Accepted Manuscript Disaster Medicine: Genealogy of a Concept Cécile Stephanie Stehrenberger , Dr. Svenja Goltermann , Prof. Dr. PII:

S0277-9536(14)00311-6

DOI:

10.1016/j.socscimed.2014.05.017

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SSM 9468

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Social Science & Medicine

Received Date: 30 September 2013 Revised Date:

3 May 2014

Accepted Date: 12 May 2014

Please cite this article as: Stehrenberger, C.S., Goltermann, S., Disaster Medicine: Genealogy of a Concept, Social Science & Medicine (2014), doi: 10.1016/j.socscimed.2014.05.017. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

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Cover Page

Social Science &Medicinemanuscriptnumber: SSM-D-13-02408

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Article title: Disaster Medicine: Genealogy of a Concept

Authors:

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Dr. Cécile Stephanie Stehrenberger, University of Zurich (Switzerland) ForschungsstellefürSozial- und Wirtschaftsgeschichte Universität Zürich Rämistrasse 64, 8001 Zürich +41 (0)44 634 36 49 [email protected] Corresponding author

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Acknowledgements: none

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Prof. Dr. SvenjaGoltermann, University of Zurich (Switzerland) ForschungsstellefürSozial- und Wirtschaftsgeschichte Universität Zürich Rämistrasse 64, 8001 Zürich +41(0)44 634 39 20 [email protected]

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Disaster Medicine: Genealogy of a Concept Article for Special Issue Medical Humanitarianism

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Journal Social Science and Medicine

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Abstract

This paper evaluates disaster medicine from a historical perspective that facilitates the

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understanding of its present. Today, disaster medicine and humanitarian medicine are inextricably linked and the terms are sometimes used synonymously. An in-depth analysis of an extensive body of concrete empirical cases from various sources (i.e. archival records) reveals, however, that they have not always been the same. A genealogical, history-ofknowledge approach demonstrates that the concept of disaster medicine emerged in the early

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20th century in Switzerland in the context of industrialization. Even though it gained important impetus during the First World War, the concept was informed by the experiences of forensic physicians in technological disasters such as mining explosions. The Cold War

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constituted the historical constellation in which disaster medicine was developed in West Germany during the 1960s and 1970s in a way that was paradigmatic for other Western

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European countries. At the same time, it was contested there in an unusual, historically unique way. Although focusing on a Western European context, this paper explores how medical interventions in disasters were international events and how the practice of disaster medicine was developed and “trained” through being applied in the Global South. It demonstrates the historicity of disaster medicine’s political character and of the controversies generated by its involvement in civil and military operations. Throughout the 20th century, the political nature and military involvement of disaster medicine resulted in a number of ethical and practical issues, which are similar to the challenges facing humanitarian medicine today. The 1

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exploration of disaster medicine’s past can therefore open up critical interventions in humanitarian medicine’s present.

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Disaster medicine, history, genealogy, history of knowledge

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Key words

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Disaster Medicine: Genealogy of a Concept

Today in every occupation we are available for questions related to severe and overwhelming,

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sudden events. Therefore I am dealing here with a chapter that is becoming ever more important for

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medicine, which I summarize under the title “disaster medicine”.... (Zangger, 1915: 129)

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Introduction

Today, disaster medicine is an extremely important part of humanitarian medicine, and vice versa. They are inextricably linked to the point that the terms are often used synonymously. A

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closer look at their histories in Central Europe reveals, however, that they have not always been the same. The two developed along different paths, paths which often crossed in the

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course of the decades, and they became interwoven in a very complex manner. The existence of these two entangled but different paths has so far not been acknowledged by either the historical or the social sciences. In order to comprehend fully the complexities of humanitarian medicine today, it is

important to study each and every one of its aspects carefully. This implies approaching each aspect as having a history of its own. We have to analyze how these aspects developed both prior to their entanglement with, and outside of, the field of humanitarian medicine. Tracing these developments reveals some of the multiple origins of the most important problems and 3

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issues faced by humanitarian medicine today. Our article provides such a history of its own. It does so by focusing on Switzerland, and the work of the physician Heinrich Zangger, where it first appeared as an explicit concept,

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and on West Germany, where its development during the 1960s and 1970s can be analyzed as paradigmatic for other Western European countries but where it was contested in an unusual, historically unique way. While some aspects of humanitarian medicine developed in the

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course of the 19th century and were closely connected to new forms of warfare, the history of disaster medicine—in the sense of the development of a proper concept, a set of defined medical problems arising in cases of “severe and overwhelming, sudden events” (Zangger,

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1915: 129) —began in the early 20th century and in a civil context in response to major explosions in factories, railway tunnels and mines. It was only institutionalized as a discipline in the 1980s.

