From the Editor

To say that Frederick M. Burkle, Jr. (known to all as “Skip”) is unique is a gross understatement. He is a pillar of our field: a true humanitarian, a founder of our discipline of Disaster Medicine, and a beloved and transformative mentor and caring friend to so many. Although the journal doesn’t generally publish book reviews, Skip Burkle’s memoir, Water on the Moon, was recently published, and (although no book can do justice to Skip Burkle’s many facets) describes his eventful life and personal development, together with additional reflections. We are delighted to publish this review by Dr. Dan Hanfling. We hope this essay will give a glimpse into Skip Burkle’s life and character, whet the reader’s appetite for reading the book (if you haven’t already), and encourage our readers to reflect on Skip’s seminal work and contributions.

Stephen S. Morse, PhD

Editor-in-Chief

Early in his memoir, Water on the Moon: A Physician’s Memoir of Service from the Vietnam War to Humanitarian Crises Worldwide, the story is told of a most remarkable medical intervention and “save.” On the front lines of the Vietnam War, at Delta Med, the Marine Corps forward casualty field hospital situated just five miles south of the DMZ, a newborn, 5 days old with the decaying umbilical cord still attached, is passed over the wire to US Marines standing guard. Dr. Burkle, a Yale-trained pediatrician (who along his storied career also became certified in emergency medicine, adolescent medicine, public health, and psychiatry), recognized that a severe infection had taken hold and understood that desperate measures were in order. He performed an exchange transfusion, a risky procedure using blood from healthy volunteers (in this case, 2 Marines) to replace the infected blood of the septic infant, passed through the umbilicus via a urinary catheter inserted directly into the vein supplying the infant’s liver. It worked. Word started to spread back over the wire into nearby Vietnamese villages. All of a sudden, the number of children being brought for care surged. And one day, a venerated village elder presented for care, pointing to his own belly button and motioning to the doctor that he, too, could get such a treatment. But this wasn’t the case. It would be too resource-intensive for such an adult, especially given the importance of blood supply needed to treat and stabilize injured US soldiers. It taught the young doctor an important lesson, one worth passing on to the legions of students and disciples who have listened to and learned from Dr. Burkle over the many years since. “Never perform a procedure that cannot be reproduced by local medical workers in their culture and in their own facilities. This mistake is still made by humanitarians the world over” (pp. 56–57). It is lessons like these, brought forth by dramatic and compelling real-life stories, that make this book a gem well worth reading.

The stories in this memoir serve to display the author’s multifaceted experiences in military, disaster, and humanitarian medicine across the globe, most occurring in the context of front-page banner headline events. But it is also a testimony and tribute to love and the importance of family. Challenges that the author faced early in life, including a stutter, dyslexia, and severe asthma, were compounded by the severe scrutiny imposed by his stern, taciturn father. It was only when Skip met Phyllis, the love of his life and wife of over 64 years, during their sophomore year of high school, that he began to develop the confidence that led him to embark upon his remarkable career. It was her love, and the unconditional support of Phyllis’ family, that served as the spark for so much that lay ahead. And this love was the glue that was critical over the many years to follow to keeping this growing family together, even as the author traveled the globe, going from crisis to crisis.

In the nearly one year since this book was published, democracy itself is in retreat, something the author himself notes in one of the appendices to the book. As a keen observer of international political trends, the author spent much of his operational career in the setting of conflict that arose as a result of autocratic leadership. In addition, there are many examples of “lessons not learned” in the aftermath of conflicts and disasters that Dr. Burkle witnessed. From the Vietnam War to the failed exploits in Iraq, nation-building and the export of democracy were lofty but almost impossible goals. From Somalia and Liberia on the African continent to the Balkans and Burma, the work of the author in response to “complex humanitarian emergencies” was increasingly fraught with challenges and a common thread – the imposition of political (and economic) will that belie longstanding “intercultural hatreds … that … were dominant and unforgiving” (p. 148). As Dr. Burkle noted during one of his deployments to the Balkans in the late 1990’s “a humanitarian medical aid program must be embedded in a way in which health care assistance interfaces with recipients getting the medical aid” (p. 148). These, too, are critically important lessons to be gleaned from this important autobiography.

Beyond all the front-line experiences, the first-hand accounts of the detritus of war and the consequences of misguided policies, the book also highlights the importance of developing and enhancing coordination amongst the many players in the humanitarian response arena – NGOs, civil authorities, the military, the UN/WHO, and the International Committee of the Red Cross. The author’s founding of the Center of Excellence for Disaster Management and Humanitarian Assistance (COE) in 1994 was focused on addressing this important area of work. The intent was to create a center that “would promote and host educational and preparatory events concerning civil-military coordination and refugee care in disasters around the world” (p. 150), with the COE in Hawaii specifically focused on the Indo-Pacific region. What better person to take this on than a retired Navy captain who had the trust of the leadership of the humanitarian response community? As it turns out, there were numerous bureaucratic pitfalls along the way, mostly focused on money and the “control” of resources and branding. The tenuous state of civilian-military cooperation was challenged by concerns raised on the part of the humanitarian response community that it not be viewed as pawns of the military. Despite the commitment and support of Hawaii’s Senator Daniel Inouye, a true champion of national security, public health, and veteran’s issues to create a true civil-military partnership, the COE became a military-led effort, retreating from its vision of promoting coordination and cooperation between military and civilian agencies. Suffice it to say, for those of us who have endeavored to build big programs, the going is never linear, never easy. “I was resolute to see my dream of civil-military cooperation through to the end, but determination just wasn’t enough. Power, ego and personal territorial disputes all played into sabotaging my dream” (p.164).

This book is “must” reading for everyone working in or interested in humanitarian response and global health. For those students of military history and crisis response, the stories in this autobiography are literally ripped from the headlines. And for those who are just looking for a little real-world adventure, this book is for you. The sixty-some-odd years of professional development captured in this remarkable autobiography—Dr. Burkle as a military physician, disaster responder, policy maven, and educator extraordinaire—makes me wonder, who is purchasing the movie rights? And what actor will play the part of the “grandfather of disaster medicine,” himself a modern age Dr. Albert Schweitzer and Dr. Tom Dooley? I have some suggestions.