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AbstractModern 21st century armed conflict is characterized by a proliferation of nonstate armed groups, asymmetric warfare, and increased explosive threats such as improvised explosive devices (IEDs), barrel bombs, and cluster munitions. Over the course of the wars in Iraq and Afghanistan, casualty data analysis of preventable deaths led to a radical restructuring of military trauma care through the Joint Trauma System. These changes increased survival among critically injured casualties in Afghanistan from 2.2 to 39.9% from 2001–2017. Many of these practices have been incorporated into civilian trauma systems in high-resource settings (e.g., bystander tourniquet application for hemorrhage control, damage control resuscitation and use of whole blood, trauma registries to benchmark outcomes and quality improvement). In contrast, the structure of humanitarian surgical care in conflict remains largely unchanged. This talk synthesizes gaps and opportunities to translate advances made in military and high-resource trauma systems to humanitarian care in low-resource settings to reduce preventable morbidity and mortality among civilians in conflict.Learning ObjectivesProvide an overview of the unique demographic populations and surgical conditions (including both trauma and non-traumatic emergencies) encompassed by humanitarian surgical care.Synthesize the evidence base on (a) civilian conflict casualty epidemiology and (b) trauma intervention in low-resource settings to provide a framework for context-appropriate translation of trauma care advances in military and high-resource settings to low-resource conflict settings.Highlight gaps and opportunities for targeted research and operational interventions to improve care for vulnerable subpopulations (e.g., pediatric patients, burn victims), leveraging enhanced coordination between the health and protection clusters.

IMPORTANCE: Armed conflict in the 21st century poses new challenges to a humanitarian surgical response, including changing security requirements, access to patients, and communities in need, limited deployable surgical assets, resource constraints, and the requirement to address both traumatic injuries as well as emergency surgical needs of the population. At the same time, recent improvements in trauma care and systems have reduced injury-related mortality. This combination of new challenges and medical capabilities warrants reconsideration of long-standing humanitarian surgery protocols. OBJECTIVE: To describe a consensus framework for surgical care designed to respond to this emerging need. DESIGN, SETTING, AND PARTICIPANTS: An international group of 35 representatives from humanitarian agencies, US military, and academic trauma programs was invited to the Stanford Humanitarian Surgical Response in Conflict Working Group to engage in a structured process to review extant trauma protocols and make recommendations for revision. MAIN OUTCOMES AND MEASURES: The working group’s method adapted core elements of a modified Delphi process combined with consensus development conference from August 3 to August 5, 2018. RESULTS: Lessons from civilian and military trauma systems as well as recent battlefield experiences in humanitarian settings were integrated into a tiered continuum of response from point of injury through rehabilitation. The framework addresses the security and medical requirements as well as ethical and legal principles that guide humanitarian action. The consensus framework includes trained, lay first responders; far-forward resuscitation/stabilization centers; rapid damage control surgical access; and definitive care facilities. The system also includes nontrauma surgical care, injury prevention, quality improvement, data collection, and predeployment training requirements. CONCLUSIONS AND RELEVANCE: Evidence suggests that modern trauma systems save lives. However, the requirements of providing this standard of care in insecure conflict settings places new burdens on humanitarian systems that must provide both emergency and trauma surgical care. This consensus framework integrates advances in trauma care and surgical systems in response to a changing security environment. It is possible to reduce disparities and improve the standard of care in these settings.

ABSTRACTWhat began in 2013 as the eruption of a political struggle between forces loyal to President Salva Kiir, a member of the Dinka ethnic group, and then–vice president Riek Machar, a Nuer, has splintered into a multifaction conflict. A dizzying array of armed groups have entered the fray, many unmotivated by political leverage that conventionally brings parties to a conflict to the negotiating table. Two years and tens of thousands of deaths after the 2015 signing of the Agreement on the Resolution of the Conflict in South Sudan, with no substantive progress toward meetings its terms, it is unrealistic to think that Intergovernmental Authority on Development’s recently announced High-Level Revitalization Forum will be sufficient to address the drivers of this conflict. Current policy proposals are poorly designed to address escalating intercommunal conflict and cattle raiding, both devastating forms of violence. As measures at the international level continue to be pursued, the conflict resolution strategy should also include a more comprehensive approach incorporating local actors in order to build momentum toward long-term stability. In this article, we highlight gaps in the current dialogue around a political solution in South Sudan, as well as domains that must be part of the next push for peace. (Disaster Med Public Health Preparedness. 2019;13:663–671)

Cattle raiding, a longstanding practice among pastoralists in South Sudan, was historically governed by cultural authorities and ritual prohibitions. However, after decades of on-and-off integration into armed forces, raiders are now heavily armed, and military-style attacks claim dozens if not hundreds of lives at a time. Beginning with the emergence of the infamous Lou Nuer “White Army” in the Bor Massacre of the early 1990s, in which Riek Machar mobilized local herders to mount a devastating attack against the heartland of Sudan People’s Liberation Army Leader John Garang, political leaders have strategically manipulated these local conflicts in order to mobilize armed herders for their political movements. Political leaders’ systematic exploitation of customary raiding practices gravely inflames the current conflict, but the role of intercommunity violence has not been part of the mainstream dialogue around political solutions. Moreover, as allegiances between pastoralist militias and political factions decay, the proliferation of informal armed groups whose motivations are often distinct from the agenda of the state or opposition forces on whose behalf they once fought poses increasing challenges to peacebuilding efforts. Neglecting local realities poses serious implications for the prospects of peace. In this article, we synthesize perspectives from anthropology, regional history, and conflict studies to offer an analysis of the interplay between local conflict and state violence in South Sudan. We highlight opportunities for conflict de-escalation, concluding with policy recommendations focused on justice and enforcement in the rural areas of South Sudan.

AbstractHumanitarian aid in settings of conflict has always been fraught with challenges. In the absence of political engagement, however, manipulation by state authorities, however, have the potential to pervert aid intervention to inflict harm. South Sudan exemplifies how states may abuse the humanitarian response to retreat from public responsibility, divert funds to further violence and conflict and dictate the distribution of aid. Recent trends toward nationalist policies in the West that favor disengagement and limited military strikes have the very effect of allowing this abuse to transform humanitarian aid into a tool for harm. (Disaster Med Public Health Preparedness. 2018;12:567–568)