to not be is unAmerican, nonDemocracy

Did Schelp read the reports as below? It appears to me that his arguing is itself exactly"arbitrary and capricious."
CDC studies find vaccines still offer powerful protection against severe Covid
Despite some evidence that the delta variant may slightly reduce their effectiveness, the shots continue to keep people out of the hospital.

Vaccinated people are less likely to spread Covid, new research finds
British scientists examined how the Pfizer-BioNTech and the AstraZeneca vaccines affected the spread of the virus if a person had a breakthrough infection.

How bad is Omicron? What scientists know so far

https://ell.stackexchange.com/

NYTimes:
THE CIVILIAN CASUALTY FILES
HIDDEN PENTAGON RECORDS REVEAL PATTERNS OF FAILURE IN DEADLY AIRSTRIKES
BY AZMAT KHAN

Dec. 18, 2021


The promise was a war waged by all-seeing drones and precision bombs. The documents show flawed intelligence, faulty targeting, years of civilian deaths — and scant accountability.

This is the first part of a series. Part 2 will examine the air war’s human toll.

Shortly before 3 a.m. on July 19, 2016, American Special Operations forces bombed what they believed were three ISIS “staging areas” on the outskirts of Tokhar, a riverside hamlet in northern Syria. They reported 85 fighters killed. In fact, they hit houses far from the front line, where farmers, their families and other local people sought nighttime sanctuary from bombing and gunfire. More than 120 villagers were killed.

In early 2017 in Iraq, an American war plane struck a dark-colored vehicle, believed to be a car bomb, stopped at an intersection in the Wadi Hajar neighborhood of West Mosul. Actually, the car had been bearing not a bomb but a man named Majid Mahmoud Ahmed, his wife and their two children, who were fleeing the fighting nearby. They and three other civilians were killed.

In November 2015, after observing a man dragging an “unknown heavy object” into an ISIS “defensive fighting position,” American forces struck a building in Ramadi, Iraq. A military review found that the object was actually “a person of small stature” — a child — who died in the strike.

None of these deadly failures resulted in a finding of wrongdoing.

These cases are drawn from a hidden Pentagon archive of the American air war in the Middle East since 2014.

The trove of documents — the military’s own confidential assessments of more than 1,300 reports of civilian casualties, obtained by The New York Times — lays bare how the air war has been marked by deeply flawed intelligence, rushed and often imprecise targeting, and the deaths of thousands of civilians, many of them children, a sharp contrast to the American government’s image of war waged by all-seeing drones and precision bombs.

The documents show, too, that despite the Pentagon’s highly codified system for examining civilian casualties, pledges of transparency and accountability have given way to opacity and impunity. In only a handful of cases were the assessments made public. Not a single record provided includes a finding of wrongdoing or disciplinary action. Fewer than a dozen condolence payments were made, even though many survivors were left with disabilities requiring expensive medical care. Documented efforts to identify root causes or lessons learned are rare.

The air campaign represents a fundamental transformation of warfare that took shape in the final years of the Obama administration, amid the deepening unpopularity of the forever wars that had claimed more than 6,000 American service members. The United States traded many of its boots on the ground for an arsenal of aircraft directed by controllers sitting at computers, often thousands of miles away. President Barack Obama called it “the most precise air campaign in history.”

This was the promise: America’s “extraordinary technology” would allow the military to kill the right people while taking the greatest possible care not to harm the wrong ones.

The ISIS caliphate ultimately crumbled under the weight of American bombing. For years, American air power was crucial to the beleaguered Afghan government’s survival. And as U.S. combat deaths dwindled, the faraway wars, and their civilian tolls, receded from most Americans’ sights and minds.

On occasion, stunning revelations have pierced the silence. A Times investigation found that a Kabul drone strike in August, which American officials said had destroyed a vehicle laden with bombs, had instead killed 10 members of one Afghan family. The Times recently reported that dozens of civilians had been killed in a 2019 bombing in Syria that the military had hidden from public view. That strike was ordered by a top-secret strike cell called Talon Anvil that, according to people who worked with it, frequently sidestepped procedures meant to protect civilians. Talon Anvil executed a significant portion of the air war against ISIS in Syria.

The Pentagon regularly publishes bare-bones summaries of civilian casualty incidents, and it recently ordered a new, high-level investigation of the 2019 Syria airstrike. But in the rare cases where failings are publicly acknowledged, they tend to be characterized as unfortunate, unavoidable and uncommon.

