd&oe =
utf8&q = protocols
WHO Health Topics: http://www.who.int/topics/en/
WHO Division of Control of Tropical Diseases: http://www.who.int/topics/tropical_
diseases/en/
WHO Oral Rehydration Solutions: http://www.who.int/medicines/publications/
pharmacopoeia/OralRehySalts.pdf
Rehydration Project (Home made solution): http://rehydrate.org/solutions/homemade.htm
Charles Cox and Hervinder Kaur
● To emphasize that in war and catastrophe, women are major

Objectives victims.
● To highlight the problem of violence against women.
● To suggest a management approach to the ill or injured
woman in a hostile environment.
● To discuss obstetric and gynaecological care in a hostile
environment.
Introduction
In 2005, there were 536,000 maternal deaths worldwide, which equates to four Jumbo
jets crashing a day or one death per minute. Developing countries accounted for 90%
of these deaths. More than half of the maternal deaths occurred in Sub-Saharan Africa
alone, followed by South Asia, which together accounted for 86% of global maternal
deaths. Maternal mortality rate was highest in developing countries (450 maternal
deaths per 100,000 live births) in contrast to developed countries (9/100,000) and
countries of Commonwealth independent states (51/100,000).The highest recorded
maternal mortality is in the Hindu Kush of Afghanistan where the maternal mortality
per 100,000 births is 6,500. Even the basic emergency obstetric services are not avail-
able in countries with high maternal mortality rates. There is either lack of trained
staff, equipment, and supplies. Because of their status in society, lack of education,
and understanding of health related issues, women delay seeking existing health care.
During conflict or catastrophe, there is a rise in maternal death because of damage to
health facilities, difficulty in reaching the facilities. This has become evident from the
war conflict in Sierra Leone, Timor, Afghanistan, and Iraq and also from natural dis-
asters like Asian tsunami. According to UNICEF, maternal mortality rate in Iraq has
gone up by 65% in last 15 years.
Maternal mortality reported was highest in Sierra Leone (2,100/100,000) compared
with those in Afghanistan (1,800), Somalia (1,400),Angola (1,400), Rwanda (1,300),Sudan
(450),Timor (380), and Iraq (300). At least 25,000 women between the ages of 15 and 29
died in 2000 as a direct consequence of conflict.
Although during conflict situation, the entire community suffers, women in par-
ticular are victims of horrific atrocities. Gender-based violence is a common feature
of war conflicts and natural disasters. This includes abduction, rape, slavery, traffick-
ing, forced prostitution, and forced pregnancy.
528 Section Five
In number of conflict situations including those in Rwanda, Sierra Leone, and the
Democratic Republic of Congo, sexual violence has been used as a weapon deliber-
ately exposing these women to HIV/AIDS. Forcible impregnation of women as a part
of ethnic cleansing campaign occurred in Bosnia, Herzegovina, East Timor, Kosovo,
Rwanda, and Sudan.
There is a growing concern on increasing incidences of rape, kidnapping, and sexual
violence of Iraqi women.
Women have to cope with their pregnancies, childbirth, caring for children, and
elderly. During conflict, as a victim of rape they have to deal with unwanted pregnancies,
raising children without support, and often socially ostracized. They are forced to
leave home and seek shelter at refugee camps where they are abused by government
officials, aid workers, and civil authorities!
Women have greater difficulty accessing health care. They are dependent on male
members of the family to escort them to clinics. In situation of rape or sexual vio-
lence, by informing male family members, women expose themselves to additional
violence from them. Moreover, women who do seek help often choose to forego treat-
ment rather than accepting treatment from a male doctor. Postconflict there is
increase in domestic violence, alcoholism, drug use, and homelessness. Women have
high rate of Post Traumatic Stress Disorder following sexual abuse.
Six years after end of the war, women in Sierra Leone who survived mass rapes,
sexual slavery, and other crimes of sexual violence continue to suffer as so-called
“rebel wives” are denied access to health care, jobs, and schools. Women were rejected
by the family and community and hence resorted to prostitution.
Equipment and Drugs

The equipment and drugs available depend on the agency involved, but are usually
limited. There are various ready-made medical kits available provided, e.g., by the
International Dispensing Association (IDA), the World Health Organization (WHO),
or the United Nations High Commission for Refugees (UNHCR). Most of them pro-
vide a special maternity or midwifery pack, which includes equipment necessary for
conducting a normal birth and episiotomy suturing. Disposable gloves, plastic specu-
lae, catheters, and urine pregnancy detection kits are usually available. Intravenous
fluids, antiseptics, and routine antibiotics are also provided.
There may be a destruction of the local medical services and the previous infra-
structure that provided the services. It is perhaps easier to cope when services have
been more primitive than when there has been a complex medical service, as expecta-
tions are lower and local provision of basic midwifery is likely to be provided by
traditional attendants. Technologically advanced systems are less portable when dis-
asters occur, and sophisticated equipment is more easily damaged. Simple obstetric
forceps, for example, are more appropriate than the vacuum extractor as they are
technology independent!
UN Millennium project aims to improve maternal health. It aims to reduce maternal
mortality by three quarters between 1990 and 2015.
The Sphere Project was launched in 1997 by a group of humanitarian NGOs and the
Red Cross and Red Crescent movement who framed a Humanitarian Charter and
identified Minimum Standards to be attained in disaster assistance, in each of five key
sectors (water supply and sanitation, nutrition, food aid, shelter, and health services).
UNFPA, the United Nations Population Fund, is an international development
agency that promotes the right of every woman, man, and child to enjoy a life of
health and equal opportunity. Reproductive health encompasses key areas of the
UNFPA vision – that every child is wanted; every birth is safe, every young person is
free of HIV, and every girl and woman is treated with dignity and respect.
Training
There are few formal training courses available to provide obstetric and gynaecologi-
cal training for such disaster settings. The Royal College of Obstetricians and
Gynecologists runs a course with the Liverpool School of Tropical Medicine called
The Diploma in Reproductive Health in the Developing Countries. The course is of
2-weeks duration and covers such areas as maternal care and safe motherhood, sexu-
ally transmitted diseases, and family planning. The United Nations International
Children’s Emergency Fund (UNICEF) also publishes useful guidelines for pregnant
women. There also a number of other shorter courses aimed at various levels of exist-
ing skills. The best known of these is the American based but international Advanced
Life Support in Obstetrics (ALSO) course. This runs over 2 days and provides a good
grounding in obstetric emergencies and is multidisciplinary including all grades and
specialties of medical staff and midwives based on the facilities, which are likely to be
available in a community hospital in the USA.
There are a number of courses dealing with obstetric emergencies. Managing
Obstetric Emergencies and Trauma (MOET) is a 3-day course for senior obstetricians
and anesthetists. This course highlights a structured approach to the management of
life threatening obstetric emergencies and trauma. St Bartholomews and the London
Medical Simulation Center (MOSES); Scottish Obstetric Teaching and Training in
Emergencies (SCOTTIE); Defense Medical Services (DMS)-Emergencies in Obstetrics
and Gynecology; Child Advocacy International (CAI). More recently a joint project
between the Royal College of Obstetricians and Gynecologists and the Liverpool
School of Tropical Medicine has developed and overseas course in lifesaving skills in
essential obstetrics care and new born care, which has rapidly become established and
has attracted major funding from the Department for International Development.
There is a UNICEF multidisciplinary course in Education for Development which
has been organized in cooperation with Technical University of Turin. The 9-week
course covers a wide range of subjects including child soldiers, sexual tourism, and
female genital mutilation.
The International Development Department (IDD) of the University of Birmingham,
UK, included a module on disaster management. The aim of the module is to impart
knowledge of “Sphere” as a part of continual effort to institutionalize the theory and
practice of Sphere standards.
530 Section Five
Rape and Sexual Assault

Sexual violence against women is increased during natural disasters and war conflicts
as women are separated from their families. An assessment by UFNPA confirmed that
women in Darfur region in western Sudan were targeted with sexual violence during
armed attack on their villages, during flight, and around the refugee camps. Women
were afraid to seek medical treatment because of cultural taboos and mandatory
reporting requirements.
Women have been victims of two decades of civil war in Afghanistan. Many women
were raped by armed guards during the period 1992–1995. Women were abducted
and detained by Mujahedeen groups and used for sexual purposes or forced into
prostitution.
Women in refugee camps are forced to trade sex with police, soldiers, or even aid work-
ers for food, shelter, and protection of their children. Iraqi women who were refugees in
other countries were forced into prostitution either by economic means or by force.
Violence Against Women in Situations of Armed Conflict

Rape has been widely used as a weapon of war wherever an armed conflict arises. It
has been used all over the world in Mexico, Rwanda, Kuwait, Haiti, and Columbia.
There may be victims of multiple rapes committed by soldiers from all sides of a
conflict. Such acts may be a demonstration of power to undermine the dignity of
victims and reinforce a policy of ethnic cleansing, e.g., the former Yugoslavia. It has
been estimated that between 20,000 and 50,000 rapes were committed during the
fighting in the former Yugoslavia.
Young girls of colonized or occupited countries became sexual slaves, “comfort
women” to Japanese soldiers during the Second World War and others were forced
into prostitution.
In Afghanistan, women are the main victims of the continuing human rights crisis.
The Islamic fundamentalist faction, the Taliban, seized control over Kabul in 1996.
This marked the beginning of a new era of repression, particularly for Afghan women.
The Taliban policy of gender apartheid is disturbing. Assassination, abduction, and
rape are being committed with total impunity by government forces and armed
political groups who are prepared to terrorize the civilian population to secure and
reinforce their power bases. The rape of women by armed bodyguards belonging to
the warring factions appears to be condoned by leaders as a method of intimidating
vanquished populations and of rewarding soldiers. Armed men target women from
ethnic or religious minorities they regard as their enemies. Party leaders and influen-
tial commanders have also reportedly forced families to sell them their younger
daughters and sons, who have then been sold into prostitution, frequently in Pakistan
and other countries.
In the case of Rwanda, it appeared that sexual violence constituted an integral part
of the genocide, as evidenced by testimonies of genocide survivors. During the
conflict, there was enormous propaganda in the Hutu militant literature against the
Tutsi women, portraying them as “seductive spies.” Thus, many Tutsi women were
raped, humiliated, and told that they were too proud and arrogant. There are stories
of rape of pregnant women by men known to have AIDS with the intention to pass on
the disease. There are also instances of brutal sexual assault. There are reported inci-
dences of gang rape where two men kept a woman’s legs apart while others cut her
genitalia with rusty scissors. Her clitoris was cut and labia were mutilated. This was
then publicly displayed for everyone to see. There are other reports of sexual violence,
including having a breast cut off, acid thrown on their genitals, or their reproductive
systems permanently damaged as a result of large objects forced into their vaginas or
through the sheer number of times they were raped. Other bodily damage incurred
includes permanently tilted heads (where machetes had not succeeded in cutting the
woman’s head off) and missing limbs.
The health problems of the genocide survivors are a major concern. Rapes and
sexual assault occurred on a large scale, and many women bear permanent physical
scars, deformities, major injuries to their reproductive organs and health problems
including HIV/AIDS; 25–30% of the population in Kigali and 90% of the prostitutes
were assessed to be HIV-positive, and this has risen since 1994. The vast majority,
with their husbands now dead, have the full responsibility of bringing up their chil-
dren. They harbor enormous feelings of hatred and revenge. Many have psychoso-
matic disorders such as palpitation, nausea, insomnia, and frigidity.
Most women victims do not appear to report their ailments to medical profession-
als or attempt traditional treatments since the shame does not allow them to speak of
the atrocities committed against them. According to many researchers and activists,
it is owing to deeply rooted Rwandan culture and tradition, the low status of women
in society, and a deep sense of privacy that women victims of violence are reluctant
to speak out about the traumatic experiences that they have suffered. In addition,
there is the social stigma attached to being a rape victim or a victim of sexual
violence.
Traditional upbringing prevents women from speaking openly about such private
matters. A cultural problem exists between the victims and witnesses on the one hand
and the investigators on the other, as most of the investigators were male. The women
are also frightened of repercussions and reprisals.
Intentional amputation of various body parts occurred during Sierra Leone’s war
including ears, lips, nose, cheek, arms, legs, fingers, toes, and genitalia. Arm ampu-
tation was either short sleeve (amputation below elbow) or long sleeve (amputation
above elbow). Most amputations were violently committed and inflicted
randomly.
Armed conflicts not only affect women but also children. It leads to displacement
resulting in disruption of education of children. Children are either orphaned or die
of malnutrition and infectious diseases. Where women are raped and infected by HIV,
children are exposed to HIV/AIDS. With availability of “small” arms, children have
been used as soldiers. Young girls are vulnerable to rape, HIV infection, and unwanted
pregnancy. Because of lack of family guidance, teenagers engage in risky behaviors
resulting in increase in teenage pregnancy and unsafe abortion rates.
532 Section Five
Impact of Natural Disaster

The Asian tsunami disaster in 2004 killed over 300,000 people. More than 40,000
women died than men. The magnitude of impact was based on preexisting vulnera-
bilities including social, economical, political, age, or gender-based. This was further
compounded by poverty, displacement, and long-running armed conflicts.
The vulnerable group (women, children, and the elderly) are worst hit by the disas-
ter. In wake of disaster, as in peace, women take on the role of looking after the chil-
dren, elderly, injured and the sick. Because of displacement, women are vulnerable to
rape, trafficking, and sexual exploitation.
Even during the recovery process, women remained at disadvantage due to gender
specific approach to housing and livelihood.
Medical Management of Sexually Assaulted Women

The most important considerations, given the limited nature of the resources, are:
1. Treatment of the physical injuries
2. Prevention of infection
3. Prevention of pregnancy
Treatment of the Physical Injuries

Sexual assault may result in a wide range of bodily injuries. Cuts on breasts or even a
whole breast being chopped off, vaginal lacerations, and bruises with concomitant
damage to the internal pelvic organs may occur. Securing hemostasis and suturing
the lacerations, along with the assessment of the internal damage, is the priority in
such cases. This is dealt with in the section on trauma in women. Appropriate pain
relief should be given. Temporary catheterization of the urinary bladder may be nec-
essary if suturing involves areas close to the urethral meatus.
Prevention of Infection
Two sources of infection should be considered. The local wounds can be infected,
especially if they are extensive. Broad-spectrum antibiotics such as Augmentin, cover-
ing most common wound infections, can be used. Tetanus prophylaxis is important
and readily available.
Screening for infection may not be practical. Depending on the resources available,
various treatment strategies can be adopted. The important issue is the treatment of
sexually transmitted diseases (STD) after rape and sexual assault – especially HIV/
AIDS. It is unrealistic to expect to provide HIV prophylaxis to all rape victims.
Postexposure Prophylaxis (PEP) for HIV/AIDS

This is significant in places like Rwanda where the prevalence of HIV is high, and rape
is committed with the intention of inflicting disease. PEP is recommended if the
assailant is known to be HIV-positive or of whom there is a strong clinical suspicion.
The risk of infection following exposure (male to female/female to male) is 1:300,
and the risk following oral sex is 1:1,000. PEP in HIV is most effective when started
within 72 h of exposure.
The recommended regimen following a high-risk exposure is:
Zidovudine 250 mg bd
Lamivudine 150 mg bd
Nelfinavir 1,250 mg bd
Typically regimens are prescribed for a 4-week period. The cost of 28-day course of
the combined treatment is £456.The risk of seroconversion is reduced by 80% with
the use of Zidovudine alone.
Gonorrhea, Chlamydia, and Other Infections

The single most effective drug against gonorrhea and chlamydia in terms of efficacy and
compliance is a single dose of Azithromycin 1 g taken orally. This is also effective against
chancroid, granuloma inguinale, lymphogranuloma venereum, and nonspecific urethritis.
The cheaper option, but one needing compliance, is doxycycline 100 mg bd for 7–21 days
for various infections. Erythromycin is also effective against chlamydia and most other
STDs. Metronidazole 400 mg tds covers trichomonas and bacterial vaginosis.
Hepatitis B Vaccination
Guidelines are available for vaccine-preventable STDs, including recommendations
for the use of hepatitis A and hepatitis B vaccine. Hepatitis B immunoglobulin may be
available.
Prevention of Pregnancy
The estimated risk of pregnancy following sexual assault is 2–4%.
Levonorgestrel, two doses of 750 μg 12 h apart, prevents pregnancy in 95% when
taken within 24 h but only in 61% when taken between 48 and 72 h.
Mifepristone, used as single dose of 200 mg postovulation has a similar pregnancy
rate to Levonorgesterel but unlikely to be available.
534 Section Five
Trauma in Women
The practical management of genital tract trauma, and the management of a normal
delivery and common obstetric and gynaecological problems are described below.
Genital Tract Trauma

Damage to the female genital tract is uncommon in trauma victims except when the
trauma is inflicted deliberately. Occasionally damage can occur to the external genitalia
with a straddle injury. This rarely damages internal organs, as penetrating injuries of
this nature are uncommon and internal organs are protected by the bony pelvis.
Treatment is control of hemorrhage with direct pressure or hemostatic sutures. Bruising
and swelling may be gross, but will usually resolve with no specific treatment.
Deliberate Damage to the Genital Tract

This may occur as a result of intentional direct damage to the genital tract and may
involve lacerations to the external genitalia with excision of the skin around the labia
and clitoris. This would include female genital mutilation or circumcision (cutting).
Lacerations around the perineum may bleed profusely and lead to exsanguination.
Treatment is the application of firm pressure and hemostatic sutures if required.
Penetrating injuries, e.g., the insertion of sharp implements such as knives or sticks,
may cause damage to the perineal and intraabdominal structures. The urethra, the
bladder, and the ano-rectal region may be damaged, and penetration may involve the
peritoneal cavity leading to bowel damage with resulting peritonitis. It is, therefore,
important to take as full a history as possible and to carry out an adequate
examination, asking for experienced help if indicated. Examination of the abdomen
may reveal tenderness and tenseness of the abdominal muscles (guarding). This
suggests damage in the peritoneal cavity and surgical help is required.
Examination of the vulva, perineum, and anorectal region should be carried out,
and it will be helpful to place a urinary catheter in the bladder if possible. If there is
a continued flow of clear urine then the bladder must be intact. Severe lacerations
around the perineum require a full examination under a general or regional
anaesthetic. If this is not available, a urinary catheter should be inserted, hemorrhage
controlled with direct pressure and transfer arranged. If this is not practicable,
antibiotics should be started and the wound reviewed at regular intervals.
Damage to the bladder or bowel requires expert help. The mortality rate from dam-
age to intra-abdominal structures leading to peritonitis is high, and damage to the
anal sphincter, if unrepaired, will lead to loss of continence.
Antibiotics are mandatory, and Augmentin is particularly useful as it covers bowel
organisms. If peritonitis is suspected, the patient should be kept nil by mouth.
In cases of rape, consideration should be given to contraception: “the morning-after
pill” and an antibiotic to cover the common sexually transmitted diseases such as
gonorrhea and chlamydia. In areas where HIV is endemic, prophylaxis should be
considered, as described above.
Gynaecological Emergencies
Most of the acute gynaecological conditions encountered are likely to be complica-
tions of pregnancy. Abortion, spontaneous or induced, accounts for approximately
20% of maternal deaths worldwide Spontaneous abortion occurs in up to 20% of
pregnancies and is characterized by bleeding followed by pain. In most cases, the pain
and bleeding will settle, but on occasion there can be severe hemorrhage and shock
may develop out of all proportion to the blood loss. Abortion spontaneous or induced
accounts for approximately 20% of maternal deaths worldwide. This may be due to
distension of the cervix by products of conception, which causes collapse due to
stimulation of the autonomic nervous system (vaso-vagal shock). This can be simply
treated by removing placental tissue from the cervix manually or with sponge forceps
to relieve the stretching.
Septic abortion is not uncommon, especially after induced abortion carried out by
an untrained person. If neglected, severe sepsis may result and the woman may
develop a bleeding disorder and septic shock with a resulting high mortality. The
treatment is to give high doses of a broad-spectrum antibiotic such as Augmentin and
to remove infected retained products of conception from the uterus.
The technique for emptying the uterus of retained products of conception is com-
paratively straightforward and can be performed under sedation without the need for
general anaesthesia. A speculum is placed in the vagina to expose the cervix. The
cervix is grasped with a pair of forceps. Sponge forceps are quite satisfactory. Any
products sitting in the cervix are removed and depending on the skill and experience
of the operator, the cavity of the uterus can be explored gently with a finger or with
sponge forceps or a uterine curette if available. An oxytocic agent (usually a combina-
tion of ergometrine and syntocinon, “Syntometrine” 1 ampoule) should be given if
available; if not, then the uterus should be manually massaged to promote contrac-
tion. Antibiotic cover is appropriate. If the case is septic, great care must be taken not
to damage the uterus, which will be soft and vulnerable to perforation.
Mifepristone 200 mg orally followed by Misoprostol 600 μg given orally or vaginally
can be used to induce abortion. Misoprostol can also be used for the management of
retained products of conception.
Pregnancy Occurring Outside the Uterus: “Ectopic” Pregnancy

It is a gynecological maxim that all women between the ages of 10 and 55 should be
assumed to be pregnant until proved otherwise! For a variety of reasons, women may
choose to deny the possibility of pregnancy. This may be particularly so in the mili-
tary environment where sexual relations are officially strongly discouraged! A urine
pregnancy test will be helpful.
Massive internal hemorrhage may occur, and failure to consider the diagnosis may
have fatal consequences. A high index of suspicion is required. Shock without an obvi-
ous source of major bleeding should be assumed to be due to ectopic pregnancy until
proved otherwise. The treatment is to remove the fallopian tube from which the
bleeding is occurring. There is no reason to remove the ovary except in the case of
uncontrollable hemorrhage from an ovarian pregnancy.
536 Section Five
Pelvic Inflammatory Disease (PID)

Acute pelvic inflammatory disease is generally due to a sexually transmitted disease
except when occurring after childbirth. It is characterized by severe lower abdominal
pain, fever, and a purulent vaginal discharge. Broad-spectrum antibiotics should be
administered and a high fluid intake maintained. Infection occurring after childbirth
(puerperal sepsis or childbirth fever) should be treated aggressively, as untreated
puerperal sepsis has a high mortality rate.
Rape victims should be offered antibiotics to reduce the risk of infection.
Management of a Normal Delivery

The baby should be delivered by maternal effort, unless there is a long delay between
the delivery of the baby’s head and the rest of the body. The birth canal can be widened
by flexing the mother’s hips onto her abdomen. Delivery may then be achieved by
pushing the baby’s head downwards, which will encourage delivery of the baby’s
anterior shoulder. This manoeuvre must be carried out during a uterine contraction.
An episiotomy can be performed to widen the birth canal, but may produce
considerable hemorrhage if not promptly repaired.
Once the baby has been delivered it should be dried. This will often stimulate
respiration. The baby should be kept warm. Placing the baby to the mother’s breast to
suckle leads to the release of maternal oxytocin and encourages delivery of the
placenta by causing the uterus to contract.
There is no hurry to ligate the cord. However, if the cord has snapped the baby’s end
of the cord should be ligated no nearer than 5 cm from the baby. When cord pulsations
have ceased, the cord may be ligated.
The placenta should be inspected to check that it appears complete. The perineum
should be checked for damage or bleeding. Uncomplicated tears of the perineum,
which are not bleeding, do not require to be repaired.
Obstetric Emergencies
Two patients are at stake. In developed countries, the unborn baby is afforded priority,
and most women would submit to a Caesarean section if they thought it would
improve the outlook for their child.
In developing countries, decisions regarding the management of obstetric prob-
lems are governed by the resources available at the time and the resources that are
likely to be available to the woman in the future. In many countries, surgical facilities
to carry out Caesarean section may be patchy, and a woman who is subjected to a
Caesarean section, which is not performed as a life-saving procedure for her, will be
left with a scar in her uterus and a significant chance of scar rupture and death in a
subsequent pregnancy.
Therefore, in many circumstances, every effort should be made to avoid this poten-
tially long-term life threatening maternal procedure (Caesarean section).
The feasibility of carrying out obstetric operations and procedures will be limited
by the experience of the medical attendant and the facilities and equipment available.
Remember the first rule of medicine: “first, do no harm.”
In the majority of cases the welfare of the baby will be at best of secondary
consideration.
The most common cause of maternal death worldwide is hemorrage, ante partum,
postpartum or combined (24%), postpartum sepsis (15%), complications of abortion
(20%), pre-eclampsia/eclampsia (12%), prolonged/obstructed labor (8%), and ectopic
pregnancy (8%). Statistics for thrombo-embolic disease are not available.
Life-threatening emergencies occurring in pregnancy are likely to be eclampsia,
severe pre-eclampsia (toxaemia of pregnancy), and hemorrhage. Other conditions
such as sickle-cell anemia are more likely to cause problems in the pregnant
patient.
Toxemia of pregnancy is characterized by fitting, swelling, especially around the face
and eyes, the finding of protein in the urine, and high blood pressure. The woman may
pass very small quantities of urine, which may be very concentrated (Coca-Cola urine).
The management of the fitting mother is to protect her airway and to wait until the fit
has stopped. Common drugs that may be useful in the control of fits include diazepam,
magnesium sulphate, and phenytoin. Magnesium sulphate is the drug of choice.
Opiates and promazine may be useful in the absence of the above. It is also important
to control the blood pressure to below 170/110-labetalol or hyralazine are the preferred
drugs. The definitive treatment for eclampsia or severe pre-eclampsia is to get the
baby delivered, which will present problems if maternity facilities are not available!
It is, however, very important to recognize the condition so that specialist advice may
be sought.
Hemorrhage occurring in pregnancy may be from the site of the placenta and is
almost always maternal blood. In one-third of cases, it may come from a normally
sited placenta, which has separated from the wall of the uterus (placental abruption).
In another one-third of cases, it comes from a placenta which is attached over the
cervix (placenta praevia). The remaining third of cases of vaginal bleeding are due to
other causes such as bleeding after intercourse, and the bleeding is not usually of a
significant amount.
Bleeding from a significant placental abruption is almost always associated with
pain and tenderness over the uterus. The baby is often dead. Delivery of the baby
should be achieved as soon as possible as problems with blood clotting and massive,
often life-threatening, hemorrhage frequently occurs.
Bleeding from placenta praevia is classically painless and the uterus is nontender.
The baby is usually still alive, despite there often being quite considerable hemor-
rhage. A vaginal examination should not be carried out in cases of suspected placenta
praevia as this may well precipitate massive vaginal bleeding. The diagnosis is
confirmed by ultrasound, which is increasingly available, or by vaginal examination
carried out in an operating theatre with the ability to carry out an immediate
Caesarean section. This condition carries a very high maternal mortality in the
absence of obstetric facilities, as the treatment is Caesarean section to deliver the baby
and an abnormally situated placenta.
538 Section Five
Sepsis is more common in women who have preexisting anemia or chronic infection
and in those women who have long difficult labors. If the baby has died or there has
been retained products of conception after delivery, the risk is further increased.
Hemorrhage may be sudden and severe after childbirth, and many women will
already be anemic and be particularly vulnerable to further blood loss, especially
those women who have had bleeding prior to delivery. (It is the antepartum hemor-
rhage that weakens and the postpartum hemorrhage that kills.)
Bleeding can occur before, during, or after delivery. If bleeding occurs before or
during labor, a wait-and-see policy should be adopted. If labor has advanced to the
second stage, low forceps delivery or vacuum delivery may be carried out if someone
of sufficient experience is available.
Bleeding after delivery of the baby (postpartum hemorrhage) may be profuse. Has
the afterbirth (placenta) delivered? Midwives and medical personnel will usually be
familiar with “controlled cord traction,” which involves gentle traction on the cord at
the same time lifting the uterus in the other direction toward the patient’s head. If this
is unsuccessful and bleeding continues a hand should be introduced into the vagina
to see if the placenta is sitting in the cervix. If so, the placenta may be grasped and
removed. If not and bleeding is continuing, rub up a contraction. If the placenta does
not deliver, an attempt should be made to deliver it by manual removal. This proce-
dure requires adequate analgesia or anesthesia, and involves the gloved hand being
passed into the uterus to separate the placenta from the wall of the uterus. The uterus
is steadied by the other hand controlling the uterus from above. The vaginal hand
passes around the placenta in the plane between the placenta and the uterus and
when the placenta has separated, it is removed from the uterus. The uterus is then
explored to check that there is no retained placenta. Blood clots should be removed,
an oxytocic agent given and a contraction rubbed up.
Many postpartum hemorrhages (PPH) can be prevented or at least controlled. The
strategies include:
Active management of third stage of labor by administration of oxytocin or another
uterotonic drug within one minute of delivery and controlled cord traction.
Uterine massage following delivery of placenta (rubbing up a contraction).
If uterine massage and a repeat dose of an oxtocic fails, the uterus should be com-
pressed between a fist in the vagina and a hand placed suprapubically behind the
uterus. The abdominal hand is on the posterior surface of the uterus and the fist is on
the anterior surface. This is uncomfortable for both the patient and the birth attend-
ant but is an effective means of controlling hemorrhage
In situation of unavailability of oxytocin and limited skills of birth attendant, miso-
prostol 600 μg orally, sublingually, or rectally can be used after the birth of the baby.
Await signs of separation of placenta, encourage mother to bear down with con-
tractions, and if necessary in upright position.
80% of post partum hemorrhages (PPHs) are due to the uterus failing to contract
(atonic post partum hemorrhage).
Misoprostol can also be used alone or in combination with oxytocin for treatment
of postpartum hamorrhage - dose is 800 mgs and is usually given rectally but may be
given orally or vaginally.
Other methods to control PPH include use of glove/condom tamponade. With

