The Mosul Trauma Response A Case Study
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.
- 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
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
Lancet Editorial on The Mosul Report
Examining humanitarian principles in changing warfare. Lancet Vol 391 February 15, 2018
Systematic Review of Cash Transfers in Emergencies – Campbell Review Dec 2017
: Shannon Doocy, Hannah Tappis
Summary - Cash-based approaches have become an increasingly common strategy for the provision of humanitarian assistance. Both cash-based approaches and in-kind food assistance can be effective means of increasing household food security among conflict-affected populations and maintaining household food security among food insecure and drought-affected populations. Cash transfers are more cost effective than vouchers which are more cost effective than in-kind food assistance.
Syria Cash Transfer Stakeholder Analysis Dec 2017
: Emily Lyles, Hannah Tappis, Shannon Doocy
Summary - As the Syrian conflict enters its seventh year, more than 13.5 million people within Syria are in need of humanitarian assistance. The response in Syria to date has largely been based on in kind assistance, which at times has been hindered by insecurity and access to move goods to areas near to active conflict lines, hard-to-reach areas and besieged locations. Globally, over the past decade, cash-based approaches have become an increasingly common form of humanitarian assistance. Cash-based approaches, which include cash transfers and voucher programs, have only been implemented on a limited scale in Syria. While most assistance to date has been delivered in-kind, there is widespread interest in expanding the use of cashbased approaches. This study explores the feasibility of providing cash-based assistance at scale, as well as stakeholder perceptions of cash-based assistance modalities, with the aim of informing future humanitarian assistance delivery strategies in Central and Southern Syria.
Effectiveness of Lean Season Transfers in Zimbabwe March 2017
: Bert Lof | : Shannon Doocy, Hannah Tappis
Summary - The decentralized evaluation of the Lean Season Assistance (LSA) was commissioned to provide an analysis of lessons learned and to formulate recommendations for future food assistance programming in rural Zimbabwe. Evaluation objectives were: 1) to assess the effectiveness and efficiency of Lean Season Assistance (LSA) with particular attention to transfer modalities and linkages with the Productive Assets Creation (PAC) Programme (implemented under the same PRRO); and 2) to provide evidence-based findings to refine ongoing activities and inform implementation of the Country Strategy Plan (CSP) that will commence in 2017.
Research agenda-setting on cash programming for health and nutrition in humanitarian settings 17 October 2017.
: Aniek Woodward | : Andre Griekspoor (WHO), Kevin Savage (World Vision), Claire Beck (Wolrd Vision), Ann Burton (UNHCR), Shannon Doocy (Johns Hopkins School of Public Health), Lara Ho (Internation Rescue Committee), Josephine Ippe (UNICEF), Fernando Maldonado (Royal Tropical Institute (KIT) Amsterdam), Ruth McCormack (Cash Learning Partnership), Egbert Sondorp (Royal Tropical Institute (KIT) Amsterdam), and Paul Spiegel (Johns Hopkins School of Public Health)
Summary - While the evidence base for cash transfer programming (CTP) in humanitarian contexts is more established for food security, it is very limited for health. The aim of this study was to develop a research agenda on CTP for health and nutrition in humanitarian settings.
Protection Needs and Risks for Migrants in Europe: A Situation Analysis of Five Countries 21 July 2017
Summary - A comprehensive review of published and unpublished reports was conducted to examine the body of evidence on protection needs and risks facing migrants and refugees in countries along the Western Balkans migration route. Findings were synthesized to identify information gaps. Qualitative research was conducted to assess the context specific protection needs and risks facing women, girls, and other vulnerable groups in Greece and Serbia. Findings are intended to inform ongoing humanitarian assistance programs and identify information gaps that should be prioritized in efforts to expand the evidence base on effective approaches for addressing protection needs of refugees and migrants in Europe.
Innovative Humanitarian Health Financing for Refugees 17 April 2017.
