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Invited Commentary
November 13, 2019

A Humanitarian House Divided—Unifying Conflict Zone Humanitarian Surgical Care

Author Affiliations
  • 1Trauma Research Program, Department of Surgery, Scripps Mercy Hospital, San Diego, California
JAMA Surg. Published online November 13, 2019. doi:https://doi.org/10.1001/jamasurg.2019.4557

“A great war leaves the country with three armies – an army of cripples, an army of mourners, and an army of thieves.”

German proverb

The protracted combat operations in Iraq and Afghanistan have once again confirmed a near-universal truism of war—that while the military and combatant forces fight the battles, the civilian population often pays the heftiest price. In addition to direct traumatic injuries related to active combat in populated areas, conflict zones create large-scale civilian medical crises by destabilization or even destruction of the local health care infrastructure and capabilities.1 The commonly resulting humanitarian crises in terms of trauma, emergency, and even semielective surgical care are only partially met by a highly variable patchwork of military and civilian players who frequently operate with little coordination or cooperation.2 It is in these scenarios that a pathologic condition, such as an uncomplicated extremity fracture, becomes a lifelong dysfunctional limb, a simple undrained abscess becomes septic shock, or a perforated appendix becomes a death sentence. Thus, it is not only a medical imperative but a moral and ethical imperative that humanitarian medical and surgical care in conflict zones is organized, coordinated, and optimized as a cohesive and integrated system.

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