aseptic precautions, a sterile urinary catheter with the catheter balloon inflated
(usually with 10–30 cc of fluid) has a condom or operating glove tied behind the
catheter. This improvised balloon is inserted into the uterus and fluid pushed into the
condom/glove via the catheter usually using a large syringe and the glove/condom is
inflated. The condom is inflated with 250–500 mL or sometimes more of normal
saline until the bleeding stops. The condom catheter is kept for 12–48 h and then
removed. If there is further bleeding the catheter can be replaced without the need for
further analgesia. If the bleeding is not controlled by tamponade another source of
bleeding must be considered e.g., genital tract damage (uterine, cervical, vaginal, and
vulval).
Obstructed Labor
Women may have been in obstructed labor for several days before they present for
medical help. The baby will usually be dead, and the fetal tissues will then soften so
that a macerated infant will usually deliver spontaneously or with the assistance of
forceps. Obstructed labor in the Third World is a potent cause of maternal mortality
and morbidity. It can lead to infection, hemorrhage, and long-term damage to the
bladder and the bowel, resulting in loss of bladder and bowel tissue, with fistula for-
mation and resulting leakage of urine and feces through the vagina. This leads to the
woman being ostracized. Treatment consists of aiding delivery without causing fur-
ther damage to the woman, dealing with infection, and the reduction of long-term
morbidity, for example by the use of in-dwelling urinary catheters to reduce the risk
of fistula formation.
Obstructed labor in a woman who has delivered vaginally before is a particularly
dangerous situation as there is a high risk of uterine rupture, with the subsequent
death of the mother and baby. This situation requires experienced advice!
Conclusion
Women will always be involved in catastrophe and conflict and are likely to make up a
majority of the surviving population. It is not unusual to find that men have been
killed in wars or deliberately killed in ethnic cleansing. The person on site must be able
to contribute fully to the whole spectrum of disease affecting women. Life-threatening
gynaecological emergencies are dealt with like any other surgical emergency. Obstetric
emergencies need some specialist advice. The priority would be to save the mother’s
life. The fetus is secondary. In these areas, rape and sexual assault is wide-spread. In any
society, this is a difficult situation to manage, but it is often more difficult when operat-
ing in a different culture, particularly with language barriers. In some cultures, female
medical personnel may be more appropriate.
Women understand the cultural factors affecting the health services and therefore
should actively participate in planning and implementation of health care.
540 Section Five
Acknowledgments
Mr Jonathan Duckett and Mrs N K Jyoti
Further Reading
Akhter S, Begum MR, Kabir Z, Rashid M, Laila TR, Zabeen F. Use of a condom to control massive postpar-
tum hemorrhage. MedGenMed. 2003; 5(3):38.
Bailey P, Paxton A, Lobis S, Fry D.The availability of life-saving obstetric services in developing countries:
an in-depth look at the signal functions for emergency obstetric care. Int J Gynaecol Obstet. 2006;
93(3):285–91. Epub 2006 Mar 6.
Coomaraswamy R. Report of the special Rapporteur on violence against women, its causes and conse-
quences. UN Doc. E/CN.4/1998/54
Crossette B. Reproductive health and the Millennium Development Goals: the missing link. Stud Fam
Plann. 2005; 36 (1):71–9.
Gardam J. Women and the law of armed conflict. Int Comp Law Q 1997; 46:74.
Gardam J. Women, human rights and international humanitarian law. Int Rev Red Cross 1998; 324:421–32
Guidelines for treatment of sexually transmitted disease 1998. Centres for disease control and prevention.
Morb Mortal wkly Rep 1998; 47(RR-1):1–111.
Human rights violation against women in Kosovo Province. Amnesty International Report, EUR 70/54/98,
1998.
Lalonde A, Daviss BA, Acosta A, Herschderfer K. Postpartum hemorrhage today: ICM/FIGO initiative
2004–2006. Int J Gynaecol Obstet. 2006; 94 (3):243–53. Epub 2006 Jul 12.
Paxton A, Bailey P, Lobis S, Fry D. Global patterns in availability of emergency obstetric care. Int J Gynaecol
Obstet. 2006; 93(3):300–7. Epub 2006 Mar 6.
Petter LM, et al. Management of female sexual assault. Am Fam Physician 1998; 58:920–6,929–30.
Pittaway E, Bartolomei L, Rees S. Neglected issues and voices. Asia Pac J Public Health. 2007; 19 Spec No: 69.
Policy on refugee women, UNHCR, 1995; Sexual violence against refugees: guidelines on prevention and
response. UNHCR, 1995.
United Nations Department of Public Information. DP1/1772/HER, February 1996.
Women and War. International Committee of the Red Cross, 2007
M. Gavalas, S. Nazeer, Claire Walford,
and A. Christodoulides
● To outline the physiological differences between children

Objectives and adults.
● To discuss the impact of infectious diseases, malnutrition,
starvation, and environmental factors on the general health
of displaced children.
● To emphasize the physical and psychological vulnerability
of children facing adverse conditions.
● To highlight significant cultural and religious factors that
may affect children at risk.
● To form strategies for the prevention of long-term sequelae.
Introduction
In spite of the huge strides that have been made toward the improvement of health and
education in developing countries, old problems are continuously confronting new gen-
erations. In addition to war, poverty, and other sociopolitical factors, the most vulner-
able countries are also plagued by natural disasters. These disasters can strain resources
and overwhelm even the most affluent of societies. However, the consequences in
deprived societies can be profound, amounting to disaster in its true definition.
As always, children, the elderly, and the infirm are particularly at risk.
This chapter is concerned with children; earlier chapters have covered other vul-
nerable groups such as lactating mothers, the elderly, and the infirm (see Chap. 10).
Plainly, many of the problems covered in earlier chapters are equally relevant to chil-
dren. This chapter is concerned with important differences in assessment and care.
Important Principles in Caring

for Children in Adverse Conditions
Children are not small adults: they have unique anatomical characteristics. The skeleton
is immature, and therefore bone and joint injuries merit special care. Assigning low
priority to fracture care in the midst of major disaster can lead to skeletal growth
542 Section Five
deformity, and this may have serious long-term consequences that will be further
amplified in a vulnerable society. Growth can also be stunted due to metabolic and
nutritional factors. Further, serious intrathoracic and intraabdominal injury may
occur without evidence of bony injury – the best example is widespread contusion
injury to the lungs with no evidence of rib fracture. This is quite unlike adult patterns
of injury.
The ratio of body mass index to surface area (i.e., the size of the head is
disproportionately large as compared with body size) predisposes children to the
development of hypothermia and complications in fluid balance. This is complicated
by low body weight, relative absence of adipose tissue for insulation, and lack of
glycogen storage, which can have profound effects on the physiological well being
of children.
Drug dosages are dependent on body weight, and hence great attention to detail is
essential when prescribing. Additionally, tubes, catheters, cannulae, and other devices
must be proportionally smaller when used in infants and children. This is particularly
important when planning an aid mission where young children are numbered among
the victims.
A child’s psyche is as fragile as his physiological status. In the very young, emotional
immaturity can be heightened by the added instability brought about by famine,
natural disasters, war, and strife. Separation from loved ones can lead to regressive
psychological behavior. Although children generally adapt well to adverse conditions
and can easily bond with rescuers, they have a limited reserve when exposed to an
unfamiliar, let alone hostile, environment.
Confounding issues that may disrupt the delivery of care need to be considered and
may include the following:
● The nature of the disaster, i.e., natural or man-made
● Variations in climate
● Environment, i.e., urban or rural
● Infrastructure, which may be intact, compromised, or destroyed
● Political situation
● Transport and communications
The array of potential medical problems facing children is vast, and therefore a
framework using the following headings is used:
● Water supply, food, and sanitation
● Mass gathering
● Climate
● Infectious disease
● Bites and stings
● Trauma (physical injury)
● Miscellaneous
These issues are not unique to children, and further details for all ages can be found
in Chap. 17
Water Supply, Food, and Sanitation

The provision of clean water and adequate food for growth and nutrition is a daily
problem in the developing world. This is further complicated in conflict and disaster
situations. Consequently sanitation poses an even more difficult problem, especially
when vector control is a major health hazard. The well-being, growth, and develop-
ment of children depend almost entirely on access to a consistent and balanced intake
of fluids and nutrients.
Water
In considering water supply one must include not only drinking water, but also an
adequate supply for preparing food, personal hygiene and, where possible, play. The
physiological need for water is influenced by climatic conditions, and the presence of
fevers and infectious diseases. The absolute minimum fluid requirements of children
vary with age and weight. In children over the age of 1 year, weight may be estimated
using the formula weight (kg) = 2(age + 4). For the first 10 kg, the fluid requirement
per day should be 100 mL/kg body weight. For the second 10 kg, the fluid requirement
per day should be 50 mL/kg body weight, and for every subsequent kilogram the fluid
requirement per day is 20 mL/kg body weight. So for a child of say 22 kg, the daily fluid
requirement should be estimated as shown here:
● For the first 10 kg: 1,000 mL
● For the second 10 kg: 500 mL
● For the last 2 kg: 40 mL
Therefore, the total fluid requirement for a child of 22 kg is 1,540 mL/day.
Fever increases the requirements by 12% per degree Celsius rise in temperature.
Fluid loss due to vomiting, diarrhea, and burns needs to be replaced over and above
the daily requirement given earlier. Total fluid needs are in excess of these figures in
times of conflict or disaster. Aid organizations estimate that 20 L/person/day is the
minimum requirement if there is to be a positive impact on the health of compro-
mised populations. It may be of value to remember that native sources of fluids for
oral consumption, e.g., coconuts contain a nutritious and sterile supply of “water”;
watermelons and melons have a very high fluid content; cacti and other succulents
provide a source in desert conditions, etc.
Food
Infants and children are more vulnerable to undernutrition than adults. Amongst the
many reasons for this are low nutritional stores and high nutritional demands. The
smaller the child the smaller the calorie reserve and the shorter the period the child
is able to withstand starvation. At 4 months of age 30% of energy intake is used for
growth, but by 1 year of age this falls to 5%, and by 3 years to 2%. There can he no
doubt that breast milk is the best diet for babies, and it becomes even more important
544 Section Five
in situations of disasters and conflict when mothers should be encouraged to con-

tinue breast feeding well into the second year of life and beyond if nutritionally pos-
sible for the mother. Even amongst breast-fed children malnutrition can affect those
aged between 6 months and 6 years. Dietary requirements of this age group are fairly
stable throughout the world. On the basis of body weight, these children will require
approximately 100 kcal/kg/day of energy and 1.5 g/kg/day of protein for normal
growth.
Sanitation
An undesirable, albeit inevitable, consequence of overcrowding and poor living con-
ditions is fecal contamination of the water and food supply. For further detailed clari-
fication see Chap. 17.
Mass Gatherings
Large groups gather under normal circumstances for a variety of reasons including
religious events and pilgrimage, political rallies, sport and music events. Large-scale
planning and resourcing still do not prevent disease and illness even in an otherwise
healthy population. The displacement of huge numbers of people is an inevitable con-
sequence of major strife, conflict, and disaster. Communicable diseases become an
important problem in addition to trauma and separation (Fig. 32.1).
Although previously much effort was put into the restoration of lost children to
their family group, in recent times the emphasis has shifted toward the prevention of
separation in the first place (see chapter 33) .
Preventing separation is important because of the following:
1. Children have the right to be with their families.
2. Children are almost always better protected with and by their families.
3. Emotional disturbance is less if children are within a family unit during conflict
and catastrophe.
Separation can be prevented by the following:
1. Involving nongovernmental organizations (NGOs) such as Save the Children and
Oxfam in forward planning
2. Involving military agencies, particularly United Nations units who may be
involved in the initial care of displaced populations
3. All agencies involved following agreed policies and strategies when children and
their families are being evacuated from conflict and disaster zones
It is considerably more difficult and expensive to undertake replacement of lost chil-
dren with their families. If lost children are to be adopted, then cultural and religious
awareness is vital and should be done only after exhaustive investigations to locate
surviving family members.
Climate
Unless relocation of the victim population is to a foreign environment, the effects of
climate are largely a problem for the expatriate aid worker who lacks acclimatization.
More details on this topic can be found in earlier chapters.
Infection and Immunity

Gatherings amassed following major disasters and catastrophes are prone to a wide
range of illnesses. Various authors have used different classifications of communica-
ble diseases. A simple and useful classification is presented in Chap. 17. This chapter
highlights some specific conditions that present in childhood.
Infectious diseases, malnutrition, and dehydration are by far the most serious
threats to children in adverse conditions. Infections spread readily among children
and may reach endemic proportions during war and natural and man-made disasters.
Diseases due to intestinal infections are very common in the developing world.
Damage to water supply systems and leakage of sewage will significantly increase the
incidence of infectious diarrheal diseases. Under normal circumstances, approxi-
mately three million children die of such diseases each year and roughly 10% of the
world’s population harbors Entamoeba histolytica, with many more carrying other
gut parasites. Children suffer from the same spectrum of diarrheal diseases as adults,
but are more susceptible to dehydration and therefore malnutrition.
Common Childhood Infections

Measles
This common infection of children still kills over one million children in the world
each year. It is a highly infectious disease caused by a paramyxovirus found through-
out the world. Transmission is by droplets spread from nasopharyngeal secretions,
with the port of entry being the respiratory tract. Because the disease is spread by
active infection, massive vaccination programs have the potential to eradicate the
disease. In the Third World, measles is still endemic, but it can reach epidemic (almost
pandemic) proportions and become the number one killer of children after trauma,
given extra burden of strife, catastrophe, and disaster. Following exposure a child will
be symptom-free for 10–12 days, and having incubated the virus symptoms will begin
with a fever, cough, and conjunctivitis. As early as 2 days later white spots appear
inside the mouth (Koplik’s spots) and by 4 days there is a high fever and the typical
rash appears starting on the face, spreading to the trunk and arms and then reaching
the feet. By this stage the fever begins to fall and the rash begins to fade, leaving a
staining of the skin for several weeks. If the Koplik spots are not identified, the later
rash can be difficult to see in children with darker skins. If the fever persists after the
546 Section Five
rash has cleared, bacterial infection, mainly of the respiratory tract, should be sus-
pected and treated, as primary pneumonitis is uncommon but severe when it occurs.
Other serious complications of measles include the following:
● Diarrhea, which can rapidly precipitate severe malnutrition
● Encephalitis, which can be severe and occurs in 1% of cases
● Xerophthalmia, a vitamin A deficiency combined with the effects of measles caus-
ing a rapidly progressive loss of vision and blindness
● Otitis media, which is common but can be overlooked in the presence of other
more serious problems
Management of a child with measles is in the main dependent on symptoms. Vitamin
A therapy in high doses is imperative in compromised children. Secondary bacterial
infections are treated with appropriate antibiotics when available. Breast-feeding
should not be interrupted, but if it is not available a lactose-free formula should be
used to help the inflamed gut.
It is obvious that prevention is of the utmost importance, and therefore mass vac-
cination programs for children aged 6 months to 15 years must be instituted as an
absolute priority within the first week following a major disaster.
Other Common Childhood Diseases

The incidence of many other childhood infections may not necessarily be affected by
the extra consequences of disasters, but it is important to recognize the existence and
significance of those listed here (Fig 32.2):
● Rubella (German measles), which is a less severe illness in childhood. Its main
importance is in its ability to adversely affect the growing fetus inside a pregnant
woman.
● Varicella (chickenpox), which is a viral condition often considered to be a benign
childhood illness with significant complications in the older child and in the
immunocompromised individual.
● Poliomyelitis, which is uncommon in developed immunized countries but can be
a serious condition with high morbidity in unprotected mass gatherings.
● Mumps, in which orchitis (inflammation of the testicles) is the most feared com-
plication but only has serious connotations after puberty.
● Impetigo, which is a bacterial skin infection that spreads rapidly in childhood.
● Tuberculosis (TB): Roughly 500,000 children die each year worldwide from TB.
Nearly half of infants and 90% of older children will show minimal signs and
symptoms of infection. Initial droplet infection can occur as early as the first 2
months of life and causes a localized area of inflammation in the lungs (pneumo-
nitis) called a Ghon focus. Organisms contained within this focus are not always
killed and can be reactivated any time during the first year of life. Diseases such as
measles, chickenpox, malnutrition, and HIV infection all greatly increase the risk
of reactivation. Also, other organs of the body such as kidney, brain, and bone can
be seeded by blood-borne organisms. Reactivation is also possible at these sites in
early childhood (1–5 years of age). BCG vaccination should be part of the extended
program of immunization for refugees and mass gatherings.
Fig. 32.1. Azeri children refugee camp 1998 (photo **courtesy: PF Mahoney).
Fig. 32.2. Health screening Azerbaijan 1998 (photo courtesy: PF Mahoney).
Preexisting Disability
Sadly most natural and man-made disasters occur in already vulnerable areas.
The mortality and morbidity of children in developing countries are significantly
higher than those in the developed world.
Preexisting disability can be congenital or acquired. The higher incidence of con-
sanguinity, the lack of formalized antenatal care, and the inadequate provision of
548 Section Five
diagnostic and treatment facilities inevitably increases the incidence of significant

congenital abnormalities. The social and cultural attitudes toward the more visible
abnormalities may result in poor parenting owing to the already scare resources
being targeted toward the more healthy members of the family. This may result in
individuals who are less able to cope with the added consequences of disasters.
Previous to any disaster, a child can acquire almost any of the known diseases/
traumas of childhood. Acquired illness may be acute or chronic. Acute illnesses, such
as respiratory infections, urinary tract infections, and food poisoning, are short-lived
and can be managed at the time of presentation within the scope of limited resources.
Acquired illnesses with the problem of chronicity, such as asthma, diabetes, osteomy-
elitis, or eczema, require long-term management by specialists (pediatricians). Access
to specialist resources may be seriously compromised due to breakdown of the infra-
structure in areas affected by disasters. It is outside the remit of this chapter to
present any details of congenital and acquired conditions of childhood. Good, read-
able books on childhood diseases are readily available, and more information can be
gathered via internet sites referenced at the end of this chapter.
Environmental Hazards
Children everywhere need a safe, healthy, and loving environment in order to grow
and develop normally. Children in the midst of disasters share the common hazards
of children everywhere, namely accidents, poisons, and abuse. The risk of environ-
mental hazards is increased by the following:
● Poverty
● Overcrowding and lack of adequate shelter
● Poor parenting skills, made worse by the disruption of family units.
Childhood accidents depend on the child’s age and stage of development. Toddlers are
explorative and inquisitive, and by their sheer nature are unaware of the consequences
of their actions. They are prone to falls, burns and scalds, ingestion of harmful sub-
stances, drowning, stings and bites from various insects, snakes, and animals. Older
children experience a different range of accidents, such as falls from heights, deliber-
ate self-poisoning, and contact-sport injuries.
Burns and Scalds

In situations of mass gatherings fires for cooking and warmth are mostly open and
unguarded, increasing the incidence of burns and scalds in all children. Standard first
aid measures, such as ice and cold running water to the affected part, may not be avail-
able. In fact help may be delayed due to the absence of parents and adults. It is common
for babies and toddlers to be left in the care of older children while the adults forage
for food and shelter. The complications of burns and scalds are as follows:
● Infection of the injured area
● Scarring, contractures, and ensuing disability
● Fluid loss with severe extensive burns
Management strategies are reliant on assessment and replacement of fluid loss, pre-
vention of infection, and attention to the positioning and placing of joints and limbs
to avoid disabling contractures. Early input from specialists can reduce the level of
disfigurement and scarring and enable the child to be rehabilitated sooner. Such spe-
cialists may be provided by organizations such as the Leonard Cheshire Centre for
Disability and Development, Medecins Sans Frontieres, and many others. Further
information may be found in the “Resources section” of this handbook.
Traumatic amputation of limbs due to land mines, bombs, and incendiaries is com-
mon in children in war zones, but poses a different and difficult management problem
in adults. For example, regular reassessment and refitting of limb prostheses will be
required as the child grows. These children can become a huge economic drain not
only due to extensive use of resources and specialist treatment, but also due to lack of
earning power in adult life.
Bites and Stings

The incidence of bites and stings may be higher in children, particularly toddlers.
Most snakebites occur on the foot or hand, but painful bites at other sites may be from
spiders or scorpions. The identification and treatment of bites and stings are outlined
in the section on medical emergencies. It is important to emphasize that envenoma-
tion is rare following a bite, and if envenomated, systemic spread of the venom can be
delayed by immobilizing the limbs with splints and a firm but not constricting band-
age. Peripheral pulses should still be felt and the child should be kept as calm and
quiet as possible (see section Bites and Stings, pages 512 to 521)
Trauma
Burns and scalds have been discussed, but it is now appropriate to discuss some par-
ticular problems surrounding pediatric trauma in general. While the injured child is
approached in the manner described for adults, there are some special features that
need to be recognized.
Airway
Maintaining and protecting the airway is the most critical element of overall
management.
In managing the airway; the following key anatomical differences should be
noted:
● Small oral cavity and large tongue
● Large head that tends to flex when supine, resulting in “buckling” of the airway
● Large tonsils and adenoids
● Epiglottis at an acute angle, making visualization difficult
● Short trachea with a risk of inadvertent bronchial intubation
550 Section Five
Breathing
Children breathe faster than adults – the smaller the child, the faster the rate. An
infant breathes at a rate between 40 and 60 breaths per minute. With small tidal
volumes (7–10 mL/kg) and delicate tissues, great care must be taken when assisting a
child’s ventilation.
Chest decompression must be performed with appropriately sized pediatric can-
nulae and chest tubes. Otherwise management is similar to that for adults.
Circulation
The signs of blood loss may be cloaked for a time due to the child’s excellent physi-
ological reserves. When children finally decompensate, it is with precipitate speed.
Consequently, diagnosis of hypovolemic shock must be made as soon as possible and
treatment commenced as a matter of urgency.
Resuscitation volumes vary with body weight. A useful formula for calculating
resuscitation fluid boluses is 20 mL/kg body weight. This formula is for electrolyte
solutions, which must be warmed. Two to three boluses may be required. For sus-
pected significant bleeding, blood should be urgently cross-matched and a surgical
opinion sought.
The good news is that, in the main, the time-honored ABCD approaches works in
infancy and childhood provided that medical attendants recognize some important
anatomical and physiological variables.
Miscellaneous
Nonaccidental Injury
Any physical action that results in, or may result in, a nonaccidental injury to a child
and exceeds that which could be considered as reasonable discipline is classed as
physical abuse. Child abuse may also be due to sexual abuse, emotional abuse, or
neglect, and may present a combination of one or more of the above.
Child abuse is often the result of severe family stress, which is ever present in situ-
ations of strife and disaster. Accurate figures for child abuse are not available because
the problem is only just being confronted in the developing world. Mass gatherings
with young single parents coping in a setting of poverty and violence produce the
ideal social setting for an epidemic of abuse.
Conclusions
The most tragic consequence of conflicts and disasters is the loss of childhood. The
Western world is beset by natural disasters that present their own sequelae, but the
disproportionate incidence of natural and man-made disasters in the Third World
makes the normal development and progression of childhood an almost unachievable

target. Millions of children live in zones of conflict and become the main victims of
those conflicts. UNICEF has estimated that in the last decade alone more than two
million children have died as a result of war, and some 15 million children have been
displaced. In these very same zones, children are exploited by both sides in the con-
flict as child soldiers, sex slaves, and servants. Poor postconflict communities need
help in advance to prepare for returning soldiers, and programs must include meas-
ures such as fostering care to prevent recapture of the children by the armed forces.
Girls require especially vigilant care following forced exploitations, and being shunned
by their own community may drive them into further sexual exploitation and
prostitution.
Education, vocational, and employment opportunities are vital elements in the
return to civil society. One example is the use of glove puppets in play therapy. Role-
playing exercises help children to resolve their feelings.
The authors would like to direct the reader to the many interesting and informative
websites available on the internet. These are listed here, and include articles on easy
access to weaponry, exploitation of children, children’s rights, and the effects on chil-
dren of natural disasters such as famine, earthquakes, and flooding.
Web Sites
http://www.unicef. org/children httrfiwww.who.intieha
http://www.savethechildren.org/crisis http://www.ihe.org
N.B. Readers are directed to the “Resources section” for further study.
33. Conflict, Terrorism, and Disasters:
The Psychosocial Consequences for Children
Richard Williams and David Alexander
Introduction
Society expresses great repugnance when the media reports children’s involvement in
violence and disaster and particularly so if they are the perpetrators (Meyer 2007).
But, families are now in the front line of war, conflict and terrorism, as well as disas-
ters as a result of paradigm shifts in the nature of conflict and war (Greenacre 1942;
Smith 2005) and growth of terror as a weapon. There are opinions that civilians,
including children, are now deliberate targets. Employing children as soldiers contin-
ues, but is not new. Furthermore, resident and displaced populations, refugees, and
famine-affected peoples are caught up in conflict (Tai-Ann Cheng and Chang 1999)
and are particularly at risk of the psychosocial consequences of their displacement as
well as the events that caused their displacement.
“Some approximated facts relating to the decade 1993 to 2003 are as follows:
1. Two million children were killed and six million children were injured or perma-
nently disabled in war zones.
2. Of war-exposed survivors, one million children were orphaned and 20 million
displaced to refugee camps or other camps.
3. Civilians comprise 80–90% of all who die or are injured in conflicts – mostly chil-
dren and their mothers” (Barenbaum et al. 2004; Dyregrov et al. 1987).
Massed events “scar the memory of the individuals and communities they touch, they
have the capacity to forever change the character and life style of individuals and
communities, and they confront one’s perceptions of the world and individual and
collective vulnerability and strength” (Pfefferbaum 1998). However, despite this
gloomy beginning, many minors appear remarkably resilient.
This chapter provides a framework for understanding children’s experiences and a
stepped approach to intervention. It draws on papers by the authors (Williams 2006;
Alexander 2005, and Alexander and Klein 2003 and 2005). It takes into account the
concerns that Summerfield (2005) and others have expressed about the risks of
overmedicalizing concepts of and responses to trauma and of being too ready to impose
Western concepts and practices on non-Western societies after major disasters through
globalization of psychiatry. It also recognizes research on children after 9/11 and
554 Section Five
adolescents from Bosnia-Herzegovina and Croatia (Bergovac et al. 2004). It has

emphasized the wisdom of endeavoring to norma-lize children’s environments as
soon as possible by, for example, reinforcing family relationships and using educational
performance as a screening criterion in assessing children’s recovery and schools as
important places for intervention (Kia-Keating and Ellis 2007; Kirkley and Medway
2003; Lasser and Adams 2007).
Children and Terrorism, Conflict, Violence, and Disasters

