‘Acceptable CIVCAS is 0’

Kunduz 0 Extract JPEG

Finally US Central Command has released a redacted version of its investigation into the US airstrike on MSF’s Trauma Center in Kunduz (see my posts here, here and especially here).  You can download it from CENTCOM’s Freedom of Information Act library here.  (All the extracts pasted below capture communications exchanges before the attack, but the report includes redacted interviews with the participants involved in clearing, executing and continuing the air strike; the image above – and the title for this post – is taken from a briefing slide included in the report).

Kunduz A extract JPEG

I’ll be spending the weekend reading it, but meanwhile the Intercept has published its own long-form account of the attack by May Jeong – ‘Death from the sky: searching for ground truth in the Kunduz hospital bombing‘.  It was written before CENTCOM’s investigation was released but includes details from a series of interviews and is truly compelling reading.

Kunduz B extract JPEG

I obviously won’t be alone in working my way through the report.  Yesterday MSF was briefed by the head of CENTCOM, General Joseph Votel, and today released this preliminary statement:

MSF will take the time necessary to examine the U.S. report, and to determine whether or not the U.S. account answers the many questions that remain outstanding seven months after the attack.

MSF acknowledges the U.S. military’s efforts to conduct an investigation into the incident. Today, MSF and other medical care providers on the front lines of armed conflicts continually experience attacks on health facilities that go un-investigated by parties to the conflict. However, MSF has said consistently that it cannot be satisfied solely with a military investigation into the Kunduz attack. MSF’s request for an independent and impartial investigation by the International Humanitarian Fact Finding Commission has so far gone unanswered….

The hospital was fully functioning at the time of the airstrikes. The U.S. investigation acknowledges that there were no armed combatants within – and no fire from – the hospital compound.

The nature of the deadly bombing of the MSF Kunduz Trauma Centre, and the recurring attacks on medical facilities in Afghanistan, demand from all parties to the conflict a clear reaffirmation of the protected status of medical care in the country. MSF must obtain these necessary assurances in Afghanistan before making any decision on if it is safe to re-start medical activities in Kunduz.

Kunduz C extract JPEG

The Pentagon has insisted that no war crimes were committed but confirmed that 16 people had been punished.  Mark Thompson explains:

None of those involved will face court martial, but the administrative punishments levied against them—ranging from removal from command, letters of reprimand, to counseling—likely mark the end of their careers in uniform. None was identified by name. Those involved—the highest-ranking was a two-star general—included those aboard the AC-130 gunship that repeatedly fired on the Doctors Without Borders hospital in Kunduz, as well as members of the Army Special Force team on the ground that called in the strikes.

MSF has, understandably, condemned this response, arguing that the punishments

are out of proportion to the destruction of a protected medical facility, the deaths of 42 people, the wounding of dozens of others, and the total loss of vital medical services to hundreds of thousands of people. The lack of meaningful accountability sends a worrying signal to warring parties, and is unlikely to act as a deterrent against future violations of the rules of war.

That last sentence is particularly important, because there has been a steady increase in the targeting of medical personnel and medical facilities in Afghanistan, occupied Palestine, Syria and elsewhere: all gross violations of medical neutrality.

Kunduz D extract JPEG

So this commentary from Joanne Liu (International President of MSF) and Peter Maurer (President of the International Committee of the Red Cross) – also published today – is much more than a response to the bombing of yet another MSF facility, this time in Aleppo:

What we are witnessing is a sustained assault on, and massive disregard for, the provision of healthcare during times of conflict. Under international humanitarian law and principles, health workers must be able to provide medical care to all sick and wounded regardless of political or other affiliation, whether they are a combatant or not. And under no circumstances should they be punished for providing medical care which is in line with medical ethics. The doctor of your enemy is not your enemy.

But we are confronted with violations of these fundamental rules, with serious humanitarian consequences, for entire communities and healthcare systems that are already stretched to the limit. And this is not just the opinion of MSF and the Red Cross Red Crescent Movement.

That is why we, as the presidents of MSF and the ICRC, welcome the proposal for a landmark UN resolution to protect healthcare. But we urge the UN security council to make the resolution effective. First, it should send a powerful political message that healthcare needs to be protected. All parties to an armed conflict must fully comply with their obligations under international law, including humanitarian law. And they must clearly state their respect for the delivery of impartial medical care during times of conflict.