Historical disaster research has elaborated on the historicity of disaster perception, e.g.

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the historically determined conception of what is and what is not a disaster (see Walter, 2010). Moreover, Cooter has pointed out that in medical discourse there has also not always been a clear conceptual difference between disaster, accident and crisis (see Cooter & Luckin, 1997:

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2). Furthermore, Nurok has shown that it was only during the Great War and an “epistemological alignment” that the “paradigm” of medical emergency emerged (Nurok,

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2003: 575). Accordingly, we find medical practices in our documents that could be classified under various, overlapping contemporary definitions, as both accident and disaster medicine. Despite such varying denominations, these documents show efforts to explicitly formulate “disaster medicine” as a proper concept. In our genealogical approach to the history of disaster medicine, we believe this conceptualization to be an especially decisive moment. Analyzing the history of disaster medicine by using a genealogical method means that we can neither pinpoint a single origin of disaster medicine nor discern any linear progressive history leading toward its perfection. Rather, we will elaborate on some crucial moments in its 4

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development while leaving out others. We will not begin our history with the theaters of war of the 19th century, which some might consider to be THE origin of practices which, retrospectively departing from a contemporary definition, can be qualified as “disaster medicine”

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practices. Literature on medical interventions in a variety of major disasters like the earthquakes in San Francisco (1906) or Messina (1908) (Davies, 2012) indicates that the early 20th century was an important point of departure in the development of medical practices in

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disasters outside of Switzerland, too. Instead of further exploring the medical efforts in these events and countries, we chose in this article to focus on the Swiss case, due to its importance

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in the history of disaster medicine’s discursive framework.

We would consider a backward projection of definitions of “disaster medicine” to be a kind of Whig interpretation of history. Instead, we try to track down the attempt to explicitly name, define and formulize the concept of disaster medicine, since we are interested in the very discursive formations that brought their object into existence, and their historical

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possibilities. We believe this approach to be well suited to pointing out the historicity of medical concepts, as well as the historicity of their “objects” – in this case, “disasters” and their medical consequences.

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Our genealogical approach therefore allows us not to deal in depth with applications of disaster medicine either in World War I or World War II, but to jump to its entangled and

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complex development after 1945.

Our article strongly relies on a history-of-knowledge perspective. We are interested in

showing how the history of disaster medicine was shaped by processes of knowledge production and transfer. We explain the historical conditions for the development and the social acceptance of knowledge concerning disaster medicine, and we are particularly interested

in

its

circulation

through

various—also

mediatic—channels

methodological approach, see also: Secord, 2004 and Sarasin, 2011).

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(for

this

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In this article, we will show how throughout the 20th century disaster medicine was confronted by some practical and ethical problems that were very similar to those faced by humanitarian medicine today. Some of them concerned critical decision-making in “chaotic”

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circumstances, while others concerned controversies regarding the involvement in disaster medicine of military doctors and military logisticians. They were connected very much to the political nature that was attributed to disaster medicine but also denied. These issues and the

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political content of disaster medicine arose in very specific historical contexts. They emerged from the constellation of industrialization and the health hazards it produced, as well as the

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Cold War, which comprised the backdrop against which disaster medicine first became entangled with humanitarian aid missions and along which it was stylized as apolitical. In the empirical section of our article, we will elaborate on these and other aspects of disaster medicine’s conflictive history by also pointing out how its practice in general and the “myth” of its apolitical nature in particular was heavily criticized. The former is one of the points that

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Methods

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we will pick up again in our discussion section.

The primary historical method applied in this article is a historical genealogy inspired by the

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French philosopher Michel Foucault. Foucauldian genealogy is a method of history writing that traces multiple origins of multilayered historical processes. It debunks teleological conceptions of linear history as a chronology emanating from one clearly definable and alldetermining event and leading steadily towards progress. Genealogy is as much interested in ruptures and discontinuities as it is in continuities. Unlike conventional historiography, it is not a holistic enterprise but a perspectival one; it is concerned not so much with detecting the one overall pattern explaining history in its totality, but with analyzing processes from a variety of angles and identifying a multitude of historical constellations from which they 6

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emerged (Foucault, 1977). Our approach of historical genealogy implies one of historical discourse analysis, also inspired by Foucauldian approaches (Foucault, 1972). We therefore understand historical processes as consisting – to an important degree, though not exclusively

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– of constructions of historical realities through discourses and discursive practices and frameworks whose historical conditions of possibility need to be unfolded.

Our analysis is based on a close reading of original source material that includes

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specialized publications, archival documents, and press articles.