Despite lengthy controversy about whether children and young people are more or
less or similarly vulnerable to the psychosocial consequences of traumatic events or
chronically unstable or abusive circumstances, it is reasonable to start by assuming
that children are at least as vulnerable as adults to the traumatizing effects of violence
(Edwards 1976; Lubit and Eth 2003; Shaw and Harris 2003; Ursano and Norwood
2003). However, despite our gloomy if realistic introduction, the resilience of minors
has also been shown to be remarkable.
Nonetheless, some children and adolescents can and do develop mental disorders
as a consequence of their exposure to and involvement in disasters and conflicts of all
kinds and many more become temporarily distressed. There is some evidence too
that catastrophes that affect our homes and sources of security and permanence, such
as flooding, have particularly powerful and longer-lasting impacts on us and on our
children.
The spectra of circumstances that traumatize children and their responses are very
wide, but there are patterns. Janoff-Bulman (1992) summarises the fundamental
assumptions that we ordinarily make (see page 360). Also, there is an extensive litera-
ture reviewing the direct and indirect psychosocial impacts of violence, serious ill
health, others’ deaths, divorce, accidents, and disaster on children and young people.
Bullying is one of the most common of childhood experiences of threat.
Children are likely to be multiply affected by conflict and disaster because they may be:
1. Direct victims of conflict and catastrophe
2. Indirect victims (as a consequence of the effects that disaster has on adults and
through compromising the abilities of carers and parents to look after, protect,
and nurture their children)
3. Perpetrators of violence (Williams 2007)
Traumatic events can be differentiated by their repetition or otherwise. Event trauma
refers to sudden, unexpected occurrences that are limited in time and space whereas
process trauma is characterized by continuing exposure to enduring stress such as war
and abuse.
Event trauma in childhood may produce classical posttraumatic symptomatology as
well as specific fears, anxiety and depressive symptoms, repetitive and regressive
behaviors, loss and grief, and developmental effects as well as changed attitudes to self
and others (Shaw and Shaw 2004; Terr 1991). Process trauma may produce posttraumatic
stress symptoms but also a spectrum of developmental, emotional, and behavioral
problems that are “associated with chronic stress and interweaving of the dramatic
experiences into the emerging personality” (Shaw and Shaw 2004).
Furthermore, exposure to conflict, displacement, and disaster may imperil, or,

perhaps, surprisingly, enhance children’s development. The notion of resilience to
disaster, violence, and all kinds of traumatic events is developmental, personal,
relational, and interactive (see Chap. 22). While there is strong evidence that exposure
to disasters and adversities in childhood may detract from resilience in the longer
term (Cabrera et al. 2007), sometimes it may be enhanced. In one large study, 75% of
Israeli adolescents exposed to one or more terror incidences reported feelings of
growth while 41% reported mild to severe posttraumatic symptoms (Laufer and
Solomon 2006).
However, repeated exposure of children and young people to continuing or repeated
disaster may result in cyclically negative effects on their reactions and also have long-
term effects on their ability to cope with stress when adults. Childhood adversity is
associated with poor adult mental health and may have a graded association with a
range of negative health outcomes (Iversen et al. 2007). Recent research, for example,
has shown that vulnerability preenlistment (based on recall of negative family
circumstances, relationships, and experiences when a child) is an important risk fac-
tor for ill health in military men and that these factors are important in understand-
ing postcombat psychiatric disorder (Iversen et al. 2007). How children are helped to
prepare for and cope with disasters is likely to be an important influence on whether
their paths are toward growth or greater risk.
Shaw and Harris (2003) observe that children’s psychological responses to over-
whelming stress are determined by the following:
● Biological factors
● Psychosocial factors
● Level of emotional and cognitive development
● Degree (i.e., intensity and duration) of exposure to stressors
● Degree of injury or life-threat
● Losses of family members
● Disruption of continuity of communities/schools/families
Barbarin et al. (2001) quote research showing links between proximity to violent
events and degree of psychosocial distress. They propose a principle of social propin-
quity in which expectations of directly experiencing violence increase when it occurs
to someone with whom a child has a relationship or identifies. Thus, violence affect-
ing families appears to have greater effects than violence in the community.
Terrorism and Children

There is no satisfactory definition of terrorism. Alderdice provides a good review of
its psychology (2007). The US Department of Justice defines terrorism as “the unlaw-
ful use of force or violence against persons or property to intimidate or coerce the
government, the civilian population, or any segment thereof, in pursuance of political
or social objectives” (1996). Terrorism has the aims of the following:
● Creating mass anxiety, fear, and panic
● Creating helplessness, hopelessness, and demoralization
556 Section Five
● Destroying our assumptions about personal security

● Disruption of the infrastructure of society, culture, or city
● Demonstrating the impotence of the authorities to protect the ordinary citizen
and his or her environment (Alexander and Klein 2003)
These effects are likely to weigh on children as much as on adults. Lubit and Eth
(2003) studied the responses of children to the events of September 11, 2001 finding
that affected people “… were likely to have been overwhelmed by the blitz of media
coverage and feelings of increased vulnerability.” The severity of the traumatic event,
degree of exposure, the developmental stage of each child, lack of family support,
social disorganization, and the degree of life disruption are important predictors of
them developing chronic posttraumatic symptoms (Yehuda and Hyman 2005).
Children Exposed to War as Victims and Soldiers

Barenbaum et al.’s (2004) review of the literature to 2003 on the psychosocial aspects
of children exposed to war is excellent.
It is a war crime to recruit children under 15 to armed forces or employ them in
combat and 18 is the minimum age, in law, at which at which people may be directly
involved in warfare. Nonetheless, using children as soldiers has a long history and is
still widespread. They may be employed in a number of logistic roles as well as in
combat. Barenbaum et al. (2004) summarize the motivation for survival and the eco-
nomic, cultural, social, ideological, and political pressures on children who become
soldiers. They also provide an account of how children are indoctrinated and hard-
ened. A particularly compelling and authoritative source of information about young
combatants, their entry into armed groups, the invisible wounds, their transition to
civilian life, and community reconciliation is provided by Wessells (2006).
There are particular threats to children’s development that stem from them being
perpetrators of violence and from their exposure to violence and brutality while they
are learning control of their own impulses and aggression (Shaw and Harris 2003).
Subsequently, on putting down arms, children’s moral outcomes may be related to the
length of time that they spent in an armed group and whether they see themselves as
victims and express remorse, or continue to use violence to exert control (Barenbaum
et al. 2004). Williams (2007) has drawn on the work of Shaw and Shaw and others to
summarize the factors that affect children’s responses. They include the following:
● The intensity, type, and duration of the traumatic experience
● The degree of participation in forced military activities
● Whether or not they were involved in victimization by mutilation
● Whether or not they witnessed the killing of their parents, family members, and
other villagers
● The increased risk of displacement faced by child combatants
● The difficulties of returning child soldiers to their communities given the events
in which they have been involved
● The children’s developmental phases at the time
● Children’s fantasy lives and their interpretation of events
The Nature of Psychosocial Problems

Affecting Children and Adolescents
Factors Affecting Children’s Reactions to Disaster and Conflict
Children’s reactions to disaster and other traumatic events are individual and vary
according to their:
● Age and developmental level
● Proximity to the events
● Exposure to events that impact on family members and whether those family
members have been directly affected or not
● Personal, family, and material losses
● Families’ and communities’ responses
As regards age and developmental level, “Pre-school children are said to be less aware
of the nature and meaning of threat, rely on ‘parental-referencing,’ and may become
disorganised in their emotions and behaviour, and lose some of their developmental
capacities such as bowel and bladder control. School-aged children have greater …
appreciation of the dangers, may be disrupted in their sleep, appetite and academic
performance, and lapse into a variety of anxiety, depressive and somatic disorders.
Adolescents may show more adult-like responses, with an open fear of death, or a
hedonistic resort to impulse, delinquent, sexual, substance misusing, acting-out
behaviours that add to the danger … They may lose faith in all adult security and
sink, ultimately, into an apathetic or angry rejection of authority” (Shooter 2005).
Staged or Phased Responses

Children’s and young people’s reactions also vary with the time that has elapsed after
an event. A number of authors talk of phasic processes through which people may
pass in their adjustment after disastrous circumstances (Tyhurst 1951; Raphael 1986).
“Therefore, what one may see when looking at children after episodic or recurrent
violence depends on where they are in their personal trajectory of [experience and]
recovery that involves responding to the impact, recoil afterwards followed by a
longer period of adjustment” (Williams 2007).
Immediate and Short-Term Distress

There is no reason to believe that children are not subject to the full range of potential
immediate reactions including the following:
● Stunning and numbness
● Anxiety and fear
● Horror and disgust
● Anger
● Loss of trust
558 Section Five
● Demoralization, hopelessness, and helplessness

● Survivor and performance guilt (Alexander and Klein 2003)
While children are remarkably resilient to traumatic events, commonly they have
temporary short-term reactions as a component of their resilient response. They may
regress behaviorally and/or emotionally immediately after traumatic events, but, usu-
ally, recover fairly promptly. Short-term behaviors and feelings (see Fig. 33.1) are
commonplace in children and constitute what might be termed anticipated reactions
or distress. Usually, they ameliorate reasonably quickly with passage of time and pro-
vision of adequate family, community, and school support.
When reactions of this nature are temporary and diminish gradually after events
subside or when the people affected are provided with adequate support, they may be
best considered to be a form of distress.
Usually, we advise that someone should not be considered to have a mental disorder
unless an adverse condition persists for a substantial period after the impacts of trau-
matic events or situations have been relieved and/or if a person is precipitated into a
persisting disorder, which meets the requirements for caseness in a classification
system (e.g., the ICD10) (Horwitz 2007).
Short- to Medium-Term Responses

While most resilient children gradually return to previous or changed patterns of
adjustment, others may also develop more enduring symptoms of mental disorder.
Conventional Western diagnoses in the short- to medium term include the following:
Emotional reactions Cognitive reactions

Shock and numbness Impaired memory
Fear and anxiety Impaired concentration
Helplessness and/or hopelessness Confusion or disorientation
Fear of recurrence Intrusive thoughts
Guilt Dissociation or denial
Anger Reduced confidence or self-esteem
Anhedonia Hypervigilance
Social reactions Physical reactions

Regression Insomnia
Withdrawal Hyperarousal
Irritability Headaches
Interpersonal conflict Somatic complaints
Avoidance Reduced appetite
Reduced energy
Fig. 33.1. Anticipated psychosocial reactions to trauma (adapted from Alexander 2005).
● Acute stress responses including acute stress disorder

● Conduct problems
● Psychiatric disorders including the following:
– Adjustment disorders
– Anxiety and phobic disorders
– Depressive disorders
– Substance misuse
– Somatoform disorders
– Affect regulation problems
Williams (2006) has summarized the symptoms of acute stress responses. Figures
33.2–33.4 are reproductions from his publications and they draw on the WHO/SEARO
Physicians Manual (2005c) and a number of other sources (Barenbaum et al. 2004; Lubit
and Eth 2003; Sphere Project 2004; Ursano and Norword 2003; Ursano et al. 2003).
Irritable, crying excessively

Clinging
Intense fear and insecurity
Excessively dependent behaviour
Fear of water – including water used for domestic purposes
Excessive quietness and withdrawn behaviour
Thumb-sucking, bedwetting, excessive temper tantrums
Play activities spontaneously involving aspects of the disaster
Frightening dreams and waking frequently
Fig. 33.2. Preschool children (reproduced from Williams 2006).
Feeling nervous and unable to concentrate

Attention and learning problems
Loss of interest in studies, school refusal, reduced academic performance
Withdrawal
Guilt
Feelings of failure
Anger, rage and aggression
Fearfulness, anxiety or suspiciousness
Low mood, decreased activity and interaction level
Irritability, arousal, insomnia and loss of appetite
Recurrent fear
Recurrent memories or fantasies of events leading to avoidance of reminders
Reactivation or intensification of specific fears
Fantasies of playing ‘rescuer’
Intense pre-occupation with details of events
Unexplained abdominal pain, headache, vomiting, rapid breathing or fainting
Dependent and regressed behaviour
Fig. 33.3. School-age children (reproduced from Williams 2006).

560 Section Five
Similar to children
In addition, young people may claim that “there is nothing wrong”
Young people may show:
• Diffuse excitation;
• Oppositional behaviour;
• Changes in preferred relationships;
• Risk-taking.
Fig. 33.4. Adolescents (reproduced from Williams 2006).
Medium-, Long-Term, and Chronic Responses

Responses that pass beyond a number of months include the following:
● Mental disorders including the following:
– Anxiety and phobic disorders
– Depressive disorders
– Adjustment disorders
– Substance misuse
– Conduct disorder
– Somatoform disorders
– Attention deficit hyperactivity disorder
– Posttraumatic stress disorder (PTSD)
Pynoos et al. (2007) provide an introductory overview of the psychiatric effects of
disasters on children and their management. The prevalences reported for PTSD in
children are variable, and population-based surveys may overestimate it. Yule (2001)
and Tareen et al. (2007) provide good overviews of PTSD in children and adolescents.
Comorbidity is common in minors who do develop a disorder meaning that
affected children have problems that fall into more than one category or more than
one domain in their lives (Shaw and Shaw 2004). They are likely to have problems in
nonhealth arenas including, particularly, their family and social relationships, schooling,
substance use, and attitudes toward risk-taking. Comorbidity is particularly common
when PTSD is the main diagnosis and that diagnosis may not be sufficient to explain
children’s responses to trauma for reason of co-occurring problems in other parts of
their lives (Levin 2006).
Effects on Psychological and Emotional Development

Disaster and conflict may have long-term effects on children’s psychological and emo-
tional development. Figures 33.5 and 33.6 (based on Dalgleish et al. 2005; Lubit and
Eth 2003; Ursano and Norwood 2003; Ursano et al. 2003) summarize these potential
impacts.
• Affect control
• Identity
• Perception of the world
• Perception of self, self-esteem & self-efficacy
• Trust
• Safety
• Interpersonal skills
• Interpersonal relations
• Moral development
Fig. 33.5. Possible areas of effect on children’s psychological development (reproduced from Williams 2006).
• Reflecting on own feelings

• Painful memories
• Poor impulse control
• Preoccupation with/compulsive repetition of aggression
• Risk-taking
Fig. 33.6. Possible areas of effect on children’s emotional development (reproduced from Williams 2006).
Interventions
A Stepped Approach to Care and Intervention
Elsewhere, Williams (2007) has drawn attention to the importance of cultural sensi-
tivity in mounting services for children and families after disasters, including their
experience of violence. There is a tension between opinion leaders. Advocates of
“cross-cultural universality” argue that syndromes hold true across cultures. They
may recommend broad application of screening, assessment, diagnostic, and
intervention techniques that have been developed in Western approaches to mental
healthcare. Proponents of “cultural specificity” argue that the significance of
experiences should be understood in relationship to the culture from which affected
people come.
“In order to provide culturally sensitive assessment and treatment, it is essential to
understand cultural practices and have local knowledge of the community. Delivery
of mental health intervention in non-Western settings needs to incorporate prevailing
cultural norms, including spiritual or religious involvement, basic ontological beliefs,
and related issues. Culturally sensitive diagnostic approaches are needed to assess
trauma symptoms and associated impairment. Immediate relief operations can start
with non-specific interventions to help groups of affected individuals organise
562 Section Five
around issues of feeling safe and promote perspectives for the future that involve
mastery and engagement in rebuilding. It is important to instruct parents and teachers
in recognising children’s distress and applying appropriate strategies to address
children’s needs. Intervention considerations and their scope should be community
orientated to prevent normalisation of life and active child involvement” (Barenbaum
et al. 2004).
The approach summarized here incorporates those principles into a stepped approach
in which interventions of graded specialization are titrated progressively against need.
They should begin with providing social support and restoration of the environment
and progress through psychosocial services provided by community organizations to
primary care and, eventually, to specialist care in the following manner:
1. Promoting resilience through psychological first aid
2. First-level psychosocial services provided by primary responders supported by
expert advisers
3. Delivering community mental health services
4. Providing specialist psychiatric and psychotherapeutic services
Greenwald (2005) has published a practical handbook on helping trauma-exposed
children. Other sources of information are available from the American Academy of
Child and Adolescent Psychiatry (a, b, c) and the National Collaborating Centre for
Mental Health (for England and Wales) (2005). O’Donnell et al (2007) have described
the development and testing of training about trauma for school staff and other
community providers of children’s services.”
The World Health Organization has produced a similar stepped model of psycho-
social care in response to the tsunami in South East Asia (WHO Regional Office for
South-East Asia 2005a, b). It is based on: (a) first, family and community care, (b)
second, primary mental healthcare provided by trained community workers, (c) third,
secondary mental healthcare delivered by psychologists and other staff; and (d)
fourth, very specialized interventions delivered by psychiatrists.
The Sphere Project (2004) has codified a framework for corporate and clinical gov-
ernance. This emphasizes core principles of good practice. It advises that special
measures (summarized in Figs. 33.7 and 33.8) be taken with respect to children and
adolescents.
Psychological First Aid

There is much in common with the approach recommended by Sphere and the con-
tents of psychological first aid (PFA). Its core components are summarized in Fig.
33.9. The National Child Traumatic Stress Network and National Center for PTSD
(2005) has manualised PFA for children.
It is difficult to distinguish the reactions of people who are resilient, but experienc-
ing distress after events from others who have an acute stress disorder, or from the
reactions of the children who are developing long-term problems, including mental
disorders. So, we support adoption of the principle of an initial 4-week period of
watchful waiting prior to specialist intervention after disasters that affect children.
This 4-week wait applies to psychiatric interventions rather than to more general
psychosocial responses that are intended to promote recovery and reintegration and
restoration of communities. We emphasise that we are not recommending that chil-
dren do not receive any services in those 4 weeks. Indeed, it is important that they do
receive sensitive responses throughout. Furthermore, the services that are provided
should follow the general approach enunciated by the Sphere Project and should be
based on the principles of PFA.
Ensure infants/children remain close to their mothers/families

Ensure adequate nutrition and meet all physical needs
Encourage and help families to re-establish children’s previous routines with eating, playing,
studying, sleeping and interacting with others
Engage children in activities: drawing, storytelling, drama, games (do not encourage too
strongly children to express disaster-related feeling; allow children control over the
decision whether or not to think about the trauma and to express feelings about it)
Encourage families (in groups) to facilitate the play activities and especially the group
games of their children
Advise families/community leaders to recommence teaching school-age children until they
are able to return to their usual schools
Advise parents and families not to discourage children when they verbalize their feelings
Fig. 33.7. Children (reproduced from Williams 2006).
Ensure privacy and confidentiality while interviewing adolescents

Be cautious about gender sensitivity issues (including interaction with
them and physical touching)
Help adolescents to decide their future courses of action
Encourage secondary and higher-education students to continue
formal education
Involve young people in forming community groups
Encourage older adolescents to participate in humanitarian activities
Fig. 33.8. Adolescents (reproduced from Williams 2006).
Comfort and consolation

Protection from further threat and distress
Immediate physical care
Goal-oriented and purposeful behaviour
Helping reunion with loved ones
Sharing the experience (but not forced)
Linking survivors with sources of support
Facilitating a sense of being in control
Identifying those who need further help (triage)
Fig. 33.9. Psychological first aid (reproduced from Alexander 2005).

564 Section Five
Conclusion
Children are developing people, and their experiences in combination with their
genetics are vitally formative in shaping the adults that they become. Universally,
adults wish to protect children. This allows us to take an optimistic position about
how most children cope with trauma and adversity. Nonetheless, there are also many
awful things that societies do to put children more at risk, and lapses in their care and
protection of children are reported recurrently. Also, we have to face the fact that a
tiny proportion of young people may become perpetrators of serious violence, abuse,
and atrocities.
Children are remarkably resilient, and most of the impacts on them can be under-
stood as manifestations of short- to medium-term distress. However, other impacts
on a smaller proportion include developing mental disorders in the short and
medium terms and, in this group of younger people, anxiety and depressive and
behavior disorders are not uncommon. Others may develop long-term disorders
including PTSD.
Although the paradigm presented in this book is that of taking resilience as the
default condition and we are optimistic about people who are more profoundly
affected making good recoveries, the risks of developing a disorder emphasize the
importance of the following:
● Providing children with adequate family, peer, and school social support
● Endeavoring to normalize the affective, if not the material, environments in which
minors live as soon as is possible
● Being aware of children’s emotional, social, cognitive, and physical needs and of
responding to those needs effectively
● Responding purposefully and effectively when children and young people develop
mental disorders
Resilience is a developmental characteristic. That capacity for being robust in the face
of challenge may be adversely affected when people are exposed to overwhelming
events during childhood. Thereby, the effects of continuing adversity on development
may lead to more profound long-term risks that extend into adulthood. These nega-
tive developmental effects appear more likely if children experience repeated or
repetitive “process” trauma or live in unpredictable climates of fear. These experi-
ences may, in turn, affect how adults respond to challenge and adversity later. Thus,
the legacy of traumatic experiences in childhood may be very wide ranging from
strengthening their development through to long-term impairment. So much turns
on how adults respond (Nugent et al. 2007; Ostrowski et al. 2007).
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SECTION
6
Introduction: Resources
James M. Ryan, Adriaan Hopperus
Buma, and Peter F. Mahoney

A – Checklists, Suppliers And Specialists advice
B – Publications
C – Internet
35. Rehabilitating diagnostic laboratories
36. Enablers and confounders
38. Accreditation in field medicine
Annex: DMCC Competencies
39. Humanitarian Work In The Era Of Modernising Medical Careers
570 Section Six
This section provides the reader with advice on where to find suitable equipment for
deployment and additional information. The enablers and confounders and ministry
overlaps are included as examples of real-life complexity in the deployed environment.
The section also includes background information on the DMCC examination.
James I.D.M. Matheson and Adriaan Hopperus
Buma
Part A – Checklists, Suppliers, and Specialist Advice
Checklists
Prepacked first aid kits are available from suppliers (see suppliers and internet resources)
but many will wish to customise their medicines and equipment, adapting to locations,
logistics, and length of tour. It is assumed that the deploying organisation will provide medi-
cines for the population at risk, and the following recommendations are for personal use.
Medicines
Pack all medicines with care, label them and, if possible, keep them in the containers
used for initial dispensing. Check expiry dates.
Detailed lists of commonly needed medicines, including their dosage schedules, can
be found in many of the manuals and guides listed in the chapter on publications and
on websites listed later.
N.B. Non-medically qualified personnel should seek pharmaceutical and medical
advice in choosing items for packing, storage, and use.
As a rule, your pack should include the items listed here:
● Analgesics
● Antacids
● Antibiotics – take expert advice on choice and routes of administration
● Antidiarrheal tablets and electrolyte replacement salts
● Antiemetics (for nausea and travel sickness)
● Antifungal creams and powders
● Antihistamine tablets and rub-in creams
● Anti-inflammatory tablets and creams
● Antimalarials
● Antimountain sickness if at risk
● Antiseptic ointments, creams, liquid sachets, or sprays
● Antiworm medicines – take advice on choice
● Bite and itch lotions or creams
572 Section Six
● Cold sore medicines – take advice

● Drops for sinusitis
● Eye drops and ointments
● Insect repellents – pure DEET liquid, spray, or gel
● Laxatives
● Sleeping medicines – take advice
● Suntan lotions/creams and sunscreen creams
● Lip salve
● Vaginal infection medicines – take advice
● Water purification tablets or solutions
N.B Check drug restrictions at all airports/ports en route
First Aid and Life Support

If making up your own packs, consider the following items:
First Aid Pack

● Contents list and documentation for customs and security checks
● Cotton wool
● Crepe bandages – various lengths and widths
● Medi-swabs
● Nonadherent wound surface dressings
● Safety pins
● Scissors
● Sterile gloves
● Steristrips for wound closure – various sizes
● Tapes – micropore and zinc oxide
● Triangular bandage
● Tweezers (tissue forceps) – toothed and nontoothed
● Wound cleaning antiseptic solutions, creams, and powders
● Wound dressing pads and gauze
● Wound plasters and Band-Aids
● Compeed (blister plasters)
Life Support Pack

● Airway maintenance devices – oro- and nasopharyngeal devices
● Cannulae for needle decompression – tension pneumothorax
● Chest drains (trained personnel only)
● Interosseous needles for children under 6 years
● Intravenous (IV) administration sets
● IV solutions – electrolyte or colloid
● Large-bore vascular cannulae (nos. 12, 14, 16 for adults, nos. 18, 21, 23 for children)
● Large wound pads for hemorrhage control
Introduction: Resources 573
● Needles and syringes – various sizes

● Selection of basic limb splints (if space allows).
Aids Prevention
If you are going to an HIV or Hepatitis B prevalent area, specialist packs containing
sterile needles, IV administration sets, and IV fluids can be purchased. Postexposure
prophylaxis (PEP) packs can be purchased or borrowed from some hospitals’ occupa-
tional health services in case of HIV exposure while abroad.
Dental Health
You should also consider taking an emergency dental kit containing emergency dress-
ings for lost fillings, temporary filling material (zinc oxide eugenol), analgesics, and
antibiotics. Some kits contain material for temporary replacement of crowns, bridges,
and caps.
Medical and Related Equipment Suppliers

Although many organizations deploying expatriate staff will provide necessary drugs
and equipment for the volunteer’s personal use, many people will wish to carry their
own emergency pack. A selection of suppliers’ contact details is provided later and
further details may be available online – see internet resources section.
– ECHO International Health Services Ltd, 2 Ullswater Crescent, Coulsdon, Surrey,
CR5 2HR, UK, 0208 8660 2220. Books, equipment, training material, and drugs.
– Interhealth, Ground Floor, 111 Westminster Bridge Rd, London, SE1 7HR, UK, 0207
9029000. Travel clinic, advice, and health supplies.
– The Hospital for Tropical Diseases (see specialist advice section for contact
details).
– MASTA Ltd (see specialist advice section for contact details).
– Mission Supplies Ltd, Airport House, King’s Mill Lane, South Nuffield, Surrey RH1
5JY, UK, 01737 823812. Items for overseas expeditions procured and shipped.
– Nomad Travellers Stores, 3–4 Wellington Terrace, Turnpike Lane, London, N8 0PX,
0208 889 7014. Multiple other locations. Travel kit, medical supplies, and
vaccinations.
– SAFA (Safety and First Aid)-Ips Healthcare, 17 Chesford Grange, Woolfton,
Chechere, Warrington, Cheshire, WA1 4RQ, UK, 0845 2302099. First aid and health-
care supplies.
– SP Services (UK) Ltd, Unit D4, Hortonpark Estate, Hortonwood 7, Telford,
Shropshire, TF1 7GX, UK, 01952 288999. Medical, first aid, and emergency rescue
equipment.
– Stanfords, 12–14 Long Acre, Covent Garden, London WC2E 9LP, 0207 78361321.
Maps and travel guides.
574 Section Six
Centres and Organizations Offering Specialist Advice

