A Case Study: the Mosul Trauma Response

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Stanford Health Policy's Paul Wise — the Richard E. Behrman Professor of Child Health and Society — traveled to Iraq last year with a small delegation of physician-academics to evaluate the World Health Organization's system to treat civilians injured in the battle for Mosul. The northern city controlled by the Islamic State in 2014 was retaken by government forces last year and the team visited field hospitals to review health care on the ground and determine whether there is a better way to distribute medical aid during armed conflict.

We wrote about their visit in November.

Now, the team members have published their findings in an in-depth report put out by Johns Hopkins University's Center for Humanitarian Health.

The Lancet also has published an editorial about their research to coincide with the release of the report.

"The Battle of Mosul provides an important case study for what might be to come," the editorial board wrote. "Above all, this should be a very rare occurrence, and The Lancet echoes the evaluation's recommendation that governments, and possibly their allies, must ensure their militaries can fulfill the obligations of protection and care for wounded citizens under the Geneva Conventions. However, in modern warfare, access to the injured may increasingly be one-sided when fighting against warring factions that see health workers and civilians as acceptable targets of war. Governments should be prepared to face this eventuality. To be able to continue providing the best standards of care and saving lives, a high-level meeting must urgently be organized to examine and answer this question: are the humanitarian principles as they are defined today still relevant for this changing warfare?"

Some of the key findings of the report include: 

  • Between 1500-1800 lives, both military and civilian, may have been saved through this trauma response.
  • By attempting to apply Western military standards of trauma care and ‘moving forward’ towards the frontline to save civilians lives, WHO and its partners challenged existing humanitarian principles, particularly those of neutrality and independence.
  • The Iraqi government and its military did not have medical capacity to fulfill their obligations to protect and care for wounded civilians on the Mosul battlefield, and the U.S.-led coalition did not provide substantial medical care for wounded civilians.
  • WHO-supported field hospitals filled important gaps in trauma surgical care, while post-operative and rehabilitative care warranted greater support.
  • Successful coordination among local leaders, partners, and civilian and military officials occurred, but field coordination could have been better resourced.


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And some of the key recommendations:

  • Warring factions, and those supporting them, need to enhance the former’s medical capacities to ensure they can fulfill their obligations under the Geneva Conventions and Additional Protocols.
  • Deliberation is needed regarding the benefits to and the moral obligations of governments who support such warring factions, like the U.S.-led coalition in the Mosul battle.
  • Humanitarians must take care to avoid being instrumentalized by governments or military in future conflicts.
  • Medical teams operating directly with a combatant force should not be identified as humanitarian;
  • Frontline medical services could be provided by specialized groups explicitly trained to work directly with combatant forces, possibly contracted as military support services focusing on providing frontline medical services for both injured soldiers and civilians.
  • Using private medical organizations (i.e., contractors) to provide humanitarian services in conflict settings needs further study. 
  • How humanitarian actors can apply standards of trauma care that compel them to move towards the frontline to save lives, and still adhere to longstanding humanitarian principles, needs debate at senior levels such as at the Inter Agency Standing Committee or at the intergovernmental level.