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Disaster Medicine 1900-1945: The legacy of industrialization

In 1915, a Swiss medical journal published an article by University of Zurich forensic physician Heinrich Zangger entitled “On Disaster Medicine”. In this article, Zangger offers a systematic conceptualization of “disaster medicine” as a set of standardized medical

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procedures to be applied in the case of natural and technological disasters. In what follows, we will show how this conceptualization gained important impetus during the First World War. As we will demonstrate, however, the most important context in which it emerged was

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that of industrialization and the experience of the medical world of its most devastating health

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hazards, which became obvious, for example, in major mining accidents.

A new concept

It is no coincidence that Zangger’s article was published during the First World War, for the latter played an important role in Zangger’s conceptualization of disaster medicine. He wrote: The reason that I would like, particularly now, to provide an overview regarding experiences in this field lies in the parallels that disaster medicine almost always had with operations in the war and because, especially in today’s war, the technical means ... create situations that, in all [of their] various gradations, can be observed in 7

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the smaller and larger disasters of the last century, and here indeed more calmly and with the use of the scientific resources of peacetime. (Zangger, 1915: 133f) The Great War gave Zangger the opportunity to present his concept of “disaster medicine” to

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a broader community of specialists, and figured in his writing as an argument for legitimating demands for “disaster medicine” during times of peace. While it therefore certainly played an important role, the most important backdrop to the development of disaster medicine was

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nonetheless constituted by the medical effects of high industrialization.

Zangger understood disasters to be “sudden, un-predictable tremendous forces, …

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especially of masses, speed, and high pressure”. For him, the most common and important disasters of his time were the “side effects of progress and technology” (Zangger, 1915: 130). As an example, he mentioned mining explosions. It is important to note that he therefore understood industrial disasters as being man-made. He believed that they could be prevented to a certain degree and that people could be held responsible for them. In Zangger’s opinion,

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medical relief in a disaster situation was characterized by time pressure, a large number of injured people, and a disproportion between the number of casualities and the rescue materials and rescue workers available. The latter aspect created a need for disaster medicine, instead of

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an ordinary emergency medicine. Furthermore, the disasters in the industrial context in which Zangger developed his conceptualization of disaster medicine were marked by features that

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had been absent to this extent in the wars of the 19th century. The most important feature was the dangerous presence of a variety of poisonous gases in factories and railway tunnels that called for specific medical interventions during disasters. It was, for example, important to rescue quickly those people who were unconscious from the gases and often mistaken for dead, and it was important also to protect the rescuers themselves – for example, with a special breathing apparatus (Zangger, 1915: 132-138, 182-183). Unlike in the context of wars, whose injured had already become the subject of attention of large-scale medical intervention, these kinds of emergencies involving mass 8

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medical care had so far not been focused on by medical sciences and governments in a similar way. Multiple documents prove that Zangger’s elaborations in his 1915 article were informed by several experiences he had had as both an observer and a practitioner in a number of

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technological disasters like the mining accident which occurred in the French commune of Courrières in March 1906, which resulted in over one thousand fatalities. The technical and medical experts arriving at the scene had advised local rescue teams in their search for buried

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victims, and had examined the injured. Zangger summarized his observations in a report published in 1907. Due to the importance this disaster had for Zangger’s development of his

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concept of disaster medicine in 1915, we will now turn to study in more depth what occurred in Courrières and how the events were perceived by Zangger and other physicians.

The experiences of a mining accident

Already in his 1907 report, Zangger problematized a range of quite specific difficulties

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confronting doctors “in disaster situations”. At the time of the Courrières mining accident, few people shared the view that coping with disasters required specific medical procedures. Reporting on the event, Zangger wrote: “But observations were also directly hampered, in

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that, for example, I was sent away from a mine despite identification” (Zangger, 1907: 1). Other sources show that one measure in particular led to conflict between various experts,

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authorities, and mining managers: “After only a few days and after there seemed to be no more survivors, here too the idea popped up, just like in other accident cases (for example, in Hamm), to submerge everything in water and thereby suffocate the fire, with the full awareness and in the conviction, naturally, that this would irrevocably forgo the rescue of survivors ... who with certainty would have been killed by these measures” (Zangger, 1915: 138). Here, we see that the practice of “letting die”, perceived in disaster medicine and other emergency medicine situations today as ethically problematic (Geale, 2012; Lübbe, 2002;

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Reid, 2010: 394; Redfield, 2013: 155-178), was already considered repulsive by Zangger. A consensus in this regard, however, was far from forthcoming. In Zangger’s eyes, the catastrophe in Courrières created a situation characterized by

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chaotic circumstances. As he later argued, such chaotic situations during catastrophes required the intervention of authorities to create order. The presence of medical doctors had a particularly important role to play in this regard. For Zangger, their task was, firstly, to advise

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technical directors, who “have more difficulty understanding the medical significance of the situation than we do as medical practitioners” (Zangger, 1915: 136). Secondly, he insisted that

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disaster situations also required the “resolute” handling of the injured: “The injured person often gives directives, expresses desires, that could directly be his demise. The doctor must purposefully fix his eye on the inner nature of the dangers threatening the injured person and, if need be, advocate with determination for a type of course of action in the rescue attempts” (Zangger, 1915: 135).