N.B. Phone numbers and addresses, while correct at the time of writing, may change.
Many organizations will have websites (see internet resources section) with up-to-
date contact details.
United Kingdom
– British Foreign and Commonwealth Office, Travel Advice Unit, King Charles St,
London, SW1A 2AH, UK, 0845 8502829. FCO travel advice.
– Department of Health, Public Enquiries Office, Richmond House, 79 Whitehall,
London, SW1A 2NS, UK, 0207 2104850.
– London School of Hygiene and Tropical Medicine, Keppel St, Bloomsbury, London,
WC1E 7HT, 0207 76368636. Specialist advice – for legal reasons, will not advise the
general public.
– The Hospital for Tropical Diseases, Capper St, off Tottenham Court Rd, London
WC1E 6AU, 0207 3889600. 24-h advisory service, 0207 79507799. Consultant-led
clinics, advice, vaccinations, and travel products.
– MASTA Ltd Registered Office, Moorfield Rd, Yeadon, Leeds, LS19 7BN. MASTA
travel clinics are a network of nurse-led immunization centers offering health risk
assessments, vaccinations, malaria prophylaxis, and first aid kits.
United States of America

– Centers for Disease Control and Prevention, Travellers Health Section, 1600 Clifton
Rd, Atlanta, GA30333, USA, Tel. 877-FYI-TRIP. Travel health advice.
– The International Association for Medical Assistance to Travellers, 1623 Military
Rd #279, Niagara Falls, NY 14304-1745, Tel. 716 754 4883. Travel health advice.
Requires (free) membership.
The Netherlands
Landelijk Coördinatiecentrum Reizigersadvisering, Postbus 1008, 1000 BA Amsterdam.
Internet: http://www.lcr.nl/
International
World Health Organization, 1211 Geneva, Switzerland (see internet resources).
Part B – Publications
Introduction
The publications listed in this chapter are in addition to references and further read-
ing recommendations at the end of other chapters in the handbook. Specialist book-
shops will carry a range of the weight of publications in the field of humanitarian
operations. The questions are what to read, what to buy and what to take on
deployments?
Publications covering topics in the field of medical care in hostile environments
subdivide into clearly recognizable categories.
Reference Texts
These can be large, specialized, and often expensive. As larger texts with multiple
authors can take years to prepare, some information may already be out of date on
publication – they are, however, usually the best source of core knowledge. For the
impecunious aid worker they are best not purchased, but consulted in a local library.
Handbooks, Manuals, and Vade Mecums

These can be specialist or general, usually affordable but often hard to access. Some
are water-proofed and suitable for deployment, and shorter publication times mean
that they are more likely to be up to date.
Journal Articles
These include editorials and reviews as well as scientific and evidence-based papers.
They are likely to provide the most up-to-date information and many are listed at the
end of chapters in this handbook.
Monographs and Position Papers

These are often produced by NGOs in-house and may be difficult to access, although
sometimes also available on agencies’ websites. They tend to be mission- or subject-
specific.
Mission Reports
Mission-specific reports are often produced by NGOs and may be more easily
accessed online than in hard copy.
576 Section Six
Guidelines and Schedules

A broad and expanding spectrum is covered by publications from government, aca-
demic, NGO, and IGO sources. Care should be taken in establishing a hierarchy of
sources in the event of conflicting advice.
Pamphlets and Booklets

Produced by various agencies as above, they typically contain advice on specific topics
such as vaccination and protection against communicable disease.
Recommended Publications
This list includes material that the authors and their colleagues have found useful but
it is far from complete and the pool from which it is drawn is rapidly expanding. The
individual’s skills and information requirements will vary as will their need for fur-
ther reading.
Reference Texts
Politics and Law
1. The Globalization of World Politics: An Introduction to International Relations. J.
Baylis et al. Oxford University Press, Oxford, 2004. ISBN 0199271186.
2. The Practical Guide to Humanitarian Law, revised edition. F. Bouchet-Saulnier.
Rowman & Littlefield, 2006. ISBN 0742554953.
3. Questioning the solution – the politics of primary health care and child survival.
D. Werner, D. Sanders. Healthwrights, California, 1997. ISBN 0965558525.
Preventive Medicine
1. Disease Control Priorities, 2nd edition. D.T. Jamison, editor. The World Bank, US,
2006. ISBN 0821361791.
2. Disease Control Priorities Related to Mental, Neurological, Developmental and
Substance Abuse Disorders. World Health Organization, Geneva, 2006. ISBN
924156332X.
Psychological Medicine
1. Critical Incident Debriefing: Understanding and Dealing with Trauma. F. Parkinson.
Souvenir Press, London, 1998. ISBN 0285633724.
2. Critical incident Stress Debriefing: An Operations Manual for CISD, Defusing and
Other Group Crisis Intervention Services, 3rd edition. J.T. Mitchell, G.S. Everly.
Chevron Pub Corp, 2001. ISBN 1883581192.
Terrorism
Globalisation, Democracy and Terrorism. E. Hobsbawm. Little, Brown, 2007. ISBN
0316027820.
Victims of Torture
Guidelines for the examination of survivors of torture, 2nd edition. Produced by the
Medical Foundation for the Care of Victims of Torture, 111 Isledon Rd, Islington,
London, N7 7JW, UK. www.torturecare.org.uk
Trauma, Surgery, and Obstetrics

1. Surgery for Victims of War, 2nd edition. ICRC Publications, Geneva, 1990. ISBN
2881450105.
2. Primary Surgery, Volume 1: Non-Trauma. M. King, P.C. Bewes, J. Cairns, J.
Thornton, editors. Oxford University press, Oxford, 1990. ISBN 0192616943.
3. Primary Surgery, Volume 2: Trauma. M. King. Oxford University Press, Oxford,
1987. ISBN 019261598X.
4. Ballistic Trauma: A Practical Guide, 2nd edition. P.F. Mahoney, J. Ryan, A.J. Brooks,
W.C. Schwab, editors. Springer-Verlag, London, 2005. ISBN 185233679X.
5. War wounds of limbs – surgical management. R.M. Coupland. Butterworth-
Heinemann, Oxford, 1993.
6. Obstetrics in remote settings: practical guide for non-specialized health profes-
sionals. A.S. Coutin et al., editors. Medecins Sans Frontieres, Paris, 2007. ISBN
290649863767X.
7. Minor surgical procedures in remote areas. Medecins Sans Frontieres, Paris, 1989.
ISBN 2218021633.
Medicine and Tropical Diseases

1. Lecture Notes on Tropical Medicine, 5th edition. G.V. Gill, N. Beeching. Blackwell,
Oxford, 2004. ISBN 063206496X.
2. ABC of AIDS, 3rd edition. M. Adler. BMJ Books, London, 2002. ISBN 0727907611.
3. Manson’s Tropical Diseases, 21st edition. G.C. Cook, A.I. Zumla. Saunders,
Philadelphia, PA, 2002. ISBN 0702026409.
4. ABC of Healthy Travel, 3rd edition. E. Walker, G. Williams. BMJ Books, London,
2002. ISBN 0727902253.
578 Section Six
5. ABC of Sexually Transmitted Diseases, 3rd edition. M. Adler. BMJ Books, London,
2002. ISBN 072790261X.
6. Control of Communicable Diseases Manual, 18th edition. D. Heymann. American
Public Health Association, USA, 2004. ISBN 0875530346.
7. The Travel and Tropical Medicine Manual, 3rd edition. E.C. Jong, W.R. McMullen.
Saunders, Philadelphia, PA, 2003. ISBN 0721676782.
8. The travellers good health guide. T. Lankester. Sheldon, London, 1999. ISBN
0859698270.
9. Travellers’ Health: How to Stay Healthy Abroad, 4th edition. R. Dawood, editor.
Oxford University Press, Oxford, 2002. ISBN 0192629476.
Handbooks and Related Publications

1. ABC of Conflict and Disaster. A. Redmond, P. Mahoney, J. Ryan, C. MacNab. BMJ
Books, London, 2005. ISBN 0727917269.
2. Engineering in Emergencies: A Practical Guide for Relief Workers, 2nd edition. J.
Davis, R. Lambert. ITDG Publishing, 1999. ISBN 1853395218.
3. Major Incident Medical Management and Support: The Practical Approach in the
Hospital. Advanced Life Support Group. BMJ Books, London, 2005. ISBN
0727918680.
4. Refugee Health – An Approach to Emergency Situations. Medecins Sans Frontieres.
Macmillan, London, 1997. ISBN 0333722108.
5. The Medic’s Guide to Working Electives Around the World. M. Wilson. Arnold,
London, 2000. ISBN 0340760982 (pb).
6. The Oxfam Handbook of Development and Relief. 3 volumes. Oxfam, Oxford,
1995. ISBN 0855982748.
7. The Sphere Project: Humanitarian Charter and Minimum Standards in Disaster
Response. Sphere Project, Geneva. ISBN 9291390496.
8. The Handbook on War and Public Health. P. Perrin. ICRC Publications, Geneva,
1996. ISBN 2881450776.
9. Where Women Have no Doctor – A Health Guide for Women. A.A. Brown et al.
Macmillan, London, 1997. ISBN 0333649338.
Guidelines and Schedules

1. British National Formulary. Pharmaceutical Press. Updated regularly. ISBN
0853697310.
2. Clinical Guidelines – Diagnostic and Treatment Manual, revised edition. Medecins
Sans Frontieres, Paris, 2007. ISBN 29064986002.
3. Essential Drugs – Practical Guidelines. Medecins Sans Frontieres, Paris, 2005.
ISBN 29064986002.
4. Guide of Kits and Emergency Items – Decision Maker Guide, 4th English edition.
Medecins Sans Frontieres, Paris, 1997.
5. Nutrition Guidelines. Medecins Sans Frontieres, Paris, 1995.
6. Rapid Health Assessment of Refugee or Displaced Populations, 3rd edition. E.

Deeportere, V. Brown. Medecins Sans Frontieres, Paris, 2006. ISBN 2906498645.
Pamphlets and Booklets

1. Health advice for travellers. Leaflet T7.1, 2006. Department of Health Publications,
PO Box 777, London, SE1 6XH, UK.
2. Health information for overseas travel. Yellow book, 2005. Department of Health,
TSO Publications, PO Box 29, Norwich, NR3 1GN, UK. ISBN 0113223293.
3. Immunisations Against Infectious Diseases. Green book, 1996. Department of
Health Publications, PO Box 777, London, SE1 6XH, UK.
4. International Travel and Health (Vaccination certificate requirements for interna-
tional travel and health advice to travellers). World Health Organization, Geneva,
2003. Available from HMSO, London.
Part C – Internet
Introduction
The internet is an invaluable resource for the humanitarian worker with access to
online textbooks, databases, and up-to-date information on situations in country. It
also provides access to thousands of NGOs and national and international organisa-
tions working in the field and can be the easiest way to find out what is required of an
aid worker and how to get involved.
At home the internet is usually easy to find but advances in technology have made
access in the field much more consistent with laptop and telephone access by satellite
and internet cafes proliferating all over the world.
The quantity of information and number of organisations on the internet is enormous,
and this section offers only a small selection of sites that are considered useful. Internet
addresses can change swiftly and, while correct at the time of writing, those listed may
differ in the future. In the event that a page will not open, try to follow links from the
organization’s homepage or use a search engine such as Google to locate the new site.
Directory and Gateway Sites

Bubl Link
A UK information service for the higher education community. Includes links to the
Humanitarian Practice Network, a mechanism for information exchange in the field
of humanitarian aid and Charity Choice, a listing of over 10,000 UK charities.
http://bubl.ac.uk/link/h/humanitarianrelief.htm
580 Section Six
Child’s Rights Information Network

An organization dedicated to disseminating information on the Convention on the
Rights of the Child. Contains themes including health, conflict, HIV, and AIDS and
lists over 1,700 NGOs as members.
http://www.crin.org/themes/ViewTheme.asp?id = 13
Community Aid Abroad

This organization, part of the Oxfam International network, features a site A–Z with
pages on many countries and useful links within.
http://www.oxfam.org.uk
See also Oxfam Australia’s site with links to campaigns, advocacy groups, and devel-
opment banks.
http://www.oxfam.org.au/campaigns/
Development Resource Centre

A New Zealand information and education centre on international development and
global issues containing links to Dev-Zone, an associated NGO information site.
http://www.drc.org.nz/links.htm
www.dev-zone.org
The dmoz Open Directory Project

Developed in the spirit of Open Source, the Open Directory Project is maintained by
a global community of volunteer editors. Headings include Disaster Relief and
Recovery, Humanitarian Issues and Aid, Medical Relief, Child Welfare, Human Rights
and Liberties, and Development. Organizations are also listed by region. Thumbnail
sketches of the major players are provided, and the site provides links to the organisa-
tions listed.
http://dmoz.org/Regional/Europe/United_Kingdom/Society_and_Culture/
Organisations/Humanitarian/
Ecumenical Links
A site maintained by the World Council of Churches as a service to the ecumenical
and humanitarian community, concerned with organizations involved in advocacy
aid, relief, and development and providing an extensive list of humanitarian and
related organizations. Organizations are listed under the headings human rights,
peace and conflict resolution, economy and development, humanitarian aid and
emergency relief, refugees and migrants, environment, intergovernmental organiza-
tions, and general interest.
http://www.wcc-coe.org/wcc/links/aidorgs.html
European Community Humanitarian Office (ECHO)

The European Union is a substantial humanitarian aid donor, providing emergency
assistance to victims of natural disasters, outbreaks of fighting, or comparable excep-
tional circumstances. This site contains details of its work worldwide with links to sites
on humanitarian aid, human rights, working for a safer world, and related news items.
http://ec.europa.eu/world/index_en.htm
European Council on Refugees and Exiles (ECRE)

ECRE is a pan-European network of refugee-assisting NGOs that promotes protection
and integration of asylum seekers, refugees, and internally displaced persons. Website
resources include papers, news, press statements and other publications giving an
excellent overview of the problems associated with refugees. It provides 14 pages of
links to related sites, including many law-related sites.
http://www.ecre.org/linksdirectory
European Forum on International Cooperation:

Humanitarian Aid Gateway
Contains links to UN sites and ECHO as well as humanitarian organizations in vari-
ous European countries.
http://www.euforic.org/detail_page.phtml?&username = guest@euforic.org&password
= 9999&groups = EUFORIC&workgroup = &page = resource_doss_humanitarianaid
Humanitarian Resource Institute

A US university consortium supporting economic, social, cultural, and humanitarian
initiatives worldwide.
www.humanitarian.net
Institute of Development Studies

The Institute of Development Studies, based in Sussex, is a leading global organisation
for teaching, research, and communications on international development. Includes
links to UK-sourced international development research and the Eldis Gateway, which
contains a health systems resource guide.
http://www.ids.ac.uk/ids/researchgateway/health.html
Reuters Foundation
Reuters provides a site called AlertNet, which provides global news and other services
to humanitarian relief agencies and workers. Contains up-to-date news on areas of
humanitarian interest and also includes job opportunities.
http://www.alertnet.org/
582 Section Six
Source Resource Library

Search this contacts database for links to international health or disability organisa-
tions and a wide variety of humanitarian agencies.
http://www.ids.ac.uk/sourcesearch/contacts.htm
Voluntary Organizations in Cooperation in Emergency (VOICE)

VOICE is a network of around 90 European NGOs, which are active across the field of
humanitarian assistance. VOICE runs seminars and meetings aimed at fostering
cooperation and the site summarizes the work of these meetings, provides regular
updates from conflict and catastrophe areas and provides links to other humanitarian
resources. VOICE also acts as an interlocutor with the European Union on emergency
aid, relief, rehabilitation, and disaster preparedness and seeks to involve its members
in information, training, advocacy, and lobbying.
http://www.ngovoice.org/
International and Intergovernmental Sites

European Parliament
The European Parliament publishes a series of fact sheets including sheet 6.4.4 on
humanitarian aid, which deals with the legal basis of humanitarian aid and is of inter-
est to humanitarian volunteers.
http://www.europarl.europa.eu/factsheets/6_4_4_en.htm
International Committee of the Red Cross

The Red Cross works exclusively with the victims of war and violence. This is a highly
recommended web site. It includes a comprehensive section on humanitarian law and
useful online resources.
http://www.icrc.org/eng
International Federation of the Red Cross

and Red Crescent Societies
This is the world’s largest humanitarian organisation consisting of 185 Red Cross and Red
Crescent societies. Its goals are to reduce death, illness and injury resulting from disease
or disaster, to increase local capacity to deal with such events, and to promote respect for
diversity and human dignity. Includes links (under partners), publications, and news.
http://www.ifrc.org
International Labour Organization

The ILO is the tripartite UN agency that brings together governments, employers and
workers in its member states to promote social justice and human and labour rights.
The site is more extensive than it appears and can be navigated by searching for a site
map of the country in question.
http://www.ilo.org/global/lang–en/index.htm
Organisation for Security and Co-operation in Europe (OSCE)

OSCE is a European security organisation of 57 participating states with an interna-
tional remit. Its purposes are early warning, conflict prevention, crisis management
and rehabilitation after conflict. Other linked areas include human rights, antiterror-
ism and education.
http://www.osce.org/sitemap/
United Nations Children’s Fund (UNICEF)

UNICEF is active in 191 countries promoting child survival and development, health,
protection and education. Information is listed by country.
http://www.unicef.org/infobycountry/index.html
United Nations Economic and Social Development Council

This UN department is concerned with the environment, human rights, human set-
tlement and other issues surrounding humanitarian assistance and governance.
Begin with the site map: http://www.un.org/esa
United Nations High Commissioner for Human Rights

UNHCR was established to care for the world’s refugees. A–Z directory including the
organisation’s links to publications, statistics, research and events. Highly
recommended.
http://www.unhcr.org/directory.html
United Nations Index to Programs

Links to UN programs alphabetically, from Accident Prevention to Youth.
http://esa.un.org/subindex/pgViewTerms.asp?alphaCode = A
United Nations Statistics Division

Useful source for global and national economic and environmental statistics. Site map
at http://unstats.un.org/unsd/sitemap.htm.
584 Section Six
Includes demographic and social statistics: http://unstats.un.org/unsd/

demographic/
World Bank Group

The World Bank Group’s mission is to work for a world free of poverty. Cooperating
closely with many NGOs, particularly in the field of development, it provides many
pertinent links.
http://www.wbg.org
World Health Organisation (WHO)

The WHO is the directing and coordinating authority for health within the UN and
its site is one of the most useful. Includes information on various health topics includ-
ing disease outbreaks and emergencies. Links to publications, statistics and programs.
Search for sitemaps by region.
http://who.int/
World Trade Organisation

International organisation dealing with global rules of trade and interfacing with
NGOs in developing countries and in regions afflicted by war and disaster. Includes
resources for NGOs and research.
http://www.wto.org
Worldwide Ministries
The worldwide ministries division of the Presbyterian Church with far-reaching pro-
grams in the fields of human rights, hunger, refugees, and development.
http://pcusa.org
Government and National Organisations

● Department of Health (UK) – http://www.dh.gov.uk/en/index.htm
● Department for International Development (UK) – http://www.dfid.gov.uk
● Foreign and Commonwealth Office (UK) – http://www.fco.gov.uk
● State Department (USA) – http://www.state.gov/
● US Agency for International Development (USA) – http://www.usaid.gov/
Nongovernmental Organisations
The editors recommend the following selection of NGO websites but many more exist.
Readers are invited to suggest useful additions.
● Amnesty International – http://www.amnesty.org

● Care International – http://www.careinternational.org
● Catholic Agency for Overseas Development (Cafod) – www.cafod.org.uk
● Doctors of the World – http://www.doctorsoftheworld.org
● Doctors without Borders – http://www.dwb.org
● International Islamic relief Organisation – http://www.iirosa.org
● Leonard Cheshire – http://www.leonard-cheshire.org
● Medicins Sans Frontieres – http://www.uk.msf.org/
● Mercy Corps International – http://www.mercycorps.org
● MERLIN – http://www.merlin.org.uk
● Oxfam International – http://www.oxfam.org
● Oxfam UK – http://www.oxfam.org.uk
● Physicians for Human Rights – http://www.physiciansforhumanrights.org
● Red R – http://www.redr.org/
● Save the Children – http://www.savethechildren.org
● Tropical Health and Education Trust (NHS Links) – http://www.thet.org
Specialist Sites
Preparation, Vaccinations, and Travel Health
● http://www.cdc.gov/travel/ – The US Government’s Center for Disease Control
provides travel advice and health warnings. Includes an A–Z of health topics.
● http://www.fco.gov.uk/travel – The British Government’s Foreign and
Commonwealth Office site for non health-related travel advice including security,
legal, and consular matters. Highlights areas of risk.
● http://www.dh.gov.uk/en/Policyandguidance/Healthadvicefortravellers/index.htm
– The UK Department of Health’s advice for travelers in Europe and further afield.
● http://www.tripprep.com – The website of Travel Health Online offers detailed
information on illnesses, vaccinations, travel medicine providers, and
destinations.
● http://www.indiana.edu/~health/healthlinks.shtml – The Indiana University
Health Center’s travel health pages and links to related sites.
● http://www.masta.org – UK-based organization offering travel advice, vaccina-
tions, and first aid kits.
● http://www.nathnac.org – The National Travel Health Network and Centre is funded
by the UK Department of Health to improve quality of travel health advice.
● http://www.thehtd.org/content/travel.asp – The Hospital for Tropical Diseases’
(London) department of travel medicine and travel clinic offers advice, travel
products, and a 24-h helpline.
Security
The following sites can provide useful information on security:
586 Section Six
● http://www.fco.gov.uk/travel – The UK Foreign and Commonwealth Office’s travel

warnings.
● http://travel.state.gov – US State Department travel advice for US citizens.
● http://www.state.gov/travelandbusiness/ – The US State Department’s travel
advice for US businessmen includes travel tips and warnings.
● http://www.redr.org/en/resources/ – Link to RedR’s safety and security advice.
● http://www.icrc.org/web/eng/steeng0.nsf/htmlall/p0717?opendocument –
Downloadable version of the ICRC publication Staying Alive: Safety and Security
Guidelines for Humanitarian Volunteers in Conflict Areas.
● http://www.aidworkers.net/?q = advice/security – Aidworkers Network guide to
field security planning.
● http://ec.europa.ed/echo/policies/evaluation/introduction_en.htm – ECHO
Generic Security Guide for Humanitarian Organizations.
Country Information and Maps

● http://www.who.int/countries/en/ – World Health Organisation information by
country.
● http://www.cia.gov/library/publications/the-world-factbook/ – The CIA Factbook
contains detailed geographic, demographic, historical and security information
on countries worldwide.
● http://www.humanitarianinfo.org – Links to several humanitarian information
centres, provided by OCHA.
● http://www.reliefweb.int/mapc/index.html – Countries and emergencies.
● http://earth.google.com – Google Earth provides free, easy-to-use satellite
imagery online.
● http://maps.google.co.uk – Google maps provides free online maps of the world.
● http://www.stanfords.co.uk – The world’s largest map and travel bookstore online.
Training Courses
● http://www.redr.org/en/What_We_Do/UK_training/Course_Calendar.cfm –
RedR’s courses calendar from basic introductions to disaster management. Also
includes security.
● http://www.reliefweb.int/rw/rwt.nsf/doc211?OpenForm – Relief Web’s training
directory.
● http://www.apothecaries.org – The Faculty of Conflict and Catastrophe Medicine’s
course in the medical care of catastrophes.
● http://www.who.int/hac/techguidance/training/hearnet/en/ – WHO’s Health
Action in Crises links to training courses.
● http://www.qeh.ox.ac.uk/short-courses – The University of Oxford’s Department
of International development’s training course list.
● http://www.international-alert.org/our_work/training/index.php – International
Alert provides training for peace workers.
Also see individual NGO websites, e.g., the UK’s MERLIN for training courses.
Relief Personnel: Providers and Employers

● http://www.redr.org – The RedR website lists organisations that provide services
and employ personnel in the humanitarian field.
● http://www.epn.peopleinaid.org/ – The Emergency Personnel Network, supported
by RedR, DfID, USAID, and various NGOs exists to assist recruitment of appropri-
ate personnel by organisations.
● http://www.idealist.org – Opportunities to volunteer at home or abroad and a list
of volunteers for organisations to access.
● http://www.interaction.org – American Council for Voluntary International
Action provides a monthly newsletter of jobs and volunteering opportunities with
international relief and development agencies but this is not a free service.
Essential Medicines and Practice

The websites listed here give expert advice on medicines, products, and techniques in
the field of humanitarian aid:
● http://www.who.int/medicines/publications/essentialmedicines/en/index.html –
WHO model list of essential medicines.
● http://www.steinergraphics.com/surgical/manual.html – WHO primary trauma
care manual.
Medical Equipment
Sites that give information on a wide variety of medical equipment and products from
individual items to complex equipment systems:
● http://www.999supplies.com
● http://www.equipped.com/medical.htm
● http://www.echohealth.org.uk
● http://www.firstaidwarehouse.co.uk
● http://www.masta.org
● http://www.missionsupplies.co.uk
● http://www.nomadtravel.co.uk
● http://www.hospital-technology.com/contractors/index.html
Resources for Medical Students

● http://www.medsin.org – MEDSIN. Network of healthcare students in the UK,
educating and acting upon health inequalities.
● http://www.physiciansforhumanrights.org/students/ – Physicians for Human
Rights’ student pages including links to online courses.
● http://www.skipkids.org.uk – Students for Kids International Projects. National
children’s charity with projects around the world conducted by students from
various UK medical schools.
588 Section Six
● http://www.star-network.org.uk – Student Action for Refugees. National organisa-

tion supporting refugees in the UK with branches at many medical schools.
● http://www.hpnepal.org – Medical school link and project established by UK
medical students.
Standards and Accountability

● http://www.tsunami-evaluation.org – The Tsunami Evaluation Committee’s
reports giving essential lessons to be learned from the disaster response.
● http://www.sphereproject.org/handbook/ – The Sphere Project humanitarian
charter and minimum standards in disaster response.
● http://www.odi.org.uk/ALNAP/ – Active Learning Network for Accountability and
Performance in Humanitarian Action.
Conflict and Catastrophe Medicine

● http://www.aafp.org/online/en/home/aboutus/specialty/rpsolutions/eduguide/
disastermed.html – US Disaster Medicine curriculum.
● http://www.abpsga.org/certification/abodm_announcement.html – US Disaster
Medicine certification.
● http://www.apothecaries.org – Society of Apothecaries of London’s Faculty of
Conflict and Catastrophe Medicine.
● http://www.rsm.ac.uk/academ/forcc.php – The Royal Society of Medicine’s
Catastrophes and Conflict Forum.
● http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/
PublicationsPolicyAndGuidance/DH_065374 – Global Health Partnerships: the
UK contribution to health in developing countries. The Crisp Report.
Additional Sites for the Netherlands

Because of the mainly international setting of conflict and catastrophe medicine most
Dutch readers will find the international sources well accessible. However some spe-
cific national sites are listed here.
Governmental Sites
● http://www.minvws.nl/ – Ministerie van Volksgezondheid, Welzijn en Sport
● http://www.minbuza.nl/ – Ministerie van Buitenlandse Zaken
● http://www.minbzk.nl/ – Ministerie van Binnenlandse Zaken en Koninkrijksrelaties
● http://www.mindef.nl/ – Ministerie van Defensie
● http://www.rivm.nl/ – Rijksinstituut voor Volksgezondheid en Milieu (RIVM)
Nongovernmental Organisations
● http://www.rodekruis.nl/ – Het Nederlandse Rode Kruis
● http://www.cordaidmemisa.nl/ – Cordaid Memisa
● http://www.oxfamnovib.nl/ – Oxfam Novib
● http://www.vluchtelingenwerk.nl/ – VluchtelingenWerk Nederland
● http://www.artsenzondergrenzen.nl/ – Artsen zonder Grenzen
Human Rights Organisations

