The objective of SICOT is "to promote the advancement of the science and art of orthopaedics and traumatology at international level in particular for the improvement of patient care; to foster and develop teaching, research and education; to facilitate and encourage exchange of professional experience and to promote good fellowship among its members."

We all agree that we must work towards progress in this endeavour. This also involves fighting against unacceptable acts, which are bringing mankind back to the dark ages.

Facing the daily trivialisation of violence and its worldwide spread, it is our duty to react against one of the most abhorrent forms of violence: the aggression towards healthcare personnel.

SICOT would like to join international organisations such as the World Health Organization (WHO) [7], the International Committee of the Red Cross and Red Crescent (ICRC) [25, 27] and Médecins Sans Frontières (MSF) [8] in the sensitisation campaign against violence towards healthcare workers.

As part of their duty, orthopaedic surgeons and traumatologists, nurses and technicians working in emergency departments are often on the front line of violent aggression.

There are two scenarios. The first is during war, armed conflicts and terrorism, which simply infringe the terms of the Geneva Convention initiated in 1864 by Henry Dunant.

"Medical neutrality may be thought of as a kind of social contract that obligates societies to protect medical personnel in both times of war and peace, and expects medical personnel to treat all individuals regardless of religion, race, ethnicity, or political affiliation. Violations of medical neutrality constitute a crime outlined in the Geneva Conventions."[35]

During armed conflicts our influence will probably not be very determinant, while facing so-called strategic priorities, financial interests or intolerance. However, it is still our responsibility to remember the International Geneva Convention and the rules imposing respect and neutrality of medical personnel. It is also logical that threatening healthcare workers will dramatically impede medical aid to millions of people in difficult areas. Despite their volunteering and courageous engagement, humanitarian missions have been abandoned by NGOs in some countries such as Somalia after dozens of violent deaths of healthcare practitioners. We cannot accept returning centuries in time and the governmental authorities must be responsible for not taking clear steps to establish positions and actions opposing these crimes against humanity.

The second situation is more insidious but has been rising in every country of the world. Violence against medical personnel due to drug abuse, ignorance, intolerance and a lack of respect has become an ordinary daily occurrence. It can come from patients, from relatives or friends, and sometimes from delinquents.

It has taken time for these aggressions to be reported as for many years they were more or less considered part of professional confidentiality by health workers and even minimised by the hospital administration. However, their frequency has increased to the point where some medical unions are now reacting. In some American states (California, Pennsylvania, …) [26], the laws have been modified and the normal penalties doubled in cases of violent acts against medical workers.

Today, not one continent, not one country is protected against this kind of violence [1–6, 9–24, 28–34]. Recently, in Belgium, a country known for its safe conditions, general physicians started a strike due to the unsafe conditions during their night shifts.

Solutions are not easy but they are varied. Realistic and non-bailable penalties should be increased significantly to dissuade such aggression, but there should also be measures to protect medical personnel including training them to manage violent behaviour. On a broader scale, the youngest members of the population should be taught to respect and assist medical personnel. Finally, reporting these aggressions will be necessary to move governmental authorities into action. The centralisation of this reporting is undertaken by the ICRC and MSF.

The objective evaluation of the problem is indispensable to counteract the trivialisation, the internalisation and unacceptable tolerance of the violence.

All these measures cannot take effect immediately and it will take time. Isolated, they will be inefficient. This problem is a problem of all societies and the different factors have to be treated jointly.

SICOT strongly endorses the campaign and recommendation of WHO, ICRC and MSF and it urges all civilian officers, lawyers and governmental authorities to be aware of the severity of this problem and take the necessary actions to fight this degradation of the healthcare system and strengthen respect towards healthcare workers.

I would like to conclude this with a statement by Margaret Chan, Director General of the World Health Organization: "The safety of facilities and of healthcare workers must be sacrosanct." [7]

Maurice Hinsenkamp

SICOT President