The nature of modern conflicts precludes adequate medical care for most people wounded in wars. The traditional military approach of echeloned care for those wounded on the battlefield has limited relevance. I present an alternative, epidemiological approach whereby some effective care may reach many more. For a surgical facility to have a positive impact by using surgical and anaesthetic competence there must be access to the wounded; security for staff and patients; and a functioning hospital infrastructure. These all depend on respect for the first Geneva convention. Early hospital admission for urgent surgery is not so important if there is adequate first aid beforehand. The hospitals of the International Committee of the Red Cross have provided surgical care for thousands of wounded people by fulfilling these conditions. People wounded in modern conflicts would fare better if these priorities were recognised and less emphasis was placed on the more spectacular aspects of surgical care that benefit only a few.

My experiences in treating casualties of recent wars have led me to an epidemiological approach to their management.

In February 1992 I visited Mogadishu, Somalia, to make a survey of the hospitals to which casualties from the heavy fighting had gone. I found between 1500 and 2000 wounded people, who were housed in various buildings; most were lying on the floor with very little in the way of nursing care or drugs and no access to surgery. Most were being cared for by relatives alone. The International Committee of the Red Cross, Medecins sans Frontiers, and the International Medical Corps were each providing a surgical service based on the presence of one expatriate surgeon; but most wounded did not reach the hospitals assisted by these agencies. There was a high operative mortality when the surgery and anaesthesia were not supervised by expatriates …