● http://www.amnesty.nl/ – Amnesty International Nederland
● http://www.johannes-wier.nl/ – Johannes Wier Stichting
Infectious Diseases and Tropical Medicine

● http://www.lcr.nl/ – Landelijk Coördinatiecentrum Reizigersadvisering
● http://www.rivm.nl/cib/ – RIVM, Centrum Infectieziektebestrijding (CIb)
● http://www.amc.nl/?pid = 56 – Tropencentrum AMC
● http://www.kit.nl/ – Koninklijk Instituut voor de Tropen
● http://www.travelclinic.com/ – Travel Clinic Havenziekenhuis Rotterdam
Emergency and Catastrophe Medicine

● http://www.alsg.nl/ – Stichting Advanced Life Support Groep
● http://ghor.startkabel.nl/ – extensive information site on GHOR
35. Rehabilitating Diagnostic Laboratories
Timothy Healing
The establishment, rehabilitation, and working of diagnostic laboratories is a complex

topic. This section is intended to highlight some important points and also to list key
references that will help in the operation of basic laboratories and the rehabilitation
process (for lab aids to diagnosis, see WHO 1991, 1993, 1994a, b, 1997a, b, 2000, 2007;
WHO CSR 2000, and for assessment, establishment, repair, maintenance, and routine
operation of laboratories, see WHO 1994b, 1997b; WHO EMRO Office 1994, 2000;
Cheesbrough 1998, 2000; Connolly 2005; Davis and Lambert 2002; Medecins Sans
Frontieres 1997; IATA 2006; ICAO 2005/2006).
Basic Principles
Diagnostic laboratories should do the following:
1. Provide a safe working environment and not present a risk to those nearby.
2. Provide a comfortable working environment (the wearing of PPE – lab coats,
gloves, masks, eye protection – is uncomfortable at temperatures >30°C).
Additionally, many commercial diagnostic assays perform unpredictably above
28–30°C, and most equipment (e.g., fridges) works better in cooler conditions.
3. Be easy to clean and maintain.
4. Operate under defined standard operating procedures.
5. Have good internal and external quality control.
6. Be provided with adequate water and power supplies.
7. Provide for safe and effective disposal of waste.
Laboratories in Emergencies
In the early stages of a disaster, setting up of diagnostic laboratories will usually be a
low priority. There are three reasons for this: firstly most of the diseases likely to occur
at this stage can be diagnosed clinically and treatment will be symptomatic or pre-
sumptive. Secondly, the pressure on the medical services, which may be reduced or
damaged by the disaster, is likely to be such that the time available to take specimens
and wait for results will be limited, and thirdly the requirements for an effective labo-
ratory listed earlier are difficult or impossible to meet at this stage. However, should a
major outbreak occur, identification of the causative organism will be essential. Basic
592 Section Six
microscopy can be used to identify malaria and other blood parasites. Rapid test kits
that can be used in basic laboratories (or even at the bedside) are available for iden-
tification of some organisms (e.g., malaria) and are being developed or validated for
others (e.g., meningitis, cholera, and dysentery) but many pathogens cannot be iden-
tified in the field by these means. In addition they cannot provide information on
antimicrobial sensitivities. It is therefore important to ensure the following:
● Medical services are provided with a wide range of equipment for collecting
specimens from patients and are aware of what samples are needed
● A system is set up to transport specimens to appropriate reference laboratories
(this can be a problem if specimens have to be sent for long distances), and suit-
able equipment must be provided to ensure safe transport.
● A network of reference laboratories is identified and arrangements are made for
these to test specimens as required (this may require special funding).
If local laboratories are still working, they may be able to undertake the necessary
tests but they need to be assessed to determine whether they can produce accurate
and consistent results.
The other type of laboratory that is likely to be needed in the early stages of a dis-
aster is a facility to type and screen blood in hospitals where operations are being
performed. Rapid tests for HIV and for hepatitis B and C as well as blood grouping
will be required.
As the situation stabilizes it will be possible to establish a more sophisticated labo-
ratory and hence to offer a range of tests that may include the following:
● Blood films (thick and thin) for malaria and other blood parasites
● Stool examinations for ova and parasites
● Hematocrit (packed cell volume)
● Differential white cell counts
● Sickle cell detection
● Clotting time
● Spot tests (malaria, meningitis)
● Sputum microscopy for TB (should only be done if the condition can be treated
in the context of a properly designed and functioning DOTS program).
At this stage training of new staff and retraining of existing technicians can be under-
taken. Expatriate staff or senior local staff with appropriate training experience are
needed at this time. There are a number of basic texts available to assist in setting up
basic laboratories and in training staff.
Equipping Basic Laboratories

Lists of the equipment, glassware, media, and reagents for an emergency laboratory
can be found in the WHO publications “Selection of Basic Laboratory Equipment for
Laboratories with Limited Resources” (WHO EMRO 2000) (which also contains
details of the correct storage, transportation, and maintenance of various pieces of
equipment) and “Health Laboratory Facilities in Emergency and Disaster Situations”
(WHO EMRO 1994) and in other references listed at the end of this chapter
(Cheesbrough 1998, 2000; Connolly 2005). Buy locally (if this does not compromise
quality) to ease supply of spares, maintenance, etc.
Laboratory Rehabilitation
Clinical laboratories are frequently damaged or destroyed in conflicts and disasters.
After the Iraq war of 2003, a large proportion of the laboratories in Iraq were looted,
a process that often included removal of fixtures and fittings as well as equipment.
Rehabilitation of diagnostic laboratories must be done in consultation with local
laboratory staff and the relevant ministries. An assessment of the standards and
equipment in place before the disaster will be required.
Rehabilitation is not just a matter of providing new equipment. It is also an oppor-
tunity to build capacity by improving the facilities available and by providing training
for staff. It is a top–down process. Rehabilitating a single local laboratory may provide
for the needs of a small part of the population but if the laboratory is not part of an
effective network and if it is not properly supported from the center it is likely to fail.
Ideally efforts should be concentrated on bringing the main national laboratories in
a country up to standard. These can then oversee the improvement of laboratories at
lower levels.
It is important that any rehabilitation produces a laboratory that meets the needs of
the populace but also it must be suited to the expertise of the available staff and
be sustainable. There is no point in providing a very advanced facility in an area
where the staff cannot support that level of work and where the government cannot
finance the running of the laboratory. Those rehabilitating the system will come
under great pressure from ministries of health and from the senior laboratory staff to
provide the latest equipment and the most recently devised tests. This pressure must
be resisted unless the equipment and tests can be supported (the reagents may be very
expensive, difficult to get, and the machines may not be able to be serviced).
The only exception to this rule is the provision of a specialist facility to deal with a
specific problem and with external funding and support. An example is the Lassa
Fever laboratory that has recently been built in Kenema in eastern Sierra Leone.
Although it is situated in a poorly equipped and underfunded regional hospital in one
of the poorest countries in the world, it is a very advanced facility with tests such as
PCR and ELISA available. It can only operate to provide an essential diagnostic serv-
ice as part of the efforts to combat a serious and widespread disease problem (it
provides a facility for countries other than Sierra Leone) because it is supported by
external funds and by expatriate staff.
Standard Operating Procedures and Quality Control

Merely meeting the basic design and safety criteria for diagnostic laboratories is not
enough. The staff must be able to undertake the required tests effectively and accu-
rately. The output of the laboratory must be validated, and a quality control system is
594 Section Six
essential. The way in which all diagnostic procedures undertaken in a laboratory

should be performed should be laid down in “Standard Operating Procedures”
(SOPs). These should also include protocols for internal and external quality assess-
ment and include reference to full risk and hazard assessments and safety
procedures.
Internal Quality Control

All procedures undertaken in the laboratory must be measured against recognized
standards. New batches of stains or reagents must be validated against the old. The
work of the laboratory staff should be validated regularly by the blind inclusion of
known positive and negative specimens in the routine diagnostic work.
External Quality Control

A suitable laboratory to undertake external quality control should be identified as
soon as possible after the establishment of the laboratory. This should at least be able
to provide known positive and negative specimens for assessment of the work of the
laboratory.
When rehabilitating a national laboratory an attempt should be made to twin the
laboratory with a reference laboratory in another country. This can provide the neces-
sary quality control input but also can act as the training center for the staff of the
laboratory that is being rehabilitated. In turn the national laboratory can pass on
expertise and provide training for the staff of other laboratories in the country and
also act as the quality control laboratory for the national network. The external labo-
ratory can also help produce SOPs for the laboratories.
References
Cheesbrough M. Laboratory Practice in Tropical Countries (Part 1). Cambridge University Press,
Cambridge, 1998.
Cheesbrough M. Laboratory Practice in Tropical Countries (Part 2). Cambridge University Press,
Cambridge, 2000.
Connolly MA (Ed). Communicable Disease Control in Emergencies – A Field Manual. WHO, Geneva,
2005.
Davis J, Lambert R. Engineering in Emergencies. ITDG/RedR, 2002.
IATA. IATA Dangerous Goods Regulations (48th Edn). International Air Transport Association, 2006.
ICAO. Technical Instructions for the Safe Transport of Dangerous Goods by Air. International Civil Aviation
Organization, 2005/2006.
Medecins Sans Frontieres. Refugee Health. Macmillan, London, 1997.
WHO, CSR. Guidelines for the Collection of Clinical Specimens During Field Investigation of Outbreaks.
WHO Department of Communicable Disease Surveillance and Response, Geneva, 2000.
WHO, EMRO. Health Laboratory Facilities in Emergency and Disaster Situations. WHO Regional Office for
the Eastern Mediterranean, Alexandria, 1994.
WHO, EMRO. Selection of Basic Laboratory Equipment for Laboratories with Limited Resources. WHO
Regional Office for the Eastern Mediterranean, Alexandria, 2000.
WHO. Basic Laboratory Methods in Medical Parasitology. WHO, Geneva, 1991.
WHO. Laboratory Biosafety Manual (2nd Edn). WHO, Geneva, 1993.
WHO. Bench Aids for the Diagnosis of Intestinal Parasites. WHO, Geneva, 1994a.
WHO. Maintenance and Repair of Laboratory Diagnostic, Imaging and Hospital Equipment. WHO, Geneva,
1994b.
WHO. Bench Aids for the Diagnosis of Filarial Infections. WHO, Geneva, 1997a.
WHO. Safety in Health-Care Laboratories. WHO, Geneva, 1997b.
WHO. Bench Aids for the Diagnosis of Malaria Infections (2nd Edn). WHO, Geneva, 2000.
WHO. Guidance on Regulations for the Transport of Infectious Substances 2007–2008. WHO, Geneva, 2007
(WHO/CDS/EPR/2007.2).
36. Enablers and Confounders:
Achieving the Mission
Ken Millar
The best laid schemes o’ mice and men gang aft agley
You have planned extensively to achieve your mission; your preparation, you think, is
perfection itself. What could possibly go wrong after all the hard work you have done?
Actually, quite a lot can either go wrong, or at least not go quite right, as the quotation
from Robert Burns in the heading of this chapter indicates. It is said in military circles
that no plan survives first contact with the enemy. This healthy cynicism is equally
applicable to any plan that relies on assumptions on the behavior of others, including
plans to deliver medical care in support of the victims of conflict and catastrophe.
Prime Minister Harold Macmillan perhaps put it in a nutshell. When asked what con-
stituted his biggest problem he replied “Events, dear boy. Events.” Events for which we
have not planned, or which are outside our control, can throw us into confusion if we
have no available response to them. Even a small event can have major consequences
– the so-called “butterfly effect” in chaos theory. As I hope you will glean from this
chapter, there are a lot of butterflies about!
So what is suggested is that to ensure that your plan has the greatest possible chance
of success, you must be prepared to ask yourself a few more questions. If you do not,
then perhaps your efforts may falter as you step on a number of banana skins, and
may not have the outcomes you foresaw or desired. There are a number of potential
enablers to maximize the effectiveness and efficiency of your efforts – conversely,
there are many confounders to frustrate your hard work. Diligent attention to the
enablers may reduce the effects of most confounders – but if the existence of these
two related spirits, benign and malignant, is not recognized, then woe betide you,
your sponsor organization, and your target population!
The questions you need to ask are designed to discover if you have harnessed all the
enablers and by so doing isolated most of the confounders. They involve looking
closely at yourself, your team, and your mission. They also involve taking a wider look
at what is going on round about you. It is often easy to become fixated by the detail of
your own, highly specific tasks and lose sight of the larger picture within which you
and your team need to operate. None of us (individuals or teams) can work effectively
in a vacuum; the proper appreciation of our necessary interfaces with others repre-
sents an important enabler; this will be enlarged upon later.
598 Section Six
It is not intended to list every enabler or confounder – indeed it would be impos-

sible to do so, as each new situation will have its own peculiarities. Each different
mission must be analyzed to seek out the confounding factors that could cause drag
or even failure and identify the streamlining enablers that will add value to your work.
Most of the factors that will be dealt with here are covered either explicitly or implic-
itly elsewhere in this book; however, this chapter gives a reality checklist, which can
be applied relatively simply to any potential situation.
We are dealing here with an almost infinite spectrum of possibilities. The emer-
gency may occur against the gamut of geographical, climatic, and political back-
grounds. The response may be defined as contingency (preplanned reactions to specific
catastrophes – such as the London Major Incident Plan) or emergency (immediate
reactions to the previously unforeseen such as response to the Asian Tsunami). The
nature of the catastrophe may be conflict, man-made disaster, or natural disaster. The
spread of possibilities is clearly too great for a detailed examination of all potential
enablers and confounders; thus an approach that should be applicable to any plan-
ning process has been adopted. This should, it is hoped, give you the necessary tools
to make the best of every situation. All that needs to be done is to apply coherent
thought, adopt a different perspective, and (perhaps most important of all) accept
with sufficient humility first that your plan may be less than perfect and second that
its success or failure depends heavily on external factors.
The chapter will use the following broad headings to cover the topic; but beware, as
this is not a compartmentalized discipline. The headings have been used purely to
allow some order in the setting down of these points on paper, rather than to separate
or allocate any priority, although the order in which the headings appear reflects a
logical sequence of planning events. These factors are all interlinked, interdependent
and of course may have quite different weighting in specific situations. Examples of
confounders are given where practical (and if the point is not already obvious) to
illustrate the importance of the thought process involved. No apology is offered for
what may appear to be blinding glimpses of the obvious; what is clear to one may be
obscure to the next reader. The broad headings are as follows:
● Preparation
● Information
● Communication
● Coordination
Preparation
Before responding to any catastrophe or indeed making major contingency plans
against foreseen major incidents, there are certain preliminaries that need to be
undertaken. There may, or may not, be time for all of these to be properly attended to
in every instance. If they are not at least considered, then matters may conspire to
confound the outcomes. The major contingency plan is not dealt with in separate
detail here, except for some words on rehearsals. This is not to say that these plans are
less important, but that the abundance of time and resources available to make such
plans is all that sets them apart. The factors that need to be taken into consideration
in the contingency plan are, broadly, the same as for any emergency response.
Intelligence
Before making any plans, certain intelligence is essential. This includes the
following:
● What is the plan meant to achieve? In military terminology, what is the mission?
If you do not know, then success in achieving it is unlikely! Does your mission
accord with that of your sponsor organization?
● To whom are you (and your team) responsible? Is this the same point of contact
you will use for all matters such as resupply? There will always be confusion here,
especially if something goes wrong. You need to know your points of contact – and
their perceptions of their responsibilities need to agree with yours!
● Are there any major constraints? These could be in terms of time, money, man-
power, or politics. If your plan fails to consider these factors, it may be
unrealizable.
● Geography and climatic considerations, including endemic disease. These may
impact on your choice of personnel, apart from anything else.
● Is anyone else involved? Other agencies are bound to impact on the execution of
your plan – the more so if you have not considered them.
● What is the size and shape of the problem? Numbers and types of casualties likely
to be involved should shape your response.
Team Selection
In selecting your team (provided you are given any choice in the matter) there are a
number of factors worth considering if you are to increase your chance of success. You
may care to think about the following:
● Motivation
● Experience
● Accreditation
● Physical and Mental fitness
● Ability to work together
Reconnaissance
The value of a visit to the affected area cannot be overstated. Actually seeing the problem
on the ground will dispel preconceptions that may be totally erroneous, and that could
lead to an inappropriate response. If it is impractical to visit in the time frame con-
cerned, the next best option is to meet with someone who has recent experience of the
area. I say “meet with” rather than e-mail or telephone – a conversation is more likely
to bring out difficulties than a response to a series of questions based, essentially, on
your preconceptions. Even if you are conducting a physical reconnaissance, do not
miss the chance to tap into the personal experience of others.
The “map recce” is the poorest option. While it may give a general impression, it
cannot show the whole picture. For example, maps of the Falkland Islands in 1982
showed an extensive network of tracks. To the UK or Northern European observer,
600 Section Six
used to that interpretation of a track, this suggested that road evacuation of casualties
would be possible. The reality was that these “tracks” merely indicated a general route
over blanket bog, passable only with extreme care by the local population using spe-
cialized knowledge, and never using the same wheel ruts twice. Any attempt to have
relied on these tracks for military wheeled transport would have been a total failure.
Luckily, the wrong conclusions were not drawn on this occasion!
Reconnaissance can deliver a host of information if it is properly conducted.
Preceding reconnaissance, the value of taking steps to speak to those with prior expe-
rience of the area is again stressed; this can avoid unnecessary work, can point you in
the right direction as to any personalities you may need to contact during your visit,
and may even cause you to alter your entire approach. Do not be afraid to ask ques-
tions or to change the nature of your planned response as a result of such conversa-
tions. Carry out your recce as early as possible, with a small team of the relevant
experts (this might be only yourself, of course). Prior to departure you need to be
aware of specific questions you wish to have answered, and if possible have a list of
people, organizations, and places you need to visit. It is not possible to give an exhaus-
tive list of questions you might like to have answered, as clearly these will vary from
situation to situation. It should also be remembered that reconnaissance is applicable
to major contingency planning, although the parameters may differ substantially.
A list of headings for a recce in preparation for emergency deployment could include
the following:
● Time and space: How long will it take you to get from your point of arrival to the
location in which you will be operating? What about your initial supplies, and
indeed resupply?
● Infrastructure: Water and food for your team and your patients? What about
power supply? Roads and routes? Telephones and other information communica-
tion capabilities? Accommodation for your team?
● Local medical facilities – indigenous: Who, what, where, how stretched, what
assistance do they need?
● Local medical facilities – other (NGO, etc.): How will you interoperate with these?
It is important to know before departure what other agencies are likely to be
involved, and if possible establish points of contact with them.
● Local political contacts: These are necessary to facilitate cooperation, manpower,
and coordination of requirements. You may need their assistance from day 1 of
your deployment, for example, to speed the passage of your team – and their
equipment – through Customs/Immigration.
● Local Sensibilities: A “feeling” for local religious and political sensibilities.
Team Preparation
The available time to prepare your team is likely to be limited. It would be ideal if the
team could be brought together before they meet in some departure lounge, but this
may not be practical. There are certain matters that need to be attended to as a matter
of urgency even if the team cannot meet before the event. As the team leader, guidance
on these will have to come from you (if things go wrong, your head is the one that is
likely to roll, even if the error is made by one of your team members). What do you
need to think about?
● Passports and visas – in date and valid?
● Immunization and prophylaxis – including antimalarials. It is remarkable how
many individuals manage to rationalize their noncompliance with these essentials
– particularly in relation to antimalarials. (Rationalization, in this context, may be
defined as the mental gymnastics involved in justifying illogical or even insane
actions!)
● Briefing of the team before departure – this can be in the departure lounge, but it
must happen.
Major Disaster Contingency Plans and Rehearsals

A major incident response contingency plan may be (indeed should be) practised,
and such practice should allow the plan to be modified prior to its having to be real-
ized. However, rehearsals will not throw up the lessons necessary if they are not con-
ducted with adequate realism, with the proper involvement of all “players” and with a
critically objective evaluation process. This demands, it is suggested, an external peer
review, rather than an internal management assessment. The plan must convince the
external assessors that it will work, not merely convince an internal team that a plan
exists! To achieve this, rehearsals should always impose real-time delays, real times for
treatments and patient movement, and must involve all departments, including sub-
contractors responsible for cleaning, catering, supplies, and the like. One phrase that
must never be heard during such rehearsals is “Ah, but for real we would……” This
(quite prevalent) attitude is perhaps the greatest enemy to genuine assessment of the
flaws in any plan.
Information
We have already hinted at the importance of information in relation to intelligence
gathering in preparation and reconnaissance. However, there is more to this topic
than the mere gathering of facts upon which to base your plan, and there are certain
caveats regarding information that need to be taken into account to bolster the
chances of success.
Information not only has to be sought by you to construct – and of course to amend
– your plan, it will also be sought of you. It is an unfortunate truth that others (your
sponsor organization, local government officials, or other aid agencies) will press for
a variety of seemingly irrelevant information from you and your team. It is also
Murphy’s law that such information will be sought when you are at your busiest,
doing what you thought you were there to do! To minimize the impact of this addi-
tional burden, it is worthwhile having in place a system that will gather such informa-
tion in advance of the question being put. This will avoid having to go back over work,
having to bother team members and having to erode the time available for either your
main effort or for rest.
602 Section Six
Basic details on numbers and types of casualties treated, any specific diseases that
may be prevalent, levels of available stocks, and any critical factors that might diminish
your capacity need to be maintained as records. Records also need to be kept for
immunizations administered; this information is likely to be sought by local govern-
ment after the initial crisis has passed. The ability to respond rapidly to requests for
such information, apart from making your team look good and reducing unnecessary
work surges, has the knock-on effect of giving you a perspective of your efforts, which
could convince you to adjust your approach. It also has the potential, when you seek
information from “above,” to convince the relevant agencies that, as an efficient and
competent team, you actually merit their urgent attention!
This sort of detail cannot be maintained without the compliance of your team. You
will need to convince them that record-keeping in the emergency situation is just as
relevant as it is in their normal environment. Without records from previous emergen-
cies, of course, there are no parameters against which to plan for the next one. Records
of your current deployment will potentially be the basis for the next emergency relief
operation; lessons can (and should be) identified from such information. You may note
that I have used the term “Lessons Identified.” Often this is quoted as “Lessons Learned”
– but unless we can be absolutely sure that this is the case, they have merely been iden-
tified. For example, it has long been identified that debridement and delayed primary
suture was the appropriate immediate surgical treatment for many penetrating battle
injuries. However, this lesson seems to have to be relearned by at least some of the
surgical participants in every new conflict! Education is required, by the proper pas-
sage of that information, to ensure that the lessons are indeed learned.
There will be a mass of information available to you if you seek it out as you must.
Not all of it will necessarily be of direct relevance to what you are setting out to do – or
it may appear to be irrelevant. Interpretation of the information is needed to apply it
to the construction and execution of your plan. First, you need to assess its veracity.
Always check your source, and ensure the accuracy of any information you receive
before acting on it. Messages may be corrupted in passage, particularly if they are less
than clear in the first place. The old chestnut of “Send reinforcements, we are going to
advance” becoming “Send three and four pence, we are going to a dance” may be silly,
but it serves to demonstrate the importance of confirming the exact text of any mes-
sage. Each snippet of information should be interrogated by the simple question “So
What?” If the answer really is “So Nothing,” you can pass on. But before doing so, it is
worth applying a second interrogation, namely “But What If….” In other words, indi-
vidual items of information may be of little apparent relevance, but when taken
together may gain importance. You need to explore in depth, investigate if the infor-
mation is incomplete, extrapolate if necessary, and thereafter adapt your approach if
that is your reasoned conclusion. Sticking rigidly to the original plan may be the easy
way, but it is unlikely to be the most successful.
Do not, therefore, be afraid to be critical of your plan, or indeed of the master plan
into which yours must fit. That does not necessarily mean that you have to shout the
odds with your employer or sponsor agency over the fine detail, but neither must you
stay silent if you perceive a major confounder. To give yourself the necessary oppor-
tunity to adopt a critical approach, as a team leader you must allow some time for
contemplation. If you are exhausted, you have neither the will nor the capacity to
make a reasoned appraisal.
Communication
Information without communication is, of course, worthless. This brings us to the
topic of communication; which does not just mean the use of radios, telephones, and
the internet – although all of these are important. I will deal with matters involving
electronic communication first, before moving on to a more general examination of
the “whys” and “wherefores” of communication.
We have all become dependent on electronic communication systems, and they
clearly are of enormous benefit to the proper conduct of a relief operation. But there
are downsides to the proliferation of electronic communication means in this context,
of which you need to be aware if only to ensure that the glitches do not come as a
complete surprise to you. These are as follows:
● Information overload: The ability to access information and communicate with
ease may produce such a quantity of information that we are unable to properly
interpret it. This is also true in reverse; the ability to seek information may mean
that an excessive amount of time is spent answering detailed questions – the
answers to which, of course, add to someone else’s information overload!
● Inappropriate conversations: The relative ease with which individuals can commu-
nicate with friends and mentors at home may produce difficulties. It is not unknown
for individuals to embark on separate therapeutic management schemes from those
agreed within the team as a result of electronic chat with others at home, who may
not be fully aware of the situation for which their advice is being sought.
● Security matters: Indeed, security does matter! Careless talk on the internet can
leak and end up in the wrong hands. The intention of the naïve correspondent on
the net is not to breach security, but his chat can end up either with “the bad guys”
or with the press. This can, at best, lead to a loss of confidence in your team by
sponsors, other organizations, or the population you are attempting to assist.
● Misinformation: The Internet is potentially a source of much more rubbish than
truth!
● Capacity limitations: The very availability of instant, personal, and worldwide com-
munication facilities means that everyone wants to use it at once. Unfortunately, the
channels available are limited in their absolute capacity to carry information – par-
ticularly if the information package is large. You may have to fight for dedicated
times, bandwidths, or radio frequencies in order to do your business effectively, as
there may be many competitors for these. The key here is to minimize the use of
your communication means, rationalize your messages, and stick to the essentials.
But there is more to communication than handsets, screens, and chat lines! For any
complex task to be successfully completed, the communication of ideas, instructions,
and methods is vital. That communication needs to be rapid, and needs to involve
(although in differing levels of detail) everyone involved in the job. Earlier, I spoke of
the need to brief your team before departure to the theatre of operations. This is the
start of a process which needs to be carried out at regular intervals from the begin-
ning of the deployment to the last moment before the team leaves for home. Everyone
will have their own methods of carrying this out based on the situation, their person-
604 Section Six
ality and the personalities of the team, but there are certain basic parameters that
should guide leaders in the proper conduct of this function.
Input: You will be unable to brief your team in an information vacuum. You need to
attend briefings yourself, take notes, and filter that information downwards. If no such
briefings exist, it is most strongly suggested that you demand them of whoever is the
head of the overall relief operation. If, of course, you are that individual, it is down to
you to brief all dependent team leaders. Input, of course, is not in one direction. As the
leader, this is your opportunity to be briefed by your key personnel on any problems
they may have, and make any necessary changes.
Clarity: You need to be absolutely clear of your mission. If this fits into a larger
operation, you need to understand fully the larger mission. This is perhaps the single
most important concept to grasp. Without clarity of your task within the larger task,
it is not only possible, but likely, that you and your team will find yourselves moving
away from the original task, driven by your essentially limited local perceptions from
day to day, and thus fail to achieve what was originally intended. This is known, in
military circles, as “mission creep” – a gradual loss of focus on the original notion for
which the operation was funded, manned, and equipped, resulting in an inevitable
limitation of success in a changed mission – for which different levels of manning,
equipment, or indeed funding would probably have been required.
Output: As a leader, you need to pass on information and instruction to your team.
If this is not formally carried out, with a set list of attendees at a regular time each day,
then mistakes will occur. In the absence of officially sanctioned information, human
nature will concoct rumor. For your part, you must avoid speculation – for if the
rumor source is the leader himself, it gains credibility. It is suggested that briefings of
key personnel within the team needs to take place daily – even if the leader is not
formally briefed daily. Only by so doing can rumors be quashed at birth, can problems
be identified before they are unmanageable, and can the team maintain its cohesion.
Identification: The formal briefing may be the only time that the various protago-
nists come together. Thus, it gives them the opportunity to have an overview of the
complete operation, therefore allowing them better to identify their place within the
whole. It also gives them the opportunity to understand that others have problems
with which they are struggling, therefore perhaps putting into perspective their own.
It also, significantly, demonstrates to each individual attending the briefing that they
are of equal importance to the success of the plan, that they are considered so by the
leader, and that their voice is heard. Their voice is heard, of course, in open forum; this
validates their viewpoint by the presence of witnesses, whereas a private conversation
with the leader may not.
Coordination
What exactly do I mean by coordination? I have already alluded to the need to fit in
with other players in the formation and execution of your plan; these players may
include some you may not have originally considered as being directly relevant. It is
the potential impact of these external forces that needs to be remembered if barriers
to the successful achievement of your mission are not to be needlessly encountered.
Let us consider some instances where a failure to recognize the impact of outside influ-
ences could diminish the effectiveness of your plan, and how proper coordination of effort
can lead to better cooperation, greater overall understanding, and increased efficiency.
Some of these external influences are glaringly obvious, and need little expansion here;
these might include such matters as airport/port capacity affecting the ability to get your
team or their supplies into the country, the existence of a military “situation” where you are
trying to deliver humanitarian aid or serious damage to the area’s infrastructure leading to
shortfalls in basic utilities (water, power, waste disposal, communications). All of these are
likely to have been taken into consideration either by you or by the major coordinating
agencies involved in the specific operation. But it is the little things that tend to pass unno-
ticed in the heat of emergency planning that are likely to cause you problems.
It is reasonably assumed that your plans will have looked at the various contingencies
that will affect it internally, that you have the manning and equipment relevant to do the
job in hand, and that within your team the plan coordinates individual functions to
deliver an effective whole. In no particular order, I will suggest some areas you may have
forgotten, and indicate how these apparently minor matters can have a deleterious effect
on the outcome of your carefully constructed plan. I mix, to an extent, the home-based
major disaster plan with the overseas humanitarian effort; the thought process needs to
be applied both to the proactive contingency plan and to the reactive relief plan.
● Exits and entrances: The “doors” to your facility are important, as are the controls
you place upon them. Access through the front door needs to be kept fairly tightly
controlled if you are not to be overwhelmed by inappropriate patients, let alone
their immediate families, the so-called worried well and of course the media and
(unfortunately) the “rubberneckers.” But care needs to be taken that this control
is sensibly applied, and that inappropriate gatekeeping does not create a problem.
For example, in a major incident, there are likely to be police cordons established
to control population movement. If the police gatekeepers are not involved and
informed, they are likely to prevent staff reaching the hospital – not just medical
staff, but all the other essential workers needed to ensure that the major disaster
plan works.
What is your plan for the management of the “worried well”? Have you identified and
secured an alternative location where they can be diverted and managed? How are
they to get there?
What about the so-called walking wounded? The operative word here is, of course
“wounded”; such cases must not be neglected or they will deteriorate. Staff and par-
ticularly space need to be dedicated to these, who are likely to represent a large pro-
portion of the overall casualty load. If possible, following Triage they should be
directed to a separate area in order that they do not inappropriately divert the atten-
tion of staff from the more serious priorities.
What about the back door of your facility? How are patients to be discharged, and to
where? Can they be traced subsequently? Have you identified a suitable area for the dead?
Are the facilities for the dead adequate, including if necessary provision of cold storage?
Is there a simple and foolproof method to identify the whereabouts of individual
patients? Relatives will be attempting to trace their kin, and without such a method
they will inevitably clog the switchboard – the electronic entrance to your facility.
606 Section Six
● Friends and neighbors: There are many who may wish to help, or be available to
help. Their assistance will be enhanced if it is planned, focused, and coordinated.
Obvious sources of this assistance include other medical organizations, such as
neighboring trusts that should be involved in major disaster plans to spread the
load. Other sources may need more careful management; the voluntary organiza-
tions will be keen to help, and it is suggested that they may be better employed as
an adjunct to, rather than a replacement for, the professional teams. It may be
tempting to allocate them to specific tasks, such as caring for the “worried well,”
but they represent an unknown quantity and as such need careful management.
Other locations may need to be examined to help in your plan, for example, the iden-
tification of nonmedical facilities to use as overflows for the less serious, as a morgue,
or for the containment of relatives seeking information. Schools, warehouses, and
halls in the vicinity can all be used; it is much easier to achieve this if major contin-
gency plans have not only identified the locations, but also ascertained the means of
access and the permission of the owners in advance.
The various levels of command involved in management of either a major disaster
plan or a relief organization are, of course, on your side. But are you sure that they
understand your thought processes – and of course that you understand theirs? Lack
of coordination at the higher levels may be caused simply by a failure to communi-
cate; it is important that the thought processes at the various levels are shared to avoid
confusion. This cannot be achieved without representation by the medical compo-
nent, or at least a recognized point of contact, at each level of command. Different
priorities will exist; the authorities may be concentrating on damage limitation fol-
lowing an event, rather than on the direct consequences of that event. Thus their focus
may be on tight control of movement, closure of routes, channeling of population, and
maintenance of order rather than on enabling the medical plan in support of the ini-
tial occurrence. Unless they are apprized of your problems, they will be unaware of
their existence and therefore can do nothing to alleviate them.
The media will inevitably be involved. If handled appropriately, they are a power for
good. However, if they are not given the facilities and information they require, they
may become a serious obstacle to the proper execution of your plan. It is important
to remember that if the media are not given facts, some of them may resort to rumor
and speculation. It is suggested that you need a dedicated media spokesman, and that
all other staff members are dissuaded from communicating with the press. You will
need to ensure that inappropriate access is not permitted if patient confidentiality
may be compromised either in words or in pictures.
● Delegation and hierarchy: The need to be able to delegate tasks is paramount.
Delegation needs to be associated with a clear demonstration that you trust the
person to whom the task has been given both to carry it out and, most impor-
tantly, to come back to you if there are any problems. Delegation does not, of
course, absolve the delegator of the responsibility of ensuring that the task is com-
pleted; so a degree of sensitive supervision is advisable, especially in the early
stages. The key word here is “sensitive,” or the perception that you trust the person
to whom the task has been delegated may be undermined!
The ability to delegate assumes the existence of some sort of hierarchy. The struc-
ture and function of that hierarchy needs to be fairly clear to all, as without that clar-
ity the potential for matters to fall between the gaps is magnified. A simple hierarchy
is best, with each individual or group within the structure having a single point of
contact in the level above. If this is not the case, instructions will be confusing, report-
ing of problems will fail to produce results, and responsibility for shortcomings in
execution may slip from the sloping shoulders of those who find a loose structure a
useful excuse for their incompetence!
The other benefit of a tight hierarchy is that it tends to drive toward a more efficient
utilization of resources. Overlaps and duplication of effort can quickly be spotted;
conversely gaps in the matrix are also more immediately obvious.
● Actions and reactions: Things will undoubtedly go wrong, even in the best of plans.
Applying the “What if…?” question may have helped to establish a set of reactions to
the problems it forecasts, but there will still be the unexpected event that throws eve-
rything out of kilter. There are two potential responses to this major confounder: the
first is the headless chicken response; this is common, highly stressful, unproductive,
and not recommended. The second is to draw together the team, work through the
factors that are confounding your activity and agree a response. The response may not
be the right one, but the process has been established, and the response can at least be
justified. To do this, you need to have thought about the following in advance – in
other words your basic plan needs to include how you will react to the unforeseen:
– Identifying and nominating your hot planning team.

