Did WHO's quest to save lives in Mosul battle get too close to the front lines?

A patient is being transferred from an EU-funded trauma stabilization point on the Mosul front line to a hospital further away from the fighting. Photo by: Peter Biro / European Union / CC BY-NC-ND

MANILA — The term “provider of last resorts” has been a point of discussion in the World Health Organization’s draft 13th program of work. In efforts to illustrate what it means, Director-General Tedros Adhanom Ghebreyesus has often made an example of the organization’s intervention in Mosul, Iraq, in 2017, where the organization made an unusual decision to run a referral chain for trauma cases from the frontlines as Iraqi forces fought the Islamic State militant group.

The decision, as Devex reported at the time, received support from multiple players and partners on the ground. Donors such as the European Commission were eager to provide financial and political support to the endeavor.

But a recent report by the Center for Humanitarian Health from the Johns Hopkins Bloomberg School of Public Health reveals the events that unfolded on the ground in Mosul — and the decisions that actors made — raised significant questions on the future of humanitarian response in today’s conflict settings.

The humanitarian scramble for trauma care in Mosul

The report talks about the provision of trauma care on the frontlines of the fighting in Mosul. As the fighting between government forces and ISIL intensified, and casualties rose among combatants and civilians, concerns emerged on the adequacy of care being provided — not just in Erbil, where most of the displaced and wounded seek refuge and care, but also on the frontlines.

Under Geneva conventions, parties to an armed conflict bear the responsibility of providing care to the wounded. But in Mosul, humanitarian actors soon realized that Iraqi and Kurdish forces lacked the medical personnel necessary to care for their own soldiers, let alone civilians injured in the conflict. Surrounding hospitals were similarly understaffed and overburdened. United States-led coalition forces, who were supporting the Iraq government’s offensive, argued they were in an “advise and assist” role and so were restricted from deploying medical units to treat civilians.

Several nontraditional actors stepped in: The Free Burma Rangers, a “humanitarian service movement” that works with local pro-democracy groups, and the Academy of Emergency Medicine, a relatively new Slovakian-based international nongovernmental organization providing emergency medical care, training, advice, and assistance in remote areas globally — but which, unlike traditional humanitarian organizations, also closely cooperates with security and armed forces.

The lack of sufficient medical personnel — along with appeals and requests for trauma care support from the Iraqi government, coalition forces, local health sector, and donors — led several actors on the ground to seriously consider setting up a structured trauma response on the frontlines. That included the WHO.

The U.N. health aid agency, whose main roles are often to coordinate health responses and provide standards of care, developed a trauma care plan that adapted military standards of care, which included providing immediate first aid — within 10 minutes of an injury — and ensuring emergency surgical care is provided within an hour. Then, WHO reached out to the International Committee of the Red Cross and Médecins Sans Frontières, two actors known for their expertise and long track record doing this type of work, to cover a geographic area on the frontlines. But both actors “declined,” according to the report, citing concerns on security and the need for them to maintain independence from the coalition forces. Moving nearer the frontlines made it difficult not to “co-embed” or be seen to be working alongside the military or rely on a heavily weaponized group for staff safety.

“WHO worked with all partners involved in the response in order to ensure best care possible for the affected population. This is consistent with our obligations as provider of last resort within the Inter-Agency Standing Committee.”

—  Altaf Musani, WHO representative in Iraq

Eventually, other NGOs stepped forward to heed WHO’s call. These included NYC Medics, a U.S.-based NGO that had previous experience working in natural disasters but not in conflict zones; and Samaritan’s Purse, which was already running two mobile medical clinics for internally displaced people coming from Mosul. In the absence of takers for its field hospitals in West Mosul, meanwhile, WHO tapped Aspen Medical, an Australian-based private company that provides medical care in remote and challenging settings. The company, the report notes, previously run emergency treatment units as part of the Ebola response in Liberia and Sierra Leone.

MSF’s and ICRC’s decision

The decision to bring trauma care to the frontlines, according to various data collected in the report, may have saved between approximately 1500 and 1800 lives, both combatant and civilian. And MSF and ICRC said there are no questions as to the relevance and urgency of setting the trauma stabilization points.

“To have trauma stabilization points provides clear medical relevance. Nobody is questioning the medical relevance of those trauma stabilization points,” said Jonathan Henry, deputy program manager for MSF’s “Cell 4,” which includes the international medical humanitarian organization’s mission in Iraq.

He did raise some questions though on the necessity of working so close to the frontlines, as he said facilities need only be positioned “within the golden hour,” which in emergency settings refers to the period of one hour or less following a traumatic injury.

Henry was emergency coordinator for MSF in Iraq around the time WHO approached the organization to come work closer and provide trauma stabilization points to the frontlines. At the time, they were doing assessments along the frontlines and in hospitals near the area. He clarified that MSF also set up their medical units near the frontlines, only that it was 700 meters farther than what WHO was suggesting. Based on their own independent analysis, it was considered a “safer location” for their staff and patients.

“When WHO lobbied and suggested for us to work on the frontline, our response was, ‘we will have an independent analysis and then we will take our own decision.’ [Then] we assessed multiple locations within a kilometer of the frontline, and we concluded that the level of risk for the patients and the teams [in the suggested location] was too high,” Henry said.

“Humanitarian aid by principle is independent and neutral, and by co-embedding you are not independent and you are not neutral.”

— Jonathan Henry, deputy program manager for MSF’s “Cell 4”

But he notes everyone was under pressure to find a way to respond to the growing need for immediate medical care there in the midst of what he says is “arguably one of the most intense conflicts since the second world war.”