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The rescue operations in the Courrières disaster constituted an international event. This was linked to the ongoing formation of medical knowledge regarding disasters within an international network. Hence, the Swiss forensic practitioner Zangger did not conduct medical

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observations on his own but rather jointly, with his French colleagues Guyot and Dervieux. Zangger and Dervieux published their results in the form of reports that, in turn, themselves

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became the subject of commentaries produced by medical practitioners outside France, primarily in Great Britain (cf. Oliver, 1907). At first this network was largely informal: scientists and specialists exchanged their opinions through letters. The first stages of formalization occurred in the 1920s and 1930s in the form of international conferences (literary estate of H. Zangger; among others, boxes, 102, 274). International collaboration on the Courrières disaster lasted for several weeks, during which time the doctors observed survivors of the disaster “day and night” in the hospital. For this purpose, they subjected them to disciplinary measures that extended beyond the 10

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immediate moment of their rescue. These included the precise monitoring of their physical activities and “experiments” to determine their cognitive abilities. After these survivors had been released from the hospital, Eduard Stierlin, one of Zangger’s students, even came back

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one year later to reexamine them in order to determine the “medical after-effects of the disaster of Courrières” (Stierlin, 1909: n.p.). Stierlin’s observations also garnered interest beyond professional circles. The Swiss daily newspaper Neue Zürcher Zeitung, for example,

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summarized Stierlin’s notes pertaining to one of the workers as follows: “In the hospital he behaved quietly, orderly, was approachable. But when he noticed the way he was being

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viewed all-round as a hero, that the other thirteen rescued persons received money and, in part, the red ribbon of the Legion of Honor, he became intractable” (Dr. E.H.M., 1909: n.p.). Evidently, not all survivors were satisfied with how rescued individuals had been treated, and questions of money played a role in this regard. This points toward a specific interest informing the practice of disaster medicine in the first half of the 20th century. The

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medical examination of disaster victims—both survivors and the corpses of the dead—was supposed to help clarify whether they had suffered damage to health or death as a result of an accident, and whether they (or their families) were therefore entitled to pension benefits (on

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this point, see also: Fassin & Rechtman, 2009). This remained a central focus for the production of knowledge in disaster medicine. As we will demonstrate below, the newly

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created field of occupational medicine and the development of social insurance schemes played a central role in this regard, conferring a social and political, as well as an economic, dimension to the production of medical knowledge concerned with disasters. On the eve of the First World War, the political tensions between various countries

provided yet another context for the development of a concept of disaster medicine. Immediately after the mining disaster in Courrières, a German team of twenty-five mine rescuers rushed to the accident scene to search for survivors in the clouds of gas by using special breathing devices. Observers interpreted this deployment as an act of international 11

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“solidarity”, thus clearly ascribing a political dimension to the practice of disaster medicine as part of the configuration of international relations. Thomas Oliver, a British professor of physiology, expressed the crux of the matter as follows (Oliver, 1907: 1768): “This humane

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and prompt act on the part of a great nation is an illustration of the fact with which we as medical men are familiar, that in the application of science to the saving of human life there is

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no such thing as nationality”.

Disaster medicine in the context of industrial hygiene and occupational medicine

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After the Great War, the doctors in Zurich did not shift their focus to the war itself. To be sure, in the 1930s and 1940s, Zangger would be active in the International Committee of the Red Cross (ICRC), bringing with him his experiences from the First World War. But his interests remained focused on disasters in civil contexts, such as railway tunnels and factories. There were several reasons for this. The importance of searching for the exact causes of a disaster

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related, firstly, to determining who was to blame, and who was responsible for compensation payments. At the same time, the doctors were concerned with preventative measures. Thus, Zangger included as one of the medical responsibilities after a disaster “the determination of

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the course of events, the detection of traces … and everything that relates to the question of causation and the question of blame, everything that enables or supports the combatting of

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similar risks and dangers in the future” (Zangger, 1915: 133). These questions arose and became relevant to the concept of “disaster medicine”

within the contexts of industrial hygiene and occupational medicine, fields that, in turn, emerged in connection with the creation of state health and accident insurance schemes (cf. Lengwiler, 2006: 145-176). Medicine figured here as a risk science that sought to calculate the probabilities of damage to health resulting as the “side-effects of progress” in a highly industrialized age (Zangger, 1915: 130). In the process, it also became necessary to consider what measures could be implemented by whom—the state, companies, or insurance 12

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providers—to avoid such damage (Schlich, 2004; Cooter & Lucking, 1997). In the course of the development of the welfare state’s insurance system, which had to provide for sick labourers, damage to health emanating from factories became a public health problem. But it

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did so also because factories created “hazards” affecting not only the people working there but also the population of the country as a whole. Thus, doctors began to take an interest not only in harmful substances but also in the hygienic (and therefore also economic) problems

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created by proletarianized urban workers for the “body of the people”.