Second, it must urge states and all parties to armed conflict to develop effective measures to prevent violence against medical personnel, facilities and means of transport. States need to bolster, where appropriate, their legislation including by lifting restrictions and sanctions impeding impartial wartime medical care.

Armed forces and all parties to a conflict should integrate practical measures for the protection of the wounded and sick and for those engaged in medical work. These should be incorporated into orders, rules of engagement, standard operating procedures and training.

Third, it must acknowledge that when attacks on medical facilities and personnel do take place, there needs to be full, prompt, impartial and independent investigations to establish the facts. It cannot only be the victims or perpetrators who attempt to establish the facts. And there should be regular and formal reporting of such attacks at the highest level and an annual debate in the security council.

Underpinning everything has to be the acceptance that the medical needs of people – no matter who they are, where they are from or what side they support or fight for – must take precedence. Medical staff are present in areas of conflict in order to care for the sick and wounded, on the basis of need. And only need. This is the fundamental principle of impartiality and is the basis of medical ethics. It is the very fact that doctors treat on the basis of need – and are not involved in hostilities – that they can claim protection under international humanitarian law.

But there is more.  John Sifton from Human Rights Watch insists that General Viotel was simply wrong to claim that war crimes must be deliberate or intentional, so that those involved in the attacks on the MSF hospital could be absolved of criminal responsibility because the acts they committed were genuine mistakes.  According to the New York Times, Sifton argued:

There are legal precedents for war crimes prosecutions based on acts that were committed with recklessness, and that recklessness or negligence do not necessarily absolve someone of criminal responsibility under the United States military code.

 

Security Theatre

Security Theatre

At the Or Gallery, 555 Hamilton Street, Vancouver: Security Theatre, an exhibition featuring works by Karl Burke, Harun Farocki, An-My Lê and the Bureau of Inverse Technology.

Security Theatre revolves around methods of simulation and documentation and their hold on respective truth claims about modern war. Specifically, this exhibition looks at how modern warfare is rationalised, remembered and portrayed across image based media such as electronic games, video and photography. The exhibition examines how these systems manifest and evolve into the 21st century, which sees war increasingly fought by proxy and through remote digital means. While claims of possessing the humanist high ground remain tied to the Western Bloc, they are no longer linked to the policy of deterrence seen in the 20th century, but instead are tied to myths of precision and expedience in a preemptive first strike context. Just as there were efforts in the 20th century to socialise people to the omnipresent threats of nuclearism, so too is there an effort to socialise people to the endless need for conflict underwritten by the ubiquitous threat of terrorist states and actors. This requires the creation of dissociative mental states. While the past mass dissociation of the Cold War addressed the need to prevent nuclear war by preparing for it, today’s dissociation follows the need to prevent terrorism by engaging in it. The technology used and the social conditions required were developed incrementally with the aid of experts in various fields, with the aim of gaining either tacit or explicit endorsement of so-called “security policies” which are largely maintained through obfuscation and manipulation. The artists included use media and techniques that provide an intrinsic sense of objective documentation when making reference to armed conflict and related events, which interpret and manage expectations of modern war.

The exhibition opens on 13 May and runs to 18 June; the gallery is open 1200-1700 Tuesday-Saturday, and admission is free.  More information (including profiles of the artists) here.

Wounded

Somme medical dispositions.001

This summer London’s Science Museum is staging an exhibition that is of direct relevance to my current research on casualty evacuation from war zones over the last hundred years:  Wounded: Conflict, Casualties and Care.  It opens on 29 June and is designed to commemorate the centenary of the Battle of the Somme:

57,000 casualties were sustained by British Forces on 1 July 1916, the first day of the Battle of the Somme, creating huge and unprecedented medical challenges. Wounded: Conflict, Casualties and Care, a new exhibition opening at the Science Museum on 29 June, will commemorate the 100th anniversary of this battle and the remarkable innovations in medical practices and technologies that developed as a result of this new kind of industrialised warfare.

