Humanitarian and medical consequences of HW

• 1. Humanitarian impacts of conventional and hybrid wars: Lawfare - International Humanitarian Law, Human Rights, and Geneva Convention

Traditional wars symbolize an armed conflict between 2 or several countries. However, they usually follow the IHL and GC. IHL is a (cf.) “set of rules, which seek humanitarian reasons, to limit the suffering, losses, and other effects of armed conflict by restricting the means and methods of warfare to protect individuals who are not or are no longer participating in the hostilities.” The Geneva Convention is a (cf.) “series of treaties on the treatment of civilians, prisoners of war, and soldiers who are otherwise rendered outside the fight or incapable of fighting.” ^{Reference Khorram-Manesh, Burkle, Goniewicz and Robinson17–21} According to IHL, “A State” is responsible for all attributable violations of IHL committed by its organs (including its armed forces) and persons or entities it empowered to exercise elements of governmental authority. ^21,22 It is also responsible for the deeds of those acting in fact on its instructions, or under its direction or control, and by private persons or groups, which it acknowledges and adopts as its conduct. ^{Reference Arakelian, Bekhrus and Yarova20–22} In contrast to conventional wars, there is constant negligence of IHL and GC implementation in modern armed conflicts since the objectives of the wars have changed, and it is more critical to achieve the tactical and strategical goals in a battle than to save civilian lives. ^{Reference Burkle15,21}

The responsibility for implementing the principles of IHL lies on the International Federation of Red Cross and Red Crescent Movement (IFRC) and the International Institute of Humanitarian Law (IIHL). The International Committee of Red Cross (ICRC) is the operational institution responsible for protecting victims of conflicts within a country and across boundaries. ^21,22 According to IHL, ICRC has the mandate to gain insights into an ongoing battle and, as an impartial, neutral, and independent organization, protect the lives and dignity of victims of war and internal violence by assisting the affected population directly, coordinating the international relief activities, promoting the importance of IHL, and drawing attention to universal humanitarian principles. ^{22,Reference Burkle23} Additionally, they also have mandates to visit prisons, organize relief operations, reunite separated families, meet the needs of internally displaced persons, raise public awareness of the dangers of mines and explosive remnants of war, and trace people who have gone missing in conflicts. ^{Reference Burkle23} These tasks allow ICRC to track war activities and present an accurate picture of casualties and deaths. In contrast to conventional wars, modern armed conflicts involve networks of state and non-state actors with various means of military and militia influences and strategies, which creates difficulties in implementing, controlling, and evaluating IHL’s “A State responsibility” principle and does not allow international organizations to gain insight into an armed conflict. ^{Reference Khorram-Manesh14,Reference Burkle15,Reference Arakelian, Bekhrus and Yarova20}

Of significance in both the current Ukrainian war and similar HWs is the emergence of Lawfare, which according to Dunlap, is ‘the strategy of using (or misusing) law as a substitute for traditional military means to achieve an operational objective.’ ^{Reference Dunlap24–Reference Pfanner26} An immediate outcome of Lawfare is its impact on the international law and judicial processes, weakening the International Humanitarian Law and Human Rights Law, which may become entirely inapplicable. ^{Reference Khorram-Manesh, Burkle, Goniewicz and Robinson17,Reference Khorram-Manesh, Goniewicz, Burkle and Robinson27,Reference Canyon and Burkle28} From an HW perspective, there is an increase in war crimes, social chaos, and internal criminality in the invaded nation by unconventional actors who can operate beyond the control of states by bypassing interstate and international borders’ norms and agreements. The clash and confrontation with these actors, whether they belong to global terrorist networks or criminal elements, aims to destabilize society and would lead to a collision beyond the physical aspects of the conflict in which media manipulation, the use of the internet, and the integration of information operations with strategic communication programs are as necessary as weapon systems on the battlefield. ^{Reference Ciobanu29}

During conventional wars, soldiers were always the primary target, and civilians were always allowed to leave the conflict area to protect themselves from deaths and injuries. ^{Reference Burkle15} On the other hand, hybrid wars bring the battlefields into the civilians’ backyards, making them vulnerable and involved in fights. ^{Reference Khorram-Manesh14} The outcomes have been many; however, the increase in civilian fatalities from 5% at the turn of the 19th century to 15% during World War I (WWI), 65% by the end of World War II (WWII), and to more than 90% in the wars during the 1990s, is without a doubt 1 of the most significant outcomes of HWs, ^{Reference Khorram-Manesh, Burkle, Goniewicz and Robinson17} stating the clear objective of HW, focusing on local populations, infrastructure, and communities, where civilians can be found. ^{Reference Razma8,Reference Burkle15,Reference Phelan16} The aim justifies the means and becomes the background and the motto for each intervention. The goal is to influence the achievement of significant geostrategic goals which promote their impact and ideology and increase their reputation globally. ^{Reference Ciobanu29}

HWs generate millions of displaced persons, which overwhelms healthcare and relief organizations’ working capacity. ^{Reference Khorram-Manesh and Burkle30–Reference Ri, Blair, Kim and Haar34} It increases the vulnerability of protective authorities, consumes legal and healthcare systems, paralyzes the national government, and finally may dissolve national unity. ^{Reference Razma8,Reference Khorram-Manesh, Burkle, Goniewicz and Robinson17,Reference Ri, Blair, Kim and Haar34–Reference Konaev43} A state of ‘no authority and no legal forces,’ enhances the violation of IHL, HR (human rights), and equality with no punishment. These scenarios endanger the mandated work of international organizations to supervise and regulate the rules of the war. It also disables receiving the correct information and enhances the possibility of belligerents and terrorists hampering a democracy. New military strategies, remote warfare, drones, proxy fighters, and hybrid warfare present the face of modern and unconventional war, which threatens and takes civilian lives and raises new ethical and moral concerns when violating IHL and GC. ^{Reference Burkle15,Reference Khorram-Manesh, Burkle, Goniewicz and Robinson17,Reference Arakelian, Bekhrus and Yarova20}

