Damage limitation

One of the most pitiful sights in conflict areas is the local prosthetics store, with its rows of artificial limbs, sized from adult down to tiny child. A poignant reminder that, whether fleeing a war or injured in one, the human body and mind are subjected to extreme damage.

Imagine triggering an improvised explosive device (IED) that shreds your leg and sends shrapnel, soil and debris deep into your body. Would you be able to apply a tourniquet to your injured leg, to prevent bleeding out from severed arteries? Soldiers are trained to do this. Some wear tourniquets in position, ready to wind tight should the worst happen.

Your village is shelled and every member of your family killed. You escape the bombs and run for months across the Middle East, see others drown in the Mediterranean, then walk overland to arrive in a temporary camp with inhuman conditions. Alone among thousands, you find neither sympathy nor asylum. Do you risk electrocution, or being crushed in the Channel Tunnel, or freezing or suffocation smuggled in the back of a lorry, in the hope of reaching a distant relative you believe lives somewhere in Manchester? How do you cope?

The military medical historian, Emily Mayhew, details extraordinary progress in blast injury medicine. In around 2008, Afghan insurgents learned from the landmine manual that wounded soldiers consume more of the enemy’s resources than dead ones: they began to ‘improve’ their IEDs to inflict maximum damage. Her book chronicles consequent improvements to the military medical response that now keep soldiers alive despite injuries that would previously have killed them.

Mayhew weaves the stories of two blast victims into a riveting description of the journey from the battlefield through every stage of resuscitation to recovery back home. By the end of the book we have seen soldiers who have lost three limbs emerge from ‘surround and sustain’ care, fitted with computerised prostheses and living full lives.

Specialised teams include plastic surgeons, who can ‘read the wreckage of the human beings brought to them like no one else’, and orthopaedic surgeons, who brought a new approach to amputees in the first world war, but were overtaken by general surgeons in peacetime, and have now come back into their own.

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Other innovations have arisen from observations by medical staff: the physio who installed a test track to encourage mobilisation on prosthetic legs, then a garden and a greenhouse where soldiers could recuperate. Soldiers often regain consciousness in panic, no longer in the desert surrounded by exuberant unit buddies, but in a UK hospital watched by weeping family. ‘What’s happened to me?’ they ask. A nurse adapted and manufactured patient diaries, wherein everyone involved with a soldier’s treatment records what happened to him, including friends who visited while he was unconscious. Extreme resuscitation makes extreme demands on survivors, and being able to piece together exactly what happened helps psychological recovery.

In her memoir, the psychiatrist Lynne Jones gives a passionate account of the psychological impact of the worst conflicts and disasters of the past 30 years. The stigma surrounding mental disorders continues to be lethal. From Somalia to Kosovo, Mozambique to Haiti, her portrayal of human suffering and the human response is vividly described.

Jones’s broad and wise observations include that suffering in itself is not a pathology, and that if all the complexities of a conflict are reduced to a disease category, PTSD, this seems to imply that there is a simple medical solution that covers all problems. Hence ‘trauma counselling’ is attractive to donors, especially as it is inexpensive. But to be truly effective, interventions must address the larger political situation as well. ‘If you do not address the miseries of the present, they will always trump the horrors of the past.’

The essential components of treatment include not just psychiatric care but love, faith, reconnection and work. The need for unscathed outsiders who can take the time to listen, and the importance of ‘home’, was clear in Aceh, Indonesia after the 2004 tsunami when survivors struggled ‘with nothing to do but think’.

Jones also examines the issues that dog humanitarian intervention, exposing the complexities and paradoxes of the aid business, with all its arbitrary generosity. Despite the concept of ‘needs assessment’, needs are often determined by politicians and the media.

The result has been huge spending in Iraq but not in Burundi or the Democratic Republic of Congo. NGOs are accountable to donors, not to the victims of war and disaster, and the reality is that agencies must run after the money or be redundant. Outside specialists often impose inappropriate remedies, walking a line between being culturally insensitive and so sensitive that abuse goes unchallenged. Agencies often compete rather than collaborate, imposing interventions without asking basic questions of the recipients, systems not unlike those of the colonial era, with locals employed at a fraction of the salary of outsiders. To be successful, outsiders bringing much-needed expertise have to form genuine partnerships with the local community.

These two excellent books come at a time when, all too frequently, we are reminded that intervention in other countries’ affairs is costly. The failure to intervene also carries a heavy price: generations of children growing up knowing nothing but war, and the continuing plight of refugees being two of many concerns.

Donald Trump’s team claim that the world is not a ‘global community’, but ‘an arena where nations, nongovernmental actors and businesses engage and compete for advantage’. Global community or not, the world is facing the biggest humanitarian crisis since 1945: famine in Somalia, South Sudan, Nigeria and Yemen. That the US and other governments, though not the UK, are shrinking their aid budgets while 20 million people are at risk of starving to death in famines that are largely man-made, born of conflict and heightened by climate change, does not bode well.