During the First World War ten million combatants were killed, but double that number were wounded and millions were left disabled, disfigured or traumatised by their experiences. The challenges were immense. For medical personnel near the front line treating blood loss and infection was the immediate priority in order to save lives. However medics also encountered new forms of physical and mental wounding on a scale that had never been seen before, creating huge numbers of veterans returning home with serious long term care needs.

At the centre of the exhibition will be a remarkable collection of historic objects from the Science Museum’s First World War medical collections, illustrating the stories of the wounded and those who cared for them. From stretchers adapted for use in narrow trenches to made-to-measure artificial arms fitted back in British hospitals, medical technologies, techniques and strategies were pioneered or adapted throughout the war to help the wounded along each stage of rescue and treatment. Visitors will also see unique lucky charms and improvised personal protective items carried by soldiers on the frontline alongside examples of official frontline medical equipment.

I’m looking forward to seeing this over the summer.  The organisers note that:

 Warfare has changed dramatically over the last one hundred years, but similarities remain with the military medical challenges faced today, both through the experiences of the wounded and in their treatment and care. The Wounded exhibition team has worked closely with two UK charities that were formed during the First World War, Combat Stress and Blind Veterans UK, to draw out these parallels and share the personal experiences of soldiers wounded in more recent conflicts.

You can find some of my preliminary thoughts on casualty evacuation from the Western Front here and here, and on twenty-first century casualty evacuation in Afghanistan here and here.  Some of the differences between the two systems are summarised in this slide from a presentation on the project I gave in 2014.

WOUNDS OF WAR Vancouver Jan 2014.001

Much  more to come!

Hollow men?

eye-in-sky-group

In my commentary on Eye in the Sky I emphasised the dispersed geography of command and responsibility involved, and it turns out that was a key concern of the film’s director Gavin Hood.  In an interview with Dan Gettinger for Bard’s Center for the Study of the Drone, he explains:

‘… we obviously designed the film frankly as a thought experiment; it is based on a very specific set of circumstances … these circumstances are not the circumstances of every drone strike. As you know, it is not the case that in every single drone strike the question of whether to fire or to not fire is referred all the way up the kill chain to the foreign secretary, or the prime minister, or in the case of the United States, the secretary of state, secretary of defense, or indeed the president. Depending on the geographical location of these strikes, different rules apply. If you are striking within an already defined conflict zone with clear rules of engagement, in areas such as Iraq or Afghanistan, then sadly this level of debate does not always happen. It very much depends on who is being targeted and where that target is taking place, as to whether the authorization of the strike is referred high up the kill chain.

In our case, in the case of the film, we wanted to create a scenario in which as much discussion as possible was possible within our film. We didn’t want to make a film where the discussion ended at the local commander level. That is a story that can and should be told—the story of the strikes over the tribal areas of Pakistan, for example, where signature strikes take place and where many civilians have been killed—but what we felt was helpful was to make a film which would allow many different points of view to be represented in order to help the conversation that is already underway, but which the public is not necessarily particularly aware of.’

See also David Cole‘s ‘Killing from the Conference Room’ here.

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It was partly for the same reason that Ainsley O’Connell travelled to Holloman Air Force Base in New Mexico for Fast Company: to see what the training program for the crews that operate the Air Force’s remote platforms reveals about today’s management.

Her extended report riffs off Tom Cruise‘s Maverick in Top Gun, and his boast that – like all pilots of conventional strike aircraft – ‘You don’t have time to think up there… If you think, you’re dead.’  In contrast, Ainsley reports:

The new Maverick represents the future of work in a fully global world dominated by complex machines, complex communications, and fluid, remote teams. A body of economic research produced over the last 15 years suggests that organizations are shifting to a model of work characterized by continuous learning and flat teams with complementary skill sets. In this model there is room for autonomy and improvisation, but it takes place in the context of managerial surveillance and shared goals. The military, though still wedded to its lock-step hierarchies, is not immune to the trend. And RPA crews, despite their image as video gamers operating in the dark, are arguably one of the best case studies for how the future of work will affect war and conflict.

She finds that remote crews have to develop not only ‘air awareness’ – since they don’t have the physical sensations of flight or situation available to conventional pilots – but also ‘social awareness’: the ability to collaborate and communicate with military actors across the network.