: Paul Spiegel (Johns Hopkins School of Public Health) | : Becky Chanis (Johns Hopkins School of Public Health), Shannon Doocy (Johns Hopkins School of Public Health), Antonio Trujillo (Johns Hopkins School of Public Health)
Summary - Providing universal health care coverage to refugees can enable the achievement of three important but often unattainable objectives: 1) affordable and cost-effective health care for refugees from the onset of an emergency until its resolution; 2) development of a (sub) national health care coverage system for refugees or the improvement of an existing health care coverage system for nationals; and 3) a reduction in dependency and an improvement in the sustainability of health care services for refugees - while reducing costs to governments and humanitarian and development organisations. Numerous innovative approaches for financing health care have been implemented successfully in a variety of contexts, but these approaches have not been sufficiently explored as solutions for financing the health care of refugees. This study aims to fill this gap by producing a white paper that will explore various options for providing universal health care coverage to refugees in different contexts. The feasibility of implementing each option will be a key part of the study.
Jenga Jamaa II Operations Research Final Report Sept 2016
: Shannon Doocy, Jilliam Emerson, Emily Lerman, Elizabeth Colantuoni, Megan Cherewick, Laura Caulfield
Summary - Jenga Jamaa II was a Development Food Assistance Program (DFAP) carried out between 2012 and 2016 with the aim of improving food security in Fizi, Kalehe and Uvira territories of South Kivu Province in Eastern Democratic Republic of Congo. In the 2013/2014 DHS, South Kivu had the highest stunting rate in the country at 53%.1 High levels of poverty, low education attainment and few employment opportunities beyond subsistence agriculture contribute to lack of livelihood opportunities. In an effort to address these and other issues, Jenga Jamaa II program activities aimed to increase incomes among food insecure farming households, improve the health and nutritional status of children under five and empower women in food insecure communities.
Anti-Human Trafficking in Thailand: A Stakeholder analysis of Thai Government efforts, the U.S. tip report and rankings and recommendations for action. 30 June 2016.
: Courtland Robinson (Johns Hopkins School of Public Health) | : Charlie Thame (Johns Hopkins School of Public Health), Casey Branchini (Johns Hopkins School of Public Health)
Summary - The goal of this study was to conduct an assessment of Thailand’s initiatives to counter human trafficking in the last five years, through a review of documents and key informant interviews (KIIs) with a range of experts, including officials from the Royal Thai Government (RTG) and U.S. Government (USG), non-governmental organizations (NGOs), international organizations (IOs), and academic institutions (ACA). This study also included an assessment of the methodology used by the U.S. Department of State’s Office to Monitor and Combat Trafficking in Persons (TIP Office) to rank foreign country efforts to eliminate severe forms of trafficking in persons.
Cash Feasibility Assessment in Northern Syria May 2016
: Shannon Doocy, Hannah Tappis, Emily Lyles
Summary - As the conflict in Syria extends beyond the fourth year, there is need for a widespread humanitarian response focused on urban areas that addresses humanitarian needs and promotes resilience for the 13.5 million people in need of protection and humanitarian assistance within Syria. The majority of humanitarian assistance both in Syria and worldwide is provided as in-kind aid. However, over the past decade a transition has occurred and cash-based approaches, including both conditional and unconditional cash-transfers and voucher programs, are becoming increasingly common. The cash-based response within Syria to date is small when compared to in-kind assistance and geographic coverage has been somewhat limited. In light of the significant challenges to providing assistance in Syria, there is a need to shift the programming focus towards sourcing assistance from within Syria rather than importing in-kind assistance; interventions to support job creation, rehabilitation of industry and local markets; and empowering beneficiaries by responding to their feedback on which type of assistance is preferred. Provision of in-kind aid has been subject to security and logistical constraints, which challenges the assumption that it is the most secure and reliable modality in the Syrian context. While the majority of assistance to date has been delivered in-kind, there is widespread interest in expanding the use of cash-based approaches. Perhaps the most significant challenge in implementing cash-based responses in Syria is the lack of a functional electronic bank system or regulated cash transfer system for movement of funds into the country; currently many use informal “value transfer” or hawala networks to transfer funds, which poses legal and other concerns. This study explores the feasibility of cash-based assistance modalities and beneficiary preferences with the aim of informing future humanitarian assistance delivery strategies in Syria.
Systematic Review of Cash Transfers in Emergencies – 3ie Review April 2016
: Shannon Doocy, Hannah Tappis
Summary - The International Initiative for Impact Evaluation (3ie) is an international grant-making NGO promoting evidence-informed development policies and programmes. We are the global leader in funding and producing high-quality evidence of what works, how, why and at what cost. We believe that better and policy-relevant evidence will make development more effective and improve people’s lives.
Back to Top