Book Review

Conflict and Catastrophe Medicine: A Practical Guide

N Engl J Med 2003; 348:1070-1071March 13, 2003

Article

Conflict and Catastrophe Medicine: A Practical Guide
Edited by James Ryan, Peter F. Mahoney, Ian Greaves, and Gavin Bowyer. 409 pp., illustrated. London, Springer, 2002. $129 (cloth); $49.95 (paper). ISBN: 1-85233-347-2 (cloth); 1-85233-348-0 (paper).

Field handbooks abound for every conceivable medical specialty, and Conflict and Catastrophe Medicine: A Practical Guide could easily fill this role for relief medicine. But what is special about this work is not its relatively brief medical section. It does include a first-aid manual of sorts, dealing with environmental illnesses and injuries from schistosome infection to traumatic amputation, but the strengths of the collection lie in its practical advice for providing care in unfamiliar environments.

For over 200 pages at the beginning of the book, a wide range of contributors offer theories about the history of conflict, musings on the ever-fading distinctions between natural and man-made disaster, thoughts on selecting a relief project that will suit one's skills and desires, and guidance for traveling in hostile surroundings. Authors later discuss recovery in the aftermath of catastrophe, develop checklists for packing for a tour of duty, and steer the reader toward other published resources.

The bulk of the collection provides practical guidance in preparing for and coping with difficult situations in the field. Collective wisdom covers topics as wide-ranging as how to identify clothing that is practical and safe (choose blue items over green, since they will be less likely to resemble military garb); how to select communications devices that will function in remote locations but that will not be confiscated at customs (choose a satellite telephone that disassembles into components that do not reveal its purpose); and how to use caution amid the grim practicalities of wartime (“Beware of booby-traps when moving either military hardware or dead bodies”). Stark realism pervades the book, but the stakes are high in relief work.

Contributors maintain a crucial awareness of the context of relief projects, for the first important judgment responsible humanitarians must make is whether their services are, indeed, needed. Aid work should not be pursued simply to indulge a worker's fantasies of rescue; an “ability to provide a specific capability is not a necessary justification for actually employing it.” Before joining a project, workers should understand not only what relief teams are trying to achieve, but why they are trying to achieve it. Uninvited providers can add confusion — and even more casualties — to an already overwhelmed system. Furthermore, since “[r]elief teams rarely include epidemiologists,” public health measures are sometimes neglected in the face of the urgency of emergency medical services. Fortunately, several essays in this collection remind us of the importance of upstream intervention and preventive medicine.

Even the most committed relief worker does not volunteer his or her services for a single task indefinitely. Ultimately, relief teams go home. It is important to ensure that such teams, while helping to directly restore the health and services of a population, are also encouraging the long-term self-sufficiency of the resident community. Strategies are offered for equipping local groups to address their own needs and to cope with future catastrophes using available resources. “Stay in your own lane” is the maxim espoused by one contributor; broadly applied, this advice reminds workers that they should remain conscious of their role in a project and not overstep boundaries to the detriment of the community they hope to help.

Contributors are also attentive to psychosocial, not just physiological, health care needs. This awareness is particularly notable considering that the “response to the acute phase of a disaster is nakedly utilitarian,” and the mental health needs of a population in conflict are often overlooked in favor of a focus on the immediate demands of assisting the physically ill or injured. The importance of the stability of the care providers themselves is emphasized as well. “Take care of yourself” is the ultimate message offered to providers in any service field. “Learn to recognize when and what stresses you and seek help. . . . If you burn yourself out you will become useless to those you may wish to help. Beware of thinking you are indispensable.” For health care providers are purposeless if they are not physically and emotionally available to the community they hope to serve.

This collection represents an ambitious project with a broad scope of interests. Although it may struggle a bit in trying to be all things to all people, it does a surprisingly good job of doing many things well. Few books take health care providers through every step of relief work, from contemplating their own motivations and suitability for the task to packing safe and practical clothing. Alternately handbook and reference book, this collection offers advice for settings in which the “medicine is often more straightforward than the logistics.” It should prove most useful for providers who are inexperienced in rendering health care outside of the traditional hospital or clinic setting, whatever their level of training.

This compelling amalgam of essays, flowcharts, and references opens with the words of Confucius, “May you live in interesting times.” In the end, it is these words, as both a blessing and a curse, that echo through the book and through the lives of those who follow the paths described in its pages. This collection does not profess to be a unified whole, nor would it benefit from becoming one. Like the cumulative efforts of so many caregivers who devote themselves to causes they deem worthy, the contributions that create this work come together not in unity but in harmony. They will provide a foundation of theory, opinion, practical considerations, and advice to anyone who risks venturing into the spaces where men, women, and children work to reconstruct their lives.

Rebecca S. Newton
Stanford University School of Medicine, Stanford, CA 94305
rsnewton@post.harvard.edu