I discuss the layered bureaucracy – and its imperfect network – in more detail in ‘Reach from the sky‘ and will post the text of those two lectures soon (see also here).

In the meantime, there is an earlier report on the training program at Holloman by Corey Mead for the Atlantic here.

Hidden in plane sight

negpub06

Just out: Negative Publicity: artefacts of extraordinary rendition by Edmund Clark and Crofton Black, with an essay by Eyal Weizman:

British photographer Edmund Clark and counterterrorism investigator Crofton Black have assembled photographs and documents that confront the nature of contemporary warfare and the invisible mechanisms of state control. From George W. Bush’s 2001 declaration of the “war on terror” until 2008, an unknown number of people disappeared into a network of secret prisons organized by the U.S. Central Intelligence Agency—transfers without legal process known as extraordinary renditions. No public records were kept as detainees were shuttled all over the globe. Some were eventually sent to Guantánamo Bay or released without charge, while others remain unaccounted for.

The paper trail assembled in this volume shows these activities via the weak points of business accountability: invoices, documents of incorporation, and billing reconciliations produced by the small-town American businesses enlisted in detainee transportation. Clark has traveled worldwide to photograph former detention sites, detainees’ homes, and government locations. He and Black recreate the network that links CIA “black sites,” and evoke ideas of opacity, surface, and testimony in relation to this process—a system hidden in plain sight. Negative Publicity: Artefacts of Extraordinary Rendition, copublished with the Magnum Foundation, its creation supported by Magnum Foundation’s Emergency Fund, raises fundamental questions about the accountability and complicity of our governments, and the erosion of our most basic civil rights.

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Here is how the always absorbing We make money not art describes the project:

Photographer Edmund Clark spent 4 years spent hunting for sites of extraordinary rendition and photographing any location associated with the programme. None of the photo printed in the book shows any clear evidence of torture, kidnapping or any other human right abuse. There is nothing spectacular to witness here, just mundane places such as the entrance to a Libyan intelligence service detention facility, the corridors connecting cells to interrogation rooms, anonymous streets or the bedroom of the son of a man formerly imprisoned in a CIA black site. Clark calls the making of these photographs “an act of testimony.”

However, the images start to bear a chilling significance when coupled with the paper trail and extracts of interview patiently compiled by Crofton Black, an investigative journalist whose research focuses on extraordinary rendition and black site cases. Over the course of his inquiry, Black has amassed incriminating documents that range from satellite maps to landing records, from border guard patrol logs to testimonies of people tortured in CIA ‘black sites’, from invoices to CIA documents released after freedom of information act litigation by the American Civil Liberties Union. He managed to give them meaning by organizing them into engrossing episodes that give a glimpse of the building and unraveling of the extraordinary rendition network.

And VICE has an interview with the authors here.  Here is their description of the origins of the project:

Edmund Clark: In 2011, while I was working on a body of work on Guantanamo Bay, I was in contact with Clive Stafford Smith at Reprieve and found out that they were doing work on extraordinary rendition. I met Crofton and discovered that was what he was also researching. I became interested in doing something on extraordinary rendition as a progression of my work on Guantanamo Bay.
Crofton Black: When he first came to me I’d been out in Lithuania, looking at this weird site—a warehouse that had been built in the woods in the middle of nowhere, on the site of a former riding school. I was building a court case around it, so when [Clark] got in touch I said, ‘Oh, you should go to Lithuania and take some photos of this strange, peculiar place.’ Which he did. After that we started formulating a more complex and ambitious scheme of trying to document the black-site network through documents, images, and prose. We spent a long time working out how to fit it all together.

Former CIA Black Site, Lithuania

Former CIA Black Site, Lithuania

Crofton explains why he was drawn to the visual:

I was aware that I had all this material, that there were remarkable stories and images and documents that were bizarre, and spoke beyond what was immediately visible in them. I knew I wanted to do something with it that was less dry than legal cases, which are quite dull. There was an opportunity to do something that spoke to a different, and bigger, audience.