This historical constellation and the broader context in which disaster medicine

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developed was at the time by no means only present in Switzerland (Porter, 1994; Sarasin, 2001). Zangger’s work, however, exemplified the expanded medical focus they implied: Zangger saw “new” and a “multitude” of “hazards” everywhere; from his perspective, society needed to protect itself above all from “invisible” factory gases and poisons, as well as from gasoline and narcotics. His work was acknowledged and reviewed, and, on 8 May 1933, the

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Neue Zürcher Zeitung reported: “Prof. Dr. H. Zangger recently revealed extremely interesting and previously little known connections, whose revelation must be valued as a service to public health”.

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While this and other reviews indicate that, in the 1930s, Zangger’s work on medical procedures during disasters also received public recognition, we should emphasize that this

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did not result in any institutionalization of disaster medicine as a discipline. Rather, the recommendations made by Zangger and his allies in the area of hazard prevention were largely ignored by politicians during the first half of the 20th century, especially since they went further than those made by insurance providers and supervisory authorities (Lengwiler, 2006: 153). In the early 20th century, industrial disasters were increasingly becoming a problem for the welfare state. The explosions that Zangger investigated were framed by severe class tensions surfacing, for example, in the aftermath of the Courrières mining disaster, when 13

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important strikes broke out. By evaluating not only medical damage but also the reasonability and the culprits of disasters, the activities of disaster medicine were set in a realm that was, politically, extremely delicate.

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It is striking that only when disaster medicine became seriously concerned with disastrous events that were considered to be a direct threat to the entire national population – as would be the case with a nuclear attack – would it become easier for disaster medicine to

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Disaster Medicine 1945-1989: A Cold War project

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gain the necessary social and political acceptance to establish itself.

During the first few years after World War II, no Western European country engaged in explicit discussions on disaster medicine. As we will see, the concept only reemerged in the course of the 1960s in the context of civil defense campaigns. The situation was similar in the

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United States (Matheson & Hawley, 2010). It was the scenario of a possible nuclear war that provided people with reasons to contemplate the introduction of specific concepts for medical disaster interventions and to call for the formation of corresponding structures. As authors like

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Chrastil (2010) have shown, medicine had already connected to civil war preparedness in the Red Cross efforts regarding the coming wars from the 1890s onwards. These efforts, however,

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were not conceptualized as “disaster medicine”. Moreover, the threat of a nuclear war and its hitherto unknown potential for destruction generated historically very specific scenarios of danger and medical care.

Civil Defense The developments in Western Germany can be analyzed as paradigmatic for this process: the German Red Cross organized scientific conferences where experts reported, for example, on nuclear physics and the effect of nuclear weapons; initiators hoped to obtain accurate insights 14

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into options for medical intervention. Work groups tested technological equipment, whose handling was taught in special training programs, and refined methods of deployment. In the process, a central concern was the ability to categorize the extent of health hazards and

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thereby take action to prevent further damage to health. Other events explicitly targeted lay persons, for a large degree of damage could be prevented—at least according to the shared creeds of “civil defense” programs—if citizens themselves were familiar with the most

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important protective measures and treatments. Like other voluntary relief organizations, the Red Cross felt responsible for enabling as many citizens as possible to provide medical first-

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aid during disasters (Riesenberger, 2002; Illustrierte Zeitschrift für den Zivilschutz 1956, 1957).

Since the Red Cross ascribed great importance to civil defense, its war and peace concerns became interrelated in many of its programmatic demands and measures in the area of medical relief. During the first two decades after the War, this interrelationship included

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first-aid “training”, the procurement of hospital equipment and ambulances, and the creation of a decentralized, finely-woven network of emergency aid stations. Sometimes it even informed humanitarian relief operations abroad, as, for example, when the German Red Cross

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was deployed in Budapest in 1956 in the course of the Hungarian Revolution. The subsequent evaluation of the operation directly affected the organization’s concept of national “civil

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defense”. On the basis of its experiences and observations in Hungary, the Red Cross leadership concluded that, compared to other countries, the German Federal Republic “remained far behind to an almost frightening degree” in its preparations for the effective protection of the civilian population during times of war. The founding of the so-called Hilfszug (i.e. teams to defend civilians against catastrophes) was just one of numerous measures subsequently introduced as a result of this evaluation (Riesenberger, 2002: 420f).

