Training on Geneva Conventions, Humanitarian Law Urged for Surgeons on Missions

By Marilynn Larkin

June 11, 2019

NEW YORK (Reuters Health) - For surgeons and other healthcare professionals working in war zones and conflict areas, training in rights and obligations under the Geneva conventions and international humanitarian law is "fundamental" to ensuring their ability to deliver humanitarian aid effectively, according to a Viewpoint paper in JAMA Surgery.

"The 21st century is a very complicated and difficult time for humanitarian workers in conflict zones," senior author Dr. Sherry Wren of Stanford University in Palo Alto told Reuters Health. "Indiscriminate weapons and targeting of hospitals, healthcare workers, and humanitarian aid workers has become common in some conflicts."

In 2017, Dr. Wren received the International Surgical Volunteerism Award from the American College of Surgeons for her work with Medecins Sans Frontieres, as well as her work in the U.S. aimed at preparing surgeons to provide international humanitarian aid.

"It is imperative that physicians and surgeons who wish to work in these types of conflicts are aware of international humanitarian law and guiding principles of the Geneva Conventions to be able to work effectively in the regions," Dr. Wren said. "The responsibility to know the relevant material rests both with the surgeon working in the area as well as the agency for whom they are working. Inadvertent mistakes could be made when handling complex situations without this training."

"At the present time in many conflict areas there are no guarantees that combatants will follow these principles and laws," she acknowledged. "It is still important for surgeons to know the material and bring attention to breaches both at the patient land humanitarian actor level. This may be the only way to advocate for change and bear witness to that is currently happening."

"We need to advocate for access and dignity for all in the humanitarian context," she said.

In their article, published online May 29, Dr. Wren and colleagues provide selected on-site and online international humanitarian law courses to help surgeons and other providers access the knowledge they need. These include:

- International Committee of the Red Cross (

- Human Rights and Justice Group International (

- Universite Catholique de Lovain (

- Universiteit Leiden (

- Human Rights Education Associates, The Global Human Rights Education and Training Centre (

- University of Geneva (

Humanitarian surgeon Dr. Adam Kushner of the Johns Hopkins Bloomberg School of Public Health in Baltimore, who recently coauthored a paper on the importance of educating healthcare providers participating in humanitarian missions (, commented, "As part of the team that reviewed the Mosul (Iraq) trauma response, we found that many healthcare providers and specifically surgeons were unprepared to deal with the ethical issues involved in treating enemy combatants."

"The line between humanitarian aid workers and military medical teams was blurred," he told Reuters Health by email. "This can cause confusion among civilian populations and create difficulties in providing safety for nongovernmental organizations and their staff. Populations may begin to think that healthcare providers are biased and that they may not receive good care from a certain group. Some patients may decide to forgo medical treatment altogether, as they fear being turned over to authorities or opposing forces."

"Surgeons and other healthcare providers working in conflict setting must be well versed in their responsibilities and ethical duty," he said. "Failure to understand international humanitarian law can lead to misunderstandings and provision of suboptimal care. While some may argue that both sides of a conflict might not always adhere to these basic tenets, we must strive to protect as many civilians, injured combatants and healthcare workers as possible."

"War crimes are committed in many conflicts and it seems as if they are getting more pervasive," he added. "That said, as healthcare providers, we are obligated to practice the highest standard of care to the best of our abilities. This includes understanding specific techniques commonly seen during conflict and understanding the laws of war."

"We must endeavor to set an example even if some of the combatants do not recognize these well known and established norms," Dr. Kushner concluded.


JAMA Surg 2019.