“It was often only people that could walk that were able to exit the IS-controlled areas. So many people died because they literally couldn’t move,” he said.

Meanwhile, despite declining WHO’s request, ICRC scaled up its health activities in Mosul, supporting hospitals there with staff, trainings, and medical supplies. They deployed four surgical teams, including at the Mosul General Hospital, said Patrick Hamilton, ICRC’s deputy regional director for Near and Middle East based in Geneva.

“The ICRC has repeatedly commended WHO and its emergency medical teams for stepping in and saving lives,” said Hamilton. “This being said, we also believe that our approach also contributed to saving lives during the battle of Mosul.”

The relevance of humanitarian principles to modern contexts

To those who agreed to work closer to the frontlines, their decision was guided with the overriding principle of saving lives, according to the report. But ICRC and MSF, while commending their actions, said they have concerns on its long-term implications for humanitarian actors.

Apart from concerns of inevitably co-embedding with the military, ICRC says setting up trauma care on the frontlines would have necessitated them to rely on a weaponized approach to security management. Relying on the military or a security company for its staff meant to the ICRC breaching the main principles of humanitarian aid and becoming too closely associated with one of the parties to the conflict — potentially putting at risk their staff and activities in Iraq and other countries where it has presence.

“The ICRC is not a military actor. The ICRC as an institution has a global approach to security management that is based on the three principles of neutrality, impartiality, and independence, and being identified as a civilian actor,” Hamilton told Devex via email. “We could have saved lives then and there in East Mosul, but in a way that could have stopped us from saving lives in Iraq and elsewhere in the months or even years thereafter.”

At a time of increased hostilities against humanitarian actors, MSF and ICRC found the principles even more relevant than ever.

The Center for Humanitarian Health report argued that, given the diversity of humanitarians’ expertise and international responsibility, it may be necessary to adopt a system in which different organizations approach humanitarian principles depending on their mandate and the context in which they operate, but note this should have its limits. Nonmilitary medical frontline services that are “co-located” or “embedded” with the military should be labeled differently, not as humanitarians.

This recommendation coincides with MSF’s and ICRC’s. The events that unfolded in Mosul led them to question whether the work provided by organizations that had “co-embedded” or “co-located” with the military should be labeled as humanitarian aid at all.

“The question is more about the ethics,” MSF’s Henry said. “Humanitarian aid by principle is independent and neutral, and by co-embedding you are not independent and you are not neutral. So the issue for me is how do we define this kind of response? Because if humanitarian aid has to be independent and neutral, then those trauma stabilization points were clearly not.”

That’s not to say it’s an easy thing to abide to. Over the years, it has become increasingly difficult for NGOs to ensure independence and neutrality in the work they do. And in the case of Iraq, there was already a question on how neutral all actors were, given there was no humanitarian dialogue established involving both parties to the conflict.

“I think in the end we were as neutral as we could have been, but it’s always a challenge,” Henry said. “But I think as an international medical humanitarian organization, we must always strive to ensure [we uphold] these principles of independence, neutrality, and impartiality [as] these are the core elements of our identity.”

For ICRC, being called a humanitarian actor meant abiding by all principles of humanity, impartiality, neutrality, and independence. Those who work directly with combatants to save lives are also bound by medical ethics and principles of the international humanitarian law. But they should not be presented as humanitarian organizations, but perhaps as “medical auxiliaries or services associated to armed forces.”

“For the ICRC, there is principled humanitarian action which works strictly to the humanitarian principles of humanity, impartiality, neutrality, and independence. Then there are forms of medical or other work to address people's needs which does not apply these principles, and which usually takes sides in one form or another as solidarist NGOs supporting a particular struggle or medical and other auxiliaries to military forces which are also taking sides,” Hamilton said.

WHO, in response to the report’s findings, says it agrees with many of its recommendations, and that it looks forward to continuing the dialogue with partners on how to collectively address critical medical gaps in today’s conflict zones while still respecting the humanitarian principles and medical ethics expected of them in the field.

The U.N. health aid agency, however, reiterated that the work they did in Mosul was rooted in the humanitarian imperative of saving lives, and that partners on the ground treated all patients impartially, adhered to medical ethics, and operated “according to best practices of trauma care.”

“WHO worked with all partners involved in the response in order to ensure best care possible for the affected population. This is consistent with our obligations as provider of last resort within the Inter-Agency Standing Committee,” Altaf Musani, WHO representative in Iraq, told Devex. “In fulfilling our duties, we had to consider the following: How to reconcile the needs to simultaneously provide timely and effective trauma care to victims of the conflict, ensure the security of both staff and patients, and act in a manner consistent with humanitarian principles.”

This is unlikely to be the last instance such circumstance will present itself, and the international humanitarian community will eventually have to find an answer to the questions raised in Mosul. The report, and a Lancet editorial, recommends a high-level meeting take place to discuss the issues, including the relevance of the above humanitarian principles in the context of today’s warfare.

The issue could well inform the agenda of a second World Humanitarian Summit in the future.

About the author

  • Jenny Lei Ravelo

    Jenny Lei Ravelo is a Devex Senior Reporter based in Manila. She covers global health, with a particular focus on the World Health Organization, and other development and humanitarian aid trends in Asia Pacific. Prior to Devex, she wrote for ABS-CBN, one of the largest broadcasting networks in the Philippines, and was a copy editor for various international scientific journals. She received her journalism degree from the University of Santo Tomas.