The World's Emergency Room: The Growing Threat to Doctors, Nurses, and Humanitarian Workers

The World's Emergency Room: The Growing Threat to Doctors, Nurses, and Humanitarian Workers

by Michael VanRooyen


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The director of the Harvard Humanitarian Initiative looks at the alarming rise in violence against doctors and aid workers, and how to stop it

Twenty years ago, the most common cause of death for medical humanitarians and other aid workers was traffic accidents; today, it is violent attacks. And the death of each doctor, nurse, paramedic, midwife, and vaccinator is multiplied untold times in the vulnerable populations deprived of their care. In a 2005 report, the ICRC found that for every soldier killed in the war in the Democratic Republic of the Congo, more than 60 civilians died due to loss of immunizations and other basic health services.

The World's Emergency Room: The Growing Threat to Doctors, Nurses, and Humanitarian Workers documents this dangerous trend, demonstrates the urgent need to reverse it, and explores how that can be accomplished. Drawing on VanRooyen's personal experiences and those of his colleagues in international humanitarian medicine, he takes readers into clinics, wards, and field hospitals around the world where medical personnel work with inadequate resources under dangerous conditions to care for civilians imperiled by conflict. VanRooyen undergirds these compelling stories with data and historical context, emphasizing how they imperil the key doctrine of medical neutrality, and what to do about it.

Product Details

ISBN-13: 9781250072122
Publisher: St. Martin's Publishing Group
Publication date: 04/19/2016
Pages: 240
Sales rank: 831,053
Product dimensions: 6.20(w) x 9.40(h) x 1.00(d)

About the Author

MICHAEL VANROOYEN is the co-founder and director of the Harvard Humanitarian Initiative, a professor at Harvard Medical School and the Harvard School of Public Health, and the vice chairman of emergency medicine at Brigham and Women's Hospital in Boston. Over the past 25 years, he has served as an emergency physician in conflict zones and disaster areas in more thirty countries including Bosnia, Chad, Darfur-Sudan, the Democratic Republic of Congo, Haiti, Iraq, North Korea, Rwanda, and Somalia.

Read an Excerpt

The World's Emergency Room

The Growing Threat to Doctors, Nurses, and Humanitarian Workers

By Michael VanRooyen

St. Martin's Press

Copyright © 2016 Michael VanRooyen
All rights reserved.
ISBN: 978-1-4668-8353-6



Much of the world seems to be on fire. The second decade of the twenty-first century has shown us some of the most complex and dangerous political struggles in recent history. Since it began in 2011, the Syrian Civil War has morphed from a one-country political uprising to a regional conflict that has displaced 9 million civilians and killed over 200,000, many of them through the use of chemical weapons. The rise of the Islamic State of Iraq and Syria (ISIS) has once again pulled the United States into Iraq, where it is providing military intervention to protect civilians and establish a corridor for humanitarian aid. An unprecedented Ebola epidemic in West Africa in 2014 threatened to destabilize the healthcare systems, economies, and governments of Sierra Leone, Liberia, and the rest of West Africa.

The human consequences of conflict and disaster are profound. Today, nearly 60 million people have been displaced from their homes by war or catastrophe, more than at any time since World War II. While such huge numbers can feel abstract, the threats to families and communities are very real and very personal. Refugees live in makeshift shelters and temporary settlements, struggling day by day to survive. They have little food, not enough clean water, and few resources for health care for their children. Rates of malnutrition, diarrhea, and respiratory infection are exponentially higher among refugees than among the population at large. The same is true for violent crimes like rape, abduction, and human trafficking.

Humanitarian aid workers are on the front lines of these conflicts. Aid organizations employ international and local staff to rapidly take the place of systems that have failed because of war or disaster. Aid agencies provide emergency relief — food, water, shelter, security, and health care — to stabilize populations in the midst of a crisis. Humanitarian medicine, the emergency provision of basic health care, serves some of the world's most acutely threatened populations.

The doctors and nurses who work at the front lines of crises, many of them local healthcare providers, save lives in places where normal healthcare systems have broken down. They work in uncontrolled and often-dangerous environments with few resources to keep hospitals open, perform lifesaving surgery, and provide essential medications for people trapped in conflict with nowhere else to turn. They innovate, improvise, and create a "safety net" for a community. These caregivers not only staff, but build a global emergency room.