And they both emphasise the banality of bureaucracy in the service of violence (an argument that resonates with what – in relation to targeting for nuclear war – Henry Nash called ‘the bureaucratization of homicide’, which I discuss here):

Black: Obviously, post-Hannah Arendt, “the banality of evil” has become a standardized phrase. For me, one of the places you see it most strongly is in bureaucracy: in these documents, in the way they are written, the way certain forms of interrogation are described, or flight routes are detailed. I wanted to make that point. None of these things would be possible without a complex bureaucratic system enabling them. In theory, the idea of a bureaucracy is that everything has its place and gets done by the right person. But in practice it often means that no one is responsible for anything. And that’s what we found in Eastern Europe—no one was responsible. There’s no one in Poland or Lithuania who is responsible for any of this stuff!
Clark: That’s something we wanted to bring out: the ordinariness, the banality of it all. When she spoke of the banality of evil, Hannah Arendt was talking about the bureaucracy of National Socialism. Here, we are talking about a mosaic of small companies—small to medium enterprises—earning a buck.

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Note the glorious correction above.

And one final comment about the geography of this sprawling bureaucracy which explains why my title is not a mis-spelling:

Black: Most of the paperwork in the book is from other entities or other countries [than the US]. If they wanted to have an entirely secret prison system, they shouldn’t have invented one that involved flying prisoners all over the world. You simply can’t fly a plane from A to B without leaving a gigantic paper trail. You just can’t, otherwise planes would be bumping into each other. They could have just held their 119 prisoners in Afghanistan and we would probably have found it an awful lot more difficult to find out about it. But the peculiarities of how they wanted—or, at times, were forced to—use different locations… that made it detectable.

All of this, of course, parallels Trevor Paglen‘s work in interesting and complementary ways: see my post here, which connects Trevor’s project to Crofton’s work on ‘the boom and bust of the CIA’s torture sites‘ and his involvement in the Rendition Project.

‘Nothing ever dies’

Nothing ever dies

I’m just starting Viet Thanh Nguyen‘s Nothing ever dies: Vietnam and the memory of war (just out from Harvard):

All wars are fought twice, the first time on the battlefield, the second time in memory. From the author of the bestselling novel The Sympathizer comes a searching exploration of the conflict Americans call the Vietnam War and Vietnamese call the American War – a conflict that lives on in the collective memory of both nations.

From a kaleidoscope of cultural forms – novels, memoirs, cemeteries, monuments, films, photography, museum exhibits, video games, souvenirs, and more – Nothing Ever Dies brings a comprehensive vision of the war into sharp focus. At stake are ethical questions about how the war should be remembered by participants that include not only Americans and Vietnamese but also Laotians, Cambodians, South Koreans, and Southeast Asian Americans. Too often, memorials valorize the experience of one’s own people above all else, honoring their sacrifices while demonizing the “enemy” – or, most often, ignoring combatants and civilians on the other side altogether. Visiting sites across the United States, Southeast Asia, and Korea, Viet Thanh Nguyen provides penetrating interpretations of the way memories of the war help to enable future wars or struggle to prevent them.

Drawing from this war, Nguyen offers a lesson for all wars by calling on us to recognize not only our shared humanity but our ever-present inhumanity. This is the only path to reconciliation with our foes, and with ourselves. Without reconciliation, war’s truth will be impossible to remember, and war’s trauma impossible to forget.

Here is the table of contents:

Prologue
Just Memory
Ethics
1. On Remembering One’s Own
2. On Remembering Others
3. On the Inhumanities
Industries
4. On War Machines
5. On Becoming Human
6. On Asymmetry
Aesthetics
7. On Victims and Voices
8. On True War Stories
9. On Powerful Memory
Just Forgetting
Epilogue

You can find an interview with the author at the LA Review of Books here: among other things, it addresses his doubled (and doubly admirable) interest in fiction and non-fiction.  There’s another with Tavis Smiley on PBS here and, since he’s just won a Pulitzer for his novel The Sympathizer – which also deals with Vietnam and the US – I’m sure there’ll be lots more….

The Geographies of Sixty Minutes

One of the cardinal principles informing modern casualty evacuation is the Golden Hour.  In 1975 R. Adams Cowley, founder of Baltimore’s Shock Trauma Institute, argued that ‘the first hour after injury will largely determine a critically injured person’s chances for survival.’  It’s not a straightforward metric, and combat medical care and evacuation has been transformed since it was first proposed, but the rule of thumb is that the chances of survival are maximised if the time between traumatic injury and definitive care is kept to 60 minutes or less.