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Disaster medicine and humanitarian aid In contrast to the artificial disaster exercises under practically clinical conditions, the task forces during humanitarian relief operations evidently faced requirements that challenged

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them to review their own competencies. Disasters in their own country rarely gave them this kind of opportunity. Thus, the actual learning and training venues for disaster medicine should actually be identified as being those foreign, non-European regions where natural

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disasters and famine had given cause for an increasing number of operations since the 1960s. One of the first examples of such an operation was the humanitarian relief effort following the

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1960 earthquake in Agadir. The violent earthquake that occurred during the night of 29 February reduced broad sections of the city to a ruined wasteland, burying thousands of people. Responding predominantly to the Moroccan government’s request for aid, members of military units—for example, from France, Spain, the United States, Great Britain, and West Germany—soon arrived on location to rescue survivors and ensure that they received medical

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treatment. For this purpose, military transport aircraft flew in doctors and medical equipment (BA-MA Freiburg BW 24/12323: n.p.). Various national Red Cross organizations provided additional relief supplies and aid workers, in part with military assistance. According to

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estimates, the number of fatalities in the end nonetheless reached at least 15,000 people (Chiari, 2010: 25).

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Even though we can only partially reconstruct the actual events in the destroyed city, various sources show that the foreign rescue efforts produced ambivalent overall results. On the one hand, during the course of the disaster operation, the foreign teams managed to ensure their own operating capability. Their efforts appeared to be far more effective in saving lives during the disaster situation than was the local infrastructure. A German commentator therefore concluded that previous work on their own civil defense program had, in that sense, been worthwhile, even though, from his perspective, the requirements to “combat the effects of each disaster with the highest level of efficiency” had not yet been met. Nonetheless, 16

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looking at the level reached at that time, he was already convinced that had “such a civil defense of the population … been operational in Agadir, more people would have been rescued” (Kaesberg, 1960: 3).

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Yet, as revealed both by public statements and internal reports, by no means everything ran smoothly for the foreign rescue teams. Indeed, the broad range of complications could even be seen as evidence of how inadequately they were prepared for

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coping with domestic and foreign disasters. In an official report, the German Press Agency pointedly summed up the situation: “The organization of the suddenly arriving wave of relief

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from all countries collapsed upon the Moroccans just like the city’s buildings three days earlier. The directives came thick and fast and contradicted each other” (BA-MA Freiburg BW 1/21653: n.p.). Indeed, the various rescue teams lacked coordination, a situation that also affected the German Bundeswehr. Without precise information about the supply situation in the disaster zone, the German army moved in with medical equipment to care for the seriously

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wounded, only to discover that the French and Americans had already covered these particular needs. On the other hand, the German medical corps was initially by no means geared up to meet the demands of epidemic control, which soon became urgent in light of the

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many bodies and poor sanitary conditions. Even the medical treatment of less severely injured people who had to be cared for in temporary camps proved difficult, due to a lack of

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competent interpreters, which not only delayed medical care but, as conceded by an internal report, also “resulted in enormous nonsense in the end” (BA-MA Freiburg BW 24/463: n.p.). The report, however, did not resolve the question of how to handle such situations in the future, precisely because questions regarding the lessons to be drawn from “the Agadir case” still remained self-referential, directed primarily toward optimizing the nation’s own civil defense and disaster response programs (Fordham, 1960; Kaesberg, 1960). Media reporting of the efforts of the humanitarian relief operation struck a different chord. Numerous images of the disaster scene recorded the rescue and medical treatment of 17

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severely injured victims by foreign doctors and paramedics (among others: Paris Match, 12 March, 1960: 38-58; Stern, 19 March 1960: n.p.; Life, 18 April 1960: 52). Furthermore, news coverage by the press repeatedly emphasized that these relief workers neither abandoned hope

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of finding more survivors, nor spared any effort to find them (Paris-Presse L’Intransigeant, 13/14 March 1960: n.p.). Accordingly, the journal Ziviler Bevölkerungsschutz [i.e. “civil defense”] maintained that during this disaster situation “politics fortunately” remained silent

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and “real humanity showed up again” (Ziviler Bevölkerungsschutz 4/1960: 3).

