The Mosul Trauma Response A Case Study

Humanitarian Health Response – Mosul

The Mosul Trauma Response A Case Study
Center for Humanitarian Health – Johns Hopkins University
February 2018 :: 67 pages
Full Report PDF:
Exec Sum. 1: Application of Humanitarian Principles | Exec Sum. 2: Quality and Effectiveness

The Battle of Mosul was one of the largest urban sieges since World War II. From October 2016 and July 2017, Iraqi and Kurdish forces fought to retake Iraq’s second largest city, which had fallen to ISIL in 2014. They were backed by U.S.-led coalition forces. More than 940,000 civilians fled during the siege, and thousands were injured as they sought safety.

Early on it became clear that the Iraqi military did not have the capacity to provide trauma care, despite its obligations under the Geneva Conventions and Additional Protocols. The World Health Organization (WHO) and its partners stepped in to fill this void. This was the first time the WHO played a leading role in coordinating care in conflict, and the first time a civilian trauma setting was attempted at the frontline.

Key findings
:: 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 fulfil 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.

:: 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.

Paul B. Spiegel MD, MPH
Professor, Johns Hopkins Bloomberg School of Public Health (JHSPH)
Director, Johns Hopkins Center for Humanitarian Health
Kent Garber MD, MPH
Research Associate, JHSPH
Adam Kushner MD, MPH
Associate, JHSPH
Core faculty, Johns Hopkins Center for Humanitarian Health
Paul Wise MD, MPH
Richard E. Behrman Professor of Child Health and Society
Professor of Pediatrics
Senior Fellow, Freeman Spogli Institute for International Studies
Stanford University


The Lancet
Feb 03, 2018 Volume 391 Number 10119 p401-512 e5
Examining humanitarian principles in changing warfare
The Lancet
Published: 17 February 2018
Violence in war must have a limit. Those who are not participating in the hostilities should be protected to prevent war from sinking into barbarity. Today, this is safeguarded by international humanitarian law (IHL), of which the cornerstones are the four Geneva Conventions of 1949 and its Additional Protocols. IHL provides for the wounded and sick to be collected and cared for by the warring faction that has them in their power, and for them to receive timely medical care. Traditionally, those entering into conflict could be expected to uphold these laws. But who will save the lives of the wounded if the warring factions are unable—or unwilling—to provide that care?

From October, 2016, to July, 2017, a US-led coalition supported the Iraqi and Kurdish forces in a battle to retake the city of Mosul from the Islamic State of Iraq and the Levant (ISIL). What became known as the Battle of Mosul was one of the largest urban sieges since World War 2. Over 940 000 civilians fled—facing bullets, mortar shells, and air strikes. Providing timely and efficient trauma care to these civilians was paramount but fraught with difficulty.

How the humanitarian community responded to this situation provides an insight into the evolving debate over the provision of trauma care in war. This was documented in an evaluation published on Feb 17, 2018 led by Paul Spiegel and colleagues of the Center for Humanitarian Health at the Johns Hopkins Bloomberg School of Public Health, who petitioned the US Office of Foreign Disaster Assistance for a grant for this study. It is based on qualitative data (interviews, and a review of publicly and privately shared documents) and a quantitative analysis of data collected by WHO and other actors.

During the Battle, it soon became apparent that a void in life-saving trauma care urgently needed to be filled. The Iraqi military lacked medical personnel and the US-led coalition deployed few medical teams, which were tasked with providing care for wounded coalition forces and not civilians. ISIL’s tactics—use of civilians as shields, shooting at fleeing civilians, and occupation of health clinics—showed disregard for civilian and health worker protection. Humanitarian actors could not negotiate safe passage with ISIL; it was the first time the International Committee of the Red Cross (ICRC) did not have contact with all sides of the conflict. Moreover, hospital overcrowding, extensive infrastructure damage, and checkpoints set up by the Kurdish forces substantially slowed access to care.

In a first-of-its-kind approach, the evaluation shows that, consequently, the UN and WHO had to take charge and coordinate a unique trauma response for injured civilians. This trauma pathway, modelled after military trauma systems, included so-called trauma stabilisation points (TSPs) located within 10 mins of the front line, and field hospitals within an hour’s drive. This ultimately required the humanitarians to be “colocated” or “embedded” within the Iraqi military for security and logistical reasons, minutes away from the combat zone.

This approach challenged accepted humanitarian principles. Rooted in IHL, the humanitarian principles—neutrality, impartiality, humanity, and independence—guide the work of humanitarian actors, and are usually considered indivisible. As was stated in the evaluation, by colocating/embedding humanitarians with the military, “the principle of humanity [to protect life and health] was consciously given precedence over the principles of neutrality and independence; we would also argue over impartiality as well”. When approached by WHO to staff the TSPs and field hospitals, ICRC and Médecins Sans Frontières both raised these concerns, and finally declined to participate in this specific aspect of the trauma response. WHO ended up contracting humanitarian NGOs, and, as a last resort, a for-profit medical company, to “move forward” towards the front line. Spiegel and colleagues estimate that this approach, complemented by the work of other actors also providing trauma care, likely saved about 1500–1800 lives—both civilians and combatants.

The Battle of Mosul provides an important case study for what might be to come. 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 fulfil 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 organised to examine and answer this question: are the humanitarian principles as they are defined today still relevant for this changing warfare?