The World’s Emergency Room
Author: Michael VanRooyen

Background

This book provides an exceptionally enlightening practical and research perspective of humanitarian medicine. It reflects the author’s vision of the field as ‘the struggle to promote human dignity‘, and it sets out how research evidence can be used to ‘drive political and operational decision-making in humanitarian crises‘. Recognising that there was little evidence to guide the emerging discipline, he set out to provide the data that would improve the domain’s efficiency. As an emergency medicine physician, he had ‘observed several common traits‘ between his specialty and humanitarian medicine, and this provided a platform for him to approach the subject. He explores the different ways by which research can provide humanitarian medicine with the evidence necessary to give it structure and order, such as by highlighting ‘the most efficient ways of setting up emergency health services for refugees‘, and by demonstrating how healthcare practitioners can ‘most effectively work in conflict settings’. Beyond its research focus, the book also chronicles the author’s hands-on field experience in various disaster settings – a narrative that concretised his intellectual concepts (pages 7-8, 49, 129 and 62-63).

Synopsis

In a chronological and largely autobiographical approach, the author traced his interest in humanitarian medicine to growing up in relative poverty and hardship, and to his reliance on grants and scholarships to complete his education. He also attributed his awareness of the health consequences of poverty to the location of his medical school in a deprived neighbourhood. A more remote driver for his altruistic predisposition was the effect of his father’s mortifying experience as a survivor of a Nazi concentration camp where he was incarcerated as a political prisoner for his involvement in the Dutch resistance; this endowed the author with personal understanding of war as ‘brutal and evil‘, and as ‘the most terrible of human endeavours’. A world atlas his father gave him for his seventh birthday also filled him with the sense of ‘some greater purpose in working overseas‘, and throughout his life he ‘continued to be drawn to the global political news of the day’; the result was that he developed ‘a powerful empathy for the victims of famine, war, and disaster‘. Another major catalyst for his humanitarian interest was the book, Witness to War, in which Dr Charles Clements narrated his humanitarian work in El Salvador, and from which the author learnt that ‘combining care of victims of conflict with the use of medicine‘ could be ‘a vehicle for political change‘ (pages 21-25 and 9-17).

The author’s first humanitarian mission was in 1992 with the organisation, Samaritan’s Purse, when he went to Somalia where ‘more than 300,000 Somalis had died and 1.5 million faced starvation‘, and where ‘nearly five million people…were completely dependent on food aid‘. He recalled that ‘the ruined city of Mogadishu had a hellish feeling, and on his first night he experienced machine gunfire just outside his quarters. It is pertinent that he identified Somalia as ‘a turning point for humanitarian intervention’ because the country’s failure showed him that ‘aid wasn’t working‘. This revelation set him ‘thinking seriously about the systemic changes needed to better prepare aid workers and strengthen international humanitarian response’. It was also in Somalia that he ‘became convinced that to improve humanitarian aid as an industry, we needed to teach leaders and practitioners how to understand their environment and make better decisions‘, and ‘we needed to invest in professional education’. This propelled the transformative research he carried out which established that ‘civilian men, women and children make up the vast majority of casualties in modern war’; that Israeli checkpoints had a disproportionally detrimental effect on the lives of Palestinian living in Gaza and the West Bank; that there was genocide of Darfuri refugees in East Chad; and that the weaponisation of rape contributed to making the Democratic Republic of Congo the site of ‘the deadliest humanitarian crisis since World War II‘ (pages 40-43, 48-52, 100-113, 114-119, 125-129 and 135-144).

The author’s depictions of global humanitarian conflicts are focused and graphic, and this is reflected in one of the key tragedies he described – the 1994 Rwandan genocide. In narrating this ghastly episode, the author noted that it was the culmination of rising ethnic tensions in the country that was fuelled by the Belgian colonial government‘s policy of promoting the elite minority Tutsis over the ‘impoverished Hutu majority’. In describing his visit to the country after the genocide, he painted the picture of an ‘apocalyptic scene‘ where ‘there were still remnants of bodies along the roads, ditches, and fields, with arms and legs strewn like parts of mannequins’. During his time in Rwanda, the stories of death and devastation he heard were so distressing that he said, ‘after a time, I really couldn’t listen to any more stories…I finally stopped wanting to know any more and stepped back to just do the work’. That work focused on rebuilding a hospital from what he said was ‘one of the darkest and most disturbing settings in which I’ve ever worked’ (page 70).