– Having a callout procedure for that team.
– Identifying points of contact in the hierarchy above your group/team.
– Maintaining clarity of purpose – your mission remains the same.
– Preidentifying alternative locations and routes.
● Infrastructure and sustenance: In order for the team to function, it needs a good
deal of infrastructure. This is often relegated to the “someone else’s problem” cat-
egory, and as such may throw up unforeseen difficulties. Although these matters
may not be your direct responsibility, it is strongly suggested that you neglect them
at your peril. The list here is potentially endless, but I will restrict myself to a few
examples where consideration prior to the event may avoid pitfalls on the day!
– Transport
▪ How does your team get to the location in which it is to function?
▪ How do casualties move out of the back door of your facility?
▪ Are there other trusts or organizations involved? What about trades unions
or contractors?
▪ Have you enough labor to act as porters?
– Communications
▪ Are there dedicated telephone lines for urgent clinical matters?
▪ Are there backup switchboard personnel to deal with the public remember-
ing the need for 24-h cover? Have the trades unions been consulted?
608 Section Six
▪ Are there direct links to other relevant agencies?

▪ Is there a policy on minimization of usage?
– Catering
▪ If the plan involves callout of all staff, have you made arrangements to feed
them?
▪ Have catering contractors (including suppliers) and the trades unions been
involved in the planning process?
▪ In humanitarian relief, have you deconflicted the needs of your team from
the food shortages in the locality?
– Clerical
▪ Have you considered the clerical workload?
▪ How and where are you going to maintain clinical records?
– Utilities
▪ Is there enough water to maintain basic hygiene in the facility (including
blood and human waste)?
▪ Is the power supply sufficient to maintain your technical equipment?
▪ Have you a backup power supply, and does it work?
▪ In humanitarian relief, is there a burial plan for the dead?
▪ Can you rely on your fuel sources?
Random Thoughts
I draw together this meandering through the potential minefield surrounding the
effective planning and delivery of medical support to a catastrophe with a few ran-
dom thoughts, and end with an apology.
The thoughts are not, of course, entirely random, but are intended as a reminder of
the complexity of the situations in which we may find ourselves, and some of the
thought processes that may help. They are in random order, however, and many are
applicable to any emergency planning and deployment, not only those with a medical
component.
● Assumptions: You are likely to have made many assumptions in constructing your
plan. One difficulty is that you first need to identify all of these assumptions, as
many will have been made subconsciously. Where at all possible, these assump-
tions should be tested. This may be simply by running them past someone else –
preferably someone with a degree of experience who will be prepared to shoot
you down. Sycophants need not apply for this task!
● Mould to the environment: The environment in which your plan must function is
outside your control. You cannot therefore mould the environment to suit your
plan, so need to adapt accordingly. The environment includes such matters as
geography and climate, but also involves religious and political sensibilities and
the other agencies with which you need to cooperate.
● Expectations: Different groups will have different expectations of the outcomes of

your plan. Be careful not to give the impression that you can do more than is
practical. Your own expectations should also be pragmatic; if your targets are set
so high that they can never be achieved, your morale, and the team’s morale, will
suffer. The expectations of the local population are also important; the delivery of
high-tech medical support for a short period in a country where this cannot be
replicated after you leave raises a number of important philosophical and ethical
problems.
● Exit strategy: When is your task over, and what do you do then? Is there a specific
end-point involved, such as your tasks being taken over by another team? Have
you a plan to hand over responsibilities without any break in function? How will
you leave the population you have served in terms of continuation of care? To
whom will you hand over your records?
● Judgment calls: The statement is frequently heard that such and such an action
was the result of a “judgment call.” What is usually meant, unfortunately, was that
a mental coin was tossed, rather than any critical evaluation taking place!
“Judgment” implies a process – however brief – balancing the potential costs and
benefits of the various options. The mental discipline to apply the “what if…”
formula to every situation is hard to develop, but it bears considerable fruit.
● Leadership: Leadership may be considered a dirty word by many, implying that
the democratic process is put in abeyance. However, when the chips are down,
most of us have the need to turn to someone for guidance – that is, we look for a
“leader.” The hierarchy referred to earlier assumes a degree of leadership; it also
assumes a degree of trust in those either appointed or elected in that capacity.
Being a “leader” means taking on the responsibility for failure as well as success,
and also implies taking responsibility for the care and maintenance of the team.
Such care and maintenance involves a number of duties, such as the following:
– Monitoring the team to identify illness or stress early.
– Ensuring that team members have adequate rest periods (do not forget that
you, as a leader, are also subject to fatigue).
– Setting an example in terms of behavior, both on and off duty.
– Intervention where interpersonal relationships become frayed.
– Ensuring that the team’s health is maintained by monitoring antimalarial
prophylaxis, personal hygiene, and the like.
– Listening to what the team members have to say.
● Critical appraisal: Stand back from your plan, try to see it from the outside, and
be rigorously critical. There will always be areas where it can be improved, either
in terms of its overall effectiveness or in terms of efficiency – making it easier for
team members to function. Despite the fact that the plan is your baby, and that the
birth pangs were dreadful, that baby needs the appropriate input if it is to develop
into a fully functioning adult. Sometimes doting parents are less perceptive of
their baby’s shortcomings or needs than they might be!
● Audit: Be prepared to substantiate the outcome of your plan, both during and
after its execution. It is likely that you will be invited (directed?) to produce a
610 Section Six
report or reports. To facilitate this, keep notes as you progress. Bear in mind that
the audit may be of assistance to future deployments, and try not to consider it as
either self-flagellation or self-justification.
● Flexibility: Be prepared to bend with the wind. Rigidity in any plan is the likeliest
cause of its failure to deliver what is required of it. But beware of gross changes on
a daily basis – this only serves to confuse, and will lose you the attention and loy-
alty of your team more rapidly than anything else. “Bending with the wind” still
implies having your roots in the same place – in your mission.
I feel I must apologize to the majority of readers for telling them what they probably
already know. I excuse that by making the point that there will always be those who
are suddenly placed in a position of responsibility in an area where their previous
knowledge and experience is deficient. Indeed, even those of us who do have that
experience and knowledge may still benefit from a checklist to help in what may be a
fairly fraught time. In contrast, I apologize for what I have inevitably left out! There
can be no absolute list, covering all eventualities, in an area of medicine that has so
many variables. Indeed, to claim any list as exhaustive would be to fall headlong into
the very trap of arrogance and rigidity that awaits us all if we are not careful, and
which this chapter specifically tries to avoid.
and Donald F. Thompson
In many countries a number of government ministries are powerful stakeholders

within the health sector and each directly manages hospitals. This has the potential to
lead to overlapping provision of services and inefficient competition for development
funds. This note describes a model we developed to enable debate between local rep-
resentatives from each of the ministries and also to demonstrate how selective invest-
ment in the Ministry of Defense health services could have wider impact across the
whole health sector. The model is shown in Fig. 37.1.
The Ministry of Finance is responsible for the allocation of funds from both
national and donor sources to each Ministry. The Ministry of Public health is respon-
sible for the procurement of curative care, public health, and preventive medicine
services for the whole population. While it is a stakeholder in both Health Education
and Training, and Emergency Preparedness and Response, the Ministry of Public
Health is not the lead Ministry. The Ministry for Higher Education is responsible for
most aspects of education for the health sector workforce. It does not need to run
medical facilities but needs to be able to place students into health-service delivery
environments and clinical teachers need to maintain their clinical practice. The
Ministry of Defense is responsible for the provision of health services to the security
forces (including Police). In a counterinsurgency campaign where military forces are
sustaining significant casualties, the Ministry of Defense is likely to have the national
lead for Emergency Preparedness and Response and its medical staff are likely to be
the best organized to manage the medical response to emergencies. While the
Ministry of Defense wishes to recruit members of the health sector workforce, profes-
sion-specific training is best delivered under the auspices and licensing arrangements
of the Ministry for Higher Education. Curative medical care for military personnel
and their dependants is best delivered through Ministry of Public Health facilities but
the Ministry of Defense may need to negotiate special access and funding arrange-
ments to ensure that the needs of the security services as an employer are met. Finally,
the Ministry of Defense may need to institute vaccination programs and other public
health interventions for military personnel but this should be coherent with wider
national public health measures.
The model provided a useful framework to develop cross-ministry discussion and
cooperation. Part of institutional development may include the signing of a
Memorandum of Understanding between the five Ministries of Finance, Defense,
Interior, Public Health, and Higher Education to establish a Health Commission to
612 Section Six
Ministry of Higher Education Ministry of Public Health
Health Education
Curative Care
and Training
Emergency Preparedness Public Health and

and Response Prevention
Ministry of Defence Ministry of Finance
Fig. 37.1. Ministry overlaps within the health sector.
coordinate health sector development. It can also enable international military devel-
opment funds to be used as “pump-priming” investment for key health sector devel-
opments including the establishment of an Allied Health Professions Education
Institute (to train pharmacists, laboratory technicians, and other essential technical
support workers for both military and civilian employment) and the establishment of
a central public health laboratory for both civilian and military reference referrals.
38. Accreditation in Field Medicine
Ken Millar
If you are reading this book, you probably already have an inkling of the benefit of
some sort of accreditation to ensure optimal delivery of care in the complex situations
likely to be encountered in this field of medicine. Some, however, may not fully share
this view, perhaps considering that the expertise they possess by virtue of their pro-
fessional qualification is per se sufficient. Others may feel that they are in some way
delivering the gift of their experience to a medically deprived population, or that they
are acting under some divine guidance, and thus their perception of any need for
either additional training or accreditation is diminished. These contrary views can be
used as arguments against the need to allocate the necessary time (in an already full
academic life) to gain accreditation in this special area. A robust defense of accredita-
tion thus has to be available in support of funding or other resource allocations!
This chapter examines the following:
● An argument for accreditation
● The components of accreditation
● Training resources
● Available routes to accreditation
● The Faculty of Conflict and Catastrophe Medicine
The Argument for Accreditation

Almost every branch of medicine1 now requires specific and focused training, backed
up by an assessment process, before its practitioners are “let loose” on the public. This
is broadly accepted as a rational approach by the majority of medical practitioners,
and indeed is expected by the general public who are their “customers.” Each separate
training and assessment scheme takes as its baseline the primary medical qualifica-
tion, and builds on skills and knowledge already in place to develop the different
expertise required for the speciality concerned. Accreditation in the chosen sphere
usually demands a recognized training scheme and a validating examination.
Conflict and Catastrophe Medicine is no different from any other specialization in
this respect. Whatever the preexisting skill set of the individual, it cannot be exercised
1
The words “medicine” and “medical” are used throughout this chapter to include medicine,
dentistry, nursing, and the professions allied to medicine.
614 Section Six
effectively in this difficult sphere without additional training and some alteration in
focus of the thought process. It is not considered acceptable for a patient base, which
is, by definition, vulnerable to be exposed to medical practice which could in any way
be substandard; indeed, with such vulnerable populations it is essential that the high-
est possible standards of care are available. Practitioners must, it is suggested, be
demonstrably “Safe to Help” their target population in the disaster setting – just as
they must be in their everyday practice.
The environment in which they may be asked to deliver care is unknown. The need
may arise at home or abroad; the emergency may occur in areas of geographical and
climatic extremes; the response could be an emergency relief operation or the bringing
into action of a detailed local contingency plan. It might involve war, natural disaster,
man-made disaster, or any combination of these. To ensure that patients are safely
cared for in all the varied and difficult environments under consideration should need
no further explanation. That safety, however, depends on every practitioner having the
necessary skills and informed mindset to respond appropriately to all of the scenarios
in which that assistance is required. If “help” is to be delivered, then practitioners must
be capable of performing to the maximum of their ability in adverse situations – with-
out themselves becoming a drain on scarce resources, or indeed a casualty.
It is worth looking at the rationale for accreditation from different viewpoints, as
these may assist in convincing individuals of the value of any extra work they may
need to undertake to become properly involved in this rewarding area of medicine.
The following viewpoints are considered:
● The dependent population
● The individual’s professional body
● The employer (whether formal or informal, Governmental, or NGO)
● The law
● The individual
The Dependent Population

The dependent population has become so because of some event (or chain of events),
which has caused an imbalance between their medical (and other) needs and the imme-
diately available capabilities (infrastructure, resources, medical skills) to meet these
needs. To restore this balance in the shortest possible timeframe, with the least possible
mortality and morbidity following intervention, only the highest standards of compe-
tence in planning, basic care and specialized medical assistance are acceptable.
That dependent population may be a large number of refugees from strife in a Third
World country, or they may be the citizens of a First World country caught up in a
terrorist incident. The deployment of untried, untrained, and well-intentioned ama-
teurs to remedy these situations is unlikely to produce the best possible outcome.
While it is probable that many of those deployed will be untried, their undoubted good
intentions need to be supported by some training, and the populations involved
deserve that such training is properly accredited. Indeed, in the case of the First World
disaster response, the population positively demands to be looked after by fully trained
personnel whose qualifications to perform their tasks are visible and quantifiable.
The Professional Bodies

The medical, dental, and nursing professions are subject, certainly in the First World,
to intense public scrutiny. Any inkling that the delivery of care is in any way substandard
– no matter what the setting – is likely to produce an adverse press response. In the
absence of a process of accreditation, it may be difficult to justify either action or
inaction in the medical response to a catastrophe. Accreditation is therefore of impor-
tance in maintaining the overall credibility of the various professions in the presence
of a potentially hostile press.
The Employer
Employers may include Government Departments and Agencies, NHS Trusts, the
Armed Forces, the larger NGOs, and smaller charitable and voluntary organizations.
Governmental employers are, of course, accountable through the government of the
day to the electorate (or perhaps it would be closer to the truth to say “to the tax-
payer”). NGOs and charitable organizations are also accountable to those who fund
them; they need to show that charitable contributions have been put to the most effec-
tive use. Again, if it can be seen that untrained, unaccredited personnel have been
deployed, it may be difficult to justify expenditure – especially where the outcomes
have been less than successful.
The Law
It is ever more important to remember that litigation may follow medical interven-
tion, no matter how well intentioned. To protect both individuals and employers from
potential litigation, a recognized system of training, with associated valid accredita-
tion, will go a long way toward reducing the number of potential legal actions related
to medical care in catastrophe situations. To bring this home, one need only consider
how one might answer the potential question from the Claimant’s Barrister; “Can you
tell me what formal qualification you held to practise medicine in this highly special-
ised situation?”
The Individual Practitioner

Any practitioner would clearly wish to give of their best in a situation where there is
much suffering to be relieved. The author of this chapter, in the distant past, found
himself in situations where he felt he had less than adequate training to equip him for
the task that faced him at the time. His chief fear was that this lack of training would
make it difficult to give the dependant population the correct level of assistance. In
those distant days, there was no training or accreditation in the various areas that
were relevant; thankfully, these days are now past, with such schemes as ATLS/BATLS,
MIMMS, and Dip IMC RCS(Ed) and the existence of such qualifications as the
616 Section Six
Diploma in the Medical Care of Catastrophes (DMCC), which will be covered later in
this chapter. What training and accreditation can give to the individual practitioner is
confidence that he or she has the necessary skills to attend to the job in hand, and
such knowledge will dispel both the fear and the reality of inadequacy.
The Components of Accreditation

The concept of the practitioner’s being “Safe to Help” has already been mentioned.
Clearly, achieving this for the huge spread of potential situations in which a practi-
tioner may be deployed in support of conflict or other catastrophe is a fairly tall order!
However, there are certain basic components that it is considered must be achieved by
any candidate for accreditation; each of these is firmly grounded in the “Safe to Help”
concept. These components include the following:
● Survival and field skills – to ensure that the practitioner, and the team, is capable
of survival and efficient operation in adverse conditions, and that they do not
represent a further drain on an already weakened infrastructure.
● Emergency medical skills – all relevant members of a team need to be competent
in appropriate emergency medical skills, such as ATLS, no matter what their base
specialty. Radiological, biological, and toxic contamination responses also need
proper consideration. Triage in the emergency situation is essential, and needs to
be appropriate to the resources available, casualty numbers, and communications
infrastructure.
● The nature of catastrophes – an understanding of the types of casualties likely to
be encountered in the different potential disaster situations is essential to prepare
and to plan.
● Tropical medicine and extreme environments – the impact of endemic disease on
both the team and the dependent population needs to be understood if it is to be
minimized. The effects of heat and cold and measures to prevent injury and ill-
ness from these climatic extremes need to be known.
● Public health aspects – this is a broad topic, and includes such matters as vector
control, waste disposal, population needs assessment, maintenance of records,
immunization, and prophylaxis. All of these areas can affect the medical plan, its
execution, and its outcome.
● Ethical, legal, and political considerations – religious sensibilities, neutrality, refu-
gees and IDPs, the Geneva Conventions, the primacy of the host government, and
the place of the military all need to be taken into consideration. Dealing with the
press is also a matter of some importance.
● Planning and mounting a response – many topics need to be appreciated here,
such as the use of intelligence, the place of reconnaissance, logistics, appropriate
skill selection, medical supply, and cooperation with other agencies.
● Psychological aspects – responses by both the target population and the team to
stresses need to be discussed. The prevention of psychiatric breakdown both during
and after the aid operation is an important facet of the plan.
This list is not intended to be in any way exhaustive; fuller exposure of the compo-
nents may be elicited from the websites of accrediting authorities shown later. However,
it gives a taste of the broad spectrum of skills and knowledge required – which, it is
suggested, are not covered comprehensively in any other formal medical training
structure.
Training Resources
Training is complex, because of the broad mix of skills required to gain accreditation.
However, many of the separate components may be achieved over a period of time as
part of more “standard” medical training; for example, ATLS training is already a
requirement in some hospital specialties. Some groups, such as the Armed Services’
medical branches, may already receive a large proportion of the prescribed training
as it corresponds with their operational role. The majority of civilian candidates for
accreditation, however, may find certain elements of the required training quite
difficult to access unless they utilize the resources provided through the accreditation
authorities. This is perhaps particularly true of the requirement to demonstrate the
ability to live and work in an adverse environment (although some would say that
NHS Trust residents’ accommodation is adverse enough!).
A full gamut of the necessary training is available via the Society of Apothecaries;
details are at http://www.apothecaries.org/.
Liverpool University also offers training; this can be accessed at http://www.liv.
ac.uk/lstm/learning_teaching/post_grad/DiplHumAssis.htm.
Available Routes to Accreditation

There are, at the time of publication, only two known routes to formal accreditation
in this area. These are the following:
The Diploma in the Medical Care of Catastrophes (DMCC): The DMCC is granted
under the auspices of the Society of Apothecaries of London. This Diploma is specifi-
cally medical, and has the basic entry requirement of full professional registration as
a doctor, dentist, or nurse. Broadly, the DMCC, as a medical Diploma, concentrates on
clinical matters in addition to the planning and ethical considerations. Progress
toward the Diploma is in two parts. Part I involves the accredited completion of a
number of Modules, followed by a viva voce examination by two sets of examiners.
Successful completion of Part I is followed by the submission of a Dissertation upon
which the candidate will be examined viva voce by a further pair of examiners. Part I
can be attempted at any time following full Registration, whereas Part II demands at
least 2 years of postregistration experience. A list of dissertations that gives a good
guide as to the breadth of the subject matter in this Diploma can be found on the
Society of Apothecaries website http://www.apothecaries.org/.
The format of the examination is constantly under review, to ensure that it is as
objective as possible, and that candidates are given any necessary assistance in the
preparation of their Dissertations. Currently, the format of the Part I Examination
is being scrutinized to decide whether or not the viva voce approach is the best
available.
618 Section Six
The Society of Apothecaries runs a specific course to prepare candidates for Part I
of the Diploma. This is run over a series of weekends, and candidates may opt to attend
those course modules they specifically require, or to attend the entire Course. Details of
the Course, and of the DMCC, are available at http://www.apothecaries.org/.
The Diploma in Humanitarian Assistance (DHA): The DHA is granted under the
auspices of Liverpool University’s School of Tropical Medicine. This Diploma is not
specifically aimed at the medical professions, but at all who may be involved in
humanitarian work. Thus, the clinical aspects are not covered in any great detail, and
the many nonclinical candidates involved in Humanitarian Assistance will therefore
find this course of more relevance than the DMCC. The DHA is, effectively, a 6-week
residential course-based Diploma.
Details of the DHA are available at http://www.liv.ac.uk/lstm/learning_teaching/
post_grad/DiplHumAssis.htm (It should be noted that Liverpool University also runs
two Masters degrees; one is the MSc in Humanitarian Programme Management, and
the other is the MSc in Humanitarian Studies. Details of these can be obtained at:
http://www.liv.ac.uk/lstm/learning_teaching/masters/HumPM/MScHumPM.htm and
http://www.liv.ac.uk/lstm/learning_teaching/masters/HumStud/MScHumStud.htm).
The Faculty of Conflict and Catastrophe Medicine