In response to questions from The Times, Capt. Bill Urban, the spokesman for the U.S. Central Command, said that “even with the best technology in the world, mistakes do happen, whether based on incomplete information or misinterpretation of the information available. And we try to learn from those mistakes.” He added: “We work diligently to avoid such harm. We investigate each credible instance. And we regret each loss of innocent life.”

Read the military’s full responses to questions from The Times.

He described minimizing the risk of harm to civilians as “a strategic necessity as well as a legal and moral imperative,” driven by the way these casualties are used “to feed the ideological hatred espoused by our enemies in the post 9/11 conflicts and supercharge the recruiting of the next generation of violent extremists.”

Yet what the hidden documents show is that civilians have become the regular collateral casualties of a way of war gone badly wrong.

To understand how this happened, The Times did what military officials admit they have not done: analyzed the casualty assessments in aggregate to discern patterns of failed intelligence, decision-making and execution. It also visited more than 100 casualty sites and interviewed scores of surviving residents and current and former American officials. In the coming days, the second part of this series will trace those journeys through the war zones of Iraq and Syria.

Taken together, the reporting offers the most sweeping, and also the most granular, portrait of how the air war was prosecuted and investigated — and of its civilian toll.

There is no way to determine that full toll, but one thing is certain: It is far higher than the Pentagon has acknowledged. According to the military’s count, 1,417 civilians have died in airstrikes in the campaign against ISIS in Iraq and Syria; since 2018 in Afghanistan, U.S. air operations have killed at least 188 civilians. But The Times’s analysis of the documents found that many allegations of civilian casualties had been summarily discounted, with scant evaluation. And the on-the-ground reporting — involving a sampling of cases dismissed, cases deemed “credible” and, in Afghanistan, cases not included in the trove of Pentagon documents — found hundreds of deaths uncounted.

The war of precision did not promise that civilians would not die. But before a strike is approved, the military must undertake elaborate protocols to estimate and avoid civilian harm; any expected civilian casualties must be proportional to the military advantage gained. And America’s precision bombs are indeed precise: They hit their targets with near-unerring accuracy.

Source: https://www.nytimes.com/interactive/2021/12/18/us/airstrikes-pentagon-records-civilian-deaths.html

https://post.m.smzdm.com/p/640591/

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Psychiatric organisations should unite voices in condemning the invasion of Ukraine