Following a fire-storm of criticism on 15 June 2009 US Secretary of Defense Robert Gates required the standard time between a call for evacuation and treatment of the critically injured to be 60 minutes or less.  For US military personnel in the Second World War the average time was 10 hours; in Korea that had been cut to 5 hours (the result of using helicopters for speedy evacuation); and in Vietnam it was already down to one hour.  The reason for Gates’s intervention was that in Afghanistan the aim was two hours…

U.S. Air Force Sgt. Daniel Fye serving on a tour in the Kandahar province of Afghanistan in April 2011. (Courtesy of Daniel Fye)

U.S. Air Force Sgt. Daniel Fye serving on a tour in the Kandahar province of Afghanistan in April 2011. (Courtesy of Daniel Fye)

The importance of those time-critical sixty minutes was no secret to the troops in the line of fire.  Here is a scene from Brian Castner‘s truly brilliant All the ways we die and kill which imagines the thoughts running through one soldier’s head – Air Force Technical Sergeant Dan Fye on his third tour of duty with Explosive Ordnance Disposal (above) – after he stepped on an IED during a clearance operation in Mushan (Panjwayi) on 27 May 2011:

They worked on Fye a long time, and the longer they worked, the more anxious Fye got about the precious minutes slipping away. “I don’t hear the bird,” he said, over and over. They wrote the time of the tourniquet application on the white headband Fye wore under his helmet. Hopkins pushed morphine into his veins.

Eventually, an eon since Hopkins arrived but only twenty-five minutes after the blast, the hyperactive thump of helo blades cutting air slowly emerged in the distance.

Fye thought it was the most wonderful sound he had ever heard. They were at the extreme limit of the NATO footprint, and so it was a sixty-kilometer flight to the main hospital at Kandahar [see map below]. If they moved quickly, Fye would just make it in the magic golden hour.

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Castner writes that as Fye was bleeding out in the back of the helicopter, he was

‘clinging to one thought and one thought only, running in a continuous Times Square news ticker across the front of his oxygen-starved brain: One hour. If I can get back to Kandahar in one hour, I’ll live. One hour, and I’ll live. That’s what they say. You’ll make it if you can get back to the hospital in one hour.’

He made it.  The new, modernised and expanded Role 3 NATO hospital at Kandahar had opened a year earlier, and its executive officer claimed that ‘They hit our doors, they live.’

Kandahar new Role 3 2010

But Fye was lucky.  Later he learned why it had taken so long for the helicopter to arrive, and why he very nearly never made it to Kandahar at all:

Over multiple radio calls between Hopkins’s platoon and the rescue operations center, his report of “bilateral amputation” had been converted, telephone-game style, into “bilateral lacerations.” The medical operations center had actually turned the rescue mission off; helos don’t fly for scraped knees. The bird that eventually picked up Fye wasn’t even a real medevac bird. That’s why the robotic flight crew ignored him, didn’t treat his wounds as they went. They weren’t medics. The helo pilots had just been in the air and happened to overhear the radio traffic, including the original call for help. They understood the mistake and had disobeyed orders to go get Fye. If the human pilot of that bird had been less stubborn, the golden hour would have been long past by the time Fye made it to KAF, and he could well have been one of the 1 percent.

(More from Brian on medical evacuation here and here).

Even without miscommunication the logistical challenges were formidable.  In 2007, two years before Gates’ intervention, ISAF produced this map showing the medevac coverage – what Fye called the ‘NATO footprint’ – that supported that two-hour standard (I have taken this map and the following one from a report prepared by Col Dr Ingo Hartenstein for NATO/ISAF in December 2008 which is available here; scroll down):

ISAF Medevac coverage 2 hours

Like Vietnam, Afghanistan was a ‘war without fronts’ with a battlefield geometry that imposed a radically different evacuation model from the classical line of evacuation that had been established during the First World War.  Here is how Brian Turner puts it in My life as another country:

We won’t hear the battle in progress and work our way toward it as baggage trains of wounded, exhausted soldiers and civilians carrying their lives on their backs travel in the opposite direction. Our battle space – and perhaps it’s a cliché now – will occur in a 360-degree, three-dimensional environment.