Yet, in contrast to what the media would have their audience believe, politics was not

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absent from the relief operations. Instead, the operation was itself a form of politics, as was the portrayal by the mass media of a depoliticized operation supposedly concerned solely with human beings. Two examples illustrate this point. First, the media concealed the fact that disaster relief in Agadir constituted an object of political speculation within the context of the Cold War, in which both the Western and Eastern powers attempted to gain ground. Internal

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reports reveal that, from the West German perspective, the operation in Agadir had paid off in this regard; it looked as if the Federal Republic’s experts had overtaken the “experts from the East Zone countries”, who looked for opportunities in Morocco to help rebuild the city (BA-

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MA Freiburg BW 24/463: n.p.). Above all, the disaster operation in Agadir—and this is the second point—was a validation strategy through which its civilian and military architects

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sought to gain more societal and political support for the expansion of civil-defense and disaster-control programs within their own respective countries. In European countries which had recently suffered from the destructive forces of war such support could by no means be taken for granted. This also applied to support for developing the programs of disaster medicine, whose close links with civil defense and military operations generated suspicions that it was merely a means to prepare for another war (Internationale Ärzte, 1986). The agencies involved in the operation fully appreciated the major importance of the mass media in this situation in terms of improving the image of disaster-control programs and 18

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winning over new advocates for their expansion. Thus, for instance, on its flight to Agadir, the German Bundeswehr brought along a number of journalists who were supposed to testify to both the need for professional disaster control as well as the military’s humanitarian

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accomplishments. The Bundeswehr even floated its own articles in medical journals and made serious efforts to prevent medical doctors from its own ranks from publishing critical portrayals of the operation (BA-MA Freiburg BW 24/463: n.p.). Meanwhile, the reports and

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photographs published by the mass media would have given little cause for such criticism, for they demonstrated—wholly in line with the aspirations of those who sought to further expand

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the civil-defense and disaster-control programs—that the industrialized world, too, remained vulnerable to disasters. Thus, the international press showed that even modern hotel complexes had failed to withstand the earthquake; captured in photographs, the heaps of rubble graphically illustrated what Europeans, too, could expect in the event of such a disaster (Paris Match, 12 March 1960: 38-58; Stern, 19 March 1960: n.p.; Life, 18 April 1960: 52).

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The corresponding question was articulated as follows: “Who can guarantee to us that such a misfortune, or one with a similar impact, will not befall us?” (Kaesberg, 1960: 2) In the pertinent specialized publications of the 1970s and 1980s, proponents increasingly enlisted

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such arguments to promote the expansion of national disaster control programs. In the process, the steadily growing number of articles on natural and industrial disasters throughout the

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world gave the impression that the risks of a disaster had increased considerably and threatened also one’s own country.

“Disaster medicine is War medicine” And yet until well into the 1980s the controversy regarding disaster control remained far from being settled. Quite the opposite: when proponents of disaster medicine purposely sought to expand its international networks (Frey & Safar, 1980; Mac Mahon & Jooste, 1980) and pushed for disaster medicine to be institutionally embedded in medical training programs, 19

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they encountered considerable suspicion (Internationale Ärzte, 1986). In the German Federal Republic, people even referred to a “deep trench” that divided the medical profession on the issue of disaster medicine (Böckle, 1984). “Disaster medicine” is “war medicine”, proclaimed

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critics in 1982 at an international medical conference “for the prevention of nuclear war”, clearly conveying that “disaster medicine” had been unable to fully divest itself of its military connotations. This association comes as no surprise, for opponents could identify numerous

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military doctors and civil defense members among those who were now very deliberately working toward the institutionalization of disaster medicine (Peter et al., 1984; Heberer et al.,

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1984). Their anxieties were further increased by the fact that even doctors working for the International Red Cross used their experiences in war zones to elucidate the nature of disaster medicine in lectures. Its proponents did not have it easy. In the context of the arms race, and in light of the fact that, since 1945, Western Europe had rarely experienced the effects of natural and industrial disasters, by no means everyone believed that disaster medicine bore

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“purely humanitarian features” (Koslowski, 1984).

With the end of the Cold War, governments in Europe and the United States drastically reduced national government budgets for civil defense. In the process, disaster

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medicine lost resources as well, but this did not imply an end to medical practices regarding disasters or a reduction in their global importance.

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In the wake of the terrorist attacks on 11 September 2001, the Western world refocused its disaster medicine scenarios to concentrate on national security risks (Levy & Sidel, 2011). At the same time, the importance of medical operations with regard to foreign disasters did not decline. Indeed, the objectives of national security and “global health” became further entwined. Medical operations in response to disasters accompanied wars waged in the name of national security, and national government agencies also pushed for interventions in pandemics outside of Europe because they viewed their spread as threats to internal security. Both government agencies (especially the military) and non-governmental 20

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groups that participated in such interventions legitimated their operations with humanitarian arguments. Thus, after the Cold War and 9/11, the operational areas of disaster medicine—

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now institutionalized—have since expanded to include wars, famines, and refugee camps.