Scientists in the line of fire
MARCIA MCNUTT AND JOHN HILDEBRAND
SCIENCE • 4 Mar 2022 • Vol 375, Issue 6585 • p. 1071 • DOI: 10.1126/science.abp8817
The devastation and despair gripping Ukraine following the unprovoked invasion by neighboring Russia is heartbreaking and unthinkable. Such a loss of life and homeland has stirred wide concern around the world. This war sets back progress to establish a peaceful and sustainable world and to address important problems faced by all humanity, including climate change, environmental degradation, public health, and inequality. The international community of scientists cooperates extensively to address the challenges of our time, and a war that is destroying a stable and healthy nation and provoking a refugee crisis is no exception. What can the scientific community do most immediately to provide support and aid to its Ukrainian colleagues in their time of need? The community should focus on strengthening regional partnerships in Eastern Europe, networking to find refugees safe havens, speaking out forcefully against this invasion, and preparing to help rebuild Ukrainian science when the time is right.
As a first step, scientists and scientific organizations around the world, including the United States, need to redouble efforts to fortify links with scientific communities in countries that border the conflict area. The scientific communities in these young democracies, including Poland, Romania, and Bulgaria, often have strong connections to colleagues in Ukraine. Such ties will be critical in efforts to strengthen civil society in Ukraine and in other parts of the region. These nations will bear the brunt of the refugee crisis. Connections can be strengthened through international scientific bodies such as the InterAcademy Partnership, direct outreach between leaders, and the development of joint programs to support refugees, both financially and professionally.
Support is also needed for those colleagues in Ukraine’s neighboring nations who are providing, often through heroic efforts, safe havens for refugees. Many Ukrainian scientists are women who have left with their families while their husbands stay to fight for their country. Many of the families of male scientists are also in need of a welcoming home outside of Ukraine, at least for now. Efforts to highlight these refugees and their plight must ensure that communications will not lead to unintentional harm by identifying individuals in electronic communications or social-media posts.
The experience of the United States National Academy of Sciences (NAS) in providing new temporary homes for Afghan scientists showed that the families crave an opportunity to establish some semblance of normalcy and dignity: a safe home, schools, and a distraction from the stress of conflict for the children. For these scientists, an opportunity to remain connected with the research community through a provisional affiliation with a research lab or university is invaluable. The US NAS has used its own discretionary funds to support travel and short-term settlement costs in welcoming nations for Afghan scientists and their families, whose prior sponsorship by US government programs put them in additional jeopardy. The US NAS intends to extend this policy to scientists in conflict zones whose US ties place them at increased risk.
Many international and national science academies and societies have issued strong statements condemning the invasion and expressing support for the scientists (and all citizens) affected. Such expressions of solidarity surely lift the spirits of our Ukrainian colleagues and encourage them in their struggles, but words are not enough. The international scientific community will need to help rebuild science and research infrastructure in Ukraine when the time is right. It is not too early to begin these discussions.
As the world seeks to support scientists from Ukraine, it must also be careful not to condemn indiscriminately Russian scientists by assuming that all of them support this conflict. Many have, at great personal peril, spoken out against the invasion. At the same time, the global scientific community must be cautious in determining which international scientific activities can continue to involve Russian science so as not to support indirectly the Russian government, economy, and military through scientific exchange and recognition.
Leaders and members of science academies in Europe and elsewhere, including the US NAS, must work together now to accommodate Ukraine’s scientists and their families until it is safe for them to return to their homes. Ukraine will urgently need the talents of these experts as they seek to rebuild their country following this devastating war. Sadly, this is not the first time that scientists have been caught in the line of fire, and it will not be the last.
(2)
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14 March 2022
Ukrainian researchers pressure journals to boycott Russian authors
Most publications are still considering manuscripts irrespective of nationality — but Russia plans to remove a requirement for scientists to publish in foreign titles.
Holly Else
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Soldiers from the Russian National Guard patrol the area surrounding Saint Basil's Cathedral on Red square in Moscow
Moscow: Russian scientists are being frozen out of international collaborations.Credit: Andrey Rudakov/Bloomberg/Getty

Following Russia’s invasion of Ukraine, many research organizations swiftly cut funding and collaboration ties with Russia. But the moves have sparked debate over whether Russian scientists should be able to publish in international journals. Some argue that a boycott is morally correct and could help end the war, but many journals say that indiscriminately isolating Russia’s scientists would do more harm than good. This week, Russian authorities seem to have responded to threats of a boycott by saying that it plans to drop a requirement that government-funded scientists publish in recognized foreign journals. That move that could further harm the country’s science, say some Russian researchers.

Ukrainian scientists have issued the strongest calls for banning Russian researchers from journals. “Russian scientists have no moral right to retransmit any messages to the world scientific community,” says Olesia Vashchuk, the head of Ukraine’s Young Scientists Council at the Ministry of Education and Science, in two letters dated 1 March. The letters, to publisher Elsevier and citation database Clarivate, call for Russian journals to be removed from databases and for Russian scientists to be taken off journal editorial boards.

Those opposed to a ban — in Russia and elsewhere — say that it would penalize scientists who oppose their government’s actions, and that science can act as a diplomatic channel. “You have to ask what this will achieve. Is it about sending a signal? If so, there are better ways,” says Richard Sever, co-founder of the preprint servers bioRxiv and medRxiv.

Scholarly exchange
Few journals have so far banned Russian scientists. Titles including Nature and Science have condemned Russia’s actions in editorials, but have also spoken out against indiscriminately isolating its scientists. In its 4 March editorial, Nature said that a publishing boycott against researchers in Russia “would divide the global research community and restrict the exchange of scholarly knowledge”.

At least one title, the Journal of Molecular Structure, published by Elsevier, has said that it will no longer consider manuscripts written by scientists at Russian institutions. The invasion violates international law, says Rui Fausto, the journal’s editor and a chemist at the University of Coimbra in Portugal. “Our decision will be in force until international legality is restored.” He adds: “It is not directed to Russian scientists, who certainly deserve all our esteem and respect, but to Russian institutions.”