• 2. Medical consequences of HW

The medical consequences of HW depend on several factors, such as the duration of the war, the place it occurs, and the population density. HW aims at attacking the infrastructure of a community by using several tools. Healthcare usually needs a capacity surge, which relies on the 4 vital elements of the surge capacity, i.e., ‘staff, stuff, space, and systems’ (guidelines and instructions). There are apparent differences between conventional wars and HW in their medical outcomes regarding the 4 elements of surge capacity and 3 decisive factors in conflict, i.e., war duration, combat field, and population involvement. ^{Reference Khorram-Manesh, Goniewicz, Burkle and Robinson27,Reference Reiter44,Reference Khorram-Manesh45}

• a. Duration of the war

The duration of a conflict is a very significant factor in the medical management of victims. Short wars may result in a high number of casualties, but in the long term, the healthcare system may be able to recover quicker than in a long and devastating conflict. ^{Reference Reiter44} More extended conflicts are associated with a lack of staff, stuff, and spaces to facilitate medical care. Conventional wars consume military service members in different positions with little impact on the civilian population who are usually not involved on the battlefield. ^{Reference Khorram-Manesh45} HW involves military and civilian populations, targeting both sides’ resources, including medical facilities and staff. Therefore, in contrast to conventional war, HW impacts the entire list of diseases and emergencies. Whereas war creates emergency cases of trauma and combat-like injuries, the longer duration of HW conflicts normally consumes all medical resources leading to the population’s difficulty to obtain equal and available care. Overwhelmed hospitals may not assess and treat people with chronic diseases, worsening people’s medical conditions while waiting to access healthcare. ^{Reference Khorram-Manesh, Goniewicz, Burkle and Robinson27,Reference Hägerdahl41–Reference Khorram-Manesh45}

• b. Field of combat

Conventional wars occur in militarized areas, with no involvement of civilians. HW, however, happens everywhere and destroys infrastructures that provide care, energy, logistics, and coordination. The most severe damages and injuries can be obtained when the invaders attack chemical, biological, radiological, and nuclear (CBRN) facilities. ^{Reference Padarev46,Reference Calder and Bland47} The outcome will undoubtedly be disastrous, involving the affected countries and even millions of people living around the conflict area. There is a high risk for the latter in an HW compared to a conventional war, requiring immediate medical response and practical support such as protective items, unaffected ambulances, and many others. ^{Reference Calder and Bland47} The damage inflicted to the infrastructure, as 1 of the main goals of HW, would also prevent the ordinary population from receiving appropriate healthcare for their diseases, meaning that benign and malignant cases, such as cardiovascular diseases and various types of cancers, will not receive the treatments they need. ^{Reference Kutikov, Weinberg and Edelman48}

• c. Population density

HW, intentionally or unintentionally, focuses on the populated areas within the invaded country. Therefore, it is logical to assume that the casualties would be much higher, and would consist of predominantly civilian populations. Earlier casualty estimation tools used in conventional war are incompatible with the current HWs and cannot be used. Consequently, the lack of knowledge and tools to assess the number and types of injuries creates particular difficulties for healthcare, whose tasks cannot be conducted without necessary resources. ^{Reference Burkle15,Reference Khorram-Manesh, Burkle, Goniewicz and Robinson17,Reference Friesendorf35,Reference Vautravers37,Reference Cincotta, Engelman and Anastasion38} Previous publications have indicated that casualties and deaths are likely too high to plan properly. Therefore, the only measure for any contingency plan is to focus on what they may be able to do. In such a situation, other medical tools such as triage, must properly categorize victims that can be saved. This, in turn, calls for discussions regarding the moral and ethical perspectives of medicine and triage under extreme conditions. ^{Reference Khorram-Manesh, Burkle, Goniewicz and Robinson17,Reference Hägerdahl41,Reference Khorram-Manesh49}

Inflicted injuries and deaths in HW

The transformation of regular warfighting to HW indicates that injuries inflicted in HW might be a mix and match of the multi-domain characteristics of HW. That, in turn, means a variety of injuries should be considered depending on the occasions and specific domain used. In this perspective, injuries and deaths may occur during riots, demonstrations, and minor armed conflicts in various unplanned places. Criminal gangs may also conduct their part by using lighter and heavier weapons. Additional injuries and deaths may also occur due to disruption in Internet Technology (IT), loss of electricity, and the damage inflicted to this infrastructure. The target of these attacks is the local communities and civilians. Explosives and suicide bombings have been the primary means of terror in previous HW terror attacks, with a variation of mortality ranging from 3 to as high as 2996, injuries ranging from 49 to 6000, and a ratio of deaths/ total casualties of 8 to 51%. ^{Reference Khorram-Manesh, Burkle, Goniewicz and Robinson17,50–Reference Williamson and Murphy57} An important denominator of these attacks is the chaos and overwhelming pressure they create for emergency services, particularly healthcare. A high number of injuries require both a multiagency approach and availability of healthcare in several hospitals and healthcare facilities, along with local preparedness at the community level for both adult and pediatric conditions and military-like injuries. The multi-level confrontations and assaults in HW result in resource scarcity, particularly within the healthcare systems over a more extended period, causing deaths and a need for critical non-traditional medical decision-making. ^{Reference Cronin58,Reference Grant and Kaussler59}