Global Action Needed to Protect Humanitarian Surgeons and Patients During Wars and Armed Conflicts—Reply

In Reply We agree with Jindal’s amplification of the fact that humanitarian workers and medical staff continue to be subjected to illegal targeted attacks in violation of International Humanitarian Law and that surgeons should join efforts to hold countries accountable for violations. We disagree with the statement by Jindal that the focus of our recommendations for predeployment training on Geneva Conventions and International Humanitarian Law was to “reduce or eliminate” risks to health care workers. Our Viewpoint focused on specific areas where surgeons, in their role as humanitarian workers, would require specific content knowledge from the Geneva Conventions and International Humanitarian Law to work within the conflict environment.¹ We explained that detailed knowledge of these laws and conventions is necessary in surgical care and triage to ensure that injured combatants receive care irrespective of their affiliations; further acts of reprisal or violence to injured combatants do not occur; and observed violations are reported. It is also clear that health care workers without this type of training may find themselves in situations where they inadvertently violate the humanitarian principles of independence, neutrality, and impartiality. A report that critically evaluated the humanitarian trauma response of the 2016/2017 battle of Mosul in Iraq raised serious concerns about violations of humanitarian principles by health care workers and cited specific examples such as “colocation or embedding of medical personnel with Iraqi security forces”² and “questions regarding neutrality … medical responders talked publicly of defeating ISIS and were not able to work with all warring factions.”² These real-world examples demonstrate why predeployment training is critical for surgeons interested in humanitarian work. The requisite knowledge base for humanitarian responses to crises in conflict zones differs significantly from humanitarian responses to natural disasters. Disaster response typically does not have a complex contextual environment including combatants. Without specific training for work in conflict zones, surgeons may not have all of the necessary knowledge to conduct themselves and their provision of care in accordance with humanitarian principles.