The Faculty of Conflict and Catastrophe Medicine arose from the DMCC, and the
recognition that this area of medicine required a coordinating base. Its aims and
objectives can be found at http://www.apothecaries.org/.
39. Humanitarian Work in the Era
of Modernising Medical Careers
James I.D.M. Matheson
● To consider how changes in UK Doctors’ training will influ-

Objectives ence undertaking humanitarian work.
Introduction
Modernising Medical Careers (MMC) is the new training and career structure in
place for UK NHS doctors from August 2007. It was brought in with the aim of deliver-
ing a modernised and focused medical career structure through major reform of
postgraduate education.
The implementation of MMC has not been without its critics within the sphere of
humanitarian operations and beyond – a number of NGOs and research organisa-
tions have felt the reduction in volunteers associated with the uncertainty of a new
career structure and there are concerns as to whether the move toward early speciali-
sation will reduce the broad spectrum of medical knowledge and skills required by
the aid worker in the field. There is also the question of whether a system geared
toward achieving completion of training as swiftly as possible will support time spent
not directly toward this goal.
Consideration, however, has been made of the benefits of humanitarian work to the
doctor in training, and a number of options as to how this may be achieved have been
included within the MMC process. In the Department of Health’s Guide to Postgraduate
Specialty Training in the UK (The Gold Guide), explicit mention is made of the recom-
mendation of Lord Crisp’s report, Global Health Partnerships: The UK Contribution to
Health in Developing Countries (2007) that:
An NHS framework for international development should explicitly recognise

the value of overseas experience and training for UK health workers and
encourage educators, employers and regulators to make it easier to gain this
experience and training … PMETB should work with the Department of
Health, Royal Colleges, medical schools and others to facilitate overseas training
and work experience.
620 Section Six
It is worth noting that while this volume is undergoing publication, an independent

review of the processes underlying MMC, the MMC Inquiry, is being conducted by Sir
John Tooke. Its findings will be reported toward the end of 2007 with the intention of
improvements being implemented for 2008 and beyond. As a consequence of this
process the information in this section may change.
Ways and Means

There are two principal ways by which doctors in training under MMC can work in
the humanitarian field of operations without jeopardising their NHS career and,
potentially, even enhancing it. These are by taking advantage of flexible training or by
taking time out of program.
Flexible Training
Flexible training has been introduced to enhance work/life balance and hence retain
doctors who might otherwise have left the profession. It may also suit the humanitar-
ian worker to take up a slot/job share position or a permanent flexible post (if avail-
able) in order to work in the field while continually progressing along the training
path. The Postgraduate Dean may also consider the creation of individualized, super-
numerary posts, with approval from the Postgraduate Medical Education and Training
Board (PMETB) to meet specific needs.
Flexible training meets the same requirements as full time specialty or GP training
except that the weekly hours are reduced. Minimum weekly commitment is 50% of
full time hours. Applications can be made at the point of application to training or at
any point after acceptance into the training process and should not affect the candi-
date’s competitiveness in selection.
Applications for flexible training and how flexible training might best be conducted
are under discussion with the Postgraduate Dean who will prioritise applications
according to “well-founded individual reasons”. Humanitarian assistance would fall
under a category 2 priority of doctors in training with “unique opportunities for per-
sonal professional development,” “religious commitment” or “non-medical professional
development”.
Limitations are the minimum overall commitment, certain specific time require-
ments, and the statement that trainees will not normally be permitted to take other
paid employment.
More details can be found in the titles under “Further Reading”.
Time Out Of Program

Under certain circumstances trainees will be permitted to take out of their chosen
specialty program. This can be time out of program for clinical experience (OOPE),
for approved clinical training (OOPT), for research (OOPR), or for a career break
(OOPC). A number of features are common to each:
● They must be agreed by the Postgraduate Dean.
● They will not normally be permitted during the first year of training unless a
request for deferral of the start of the program has been agreed.
● As much notice as possible to the Postgraduate Dean and the employer will facili-
tate the process. Three months is the minimum notice required.
● As much detail as possible will also assist, especially where PMETB approval is
required.
● The Out of Program documentation must be submitted annually to maintain
contact and demonstrate continuing commitment to return to the program.
OOPE
Time out of program for clinical experience is the most obviously intended device for
humanitarian work. It can be requested in order to, “…enhance clinical experience for
the individual so that they may experience different working practices or gain specific
experience in an area of practice and/or support the recommendations in Global
Health Partnerships…”
It does not require prior PMETB approval but will not count toward the Certificate
of Completion of Training (CCT). OOPE is usually for 1 year in total but may be
extended up to 2 years with the agreement of the Postgraduate Dean. The trainee can
retain their National Training Number (NTN) throughout this time.
The principal disadvantage of this means is that the experience gained, while theo-
retically recognised as personal professional development, will not allow competen-
cies to be signed off and will not progress the trainee along the program of training.
OOPT
Time out of program for approved clinical training can potentially include overseas
training posts, which may suit the humanitarian worker. Training can count toward
CCT but it is critical that PMETB prospectively approves the training and assessment.
The Postgraduate Dean will advise on seeking prospective PMETB approval and must
approve and sign the application. It is a legal requirement that this training be super-
vised. Colleges and Faculties must confirm that training has been completed satisfac-
torily and that it satisfies curriculum requirements.
Trainees’ NTN will be retained as long as there is prospective approval; assessment
requirements are maintained and the OOPT document is completed. OOPT is usually
granted for a maximum of 1 year but in exceptional circumstances this may be extended
to 2 years with approval from the Postgraduate Dean.
Opportunities to utilize this means may be limited by the ability and indeed willing-
ness or appropriateness of institutions in the developing world to satisfy the training
and assessment criteria of PMETB and careful consideration should be taken of whether
it is achievable. Possible avenues to consider are training conducted in developing world
institutions linked with NHS Trusts – see the Tropical Health and Education Trust
(resources section) for such links – and the possibility of trainees abroad being super-
vised by UK-qualified consultants.
622 Section Six
Drawbacks are that while this maintains training progress, it may be hard to satisfy
PMETB training and assessment requirements and many organizations working
within the humanitarian field state that priority must be placed on the clinical work
or training local health workers, precluding time for expatriate training in the field.
OOPR
Research is an area of focus in the Chief Medical Officer’s report, Health Is Global:
Proposals for a UK Government-wide Strategy (2007) and the Gold Guide states that
trainees with an interest in research should be encouraged and facilitated. Research
in the humanitarian area may be included as long as its relevance to the program of
training or higher educational degree is demonstrated.
Time out of program for research requires approval by PMETB if to count toward
CCT. PMETB states that if the trainee’s curriculum includes research as an optional
element, time OOPR will be recognized toward CCT. Both the college/faculty and the
deanery must support applications for OOPR and, once complete, the college/faculty
must confirm that the training and research satisfies the curriculum requirements in
order for PMETB to award the CCT. Formal assessment documentation must be sub-
mitted annually to the review panel.
If OOPR is not to count toward CCT then PMETB approval is not required.
If a clinical element counting toward CCT is to be maintained throughout the
OOPR, it must be prospectively approved by PMETB and at least 50% of time must be
spent in approved clinical training. The Training Program Director should be con-
sulted as to the suitability of the clinical training. The NTN can be retained.
OOPR is usually for a registerable higher degree, for example, Master’s, MD, or PhD.
Duration will normally be 3 years or under and OOPR is not usually granted in the
final year of training.
As an alternative to OOPR, trainees may wish to undertake academic training,
which includes dedicated amounts of research time, which it may be possible to tailor
toward humanitarian areas, in the program.
OOPC
Time out of program for career breaks allows a trainee to take time out but with a
guarantee of being able to return to the program at an agreed date and can be used for
other interests or responsibilities, for example, humanitarian deployments abroad.
The break must be agreed with the Postgraduate Dean who is limited by the ability of
the program to cover the resulting gap (a temporary replacement NTN may be available)
and must confirm the trainee’s commitment to an eventual return to training. Priority
can be given to those with, “a clearly identified life goal which cannot be deferred”.
OOPC cannot be used to defer start of training and duration is usually limited to 2
years although this may be negotiated higher with the Postgraduate Dean in excep-
tional circumstances. The NTN may be retained for 2 years but after a longer period
will usually be relinquished and reapplication will be competitive.
Six months’ notice of return is required and trainees may have to undergo skills
refreshment. In the future, trainees will have to consider the effect on their ability to
maintain the GMC license to practice.
For all time out of program the message from the Postgraduate Deans is clear – approval
must be sought with as much notice and as much attention to detail as is possible to facili-
tate applications being approved. For time to count toward CCT prior PMETB approval is
mandatory with appropriate supervised training and assessment in place.
Short-Term Deployments
Not all humanitarian deployments will require great lengths of time out of country.
Natural disasters may require foreign medical assistance for a week or 2 and some
medical NGOs may rotate specialized personnel, often surgeons and anesthetists, as
frequently as every 3 weeks.
For short-term commitments, the major consideration is not for training, which can
be made up before or after, but for employment concerns. Individual NHS Trusts have
their own guidelines for granting doctors time to work abroad but NHS Employers
recommend the following to facilitate the process:
● To discuss plans with managers as soon as possible
● To help the employing Trust to ensure they have adequate cover at home before
they leave
● To arrange aid work through an aid relief organization, which would be prepared
to support them when applying for leave from their employer
When to Go
The question of when in training to deploy is a matter of striking a balance. In the
field, a volunteer may be the only doctor in the area, unsupervised, unsupported, and
without the ability to consult colleagues or the luxury of a library of books. If deployed
too soon in training, the doctor may not possess sufficient skills, experience, and
confidence to work effectively. As training progresses, however, especially under
MMC, the trainee becomes more and more specialised and may leave behind the
broader base of knowledge that is so useful in the field. Leaving voluntary work
abroad until consultant level has been reached avoids concerns over time out of training
but at this level, skills have become specialised and UK commitments at work and in
terms of home and family life are likely to have increased.
Pay and Conditions

The earlier options all refer to varying times away from home, hospital, and program
and these will have differing effects on the trainee’s pay and statutory rights under
terms and conditions of service. Those considering time out of program should seek
expert advice from the Deanery’s human resources department and from their
624 Section Six
professional associations such as the British Medical Association on career and finan-
cial effects such as pay, increments to salary, maternity leave, and related interests.
Conclusion
The message from the Department of Health, PMETB, the Royal Colleges, and NHS
Employers remains that experience in the field of humanitarian operations greatly
enhances doctors’ personal professional development as well as their life skills and
this message is now incorporated into options to take time out of training for such
work. As current trends toward the establishment of a specialty of Disaster Medicine
progress, there may be options for permanent paid employment in the field.
At present, however, the situation continues as it has been and dedication, persistence,
and a willingness to sacrifice will be required by the doctor in training. Where there
is the will, however, MMC has offered a number of ways and how easily these are
achieved will become clearer over years to come. Some final advice for those who do
deploy in training is offered by the Royal College of Surgeons: “Trainees who choose
to undertake a period of this kind of work during their specialty training should
ensure that they document their experiences, are able to reflect on it and discuss how
it has enhanced their capabilities as a surgeon.”
Further Reading
Department of Health (2007) A guide to postgraduate specialty training in the UK. The Gold Guide. London,
Stationary Office.
NHS Employers (2005) Doctors in flexible training: principles underpinning the new arrangements for flex-
ible training. London, Stationary Office.
Online, visit www.mmc.nhs.uk for up-to-date information on MMC and both publications above as
downloads.
The editors and authors recommend the code of behaviour that follows and completes
this handbook
Code of Behaviour
Humanitarian volunteers are not tourists. They arrive, often uninvited, in a country
or region devastated by war or disaster. The atmosphere in a war or disaster setting is
unique. Displaced people are vulnerable and dependent on volunteers who may have
little knowledge of their religious beliefs, culture and way of life. They may never have
encountered foreigners. There is enormous potential for misunderstanding, suspicion
and, on occasion, downright hostility. Ideally, expatriate volunteers should be fully
briefed on these aspects, but urgency and crisis may mean deployment at short notice
without adequate political or cultural briefing. Volunteers must approach displaced
people with great sensitivity if they are to avoid gaffes. As an example, a group of
soldiers deployed in a humanitarian setting and working with refugees were seen to
wear T-shirts with the logo: “Travel the world, see interesting places and people – kill
them!”. Although meant in jest, the potential for offence is obvious. The following
items of advice have been gleaned from a variety of sources and individuals and may
help to keep you out of trouble.
● Do your work in a spirit of humility and understanding – keep a low profile.
● Take time to listen and understand the cultural mores of the peopel you are
helping.
● You are not a tourist. Be sensitive when using your camera always ask permission.
● Avoid displays of wealth and ostentation – do not give gifts of money.
● Do not make promises that cannot be kept.
● Do not collect war souvenirs and keep away from unexploded ordnance (mines
and bomblets).
● Avoid drugs and be temperate in your use of alcohol.
● Treat local staff with kindness and respect – listen when they offer advice.
● Avoid political debates and keep away from political meetings and gatherings.
● If provoked, be polite, patient and courteous.
625
Index
A Acute watery diarrhea, 501

ABC news, Iraq, 262 Adequate oral rehydration therapy (ORT),
Abdominal complaints 170–171
differentiation and management Advanced Trauma Life Support (ATLS)
acute mesenteric ischaemia, 458–459 techniques, 245
acute pancreatitis, 458 Aegis Defence Services
bleeding, 455–458 BLS techniques, 68–69
hollow viscus obstruction, 451–455 golden hour rule, 65–66
inflammation, 450–451 medical equipment, 62
testicular torsion and acute medical training, 61–62
epididymo-orchitis, 460 Morland’s autobiography
types, 449 BLS techniques, 67
urinary tract infection and acute British Army, 63
pyelonephritis, 459 civilian surgical sector, 64
history, 447–448 dressing, 66–67
physical examination, 448 lifesaving techniques, 69
Abscesses medical assistant’s course, 63
anorectal type, 461 Operating Theatre Technicians
breast abscess, 461 course, 64
soft tissue type, 460 OTT/ODP training, 64
Active Learning Network on Accountability out-of-date teaching and techniques, 66
and Performance in Humanitarian Parachute Field Ambulance, 64
Assistance (ALNAP) project, 153 personal security detail (PSD) team
Acute bloody diarrhea, 503–504 medic, 65
Acute epididymo-orchitis, 460 security operatives, 66
Acute limb ischaemia, 461–462 program value, 62
Acute mastoiditis, 470 Afghanistan health situation, 78–79
Acute medical problems. See Mass gathering Air/droplet transmission
Acute mesenteric ischaemia, 458–459 measles and influenza, 507
Acute mountain sickness (AMS), 117–118 tuberculosis and meningitis, 508
Acute necrotising ulcerative gingivitis Al Maliki government, Iraq, 261
(ANUG), 468 Amoebiasis, 504
Acute otitis externa, 469 Anaesthesia
Acute otitis media, 469–470 conscious sedation
Acute pancreatitis, 458 definition, 487–488
Acute pericoronitis, 468 equipment and supplies, 488
Acute pharyngitis and tonsillitis, 470 definition, 479
Acute urinary retention. See Lower urinary local anaesthesia
tract obstruction limitations, 489–490
627
628 Index
Anaesthesia – cont. snake bites

safety and pharmacology, 490–491 antivenom and other treatments, 519
selected procedures, 491–492 first aid management, 517
medications used, 489 investigation and initial patient
Analgesia management, 518–519
administration routes, 480–482 prevention, 516–517
definition, 479 snake venom, 515–516
pain treatment principles and clinical spider bites, 520–521
assessment, 480 Blast injuries
pharmacology primary injuries, 442–443
inhalational analgesia, 486–487 secondary injuries, 443
nonsteroidal anti-inflammatory drugs shock wave effects, 442
(NSAIDs), 484 tertiary injuries, 444
opioid analgesics, 484–486 treatment, 445–446
paracetamol, 483–484 Bleeding
WHO’s pain ladder and oral analgesics, intraluminal, 457–458
482–483 intraperitoneal, 455–456
Anorectal abscess, 461 retroperitoneal, 456–457
Antarctic medical problems Bosnian Ministry of Health, 243
environmental, occupational, and public Breast abscess, 461
health, 110–111 British Association of Plastic Surgeons
physical health, 109–110 (BAPS), 243
psychological health, 111–112 Bubl link, 581
Arctic medical problems, 112 Burns, 434–435
Area of operations (AO) Iraq, 261
Armed conflicts, violence against women,
532–533 C
Asynchronous transfer modes (ATM), 329 Caesarean section, 538
Casualties, Ibn Sina. See Ibn Sina casualties
Caucasus–Azerbaijan, 384–385
B Cavitation, 439–440
Baghdad Christmas, 3 Cellulitis, 437
Balkans–Pristina/Kosovo, 383–384 Central Emergency Revolving Fund (CERF),
Ballistic injuries 46–47
mechanisms Central nervous system dysfunction,
cavitation, 439–440 426–427
energy transfer, 438–439 Chain of Care, 513–514
fragments, bullets and wound track, 439 Chemoprophylaxis, vaccination program, 216
indirect injuries, 440 Children, psychosocial consequences
treatment principles, 441–442 approximated facts, 555
wound contamination, 440 bullying, 556
Biliary tract obstruction, 453–454 childhood adversity, 557
Bites and stings community organizations and cultural
effects on humans, 514–515 sensitivity, 564
marine envenomations, 521–522 disaster and conflict, 559
scorpion stings, 520 emphasize disorder, 567
Index 629
exposed to war, 558 Civil Contingencies Act 2004, London

exposure to war, 558 bombing, 148
immediate and short-term distress, 559–560 Civil–Military Operation (CMO), 81
medium-, long-term and chronic Clinical Governance, human resources
responses, 562 and training, 174
overwhelming stress, 557 Codeine phosphate, 485
parental-referencing, 559 Code of Conduct, Red Cross movement, 152
posttraumatic stress disorder, 562 Cold injury, 511
psychological and emotional Committee Against Torture (CAT), 256
development, 563 Common Humanitarian Action Plan (CHAP),
psychological first aid, 566 46–47
resilience development, 567 Communications technology
short-to-medium term responses, bandwidth, 325–326
560–561 box, 327
Sphere Project, 565 catastrophe medicine, 323–324
terrorism, 557–558 cost calculation, 327–328
traumatic events, 556 equipment, 324
Children’s health fixed wire links
airway protection, 551 analog, 328–329
blood circulation and breathing, 552 broadband, 329
care in adverse conditions, 543–544 digital network, 329
caring principles, 543–544 emergency services, 331
climate, 547 GSM mobile telephones, 330–331
common childhood infections internet, 329
measles, 547–548 functionality, 325
other diseases, 548 GSM vs. satellites, 327
conflicts and disasters, 552–553 overview, 324–325
environmental hazards, risk factors satellite networks
bites and stings, 551 geostationary earth orbit (GEO), 331
burns and scalds, 550–551 inmarsat BGAN, 334
food, 545–546 inmarsat B portable systems,
infection and immunity, 547 331–332
mass gatherings, 546 inmarsat M4, 331–332
nonaccidental injury, 552 inmarsat Mini-M, 331
pediatric trauma, 551 inmarsat RBGAN, 334
preexisting disability, 549–550 iridium, 335
resuscitation volumes, 552 radio, 336–337
sanitation, 546 thuraya, 335–336
UNICEF, 553 spectrum capabilities
water supply, 545 austere environment, 342
web sities, 553 high bandwidth, 340
Childs’ Rights Information Network, 582 low bandwidth, 338–340
Chlamydia, 535 planning, 340
Cholera, 501–502 principles and user requirements, 341
Christmas, Baghdad, 267–268 synchronous, 326
Chronic periodontal disease, 467–468 wired vs. wireless, 326–327
630 Index
Community Aid Abroad, 582 Conflict surgery, 393–395

Conflict spectrum Consolidated Appeals Process (CAP), 47
characteristics Crude mortality rate (CMR), 159
changing patterns, 17, 27
cycle, 29
failed states, 27–28 D
model, 28–29 Death penalty, 253
humanitarian law and United Nations, Deforestation, 133
29–30 Dental abscess, 464
law’s significance, 30 Detainee, definition, 252
massacre, genocide, and criminal behavior, Development Resource Centre, 582
18–19 Diagnostic laboratories
media basic principles, 593
BBC, 93 causative organism identification, 593
checklist, 99–100 equipments, 594–595
communication, 96 internal and external quality controls, 596
dislikes, 98 rapid test kits, 594
funding, 94–95 rehabilitation, 595
humanitarians’ role, 95–97 validation and quality control system,
international, 98 595–596
journalists and reporters, 91–92 Disasters
local or regional, 97–98 complex emergency, 128
negative stories, 99–100 earthquakes
newspaper circulation, 92 Bam city, Iran, 130–132
public service, 93 electrocution and fires, 130
roles, 92 epicentre and Richter scale, 129
TV news, 90–91 emergency medical aid, 136–137
vs. individual reporters, 93 famine, 135–136
world issues coverage, 92 floods, 133
modern military philosophy humanitarian crises
asymmetric warfare, 24 medical needs, 139–140
maneuvrist approach, 25 needs assessment, 137
protracted struggle, 24–25 potable water, 138
symmetric warfare, 24 sanitation, food, shelter and security, 139
technocentric war, 25–26 UNDAC, 137
Van Creveld’s alternative view, 26 issues, 125
nature of war, 18 Kurdish refugee crisis, 129
rational intention, 18 landslides, 133
traditions mass casualty incident
absolutist views of warfare, 19–20 developed countries, 126–127
Just War theory, 20–21 developing countries, 127–128
Mao, Giap, and revolutionary warfare, 23 planning and preparation, 126
Marx, Lenin, and political conflict, 22–23 population’s vulnerability, 129
moral basis, 20 prevention methods, 142
Sun Tzu and art of war, 21 On Site Operations Coordination
Von Clausewitz on war, 21–22 Center, 141
Index 631
tropical storms Fecal contamination

cyclones, hurricanes and typhoons, 134 acute bloody diarrhea (dysentery),
Expanded Programme on Immunization 503–504
(EPI), 135 acute watery diarrhea and cholera,
Hurricane Andrew and health 501–502
coordination, 134–135 amoebiasis, 504
tsunami case definition, 502
earthquakes, 132 drancunculiasis, 507
Sri Lanka, 133 enteric fever, 504–505
volcanoes, 134 non-typhoid Salmonellae, 503
Disintegration, world political scene, 8–9 viral hepatitis, 505
Drancunculiasis, 507 worm infestations and
Driving safety schistosomiasis, 506
benefits, 290 Femoral nerve block, 491
Terp, 291 Fentanyl lozenge, 486
Dynamic risk assessment (DRA), 144 Fentanyl opioid, 489
Dysentery. See Acute bloody diarrhea Field Clusters, 42
Field medicine accreditation,
argument, 615–616
E components, 618–619
Ear, nose, and throat injuries dependent population, 616
foreign bodies, 471 Diploma in Humanitarian Assistance
infections, 469–470 (DHA), 620
Ectopic pregnancy, 537 Diploma in the Medical Care of
Electronic personal dosimeters (EPDs), 147 Catastrophes (DMCC), 619–620
Entamoeba histolytica, 504 employer, 617
Enteric fever, 504–505 Faculty of Conflict and Catastrophe
Enteropathogenic E. coli (EPEC), 502 Medicine, 620
Enterotoxigenic E. coli (ETEC), 502 individual practitioner, 617–618
Epi Info™6 epidemiological data tool, 222 law and professional bodies, 617
Ethnic cleansing conflicts, 10 training resources, 619
European Community Humanitarian Office First-line medical care. See Aegis Defence
(ECHO), 583 Services
European Council on Refugees and Exiles Forced psychiatric treatment, 253
(ECRE), 583 Forensic medicine, 259
European Forum on International Fractures and dislocations
Cooperation, 583–584 management strategy, 432–433
European Parliament, 584–587 pathophysiology, 431–432
Expanded Programme on Immunization treatment, 433–434
(EPI), 135
Eye injuries, 469
G
Genital tract trauma, 535–536
F Geostationary earth orbit (GEO), 332
Facial bone injuries, 466–467 Globalization, 7–8
Falkland Islands, 381–383 Gonorrhea, 535
632 Index
H information evaluation, 236