As a humanitarian physician, I've worked in hot spots and conflict areas all around the world. I return from missions abroad and dive right back into busy urban medical centers in Detroit, Chicago, Baltimore, and now at home in Boston, places where emergency room physicians serve as providers of last resort, caring for many who have no regular health care. Throughout the past twenty-five years, I've tried to balance my international work with practicing medicine in urban ERs in the United States. During this time, I have observed several common traits in these two diverse fields.

My patients in Boston are, of course, a world apart from my patients in Rwanda or Sudan. They face different struggles and have profoundly different vulnerabilities. But the systems that serve them have some important similarities. In a humanitarian crisis, nongovernmental organizations (NGOs) like Médecins Sans Frontières (MSF, also known in the English-speaking world as Doctors Without Borders) struggle to provide medical assistance to those who are displaced or threatened. In the emergency departments of our nation, the medical staff stands ready to provide care for anyone, anytime, regardless of ability to pay or the nature of their ailment. The ER serves as a safety net for many in our communities who suffer from acute illness, trauma, or untreated medical problems.

During my years of work abroad, I've found that the international aid community — a web of NGOs, United Nations (UN) agencies, and governmental departments — provides a similar safety net. Conflict and disaster affect many more civilians than soldiers and often lead to high mortality rates, particularly in infants and children. The unchecked spread of preventable infectious diseases like measles and diarrhea drives high death rates in refugee and malnourished populations. War and displacement have predictable and devastating effects on health. In these contexts, humanitarians provide the rapid, large-scale aid that is critical for stabilizing populations and providing the first step toward recovery and resilience. What the emergency room is to Detroit, Chicago, and Baltimore, humanitarian medical relief is to the world's crisis zones.

The problems and threats created by a humanitarian crisis require specialized and nuanced skills that are distinct from those employed in long-term development pursuits like agricultural projects and public health programs. Humanitarian medicine is a unique field with a specific base of knowledge and, much like emergency medicine, requires a specialized skill set. While the actual services delivered by each field are very different, many aspects of their environments are strikingly similar.

Paradoxically, the humanitarians who care for some of the most vulnerable populations in the most hostile settings in the world are often not trained for the job. Most of the world's 450,000 humanitarian aid workers lack any formal training, certification, or professional identity. As the aid community grows and matures, there is an increasing awareness of the importance of professional development and the need for better research and evidence to advance the field. Within the wider aid community, the quality and accountability of aid are major new foci. Humanitarianism must evolve to better face the challenges of ever-more complex humanitarian crises.

I've grown as an ER doctor and as a humanitarian physician simultaneously, at a time when both fields have faced tremendous challenges and seen major improvements. As new crises emerge, our only appropriate response is to adapt and apply lessons we've learned to create new tools to make a better, more efficient relief world. The lives of our patients, and the world's most vulnerable populations, depend upon it.

The seeds for my work were sown early. Like any child, my interests were the product of a unique blend of influences and inspirations. In many ways, my childhood in St. Johns, Michigan, was typically American. But my parents — and their journeys through life — subtly led me toward both medicine and traveling the world. That voyage began with the numbers tattooed on my father's arms.

My earliest impressions of the world outside of small-town Michigan came from my father. Johannes (Joe) VanRooyen was a Dutch immigrant and Holocaust survivor. Like all fathers, he told many stories of his boyhood and growing up. He had a rich library from which to draw, and my brother Rick and I spent many hours hearing about his early life in the Netherlands and the numerous colorful characters in my extended family. But for all the memories my father shared, he spoke little of the most impactful period of his life: his experience with the Dutch Resistance and his imprisonment in Nazi concentration camps.

The Nazi army invaded the Netherlands on May 10, 1940. After a five-day campaign, a brutal occupation began. The German stranglehold on the Netherlands was severe, with the army intent on extracting resources and wealth to feed their war machine and, in the process, starving the country. My father and grandmother buried silverware and other valuables — even his beloved motorcycle — in their garden to prevent them from being looted by the Nazis. At seventeen, unbeknownst to his parents, my father joined the Dutch resistance movement that sought to hide Jews and assist in their escape. He snuck fugitive Jews to the port town of Vlissingen, where boats waited to carry them to England, and aided a downed American pilot trying to reach the border via bicycle (the pilot eventually made it to neutral Spain). "Many times there were narrow escapes," my father later wrote, "but in 1943, I finally got caught."