Elsevier told Nature that it couldn’t give a figure for how many of its journals had taken a similar position, but that it was “very low”. The publisher has not introduced restrictions on accepting papers that include Russian authors. “We won’t enforce our preferred approach if individual editors feel very strongly about this topic,” Elsevier said.

By contrast, in response to Russia’s invasion, Clarivate, which runs the citation database Web of Science, announced on 11 March that it would cease all commercial activity in Russia and immediately close an office there. It had previously suspended the evaluation of any new journals from Russia and Belarus — which has supported Russia’s war — that are seeking to be included in the Web of Science. Lisa Hulme, Clarivate’s global head of external communications, says that it is engaging with Ukraine’s science minister.

Ukrainian scientists welcome such moves. “[By] rejecting manuscripts written by Russian authors and excluding the Russian journals from Scopus and Web of Science, Elsevier and Clarivate can contribute to the end of this war,” says Myroslava Hladchenko, who studies higher-education policy at the National University of Life and Environmental Sciences of Ukraine in Kyiv. Hladchenko says that Russia has bombed more than 60 educational institutions in Ukraine, which highlights their “attitude towards science and education”.

Policy change
Many researchers in Russia have spoken out against a publishing boycott. Most scholars there who strive to be part of the global scientific community oppose the war, says a political scientist at a Russian university who asked not to be named because of fears about their safety. “Many take personal risks to protest it,” says the researcher, who says they narrowly escaped arrest in an anti-war demonstration. A blanket refusal to review and publish manuscripts “will have zero impact on Kremlin’s policy”, they say.

But Hladchenko says she feels that Russian scientists should be doing more to stop the war. Excluding Russian authors and journals will force those academics to “reassess their activity and to make a contribution to the development of civil society in their own country”, she says.

For its part, Russia seems to have responded to its growing isolation by the international community. On 7 March, the office of the Russian deputy prime minister Dmitry Chernyshenko announced that it plans to cancel existing requirements for scientists to publish in journals indexed in Web of Science or Scopus, according to Russian news reports. Institutions in Russia currently receive a higher evaluation rating if their scientists publish in foreign journals, and researchers who receive grants from the Russian Science Foundation and other government programmes must publish their results in indexed journals. Chernyshenko has also asked the Russian Ministry of Science and Higher Education to introduce its own system for evaluating research.

That move could harm Russian science, say some researchers. The requirements to publish in international journals have helped to stimulate the best research groups and increased the quality of research in Russia, says Andrey Kulbachinskiy, a molecular geneticist at the Institute of Molecular Genetics in Moscow. Kulbachinskiy worries that there could soon be a ban on Russian scientists publishing in international journals. Kulbachinskiy, who was speaking in a personal capacity, says that although removing these requirements might relieve the pressure to publish for many groups, he says, it will likely lead to a “rapid decline in the quality of publications”. It “will make doing science senseless”.

Yuri Kovalev, an astrophysicist at the Lebedev Physical Institute in Moscow, fears that following the imposition of financial sanctions, people in Russia are soon likely to struggle to pay for goods and services. This could leave institutions unable to pay article processing charges or for journal subscriptions, he says. “I guess we will use arXiv and Sci-Hub,” he says.
https://www.nature.com/articles/d41586-022-00718-y
doi: https://doi.org/10.1038/d41586-022-00718-y

With a Flurry of High-Profile Coronavirus Cases, Washington Is Again on Edge
The cases have raised questions about the trajectory of the pandemic, even as the White House has signaled confidence about resuming normal activities.

By Michael D. Shear
March 17, 2022
https://www.nytimes.com/2022/03/17/us/politics/washington-coronavirus-cases.html

WASHINGTON — A flurry of high-profile coronavirus cases in the nation’s capital — including in people who have been around President Biden — has raised new questions about the trajectory of the two-year-old pandemic, even as the White House has signaled confidence in the country’s ability to resume normal activities.

On Thursday, Mr. Biden canceled face-to-face meetings with Prime Minister Micheal Martin of Ireland after the prime minister received a positive result from a coronavirus test during a gala event on Wednesday night that both men attended.

In the past week, Doug Emhoff, the husband of Vice President Kamala Harris, tested positive for the virus, as did former President Barack Obama. At least nine House Democrats received positive tests this week after a party retreat in Philadelphia and late-night voting at the Capitol.