Head-injuries priorities, 236–237
military situations, 472 psychological stress, 237–238
prehospital care, 473 sexually transmitted disease, 238
primary survey, 473–474 therapeutic or preventive measures, 237
secondary survey World Health Organization, 236
conservative treatment and observation, migrant population, 233–234
477–478 mission statement, 228–229
history and physical examination, refugee camps, 233
474–475 risk assessment process, 225
laboratory and imaging, 475–476 sewage-disposal process, 234–235
treatment and surgical management, shelter and climatic factors, 232
476–477 state components, 231
therapeutic goals, 472–473 therapeutic feeding programs, 235
Health planning, Sarajevo types of hazards, 226
foreign medical team, 243 UK military intervention on, 227
hospitals, 241–243 water and sanitation, 234
Operation Phoenix Health risk management matrix, medical tool
achievements, 248–250 hazard identification
Advanced Trauma Life Support hierarchy, 192
techniques, 245 malaria, 191
aims, 244 Medical Force Protection, 189–190
Bosnian Ministry of Health, population at risk, 192
WHO, ODA, 243 processing stages, 190
costing, 247–248 risk assessment, 192–193
debriefing, 247 risk management
medical evacuation, 248 control activities, 193–194
mission, 244–248 control measures hierarchy, 194
ophthalmology program, 250 monitoring activities, 195
protective bubble, 248 Health surveillance and communicable
refurbishing room, 246 disease control
symptoms, 247 chemoprophylaxis, bacterial infections, 216
treatment, 245 commonly occuring syndromes, 211
traumatology, 242 comprehensive and sentinel surveillance
UK/US mission, 241 systems, 204
Health planning action, Rwanda crisis contaminated materials disposal, 211
agencies, 224 data collection, 199
displaced Hutu population, 232 data-handling systems issues, 209–210
food provision, 235 data sources, 207–208
hazard and risk, 225 death, infection risks, 212–213
humanitarian protection zone, 229 definition of, 199
human needs, 230 demographic data, 203–204
law enforcement capability, 230–231 disasters and disease, prevention, 198
medical interventions, 223 disease vectors control, 211
disaster–development continuum, evaluation of, 210
238–239 fundamental principles, 197
Index 633
health services activities, 207 Balkans–Pristina/Kosovo, 383–384

immunization programs, 207 Caucasus–Azerbaijan, 384–385
information propagation, 217 emergency response, 380–381
morbidity figures, 205 Middle East–Iraq, 385–386
mortality, 206 transition, 381–383
nutritional status, 206–207 Heat injuries, 50–511
physical condition provision, 211 High-altitude cerebral edema (HACE),
population under surveillance, 202 118–119
potential outbreak and epidermic High altitude medical care
control activities and evaluation, acclimatization, 117
221–222 emergency deployment, 120
control team, 219–220 environment
definition, 218 barometric pressure, 115–116
diagnosis, 220–221 humidity, 117
Epi Info™6 epidemiological data, 222 temperature, 116
information, 220 wind chill, 116
investigation statistical tools, 221 illnesses
laboratory confirmation, 219 acute mountain sickness (AMS),
preparation of, 219 117–118
preventive measures, 210 high-altitude cerebral edema (HACE),
priorities setting, 204–205 118–119
public health education, 216 high-altitude pulmonary edema
related sectors activities, 207 (HAPE), 119–120
surveillance systems mountains, 114
criteria for, 200–201 other problems, 120
designing, 202 High-altitude pulmonary edema (HAPE),
importance of, 199 119–120
treatment HIV-AIDS. See Sexually transmitted diseases
antimicrobial agents, 217–218 HIV/AIDS. See Postexposure prophylaxis (PEP)
laboratory facilities and specimen Hollow viscus obstruction
transport, 217 biliary tract, 453–454
types of cases, 208 large bowel, 452–453
vaccination programs, disease prevention lower urinary tract, 454–455
cold chain equipment, 214 small bowel, 451–452
diluents, 215 upper urinary tract, 454
effectiveness of, 216 Hospitals and health systems
in emergencies, 213–214 blues, 413
storage procedure, 215 conflict surgery, 393–395
vital item needs, 207 development, 388–389
Health systems environment, 379–380
conflict environment, 379–380 military health services support
development, 388–389 healthcare, 397–399
principles operation, 402–403
preparation and deployment, 386–387 organizations and resources, 399–401
traps and pitfalls, 387–388 planning process, 401–402
time lines and phases principles
634 Index
Hospitals and health systems – cont. preparation/predeployment

preparation and deployment, 386–387 separation, 346
traps and pitfalls, 387–388 systems, 346–347
Pristina, 391–320 Humanitarian assistance
security sector reform (SSR) aid work and career, 270–271
embedded training teams (ETTs), 406 arrival hassles, 278–279
framework, 411 motivation, 269
international military medical tasks, NHS career, 270
407–411 nongovernmental organisations (NGOs),
medical services, 406–407 271–272
OECD defines, 405 preparation
time lines and phases clothing and equipment, 275–276
Balkans–Pristina/Kosovo, 383–384 insurance, 274
Caucasus–Azerbaijan, 384–385 packing, 278
emergency response, 380–381 passport and visas, 274
Middle East–Iraq, 385–386 personal kit, 276–278
transition, 381–383 travel documents, 274–275
Hostage, 253 qualifications and skills, 269–270
Hostage and ambush rest and recuperation, 281–283
hostage-taker psychology, 297 return from overseas mission, 279–280
military intervention, 297 team building and maintenance
organizations, 299 dissolving teams, 286
self protection tips, 297–298 life-cycle, 285
survival guides, 299–300 potential risk, 284–285
theatrical purpose, 298 willing and trained individuals, 284
Human African trypansomiasis, 500–501 Humanitarian health interventions
Humanitarian aid Code of Conduct, 152
constriction, 345–346 communicable disease control system
deployment diarrheal diseases, 170–171
expatriate issues, 349–350 major causes of death, 170–171
work-related issues, 347–348 malaria, 171
postdeployment coordination
acute stress reactions, 352 cluster approach, 174
coping mechanisms, 356 various agencies, 173
counterproductive, 351–352 crude mortality rate, health status and
postincident support, 354 medical care, 159–160
posttraumatic stress disorder (PTSD), 353 demographic concerns, 155–156
posttraumatic stress reactions displaced populations, 155
and grief, 355 effective shelter and site planning, 166–167
preventive measures, 354–355 environmental issues, 156–157
PTSR genesis, 353 food and nutrition, availability of
recognition, 353–354 agencies invovled, 165–166
repatriation, 350–351 general ration, main components, 165
reunion, and readjustmen, 351 malnutrition prevalence, 157
stress, 352 nutritional assistance programs, 164
stress management, 356 vitamin A deficiency, treatment of, 166
Index 635
health care, emergency phase military, 44

facility levels, 169 reform
key features of, 168 coordination benefits, 34–35
main diseases groups, 167 coordinator role, 46
UNOCHA health cluster, 169 financing, 46–47
human resources and training United Nation (UN) structure and
‘Clinical Governance,’ 173 purpose, 32–34
intervention program, 172 Hurricane Andrew, 134–135
logical framework planning method, 153
measles immunization, 161–162
personnel resources and logistic I
considerations, 157 Ibn Sina casualties, 13–15
priorities for, 157, 159 Improvised explosive devices (IEDs), 143
provision of adequate security, 174 Influenza, 507
public health surveillance Initial assessment
data collection, 172 airway and cervical spine
vital information, 171 protection, 422
Relief Web database, 154 breathing and ventilation, 422–423
Rwanda, emergency assistance, 152 catastrophic hemorrhage, 421
safe water and sanitation, 162–164 central nervous system dysfunction,
SPHERE Project 426–427
field definitions, 169 circulation and hemorrhage control,
health assessment checklist, 160–161 424–426
key elements of, 153 reassessment and secondary
standards in accountability and service survey, 427
delivery, 154 Inmarsat packet data service (IPDS), 333
Humanitarian missions, 9–10 Integrated services digital network (ISDN)
Humanitarian organizations line, 329
CERF, CHAPs, and CAPs, 46–47 Intercostal nerve block, 492
coordination problems, 45–46 International Committee of the Red Cross
emergencies (ICRC), 41–42, 243, 584
coordination and cooperation, 35–36 International Court of Justice (ICJ), 254
reform, 34–35 International Decade for Natural Disaster
UN cluster system, 36–38 Reduction (IDNDR), 141
global cluster International Federation of the Red Cross
Field Clusters, 42 and Red Crescent Societies, 584
International Committee of the Red International Health Exchange, 11
Cross (ICRC), 41–42 International Labour Organization, 585
International Organization of Migration International Organization of Migration
(IOM), 41 (IOM), 41
other agencies and organizations, 42–44 Internet
United Nations High Commission for directory and gateway sites, 581–584
Refugees (UNHCR), 39–40 international and intergovernmental
World Food Program (WFP), 38–39 sites, 584–586
World Health Organization (WHO), 38 Intraluminal bleeding, 457–458
Médecins Sans Frontières (MSF), 43 Intraperitoneal bleeding, 455–456
636 Index
K fecal contamination
Ketamine, 489 acute bloody diarrhea (dysentery),
Koševo Hospital and State Hospital, 241 503–504
acute watery diarrhea and cholera, 501–502
amoebiasis, 504
L case definition, 502
Large bowel obstruction, 452–453 drancunculiasis, 507
Local anaesthesia enteric fever, 504–505
limitations, 489–490 non-typhoid Salmonellae, 503
safety and pharmacology, 490–491 viral hepatitis, 505
selected procedures, 491–492 worm infestations and schistosomiasis, 506
Local injuries, 511–512 means of transmission, 497
London bombing, forward medical response medical conditions, 496
Civil Contingencies Act 2004, 148 sexually transmitted diseases, 508
command infrastructures, 146 vector transmission
communications, 147 malaria, 498–499
CSCATTT2 principle, 145 plague and human African
dynamic risk assessment, 144 trypansomiasis, 500–501
improvised explosive devices, 143 yellow fever and typhus, 499–500
Joint Services Emergency Control Materials and information resources
point, 146 first aid and life support
joint Strategic Co-ordination Centre, 143 aids prevention and dental health, 575
Medical Incident Commander, 145 first aid pack, 574
present and potential hazards, 144 life support pack, 574–575
safety, 146–147 government and national organizations, 586
treatment, 148 internet
triage, 147–148 directory and gateway sites, 581–584
Lower urinary tract obstruction, 454–455 international and intergovernmental
Ludwig’s angina, 468 sites, 584–587
medical and related equipment suppliers, 575
medicine pack checklists, 573–574
M nongovernmental organizations, 586–587
Malaria, 498–499 publications
Marine envenomations, 521–522 guidelines and schedules, 578
Mass casualty incidents handbooks, manuals, vade mecums,
developed countries monographs and position papers, 577
multidisciplinary approach, 126–127 pamphlets and booklets, 578
triage, principles of, 126 reference texts, mission reports, and
developing countries journal articles, 577
leading causes of death, 127 reference texts
leading causes of global disease guidelines and schedules, 580–581
burden, 128 handbooks and related publications, 580
Mass gathering law and politics, 578
air/droplet transmission medicine and tropical diseases, 579–580
measles and influenza, 507 obstetrics, trauma, and surgery, 579
tuberculosis and meningitis, 508 pamphlets and booklets, 581
Index 637
preventive medicine, 578 international type, 98

psychological medicine, 578–579 journalists and reporters, 91–92
terrorism and victims of torture, 579 local and regional, 97–98
specialist advice centers and negative stories, 99–100
organizations, 576 newspaper circulation, 92
specialist sites public service, 93
conflict and catastrophe medicine, 590 roles, 92
country information and maps, 588 TV news, 90–91
emergency and catastrophe medicine, 591 vs. individual reporters, 93
essential medicines and practice, 589 world issues coverage, 92
governmental sites, 590 Medical ethics, 75–77
human rights organizations, 591 Medical Force Protection (MFP), 189
infectious diseases and tropical Medical interventions, Rwanda crisis
medicine, 591 disaster-development continuum, 238–239
medical equipment, 589 information evaluation, 236
Netherlands, additional sites, 590 priorities, 236–237
nongovernmental organizations, 591 psychological reaction, 237–238
preparation, vaccinations, and travel sexually transmitted disease, 238
health, 587 therapeutic or preventive measures, 237
relief personnel, (providers and Medicine
employers), 589 case study
resources for medical students, 589–590 car bomb, 321–322
security, 587–588 injuries, 321
standards and accountability, 590 traumatic amputation, 319–320
training courses, 588 US Paratrooper, 321
Maxillofacial surgery vehicle-mounted operations, 320
ear, nose, and throat experience, 318–319
foreign bodies, 471 security operator, 317
infections, 469–470 traning, 317–318
eye injuries, 469 Meningitis, 508
hard tissues Mental health
facial bone injuries, 466–467 humanitarian aid
postextraction hemorrhage, 465 constriction, 345–346
teeth injury, 465–466 deployment, 347–348
toothache, 463–465 expatriate issues, 349–350
nomenclature, 463 preparation/predeployment, 346–347
soft tissues, 467–469 repatriation, reunion, and readjustment,
Measles, 507 350–356
Médecins Sans Frontières (MSF), 43, 242 psychosocial trauma
Media and conflicts distress, 360–361, 363–366
BBC, 93 fundamental assumptions, 360
checklist, 99–100 hardiness, 363
communication, 96 planning service responses, 369–373
dislikes, 98 resilience, 361–363, 366–369
funding, 94–95 resistance, 363
humanitarians’ role, 95–97 requiem, 374–376
638 Index
Methoxyflurane, 487 Military philosophy conflicts

Midazolam, 489 asymmetric warfare, 24
Middle East–Iraq, 385–386 maneuvrist approach, 25
Mid upper arm circumference measurement protracted struggle, 24–25
(MUAC), 157 symmetric warfare, 24
Military health services support technocentric war, 25–26
healthcare Van Creveld’s alternative view, 26
Armed Forces, 397 Military planning medical approach
medical treatment facility (MTF), 399 background information, 178–179
scope, 398 effective interagency working, 178
operation, 402–403 estimate process
organizations and resources assessment of tasks, 185
functions, 401 casualty estimate, 182
MEDEVAC medical system, 399–400 Commanding Officer’s role, 186
medical treatment facilities (MTF), 400 coordination, 184
roles and tasks, 400–401 courses of action, 185
planning process, 401–402 decision-making tool, 186
Military medical services development plan, 186
Assistant Director Medical Services vs.diagnostic process, 178
(ADMS), 49 discrete outputs, 177
complex emergencies evaluation of factors, 180–183
civil-action programs, 51 generic structure, 180
civil–military coordination, 53 geography of, 180–181
international guidelines, 52–53 hostile forces, 181
reconstruction and development humanitarian factors, 183–185
principles, 53–54 medical CBRN, 183
stability operations, 52 medical C4 system, 183
strengths and weakness, 52 medical facility requirement,
direct clinical care 182–183
obstetric emergencies and trauma medical force protection, 182
management, 58 medical logistics, 183
preliminary medical assessment, 56 mission analysis, 179
Vietnam, 57 overall plan, 181
Western styles, 57 population at risk, 181
employment security, 182
civil action programs, 55–56 time, vital factor, 182
civilian healthcare programs, 54–55 web sities, 186–187
potential nonmilitary populations, Military Provincial Health Assistance
54–55 Program (MEDCAP). See Village
medical facilities development Medical Outreach (VMO)
infrastructure health projects, 58–59 Mines and weapons awareness
pitfalls, 59 AP and AT mines, 305
NATO, 50–51 military ordnance, 305
Operation Shoveller, 50 threat, 303
Suez operation, 50 types, 303–304
Index 639
Ministry overlap within health sector, N

613–614 Nalbuphine, 485
Mission enabling and confounding factors National Center for PTSD (2005), 566
communication, 605–606 National Child Traumatic Stress Network, 566
coordination Natural disasters, changed world, 9
actions and reactions, 609 Necrotizing fasciitis, 436
delegation and hierarchy, 608 Neisseria meningitids, 508
exits and entrances, 607 Nongovernmental organisations (NGOs),
friends and neighbors, 608 271–272
home-based major disaster plan, Nonsteroidal antiinflammatory drugs
606–608 (NSAIDs), 484
infrastructure and sustenance,
609–610
media, 608 O
information, 603–604 Oil and gas industry
preparation AIDS amplification, Africa, 72–73
intelligence, 601 exploration and production, 70
major disaster contingency plans and Kuwait oil fires, 72
rehearsals, 603 local community, 71
reconnaissance, 601–602 pipeline fires, 73
team preparation, 602–603 reconnaissance and planning, 71
team selection, 601 security, 72
random thoughts Oil and gas industry, safety
assumptions, 610 blood-borne diseases, 308
audit, 611–612 camp standards, 306–307
critical appraisal, 611 diseases, 307
environment, 610 health management system, 309
exit strategy and expectations, 611 imported medical support, 310–312
flexibility, 612 international medical support, 313
judgment calls and leadership, 611 lifestyle habits, 307–308
Modernizing medical careers (MMC) local medical support, 309–310
pay and conditions, 625–626 work environment, 308–309
principal ways Operation Phoenix
flexible training, 622 achivements, 248–250
OOPC, 624–625 Advanced Trauma Life Support
OOPE, 623 techniques, 245
OOPR, 624 core of, 242
OOPT, 623–624 estimated costs, 247–248
time out of program, 622–623 humanitarian assistance, 241
short-term deployments, 625 medical evacuation, 248
Modern military philosophy. See Military Ministry of Health, 244
philosophy conflicts mission, 244–248
Morphine, 485 opthalmology program, 250
Mortality and Morbidity rates, 159–160 principal aims, 244
Myonecrosis, 437 prominent symptoms, 247
640 Index
protective bubble, 248 Population at risk (PAR), health service

refurbishing room, 246 plan, 181
treatment, 245 Postexposure prophylaxis (PEP), 534–535
Opioid analgesics, 484–486 Postextraction hemorrhage, 465
Organization for Security and Co-operation Postpartum hemorrhages (PPH), 540
in Europe (OSCE), 585 Posttraumatic stress disorder (PTSD), 353, 562
Outbreak and epidermics Posttraumatic stress reactions (PTSRs)
control activities, 221 genesis, 353
control team, 219–220 grief, 355
diagnosis and investigation, 220–221 normality and ubiquity, 353
epidemiological data tool, 222 recognition, 353–354
evaluation, 221–222 Preexisting disease, 513
features, 218–219 Prisoner of War (POW), 252
information about, 220 Prisoners and detainees, health care
laboratory confirmation, 219 ethical dilemmas, 259
Out of programme experience (OOPE), 623 forensic medicine, 259
Overseas Development Administration guidelines, 259–260
(ODA), British government, 241 human rights
Overseas Development Institute (ODI), Committee Against Torture (CAT),
UK, 152 256–257
definition, 254
legislation, 254–255
P United Nations Convention against
Paracetamol, 483–484 Torture and Other Cruel, Inhuman
Parental-referencing, pre-school or Degrading Treatment or
children, 559 Punishment, 255
Pelvic inflammatory disease (PID), 537 international laws, 254
Pentazocine, 485 physicians’ responsibilities, 258
Periapical periodontitis, 464 special problems in prison, 257–258
Personal safety terminology, 251–253
camp safety, 288 Pristina hospitals, 319–320
clothing, 287–288 Psychological first aid (PFA), 566
food and weapons, 289 Psychosocial trauma
fraternization, 289–290 distress, 365
information security, 288–289 dysfunction/impairment, 365
mental health, 290 hypothetical graph, 363–364
Pertussis, 507 mental disorder, 360–361, 365–366
Plague, 500 minor/transient, 364
Polar medicine. See Antarctic medical substantial level, 364
problems fundamental assumptions, 360
Political prisoner, 252–253 hardiness, 363
Population and people, Baghdad, Iraq planning service responses
Marine unit, Haditha, 263 framework, 371
Medevac unit, 262 operational considerations, 372–373
Memorial Day, 261 principles, 369
Population at risk (PAR), 190 strategic considerations, 370–371
Index 641
resilience UK submarine missions, 102

biological influences, 368 Retroperitoneal bleeding, 456–457
collective, 362–363 Richter scale, earthquakes, 129
colloquial term, 361–362 Risk management, health risk management
developmental concept, 366 control activities
hallmark characteristics, 369 components of, 193
natural shape, 362 control measures, hierarchy of, 194
static attributes, 367 mobile health instruction team, 194
resistance, 363 monitoring activities, 195
R S
Remote and volatile areas, medical facilities. Safety and security
See Oil and gas industry ballistic protection
Remote medicine individuals, 300–301
Antarctic base stations, 102–103 vehicles, 301
Antarctic medical problems checkpoints and road blocks, 294–295
arctic, 112 corruption, 296
environmental, occupational, and public drivers
health, 110–111 benefits, 290
physical health, 109–110 terp, 291
psychological health, 111–112 hostage and ambush
Arctic medical problems, 112 hostage-taker psychology, 297
casualty evacuation, 105–106 military intervention, 297
current mission and medical profiles, 102 organizations, 299
factors, 101–102 self protection tips, 297–298
high altitude medical care survival guides, 299–300
acclimatization, 117 theatrical purpose, 298
acute mountain sickness (AMS), housing selection
117–118 building, 301
barometric pressure, 115–116 enhanced protection, 302
emergency deployment, 120 location, 301
high-altitude cerebral edema (HACE), mines and weapons awareness
118–119 AP and AT mines, 305
high-altitude pulmonary edema military ordnance, 305
(HAPE), 119–120 threat, 303
humidity, 117 types, 303–304
mountains, 114 oil and gas industry
other problems, 120 blood-borne diseases, 308
temperature, 116 camp standards, 306–307
wind chill, 116 diseases, 307
International Space Station (ISS), 102 health management system, 309
medical challenges, 102–104 imported medical support, 310–312
medical personnel choice, 105 international medical support, 313
perceived medical risks, 104 lifestyle habits, 307–308
research, 106 local medical support, 309–310
642 Index
work environment, 308–309 investigation and initial patient

personal issues management, 518–519
camp safety, 288 prevention, 516–517
clothing, 287–288 snake venom, 515–516
food and weapons, 289 Soft tissue abscess, 460
Safety and security – cont. Soft tissue infections, 435–436
fraternization, 289–290 Spectrum capabilities, communications, 340
information security, 288–289 austere environment, 342
mental health, 290 high bandwidth, 340
vechicles low bandwidth
driving companions, 293 broadcast, 338
equipment radios and servicing, 292 clinical emails, 339–340
history, color and driving, 292–293 internet, 340
mines and IEDs, 293–294 paper-based, 338
pornography, drugs and contraband, 294 voice communication, 338–339
Satellite networks principles, 341
advantages, 331 user requirement, 341
geostationary earth orbit (GEO), 331 SPHERE Project
inmarsat BGAN, 334 field definitions, 169
inmarsat B portable systems, 331–332 health assessment checklist, 160–161
inmarsat M4, 331–332 key elements of, 153
inmarsat Mini-M, 331 standards in accountability and service
inmarsat RBGAN, 334 delivery, 154
iridium, 335 Sphere Project (2004), 565
radio, 336–337 Spider bites, 520–521
thuraya, 335–336 Sprains and strains, 434
Schistosomiasis, 506 Standard Operating Procedures (SOP), 596
Scorpion stings, 520 Supraglossitis, 470
Security sector reform (SSR) Surgical infections
embedded training teams myonecrosis and cellulitis, 437
(ETTs), 406 necrotizing fasciitis, 436
framework, 411 soft tissue infections, 435–436
international military medical tasks Suspect, 253
field medical system, 407–409 Systematic approach, trauma, 420–421
infrastructure, health, 409–411
role, 411
medical services, 406–407 T
OECD defines, 405 Team building and maintenance
Septic arthritis, 437 dissolving teams, 286
Sexually transmitted diseases, 508 life-cycle, 285
Sleeping sickness. See Human african potential risk, 284–285
trypansomiasis willing and trained individuals, 284
Small bowel obstruction, 451–452 Teeth injury, 465–466
Snake bites Testicular torsion, 460
antivenom and other treatments, 519 Therapeutic feeding centers (TFC)
first aid management, 517 malnutrition management, 152
Index 643
resource intensive programmes, 166 Urinary tract infection and acute

Toilets, 315–317 pyelonephritis, 459
Toothache, 463–465 US Department of Justice, 557
Torture, 253
Tramadol, 486
Trauma V
definition and mechanisms, 418–419 Vaccination programs
initial assessment antimicrobial agents, 217–218
airway and cervical spine protection, 422 chemoprophylaxis, bacterial
breathing and ventilation, 422–423 infections, 216
catastrophic hemorrhage, 421 cold chain equipment, 214
central nervous system dysfunction, diluents, 215
426–427 disease prevention, 213
circulation and hemorrhage control, effectiveness of, 216
424–426 laboratory facilities and specimen
reassessment and secondary survey, 427 transport, 217
systematic approach, 420–421 public health education and information
Traumatology, plastic surgery, 242 activities, 216–217
Triage, 419–420 requirements during emergencies,
Tuberculosis, 508 213–214
Typhoid fever. See Enteric fever storage methods, 215
treatment, 217
Vechicle safety
U driving companions, 293
United Nations Children’s Fund (UNICEF), equipment radios and servicing, 292
585 history, color and driving, 292–293
United Nations Disaster Assessment and mines and IEDs, 293–294
Coordination (UNDAC), 137 pornography, drugs and contraband, 294
United Nations Economic and Social Vector transmission
Development Council, 585 malaria, 498–499
United Nations High Commissioner for plague and human African trypansomiasis,
Human Rights, 585 500–501
United Nations High Commission for yellow fever and typhus, 499–500
Refugees (UNHCR), 39–40 Vehicle born improvised explosive device,
United Nations Human Rights Council, 254 VBIED, 261
United Nations Index to Programs, 585 Vibrio cholera, 501
United Nations Office for the Co-ordination Village Medical Outreach (VMO)
of Humanitarian Affairs (OCHA), 184 Afghanistan health situation, 78–79
United Nations Security Council, 11 Civil–Military Operation (CMO), 81
United Nations Statistics Division, 585–586 definition and general guidance, 81–82
United Nations (UN) generic layout, 84–85
cluster system, 36–38 medical supplies and infrastructure
structure and purpose, 32–34 development, 87
UN Millennium project, 530–531 patient throughput, 84–85
UNOCHA health cluster, 169 postmission activities, 87
Upper urinary tract obstruction, 454 spectrum, 81
644 Index
tactics, techniques and procedures, 83–84 disintegration, 8–9

Vietnam War ethnic cleansing, 10
DENTCAP, 80 failed state, conflict in, 7
mobile medical clinics, 80–81 globalization, 7–8
US military assistance, 79 guarantee of safety, 10–11
US military medical policies and humanitarian missions and community,
activities, 80 9–10
VETCAP, 80 IGOs and NGOs, 6, 11
Viral hepatitis, 505 International Committee of the Red Cross,
5–6
natural disasters, 9
W personal preparation, 11–12
Whooping cough. See Pertussis professional preparation, 12
Women’s health sovereign, independent state, 5
equipment and resources United Nations Security Council, 11
training, 531 World Trade Centre and Pentagon,
UN Millennium project, 530–531 destruction of, 6
maternal mortality, 529 World Bank, 9
medical management World Bank Group, 586
postexposure prophylaxis (PEP), World Food Programme (WFP),
534–535 10, 38–39, 165
pregnancy prevention, 535 World Health Organization (WHO),
treatment and prevention, 534 38, 177, 241, 586
natural disaster impact, 533–534 World Trade Organization, 586
normal delivery management, 538 Worldwide ministries, 586
obstetric emergencies Worm infestations, 506
caesarean section, 538 Wounds
obstructed labor, 541 fractures and dislocations, 431
postpartum hemorrhages (PPH), 540 general statement and types,
toxemia and hemorrhages, 539–540 428–429
rape and sexual assault, 531–532 management strategy
trauma in women early priorities and relief, 429–430
ectopic pregnancy, 537 postoperative care and delayed closure,
genital tract, 535–536 431
gynaecological emergencies, surgical technique, 430–431
536–537
violence against women, armed conflict,
532–533 Y
World after 9/11 Yersinia pestis, 500

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Conflict and Catastrophe Medicine: A Practical Guide

Foreword by Norman M. Rich, MD, FACS, DMCC

ISBN 978-1-84800-351-4 2nd edition e-ISBN 978-1-84800-352-1 2nd edition

Library of Congress Control Number: 2008941005

© Springer-Verlag London Limited 2002, 2009

Printed on acid-free paper

Springer Science+Business Media

A – Medicine at the Ends of the Earth: The Antarctic

18. Getting There and Being Involved

23. Conflict Recovery-Health Systems in Transition

25. Conflict Surgery: A Personal View

29. Trauma and Surgery

34. Materials and Information

David A. Alexander Daloni A. Carlisle

Rowland Gill Maria E. Kett

Adriaan P.C.C. Hopperus Buma Kenneth N.A. Millar

Hervinder Kaur Gareth Moore

Kenny Morland James M. Ryan

Ian P. Palmer Donald F. Thompson

Kenneth I. Roberts Claire S. Walford

Jan L.N. Roodenburg Richard Williams

Chris Bleeker Maarten J.J. Hoejenbos

● To introduce the subject

The World After 9/11

Background to the New Paradigms

Conflict in Failed States

Globalization and Disintegration

“Globalisation is a source of new challenges for humanity…Only a global organisation

Disintegration and Backlash

Humanitarian Volunteers and the Changing World

Choosing an IGO or NGO

Flying sick patients in a combat zone ain’t that easy is it doc?

The Changing Nature of Conflict

The Essence of Conflict

The Nature of War

Massacre, Genocide, and Criminal Behaviour

indiscriminate killing in large numbers. It may occur in conflict as a result of tempo-

Traditions of War and Conflict

The Absolutist Views of Warfare

Moral Basis of Conflict

Just War Theory

1. Noncombatant immunity must be respected. Fighting must be directed against

Sun Tzu and the Art of War

Von Clausewitz on War

Marx, Lenin, and Political Conflict

Mao, Giap, and Revolutionary Warfare

Modern Military Philosophy

depends upon an understanding of and commitment to the rationality of force; mili-

Van Creveld: An Alternative View

The Changing Pattern of Conflict

Conflict will almost always be a further complicating factor in the mixture,

The Spectrum of Conflict

Fig. 4.1. Spectrum of conflict.

Fig. 4.2. Cycle of conflict.

Humanitarian Law and the United Nations

The Role of Law

Part A – Humanitarian Organizations and Their Coordination

● To describe the agencies and organizations that health care