He was sent to a detention center at Amersfoort, where he was questioned for several weeks. From there he was taken to a crowded boxcar that brought him to another camp, and he eventually ended up in Bergen-Belsen, the infamous Nazi camp located in northern Germany that held tens of thousands of Jews, prisoners of war, and political prisoners. There were no gas chambers at Bergen-Belsen, but over the course of the war, more than 50,000 prisoners would die there, mostly from malnutrition, tuberculosis, or typhus.

Upon arrival at Bergen-Belsen, Joe VanRooyen was registered, hosed off, de-loused, and given the typical striped uniform. Ultimately, during his time in the camps, the number 69196 was tattooed on his left forearm, and 14710 on his right. As a child, I asked my father about the tattoos, about the camps, and about his life before emigration to America. Like many men of his generation, he spoke little about his experiences during World War II. Only rarely, while we were fishing or puttering in his workshop, would he quietly reflect on those times. But he left out the most graphic details of imprisonment. Only gradually, over the course of years, would I learn the horrific, full story of his capture, the starvation and torture prisoners faced in the camps, and the physical and mental abuse he suffered.

After arriving at the camps, my father was put to work at Bamag-Meguin, a factory where steel was shaped and molded for the Nazi war effort. Classified as a political prisoner, he was thought to have information about the resistance movement. Not yet twenty years old, Joe was brought several times from Bergen-Belsen to Alexanderplatz in Berlin to undergo interrogation by the Gestapo in a room deep underground. First Nazi interrogators wound his body in rawhide leather straps soaked in water and laid him on the floor. As the leather slowly dried and contracted, his fingernails were driven into his hands. The pain was excruciating. He was questioned for several days and then returned to his barracks, only to be brought back for questioning again a month later. He recounted the experience in an audio journal later in life:

A month later, the questioning started again; this time I was strapped in a chair. A hole was drilled in my tooth and a small chain with a winch fastened on that. Every question got a little tap on the winch and after several hours the tooth came out and another one was started. After three days (or was it four or five? I don't remember) they started to drill a hole into the roof of my mouth to hook the chain on. Then I passed out, knowing that this was the end. Somehow, they didn't do much damage to my mouth. How and what happened then, I don't know, but I woke up in my barracks where my roommates took care of me and had washed my face and gave me some warm water to drink.

He had little information that would have been of value to his captors, but saw silence as his only hope: "I could not tell anything because my chance to survive would be gone," he remembered. "I'd become useless to them." He managed to endure the torture, the forced labor, and the near-starvation, and was liberated by Allied troops in April 1945. On the day he was liberated, my five-foot, eight-inch father weighed seventy-eight pounds. Returning to the Netherlands, he found a country ravaged by the war. The mass starvation of the 1944–1945 "Hunger Winter" and the collapse of the economy had left my father's world in tatters. Upon his return, he eagerly dug up the motorcycle that he had buried in the backyard, but found it rusted and rotted away. He struggled with depression, made worse by the failure of a brief business venture. He felt like a stranger in his own hometown and struggled to relate to his family. The economy of postwar Holland was devastated, and he, like many of his generation, looked across the ocean for a chance to start anew. He met and married my mother, Gertrude Breed, a young woman from Haarlem. My parents pinned their hopes for the future on moving to America. On Christmas Eve 1954, they received their long-sought visas.

Joe and Trudy VanRooyen emigrated in 1955, eventually settling in St. Johns, Michigan. Dutch heritage runs deep in that part of the state, but St. Johns could not have been more different from the wartorn Netherlands. Grateful for a fresh start, my father set to work with an immigrant's drive and industriousness, first at a furniture store, then as a shoe salesman, and finally as a cobbler, with his own shoe repair shop. He and my mother were proud to become US citizens, and prouder yet to start their own American family with the birth of my brother Richard in 1957. I was born four years later.