White House officials said Mr. Biden, 79, had not been in close contact with anyone who tested positive and did not appear worried about his safety. They said that the administration was monitoring a highly transmissible subvariant known as BA.2, which is spreading rapidly in parts of China and Europe, but that there appeared to be little reason to think there would be a U-turn back to social distancing and universal mask wearing in the United States.

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Jen Psaki, the White House press secretary, said on Thursday that the nation was in a better position to combat the new variant because of the number of people who have been vaccinated and the quality of the vaccines used.

“It has been circulating here for some time,” Ms. Psaki said of BA.2. She noted that China had not used mRNA vaccines like the ones made by Pfizer and Moderna, calling it “an important component” of why caseloads are so high there.


Image
Doug Emhoff, the husband of Vice President Kamala Harris, tested positive for the virus this week.
Doug Emhoff, the husband of Vice President Kamala Harris, tested positive for the virus this week.Credit...Pete Marovich for The New York Times
But the recent cases in Washington, and the spread of yet another variant around the world, highlight a challenge for Mr. Biden and his team: how to embrace the country’s desire to move on while being careful not to declare victory over a virus that is still making people sick and killing more than 1,000 Americans each day.

“Just because Covid isn’t disrupting some of our lives in certain communities as much as it was a few weeks ago, it doesn’t mean it’s gone,” Ms. Psaki said. “It’s not gone. And I think this variant is an example of that.”

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The tension over how to approach this juncture of the pandemic was evident in a statement announcing the departure of the president’s coronavirus response coordinator on Thursday.

Mr. Biden said the United States had entered “a new moment” in the fight against the virus and acknowledged the pleasure that many people were feeling as they emerged from more than two years of fear and anxiety.

“Americans are safely moving back to more normal routines, using the effective new tools we have to enable us to reduce severe Covid cases and make workplaces and schools safer,” Mr. Biden said.

But he quickly added, “Our work in combating Covid is far from done.”

That work includes persuading lawmakers in both parties to approve billions of dollars to continue fighting the virus. Administration officials say the money would be used to replenish supplies of vaccine, masks and new viral drugs used to treat Covid.

Jeffrey D. Zients, the departing coronavirus response coordinator, insisted this week that the additional money for Covid “is not nice to have; this is need to have.” But a bipartisan agreement between lawmakers and the White House to repurpose money that had already been approved for states fell apart when some Democratic lawmakers refused to go along.

The difficulty of passing a new Covid spending package underscores how much the national attitude has changed since the pandemic began. A year ago, the $1.9 trillion American Rescue Plan included more than $178 billion for vaccinations and other Covid-related health care expenditures. Now, Mr. Biden is struggling to make the case for much less.

At the White House on Thursday, Ms. Psaki said Mr. Biden tested negative for the virus on Sunday and continues to be tested at least once a week, but had not done so since the disclosure of the Irish prime minister’s test.

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Daniel Mulhall, Ireland’s ambassador to the United States, confirmed Mr. Martin’s positive test early Thursday.

Mr. Biden, who has been vaccinated and received a booster shot in late September, was scheduled to meet with Mr. Martin on Thursday morning at the White House, followed by a luncheon at the Capitol and a shamrock presentation at the White House.

Instead, the leaders met virtually, with Mr. Biden seated near a bowl of shamrocks on a table and a television monitor showing Mr. Martin. The president said he was “deeply sorry for the inconvenience” of the virtual format.

White House officials said Mr. Biden was not in close contact with Mr. Martin during Wednesday night’s gala, which the Centers for Disease Control and Prevention defines as being within six feet of someone for at least 15 minutes.

Mr. Mulhall said on Twitter that he had accepted a leadership award for Mr. Martin on Wednesday at the gala for the Ireland Funds in Washington, an event that Mr. Biden and Speaker Nancy Pelosi also attended.

“I filled in for the Taoiseach after he tested positive for #Covid19,” he wrote, using the Irish word for the country’s leader. “I wish the Taoiseach well for his recovery.”

Irish journalists traveling with Mr. Martin’s delegation reported that he had attended the early part of the gala, and photos from the event appeared to show him seated next to Ms. Pelosi.

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The speaker’s office confirmed that Ms. Pelosi, who is vaccinated and boosted, had received a negative P.C.R. test result on Thursday morning, and would continue to test regularly and follow C.D.C. guidelines, though it was not clear which ones. It was also unclear whether the Office of the Attending Physician considered Ms. Pelosi, 81, to be a close contact of Mr. Martin.