More technically, here is Brigadier Martin Bricknell, who served (among many other roles) as Medical Adviser to ISAF’s Regional Command South in Kandahar in 2010:

The tactical geometry for the current operating environment is based upon security forces holding areas of ground and securing this space from opposition activity. This converts the battlefield from the conventional force-on-force linear geometry with an identifiable confrontation line to an area battlefield with multiple nodes of contested space. Thus the MEDEVAC mission is converted from a linear flow to area support, hence MEDEVAC planning is based upon a ‘range ring’ coverage with a radius of 40–60 nautical miles.

Given the available resources, a second map showed how those ‘range rings’ would contract if the Golden Hour were to be imposed over the evacuation grid:

ISAF MEDEVAC coverage allowing 1 hr from POI to surgery HARTENSTEIN

In practice, the situation was more variable than these maps imply – not least because there was a significant difference between the ways in which American and British contingents organised medical evacuation.

The US military, drawing on their experience in Vietnam, used Blackhawk or Pavehawk helicopters to get paramedics or combat medical technicians to the casualty as fast as possible:

DUST OFF Afghanistan.001

DUST OFF Afghanistan.002

The British used larger Chinook helicopters to dispatch a Medical Emergency Response Team (MERT) with a trauma surgeon onboard to the casualty close to the point of injury (POI):

MERT Afghanistan.001

The response time was usually longer but the MERT enabled advanced trauma care to begin as soon as the patient was onboard.

There has been considerable debate and disagreement about the robustness of the ‘Golden Hour’ in military trauma care and its relation to evacuation pathways: see, for example,  Jonathan Clarke and Peter Davis, ‘Medical evacuation and triage of combat casualties in Helmand Province, Afghanistan: October 2010-April 2011’, Military Medicine 171 (11) (2012) 1261-6.  But a research team has now calibrated the effects of reduced evacuation time on US casualty fatality rates (CFR) in Afghanistan between 2001 and 2014 [Russ Kotwal et al, ‘The effect of a Golden Hour policy on the morbidity and mortality of combat casualties’, JAMA Surgery 151 (1) (2016) 15-24; see also here]:

KOTWAL Case fatality rate and transport time

For 4,500 cases of US military casualties with detailed data the study showed a substantial change in the CFR following the Secretary of Defense’s mandate to evacuate casualties within 60 minutes: as the median evacuation time fell from 90 minutes to 43 minutes the CFR fell from 13.7 to 7.6; before the mandate 25 per cent of casualty evacuation missions fell within the Golden Hour, after the mandate the proportion soared to 75 per cent.

The interpretive field is a complicated one – while a significant number of casualties who would previously have died from their wounds now survived, a proportion of those who would previously have been recorded as ‘killed in action’ (KIA) none the less now ‘died of wounds’ (DOW) – and the reasons for the improvement in survival rates are also multivariate:

‘Secondary effects resulting from the mandate that contributed to achieving the mandated time included stream-lined authority and helicopter launch procedures, increased number and dispersion of Army helicopters, and the addition of Air Force helicopters to assist with the Army prehospital transport mission. As decreased time from critical injury to treatment capability was the underlying goal, personnel with increased expertise (blood transfusion protocol-trained basic medics, critical care paramedics, and critical care nurses) were trained and assigned to prehospital flights more routinely, resulting in earlier availability of blood products and other advanced care.

In addition, an increase in the number and dispersion of small but mobile forward surgical teams across the battle-field brought major surgical capability even closer to the point of injury and provided an alternative to transporting patients longer distances to large, but less mobile, civilian trauma center–equivalent [Combat Support Hospitals].’

GoldenHourFig1

These findings – together with the experience of the British MERTs – intersect with a recalibration of the Golden Hour.  The US Combat Casualty Care Research Program (CCCRP) has proposed an ‘evolved concept’ (see the figure above) that moves from a location-based protocol to a physiological one:

The program must be willing to turn the doctrine of fixed or traditional echelons of care on its side and innovate for scenarios in which Level II and III care is performed aboard transport vehicles (land-, air- or sea-based) or within local structures of opportunity. In such circumstances, field care may be prolonged, lasting for days or even weeks. Combat casualty care research with these complex scenarios in mind promises to enhance resuscitative capability for injured service personnel regardless of environment, leveraging communications networks (i.e., telementoring) and targeted resupplies of materials. In the future, CCCRP must focus on transforming the concept of the golden hour into one bound not by the time to reach traditional echelons of care or fixed facilities, but the time until enhanced resuscitative capability can be delivered to the injured troop, regardless of location or need for transport.

