Wilderness medicine in disasters and humanitarian crisis.

doi:10.1017/S1049023X11006479 In the wake of highly publicized recent disasters in Haiti, Pakistan, and elsewhere, discourse among those concerned with the management of public health emergencies has focused on defining a standard of professionalism for humanitarian and disaster responders.1 Few “prerequisites” exist for the diversity of casual responders, experienced providers, and humanitarian professionals who respond to acute events by the thousands. Efforts have been made to develop core curricula, enforce standards, and develop professional organizations for humanitarian practitioners.2,3 In developing inroads to a standard pre-deployment knowledge base for disaster and humanitarian responders, the basics of wilderness medicine education can introduce the fundamental concepts of selfpreservation, improvisation and, most importantly, resource allocation. Wilderness medicine and disaster medicine have grown substantially in the past decades, each maturing to include specialized bodies of knowledge. These specialties initially developed with little contact. However, the two fields share common principles and practice settings as well as a dynamic and improvisational nature. Their most important commonality may be the skill of resource allocation. As practitioners in both fields continue to broaden their practice, opportunities exist for innovative teaching and research. The wilderness often is devoid of human influence, while disasters may be defined on the basis of affecting humankind. Yet many individuals participate in both types of medicine, with common interests and skills. Both fields stress improvisation and decision-making with limited information. Wilderness medicine texts now include chapters on disaster response, while disaster medicine texts pay special attention to practice in resource-poor (“austere”) settings.4,5 Traditionally, wilderness medicine involves the practice of medicine in remote environments. Wilderness practice includes environmental illnesses, mountain medicine, travel medicine, as well as global health issues related to austere settings.6 Such practice nearly always requires decision-making—with limited information—about how to distribute scarce resources. Disasters in resource-poor settings (including humanitarian emergencies and urban disasters with loss of infrastructure) may be considered austere environments as well, with similar resource allocation challenges. After the September 2001 attacks in New York City, Outside magazine reported on responders from the world of wilderness medicine.7 While the technical skills of those professionals were their chief asset, the similarity of the disaster setting to the resourcepoor wilderness was obvious. “The scale of the catastrophe,” Outside observed, “blurred the distinction between what is urban and what is wild. Parts of New York became wilderness, not metaphorically, but literally.” In 2010, earthquake responders in Haiti experienced an analogous situation. In any austere setting, how should limited resources be distributed? Distribution strategies might benefit some and potentially hurt others. Which resources are most important, given limited space, time, and funding? Resource allocation is based on aggregate rather than individual good—perhaps one of the strongest similarities between these two diverse fields, making the decisionmaking processes concordant.8,9 For example, mountain search-and-rescue teams limit the resources they carry during a search. They operate with only the supplies they have transported to a remote setting, and make allocation decisions about whom to evacuate first, or which patients will benefit from access to a helicopter. In disasters, limited resources such as medications, vaccines, and airlifts are allocated via a similar thought process.