Ms. Pelosi appeared at her weekly news conference on Thursday, saying that she was tested nearly every day. Mr. Martin remained masked until food was served, she said, and was pulled aside during the appetizer course about his positive test.

“We’re very, very sad that on St. Patrick’s Day, the taoiseach has this diagnosis,” she said at her indoor news conference, where she removed her mask to speak and take questions.

The scheduled lunch — the Friends of Ireland Luncheon on Capitol Hill — proceeded on Thursday without Mr. Martin. Ms. Pelosi addressed the room, where lawmakers sat at round tables, while introducing Mr. Biden, who sat on a stool a few feet away. Neither wore a mask, and there were few face coverings in the room.

“America has been blessed by Irish children, and one of those Irish children is now the president of the United States,” Ms. Pelosi said, just before they shook hands and Mr. Biden took the lectern. He did not stay for lunch.

In a tradition going back to 1952, Irish ambassadors or political leaders present the American president with a bowl of shamrocks on or around St. Patrick’s Day, usually in the White House. The tradition is valued in Ireland, and by many Irish Americans, as a sign of the close ties between the two countries.

Mr. Martin may now never visit the Oval Office in his official capacity: His first scheduled visit last year was canceled because of the pandemic and, as part of a coalition deal with two other Irish political parties, he is expected to hand over the prime ministership before next March.

On Wednesday, Claire Cronin, the U.S. ambassador to Ireland, said on Twitter that she canceled her plans to join Mr. Martin on his trip to Washington because she had tested positive for the coronavirus.

Emily Cochrane contributed reporting from Washington, and Adeel Hassan and Alyssa Lukpat from New York.

Michael D. Shear is a veteran White House correspondent and two-time Pulitzer Prize winner who was a member of team that won the Public Service Medal for Covid coverage in 2020. He is the co-author of “Border Wars: Inside Trump's Assault on Immigration.” @shearm

Memo
https://twitter.com/i/status/1504684097829933057
https://twitter.com/i/status/1504691320119443458
https://twitter.com/i/status/1504654385409785856