There are two riders to add.  First, embedded within the Golden Hour are ‘the platinum ten minutes’: the imperative to stop bleeding (which has led to the re-emergence and re-engineering of the tourniquet) and to control the casualty’s airway within 10 minutes of wounding.

Combat Medical Technician and Platinum 10 minutes.001

The second is that the speed of treatment and trauma care available to American and British soldiers is radically different from that available to Afghan soldiers and police officers.  Previously, they could rely on aeromedical evacuation by their allies.  But now most of their medical evacuations take place by land, over difficult and dangerous roads.  Last September Josh Smith reported:

Under the dim light of a single bulb, a local Afghan policeman lay severely injured, slipping in and out of consciousness. A military doctor reported to an Afghan army brigade commander that the man was unlikely to live through the night.

Injured Afghan policeman examined by Afghan Army doctor August 2015

Despite the doctor’s pleas, the commander stood firm. The army could not spare any soldiers or ambulances [below] to make the five-hour drive to a better hospital at that late hour through territory teeming with Taliban ambushes and roadside bombs.

, Nangarhar province, August 2015

The lack of speedy evacuation is a tragically common problem for the rising number of Afghan police and soldiers being injured on the battlefields of Afghanistan. U.S. advisers have worked to help close the capability gap, but mostly behind the scenes, far from the battlefields where many Afghan troops say they increasingly feel alone.

Although the American forces still stationed in the country have conducted more than 200 airstrikes since their combat mission was declared over at the end of 2014, as of July, U.S. military aircraft had not flown a single conventional medical evacuation mission, according to data released by the U.S. Air Force Central Command.

U.S. military officials say they haven’t flown evacuation missions because they haven’t been asked. Also, there are far fewer American resources available for such missions now.

The difference shows up in the ratios of those killed and those who survived their wounds.

About 2,363 Americans have died in Afghanistan, with a little more than 20,000 wounded, a ratio of roughly 1-to-10.  In the first half of 2015 alone, 4,302 Afghan soldiers and police were killed in action and 8,009 more were wounded, a ratio of about 1-to-2.

Even where aircraft and trained medical technicians are available, Jeff Schogol found that the Afghan capability falls well outside the Golden Hour:

The time it takes to fly patients to hospitals varies depending on the point of injury, but it can take between 90 minutes and two and a half hours to fly an aeromedical evacuation mission in a C-208, plus one hour to transfer patients from Kandahar to Kabul in a C-130.

Injured ANA soldier lifted from Afghan Air Force C-27A

And the situation for Afghan civilians – as I explored in detail in ‘The prosthetics of military violence‘ – is still worse.

This is not a problem confined to Afghanistan: think of how the possibility of the Golden Hour recedes in urban combat zones subjected to artillery fire and bombing – the difficulties faced by first responders in Gaza or in the ravaged, rubble-strewn towns and cities of Syria (see also Annie Sparrow‘s report here).

 A Syrian youth walks past a destroyed ambulance in the Saif al-Dawla district of the war-torn northern city of Aleppo on January 12, 2013. An accident and emergency centre in Aleppo uses an abandoned supermarket to conceal a fleet of 16 ambulances, just 10 of which are in working order and are driven by 22 staff members. AFP PHOTO/JM LOPEZ/ (Getty Images)


A Syrian youth walks past a destroyed ambulance in the Saif al-Dawla district of the war-torn northern city of Aleppo on January 12, 2013. An accident and emergency centre in Aleppo uses an abandoned supermarket to conceal a fleet of 16 ambulances, just 10 of which are in working order and are driven by 22 staff members. AFP PHOTO/JM LOPEZ/ (Getty Images)

And there is no guarantee of safety even once casualties reach hospital since the principle of medical neutrality is now being routinely and systematically violated.