Even though my father was guarded about his wartime experiences, cautious about sharing too much detail and rarely speaking about his captivity, I formed a strong impression of what war meant to ordinary people. I understood that conflict had devastated my father's homeland and nearly killed him. I knew that he was lucky to be alive, and that I was doubly lucky to be here, in America, safe and free. To me, war was never about patriotism, uniforms, and salutes. While I admired the bravery of soldiers and understood the necessity of some conflicts, I never thought war was noble or idealistic; I always saw it as brutal and evil, the most terrible of human endeavors.

My father was immensely proud of his adopted country and of the stable and happy life he and my mother built for their sons. But a decade after their emigration, the foundation of that life was rocked when my thirty-six-year-old mother received a grave medical diagnosis: stage IV metastatic melanoma, the deadliest type of skin cancer. Doctors gave her less than a year to live. I was five years old, and my brother was nine.

She managed to survive for three years, with the help of surgery, chemotherapy, and increasingly long hospitalizations, as the medical system in the 1960s supported extended hospital stays for cancer patients. She spent her days at home trying to create a normal life for us, but I could see her becoming more frail as the disease progressed. Late in her illness, my mother was gone for what seemed like months at a time. In those days, children my age were not allowed in patients' rooms, so I spent countless hours in hospital waiting rooms and parking lots while my father and brother visited her. I can still picture her waving to me from the window of her third-floor hospital room while I waited in the car.

I spent my seventh birthday in the cafeteria of the University Hospital in Ann Arbor. After cake and presents, my father and brother went upstairs to visit my mother while I waited in the hospital cafeteria. My dad had given me a rather unusual gift for my birthday: a world atlas. I sat in that busy cafeteria by myself, poring over maps of Africa, tracing the line of the Congo River and memorizing the names of countries — Sudan, Ethiopia, Tanzania, Kenya — that seemed so exotic and far away. My imagination was already captivated by the television series Daktari, about a veterinarian in East Africa, and by stories I'd heard in school about missionaries and military doctors. I sensed there was some greater purpose in working overseas and dreamed about being a doctor in the distant countries that filled the pages of my atlas.

As the months passed, I largely experienced my mother's illness through my father, overhearing his conversations with the doctors and nurses caring for her and the many friends who pitched in to help. He carried on with stoic calm, always telling my brother and me that everything would be all right. But we could sense the strain was taking a toll. Like anyone would, my father struggled to manage my mother's worsening illness and mounting medical bills while taking care of two small children.

My mother had cancer at a time when patients and families didn't question doctors, and doctors rarely involved them in making medical decisions. I knew my father was frustrated by the lack of information, and I remember him going back to her doctors many times to try to understand the next phase of her treatment. I didn't understand what was happening and felt confused by it all. I felt like a burden. I could only stand back, confused, excluded, and helpless, waiting for the next bit of news from my father. And the news only grew worse. On November 16, 1969, my mother died at the age of thirty-nine. She was buried three days later, on my eighth birthday.

My father, brother, and I went on, as families do, with work, school, and life. In time I came to enjoy our bachelor existence. In our single-parent household, I had an unusual degree of independence for a boy my age. I was free to roam our small town on my own, making Tang sandwiches and riding bikes with my friends, exploring the woods, cattle yards, and construction sites around town. But for my father, the life of a widower was a lonely one. While there was always help from our community, he needed companionship. In time he began seeing Carolyn Riley, a close friend of my mother's who had helped our family during her illness. They had reconnected when my father volunteered in the "Big Brothers" program to work with her oldest sons. Their friendship grew, and they fell in love. Three years after my mother's death, they married.


Excerpted from The World's Emergency Room by Michael VanRooyen. Copyright © 2016 Michael VanRooyen. Excerpted by permission of St. Martin's Press.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
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Table of Contents


Title Page,
Copyright Notice,
1: Discovering Humanitarianism,
2: First Steps,
3: Career Humanitarian,
4: Growing Challenges,
5: In the Field,
6: Finding Humanitarian Space,
7: A New Era of Challenges,
8: Protecting Humanitarian Medicine,
9: Designing the Future of Humanitarian Medicine,
About the Author,
Copyright Page,

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