War surgery and transfusion in makeshift hospitals in beleaguered cities
David N Naumann
Michael W Robinson
Douglas M Bowley
David Nott Published:March 17, 2022DOI:https://doi.org/10.1016/S0140-6736(22)00525-6
PlumX Metrics
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(22)00525-6/fulltext
In 1714, the satirist Jonathan Swift stated that the “blessing of liberty” must be paid for in “blood and treasure”.1 As we look to events in Ukraine, the terrible price of freedom again becomes apparent. Yet war has also been the impetus for improvements in medical care, from Jean-Louis Petit's screw tourniquet and Dominique Larrey's ambulance volante to the modern concept of damage control resuscitation (DCR). Contemporary DCR is characterised by haemostatic resuscitation, permissive hypotension, and damage control surgery,2 which originated on the battlefield and is now entrenched in civilian practice. It is predicated on the ability to provide massive transfusion, and protocols ensure high volumes of universal donor blood products (eg, packed red cells, plasma, platelets, and cryoprecipitate) are transfused in prespecified ratios, along with pharmaceutical adjuncts such as calcium and tranexamic acid plus point of care viscoelastic testing for trauma-induced coagulopathy.3 Delay in initiating massive transfusion has been shown to worsen survival,4 and more recently, fresh whole blood has been used for trauma resuscitation of combat casualties.5 The United States Defense Committee on Trauma, Armed Services Blood Program, and Joint Trauma System have reached consensus that whole blood is the product of choice for resuscitation following traumatic haemorrhagic shock.6
Modern conflicts might not be as well resourced as previous settings where massive transfusion could be facilitated.7 Transfusion supplies (and clinicians able to administrate and deliver these) might be severely limited. A trend towards loss of respect for the neutrality of medical facilities is also concerning. In the Syrian civil war (2011 to the present), beleaguered populations endured regular targeting of hospitals and health workers.8 David Nott travelled to Syria with other Médecins Sans Frontières staff from all over the world. In 2013, in western Aleppo, regime attacks had targeted hospitals and health-care workers with snipers, shelling, and mortar fire. Makeshift hospitals were created in covert safehouses. From point of injury, patients were transported to these safehouses in unmarked vehicles, and the time from point of injury to arrival was typically 5–10 min.
Under these most austere circumstances in Aleppo, Nott recorded the patient outcomes in a personal series of 57 consecutive war-injured patients undergoing surgery. 55 (96%) patients were acutely injured, with two having been transferred for further surgery from other makeshift hospitals after primary laparotomy for war injury undertaken by other surgeons, complicated by intra-abdominal sepsis. Of the 55 patients, 17 (31%) were children. The median age of the whole cohort was 25 years (IQR 16–35), and the oldest patient was 52 years. Mechanism of injury was not recorded in one patient, 32 (59%) of 54 patients had been injured by blast, and 22 (41%) patients were injured by gunshot wound. Gender was not recorded in four patients, and of the remainder, 42 (82%) were men. Female patients were more likely to be injured by blast when compared to male patients (eight of nine vs 22 [43%] of 51; two-sided Fisher's exact test p=0.025; odds ratio 6.91, 95% CI 1.12–134.2), reflecting that generally, men were actively fighting, and women were injured in a domestic setting. 40 (73%) of 55 patients had extremity injury, and 20 amputations were undertaken in 14 (25%) patients. 12 (22%) of 55 patients had laparotomy, and of those 12 patients, seven (58%) had staged surgery with a primary so-called damage control laparotomy utilising abdominal packing and closure of skin only, with planned re-laparotomy after 24 h. A policy of mandatory stoma was instituted for colonic injury, and two of 55 patients had thoracotomy (one for control of pulmonary haemorrhage and one for a cardiac fragmentation wound).
All patients were brought in by civilian vehicles with no formal prehospital treatment, and without any physiological observations. Selection of patients for surgery was by classical surgical triage (ie, screening for the most critically ill in order to prioritise patients for treatment). Decisions had to be made based on status of the patient and availability of resources (rather than using formal algorithms); if considered unsalvageable, patients were palliated or simply comforted until death.9, 10 No patient with a penetrating cranial injury was selected for surgery. All patients received fresh whole blood after surgical control of bleeding had been achieved, with most receiving one unit, several receiving two, and some patients receiving three units. No patient received more than three units of fresh whole blood. The principles of care were triage followed by immediate, expert surgical control of haemorrhage, with no intensive care or postoperative artificial ventilation available. All patients selected for surgery survived and had haemoglobin levels drawn at 72 h after surgery. The median haemoglobin concentration was 62 g/L (range 45–98 g/L), and 36 (65%) of 55 patients had haemoglobin concentration below 70 g/L.
Humanitarian war surgery is characterised by austere conditions, resource and logistic chain constraints, and isolation. To these traditional challenges should now be added active targeting of medical facilities and health workers by malign actors. In such settings, the humanitarian surgical team must accomplish the greatest good for the maximum number of patients under enormous pressure and without access to accepted standards of transfusion support and critical care.
The hallmark of war injury is high and early lethality. In a review of nearly 500 British Service Personnel who were killed in action, 68% were dead within 10 min of wounding, and 99% had died within 2 h.11 If potentially salvageable patients are to be saved, surgical expertise must be available as soon as possible. We propose that this case series generates the following hypothesis: that for young adult and paediatric patients who have sustained blast and penetrating war trauma, short prehospital times, decisive judgement, and early surgical control of haemorrhage are the key principles to achieve success. For these patients, minimising all infusions (including blood) and tolerating (very) low post-operative haemoglobin appeared to be safe, preserved scarce blood stocks, and might have even be clinically beneficial.12 Since the patients were relatively young, it is unknown whether this hypothesis can be extended to older patients or those with significant comorbidities, and we are unable to determine the extent of survivorship bias in the patient cohort.
What might these experiences mean for humanitarian and military providers of surgery for the war-wounded? The approach in Syria was borne from necessity in the presence of unavoidable resource and logistic constraints; yet all patients selected for operation survived, despite what might be considered under-resuscitation within modern DCR doctrine. Furthermore, no framework was established in which prehospital treatment, permissive hypotension, or formal timelines (such as the golden hour) could be achieved. Instead, a scoop and run approach was used by local civilians, with ad hoc modes of transport, followed by expedited surgery on arrival.
Although we acknowledge that humanitarian operations vary considerably, and there is always going to be some uncertainty about the translatability of experiences, circumstances such as these are likely to be encountered again by humanitarian clinicians. Russia's invasion of Ukraine is forcing hospitals underground, and resources will soon become extremely scarce.13 The observation in Syria of the primacy of good judgement, earliest possible surgical intervention, and minimal transfusion of whole blood leading to better than expected outcomes should be acknowledged by those brave Ukrainian health workers treating patients under terrible conditions; they also should be acknowledged and further tested in safer conditions in hospitals that are not resource-deprived.14
DN is a general and vascular surgeon based in London, UK. He has provided humanitarian assistance in multiple countries and provides surgical training for health-care practitioners who work in disaster and conflict zones. The authors with current affiliation to UK Defence Medical Services within the UK did not participate in any operations in Syria and declare no competing interests. Opinions expressed in this Correspondence are personal and do not necessarily reflect UK Armed Forces or Defence Medical Services policy.
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EDITORIAL
To solve climate, first achieve peace
H. HOLDEN THORP

