After enduring more than two years under the control of so-called Islamic State, the people of Mosul were again thrown into war when Iraqi and allied forces moved to retake the city in October 2016.

In the extreme destruction that results when heavy munitions meet urban structures, an estimated 9,000-11,000 civilians were killed and thousands more wounded. Many of those wounded had the improbable experience of being treated not by military medics but by volunteer emergency medical technicians from New York City.

As the response of the Iraqi state and armed forces was lacking, the World Health Organisation arranged with the pro-government forces to coordinate the emergency trauma response system within the military operation – an unheard of frontline military-humanitarian collaboration on such a scale. When most of the usual non-governmental outfits it works with declined to participate – for reasons of principle, security or both – WHO turned instead to an assortment of private and volunteer-based groups. Many volunteers had never before worked in a conflict setting. As the troops moved in, the trauma response system, designed along a standard military model, was quickly up and running. Traditional humanitarian responders, such as Médecins Sans Frontières, remained at a distance, providing medical services further from the fighting.

How did this improbable scenario emerge: the erstwhile slow-moving WHO taking rapid action to meet critical humanitarian needs in dangerous areas while the famously intrepid MSF hung back? And what does it mean for humanitarian action in conflicts?

This week, the findings of a study commissioned by MSF itself to answer those questions were released as a report, authored by my colleague Hosanna Fox, who led the research.

The trauma response and referral pathway coordinated by WHO unquestionably saved lives: 1,500-1,800 of them, according to a case study by Johns Hopkins. It also should not have been necessary. The humanitarian-run trauma system was the result of multiple “layers of failure” within the international community. It is never easy to balance competing humanitarian principles, but the humanitarian community’s response to the military’s failure to provide trauma services should have been intense advocacy and pressure to hold them to their legal responsibilities, rather than readily stepping in to fill the gap.

Success amid failure

The battle for Mosul was the largest military operation since the 2003 invasion of Iraq, and humanitarian actors knew in advance to prepare for a major crisis.

Fundamentally, the state actors in the conflict failed to discharge their duty under International Humanitarian Law to make “best efforts to provide protection and care for the wounded”, leaving the humanitarian sector to fill this role. The UN-led humanitarian response abetted this dereliction by agreeing to staff and run the Iraqi military’s medical system.

The horrors of IS make it easy to understand how some humanitarians aligned themselves with the military objectives and adopted the “liberation narrative” of Mosul. However, they failed in their own responsibility to advocate forcefully for a stronger medical response by military actors, resourced by those governments. The UN and the International Committee of the Red Cross, in particular, had a duty to insist – strongly and publicly – on a more principled response, including greater distinction between humanitarian, medical and military actors and stronger protection of patients.

A worrying precedent

The pro-government forces could argue that if their responsibility was to provide or arrange for the collection and treatment of the war-wounded, then that is precisely what they did, through the UN-coordinated humanitarian system. Why is this problematic?

First, by setting a precedent that the responsibility can be offloaded to humanitarians, it weakens the fundamental obligation of the warring parties. This erodes important international norms.

Second, it risks weakening humanitarian action in the long and short terms. The battle of Mosul did not put an end to need and suffering in Iraq, and humanitarian organizations that wish to remain present and able to serve all groups in this contested region cannot appear to be co-opted by any party. Additionally, our research found instances where impartiality and neutrality were compromised: soldiers pressured doctors to prioritise their wounded comrades over civilian patients and screened out ISIS-affiliated patients for interrogation.

Finally, at least a small number of Iraqis were scared off by the militarized medical care. Our survey of people who were in Mosul during the battle found 11 percent of those with urgent medical needs avoided the facilities, citing fears for their safety as the primary reason. Of those that did receive care, a significant minority reported similar concerns.

No heroes, or easy answers

The traditional humanitarian actors who stayed out of the militarized medical response do not come out looking especially good, either. Our research found that despite an unusually long planning period, many NGOs were slow to ramp up and do the basic preparatory work necessary to take rapid and effective action when the anticipated crisis began.

The clash of humanitarian principles is nothing new, particularly the tension between the humanitarian imperative (provide critical aid now) and the principles of neutrality and independence. As one volunteer medic put it: “If you want to be close to the front lines, you have to accept military presence, there's just no way around it. So, the question is, are the lives saved worth this price? We think so.”

The choice may seem simple, but in protracted conflicts the calculus is often more complicated. Paying the price required to save lives today can reduce the ability to save lives tomorrow. And then there is the more basic question of state responsibility. In Mosul, a humanitarian medical intervention filled a gap – but to what extent did humanitarians allow the gap to exist in the first place?

(TOP PHOTO: Two siblings walk in an area near Mosul’s front line. CREDIT: Peter Biro/EU/ECHO)