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News from the American College of Surgeons

For Immediate Release


Sally Garneski
Dan Hamilton

New framework for humanitarian health systems aims to improve civilian care in conflict zones

Interdisciplinary medical and humanitarian response group encourages training for civilian first-responders and other steps to overcome challenges non-government organizations encounter in wartime

CHICAGO (November 13, 2019): Well-developed military trauma systems in war zones have drastically reduced death rates of combatants, but civilians who rely on humanitarian caregivers in these areas have not fared as well. To help improve surgical care humanitarian groups provide in conflict zones, representatives of a number of medical and non-government organizations (NGO) convened at Stanford University and developed a framework that organizations like the International Committee of the Red Cross and Médecins Sans Frontières/Doctors Without Borders can use for setting up health care systems in conflict zones. The group has published its findings on the JAMA Surgery website ahead of print.

“We would like to see the humanitarian response in these complex settings adopt many of the principals learned from trauma system development,” said lead author and organizer Sherry M. Wren, MD, FACS. “In the majority of humanitarian responses, there is no system of care to move patients through the process and, consequently, there are preventable deaths.” Dr. Wren is vice chair and professor of surgery at Stanford Medicine and director of global surgery at Stanford’s Center for Global Health and Innovation.

“Dr. Wren was very thoughtful about including all the representative groups as part of this summit, all groups that do a lot of this work,” said Eileen Bulger, MD, FACS, who represented the American College of Surgeons Committee on Trauma. “That’s critical. You can’t set up a framework that people don’t believe in.”

The Stanford Humanitarian Surgical Response in Conflict Working Group developed the framework after soliciting input on key issues from the expert panel followed by a three-day conference in August 2018. In addition to the International Committee of the Red Cross, Médecins Sans Frontières/Doctors Without Borders, and American College of Surgeons, the working group consisted of representatives from other major humanitarian NGOs, such as Samaritan’s Purse, along with the World Health Organization, representatives of the U.S. military , and trauma and humanitarian aid experts from around the world.

The group essentially applied best practices from civilian and military trauma systems as well as humanitarian settings to develop a tiered structure that goes from the first encounter with an injured patient through rehabilitation. The care levels include:

  • Training civilian first responders in early interventions such as clearing obstructed  airways and controlling bleeding.
  • Using a trauma stabilization point, which is a far-forward site utilizing trained medical staff, although not surgeons specifically, to stabilize patients.
  •  A definitive care facility to act as the first point where injured patients undergo surgery.
  • A contingency facility to provide backup when casualties surge or when injured patients cannot get to the definitive care facility quickly enough after injury.
  •  A standardized advanced capability package to definitive care facilities to provide high-level specialty surgical and critical care.
  • Basic reconstructive and rehabilitative services. This level would include education for amputees, extended care for burn victims, and, if possible, mental health services.

The consensus report noted that humanitarian surgical responses in conflict zones face a number of challenges, including shifting security needs, simply gaining access to patients, operating in communities with high medical needs, having limited surgical assets and other resources, and having to provide not only trauma care, but also emergency surgery of serious non-traumatic injuries. “There are many challenges, especially coordination and transport in these very complex environments,” Dr. Wren said.

What’s more, they must also adhere to principles of humanity, neutrality, impartiality and independence that are grounded in International Humanitarian Law, which itself is based on the Geneva Convention of 1949. These principles include unimpeded passage of humanitarian relief and the freedom of movement of humanitarian relief personnel. As Dr. Wren explained, humanitarian organizations may not  embed with military units or armed protection forces, and their care must be neutral and impartial.

Another working group member, Captain Eric Elster, MD, FACS, chairman of the department of surgery at Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Md., explained the importance of having the various groups come together. "The ability to organize multiple international groups around core principles based on data and hard-won experience is a critical step forward in ensuring that victims of conflict receive the best care possible,” he said.

Working group member Adam L. Kushner, MD, MPH, FACS, founder and director of Surgeons OverSeas, explained that the need for new interventions had been known for years, but the tipping point came during the battle of Mosul in in 2016-2017, when the Iraqi army retook the city from the Islamic State. “The Iraqi military was unable to care for civilian injuries, and an ad-hoc system developed that combined military and non-military groups caring for the wounded,” said Dr. Kushner, who is also an associate at Johns Hopkins Bloomberg School of Public Health. “This mixing of traditional humanitarian roles raised concern by many humanitarians who said the system did not take into account the rules of neutrality and impartiality and would lead to insecurity for aid workers and long-term problems with providing care for civilians on the battlefield.”

Added Dr. Wren, “The humanitarian NGOs do not have the sophisticated coordinated transportation system seen in the military.  Humanitarian care can be provided by military units, but it is governed under the Medical Rules of Engagement and is not consistently performed. The sole obligation of humanitarian groups is to care for all people regardless of affiliation or combatant status.”

The next steps, said Dr. Bulger, are to disseminate these findings among all the participating groups for ongoing discussion and to work in collaboration with WHO, which has taken a lead role in trying to implement the framework’s recommendations. “There is work that can be done pre-conflict, mostly around training community first responders in basic life-saving skills in areas that are at particular risk of conflict,” she said. “That undertaking doesn’t solve the problem entirely; these victims still have to get them to medical care, but it can save some lives in the short term. That’s work that can be done everywhere.”

In addition to Drs. Wren, Bulger, and Kushner, the working group’s publication had 24 coauthors.

Dr Wren reported receiving grants from Stanford Center for Innovation and Global Health during the study process.  Other author disclosures can be viewed at the conclusion of the full text article.

Citation: A Consensus Framework for the Humanitarian Surgical Response to Armed Conflict in 21st Century Warfare. JAMA Surgery, DOI:

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The American College of Surgeons is a scientific and educational organization of surgeons that was founded in 1913 to raise the standards of surgical practice and improve the quality of care for surgical patients. The College is dedicated to the ethical and competent practice of surgery. Its achievements have significantly influenced the course of scientific surgery in America and have established it as an important advocate for all surgical patients. The College has more than 82,000 members and is the largest organization of surgeons in the world. For more information, visit