The horrific invasion of Ukraine by Russia has many devastating effects. The most immediate are on the people of Ukraine, but the long-term implications for the entire planet are enormous. For science, the disruption to international collaboration must be addressed and we must give our strongest support to Ukrainian scientists, as outlined by Marcia McNutt and John Hildebrand in a recent Science editorial. But for climate change, the effects may be the greatest. If we want a positive energy future for a healthier climate, the West must start by recasting foreign policy with climate and energy issues at the forefront. That can only succeed if nations strengthen the commitment to settle differences with diplomacy, not war. The only truly life-sustaining climate will be one accompanied by international peace.
The impact of climate change on national and global security is not new. But this association was not always front and center. The push for renewable energy has deep roots in geopolitical and security concerns rather than in climate. But for too long, this geopolitical tension has been kept in a separate bucket from climate dangers. Last week, in addressing the Ukraine war, President Biden pledged that the United States would help Europe become less dependent on Russian oil. But nothing was said about climate. People should be made aware that the future of the planet is inextricably intertwined with international conflict. Many fossil-fuel–dependent countries, including the United States, have long been subjected to a volatile global oil market that is largely controlled by the Middle East. The war in Ukraine has served as a grim reminder that Europe has allowed itself to become dependent on fossil fuels from Russia—a country that is now an enemy. Without Russian oil, which nations can Europe turn to for fossil fuels without leaving itself the potential victim of future conflicts elsewhere on the planet? And that may be a short-term solution while it tries to transition to renewable energy.
Meanwhile, China keeps building coal-fired electricity plants. Why aren’t countries working with China to slow this down? While the United States hurls invectives toward Beijing about the origins of COVID-19, economic espionage, and intellectual property protection, it is losing the opportunity to cooperate with China on energy sources cleaner than coal. Is a purely adversarial foreign policy the best strategy when China produces greenhouse gases (more than any other country in the world) at its discretion?
Unfortunately, solar and wind power won’t provide enough energy in the foreseeable future. That leaves an opening for more nuclear power—but again, the war in Ukraine reminds us that it’s not only a matter of building more nuclear plants but also of reducing the risks they present during times of tension. A nuclear power plant is a dangerous military target. The attacks by Russia on Ukrainian nuclear facilities are alarming—they have the potential to scatter nuclear waste over large areas and even provide the ingredients for a dirty bomb. Nuclear power cannot provide a path to a more equitable and healthy energy future in a world of geopolitical conflict. Also, if a country can build a nuclear power plant, it can build a nuclear weapon. The scientific case for replacing fossil fuels with nuclear power is strong, but the political case gets much weaker in a hostile world.
Last year, President Biden said that climate change was the greatest threat to national security. That is correct and a reassuring statement from a president when so many climate deniers vie for power in the United States and around the world. But the reverse is also true. A hostile world is the greatest threat to a generative policy for dealing with climate change.
It’s time for US and European foreign policy to be reframed in the context of addressing climate change. People around the world must better understand that a healthier world where all forms of energy are appropriately utilized requires a world that focuses first on peace. Without working toward peace as the first step, international efforts to tackle global climate change and promote renewable energy and sustainable development cannot progress. Global governance becomes more fragile, and as climate change worsens, it will threaten world stability, trigger humanitarian crises, and provoke more war, in a deadly cycle.
To win the climate war, we must win the climate peace.
https://www.science.org/doi/10.1126/science.abq2761