Beside Rwanda, the book also documents the horrors of countless other conflicts, prominent among which was the 10-year Yugoslavian conflict – a hostility the author depicted as ‘a macabre carnival of human rights abuses and atrocities‘, and as ‘the most deadly conflict in Europe since the end of World War II, killing over 120,000 people, mostly civilians, and displacing over 2.2 million‘. He portrayed how this war was further tainted by ‘the rape of an estimated 20,000-50,000 women, mass murder, and Nazi-style concentration camps‘. Other crises he discussed were the Serbian ethnic cleansing campaign in Kosovo; the civil war in South Sudan; the response to the 2004 Indian ocean tsunami – ‘one of the most wasteful humanitarian responses in history’; and the response to the Haitian earthquake of 2010 that ‘represented both the best and the worst of the aid world’ in terms of ‘large scale’ waste and incoordination. He also explored the conflict in Syria describing it as ‘the most destructive and far-reaching humanitarian crisis of the decade’ – one that ‘created the most complex humanitarian aid problems of our time’, and which was symbolised by ‘the complete loss of medical neutrality‘ (pages 55-56, 76-79, 232-233,  81-96, 145-148 and 158-164).

A central theme of the book is the comparison it makes between humanitarian and emergency medicine; in this juxtaposition, the author repeatedly stressed the ‘common thread‘ of how ‘poverty, instability, and political impotence‘ leave victims of both specialties ‘more vulnerable to violence‘. It is indeed because the author saw both fields as medical safety nets for the poor and dispossessed that he conceived humanitarian medicine as ‘a global emergency room‘. This is also why he sought to elevate humanitarian medicine to the status of emergency medicine by providing it with ‘a unique and discrete base of evidence to inform the work of aid providers’ – a necessity if it was ‘to emerge as a respected profession‘. His background enabled him to readily apply ‘the lessons learned from the growing field of emergency medicine to guide the development of the nascent field of humanitarian relief’. The author particularly emphasised the importance of establishing ‘dedicated centres for high-quality research of practical issues in humanitarian aid’ which will provide ‘a professional pathway for aid providers’. To attain this objective, he founded the first International Emergency Medicine Fellowship, and he set up the Harvard Humanitarian Academy which ‘helped build the all-important pathway to professionalization‘ (pages 38, 6, 72-73, 167-191, 153 and 121-122).

 

Opinion

This uniquely enlightening perspective of humanitarian medicine highlights the importance of the effective coordination of humanitarian responses in a world awash with conflicts and horror. The book illustrates how the author’s field work and academic research work provided the burgeoning field of humanitarian medicine structure and professionalism. The book also depicts the  gruesome reality of humanitarian crises, and the heroic responses that have defined the field of humanitarian medicine. The author’s personal harrowing accounts of the wretchedness that symbolises humanitarian field work further brings home the importance of the type of research he undertook. It is a thoroughly detailed and absorbing read with little to fault.

Overall assessment

This is an inspiring commentary on the need for all practical work to have academic and research underpinnings. It is particularly appropriate that the author was at the forefront of the work and the training that was required to provide the proficiency and competence that the relatively new and growing field needed. His specialty background also helped to draw the helpful similarities between emergency and humanitarian medicine as this provided the platform on which he built the case for his work. This book is a comprehensive account of a specialty that is becoming increasingly relevant to healthcare, and to humanity, and I recommend it to all doctors.

Book details

Publisher, Place, Year: St. Martin’s Press, New York, 2016
Number of chapters: 9
Number of pages: 210
ISBN: 978-1-250-07212-2
Star rating: 5
Price: £7.55