Discussion

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In this article, we have discerned the following major stages in the development of disaster medicine. The conceptualization of disaster medicine was initially formulated in a civil

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context in response to major accidents in factories, railway tunnels, and mines. It emerged in a social and political environment shaped by concerns regarding damage to health that, as a result of industrialization, was increasingly viewed as a public health problem. Risk experts attempted to calculate hazards and participated in political debates related to questions of which agencies should be held responsible for the costs of this damage. After the Second

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World War, the Cold War constituted the political context for the development of practices in disaster medicine. Thus, in Western Europe and the United States during the 1950s and 1960s, the architects of disaster medicine scenarios and programs predominantly had civil defense in

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mind. At the same time, they ascribed foreign policy relevance to the international deployment of disaster medicine. However, the outlines of this perspective had already

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emerged during the first half of the century, when such interventions were stylized as acts of German-French solidarity in the tense political situation prior to the First World War. During the Cold War, they developed at specific points into components of allied policy within the framework of the East-West conflict. Disaster medicine therefore has “a history of its own”. Starting out as a concept developed in the early 20th century in the context of civil industrial disasters, it shifted to foreign operations—often in the Global South—conducted by Western agencies during “disasters” after 1945 and increasingly after the end of the Cold War. The larger context for 21

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the development of disaster medicine in the second half of the 20th century would then be provided by the increasingly interwoven sectors of public health, “international health”, and humanitarian medicine. Interestingly, the idea of “international health” and later “global

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health” would coalesce with the quest for “bio security” (cf. Lakoff & Collier, 2008) and concepts of a “worldwide moral community” (Fassin, 2012: 98), something that can be demonstrated through the history of disaster medicine, which operated at the point where

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these sectors overlapped. This shift shows that what is actually perceived as a disaster and as a legitimate object of medical intervention has its very own historicity and is determined by

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local and global social and political constellations.

It is extremely important in today’s reflections on humanitarian medicine to emphasize the political character of disaster medicine as a historical phenomenon, especially because the argument of ostensibly apolitical humanitarian intentions—particularly in connection with the emergency dictum—largely conceals this political content. New media opportunities to

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participate in the sufferings of “others” have played a major role here. The use of the argument of supposedly apolitical humanitarian motivations also has a history. However, such arguments did not always enjoy the same degree of success: in the

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1980s, the political nature of disaster medicine was pointed out by groups that rejected disaster medicine for being “war medicine”. During the first half of the 20th century, the

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concept of disaster medicine had not yet gained this reputation. Yet, even back then, this did not preclude dissatisfaction with its practices, for even recipients of medical aid did not always show their gratitude; sometimes they became intractable or even insisted that rescue operations be broken off.

There are undoubtedly many reasons why dissatisfaction set in repeatedly during the course of operations in disaster medicine. First, such operations were linked with disciplinary measures; second, rescue measures also involved problematic decisions, such as knowingly

22

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allowing people to die, as clearly demonstrated by our discussion of the mining disaster in Courrières. Today, specialists take for granted the impossibility of providing everyone with timely

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medical care during a disaster; since 9/11, this has been widely accepted by the public as well. The Western public hardly even notices any longer the interconnections between the civil and military sectors during the course of operations in disaster medicine. This is one of the

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reasons why such operations are, generally speaking, not only well accepted but even actively supported (e.g. through donations). A historical perspective allows us to disclose that this

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connection, which today might be one of the core ethical problems of disaster medicine, is by no means a natural necessity. Generally, what appears self-evident today is in no case selfevident, but rather the result of specific historical constellations that need to be explained accurately. The acceptance of disaster medicine—by specialists and society at large—was subject to conjunctures that were dependent upon the extent to which people understood—and,

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as such, welcomed or rejected—medical practices in response to disasters as political interventions.

Historical processes are open-ended. Approaching them in a more careful manner that

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traces their genealogies in multiply different origins with their own histories allows for a better understanding of not only the past but also the present. Such an understanding then

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opens up possibilities for changes in the future. A better understanding of the historicity of disaster medicine as a political phenomenon and of the discourses denying its political nature may therefore invite more critical scholarly/political interventions in contemporary humanitarian medicine.

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Social Science and Medicine Manuscript SSM-D-13-02408 Article for Special Issue Medical Humanitarianism Journal Social Science and Medicine Disaster Medicine: Genealogy of a Concept

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Cécile Stephanie Stehrenberger and Svenja Goltermann

Research highlights

Humanitarian and disaster medicine developed along entangled but different paths.

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Disaster medicine emerged and was developed in the context of industrialization and the Cold War.

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Some of humanitarian medicine’s present issues date back to early 20th Century disaster medicine. Throughout its history, the political character of disaster medicine has been both affirmed and denied.

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Disaster medicine was heavily contested as “war medicine”.