Trauma Geographies

I’ve been invited to give the Antipode lecture at the RGS/IBG conference on 29 August.  Here’s the abstract:

Trauma Geographies: broken bodies and lethal landscapes  

Elaine Scarry reminds us that even though ‘the main purpose and outcome of war is injuring’ this ‘massive fact can nevertheless ‘disappear from view along many separate paths.’ This presentation traces some of those paths, exploring the treatment and evacuation of the injured and sick in three war zones: the Western Front in the First World War, Afghanistan 2001-2018, and Syria 2012-2018. The movement of casualties from the Western Front inaugurated the modern military-medical machine; it was overwhelmingly concerned with the treatment of combatants, for whom the journey – by stretcher, ambulance, train and boat – was always precarious and painful. Its parts constituted a ‘machine’ in all sorts of ways, but its operation was far from smooth. The contrast with the aerial evacuation and en route treatment of US/UK casualties in Afghanistan is instructive, and at first sight these liquid geographies confirm Stephen Pinker’s progressivist theses about ‘the better angels of our nature’ [see also here]. But this impression has to be radically revised once Afghan casualties are taken into account – both combatant and civilian – and it is dispelled altogether by the fate of the sick and wounded in rebel-controlled areas of Syria. For most of them treatment was dangerous, almost always improvised and ever more precarious as hospitals and clinics were routinely targeted and medical supplies disrupted, and evacuation impossible as multiple sieges brutally and aggressively tightened. Later modern war has many modalities, and the broken bodies that are moved – or immobilised – in its lethal landscapes reveal that the ‘therapeutic geographies’ mapped so carefully by Omar Dewachi and others [see here and here] continue to be haunted by the ghosts of cruelty and suffering that stalked the battlefield of the American Civil War in the years following Lincoln’s original appeal to those ‘better angels’.

The presentation will tie together several strands I’ve laid out in posts on Geographical Imaginations; the next installment of my analysis of siege warfare and geographies of precarity in Syria will appear shortly.

Journey of a wounded soldier

I’ve written before about Harry Parker‘s Anatomy of a soldier – an extraordinary novel(for multiple reasons) that reconstructs the journey of a British soldier who steps on an IED in Afghanistan through the evacuation chain to Camp Bastion and on to Selly Oak in Birmingham (see also ‘Object Lessons’, DOWNLOADS tab).  I’ve also sketched out an ‘anatomy of another soldier‘, describing in similar terms the precarious journey of a soldier wounded on the Western Front in the First World War back to Blighty.  It’s part of my project on medical care and casualty evacuation from war zones – the Western Front, the Western Desert, Vietnam, and now Afghanistan, Syria and Iraq.

Much of my archival work (on the First and Second World Wars) has been done at the Imperial War Museum and the Wellcome Library in London, and now the IWM has provided a series of short but sharp insights into the journey of a wounded soldier from Afghanistan back to Britain.

It’s not the experiment that Harry conducts – which isn’t to disparage either of them, and in fact Harry did a reading from ‘Anatomy’ at the IWM – but works through the IWM’s signature mix of objects, documentary and interview.  It includes an interview with Corporal Harry Reid, recalling his experience of being wounded;

‘… a vague recollection of spinning round in the air, not sure if I did or not…  I lay on my back, looked down, I couldn’t see my legs at that stage, a big dust cloud all around, so I couldn’t really see anything, and I couldn’t hear anything…  I weren’t in any pain at that particular time, I just felt like shock and numbness, as if I’d walked into a door…

I looked across to this left hand, thinking right, I need to get a first aid kit out here, because your training kicks in straight away, in your right-hand pouch you’ve got your tourniquets, your first field-dressing, and your morphine…  I knew something violently had just happened… I looked across and this finger was hanging off … so I kept hold of that and I thought I’m not losing that as well…  I looked across at my right arm and it were twisted up around my back so then I shouted for a medic … but obviously I shouted but I couldn’t hear myself shouting, which was quite strange…

He crawled back towards me, risking his own life … and he gave me some morphine and started putting tourniquets on.  He put  a tourniquet on my arm, pulled it obviously really tight to stop the blood flow but I felt it pinch my skin … that felt painful, I couldn’t really feel anything else, so I told him not very politely to calm down a bit because it was pinching my skin…

Then I remember being in and out of consciousness..’

That last sentence is crucial; it turns out that one of the most traumatic after-effects of blast injuries is the inability to remember what happened between the initial shock and recovering consciousness in hospital.  Many of those wounded in the First and Second World Wars recalled only too well what they suffered during their evacuation, but later modern war is accompanied by powerful narcotics that combine analgesics with amnesia.    Here is Emily Mayhew in A Heavy Burden:

As ITUs [Intensive Therapy Unit] became more advanced, so did a condition known as ITU-PTSD –the stress induced, post-traumatically, by not knowing what has happened to the patient during the hours and days that are missing from their memory.

How much worse … would this be for the soldier who fell in the desert, was swooped away by MERT {Medical Emergency Response Team], saved and nursed at Bastion, flown half a continent away and then woken, not with their unit around them dusty and shouting, but their family, strained and weeping.

Recovering those lost hours, days and even weeks is a central part of my own work (see also ‘The Geographies of Sixty Minutes’ here).

So it’s good that the web page for Journey of a Wounded Soldier also features a triptych of images from the brilliant work of David Cotterell showing evacuation from Bastion to Britain (above), and interview clips addressing treatment and rehabilitation at Birmingham.

Losing sight

May Jeong – whose excellent investigation of the US air strike on the MSF Trauma Centre at Kunduz I’ve commended before – has a new, equally enthralling extended report over at the Intercept on the sole survivor of a US drone strike in Kunar province in eastern Afghanistan on 7 September 2013: ‘Losing Sight‘.

It’s a long, rich read, but there are two issues I want to highlight.

First, May captures the stark, bio-physical horror of an air strike with an economy and force I’ve rarely seen equalled.  As I’ve noted before (see here and here), many critical analyses emphasise the bio-convergences that animate what happens behind the digital screens of the kill-chain and say remarkably little about those that lie on the other side.  It’s all too easy to lose sight of the embodied nature of remote warfare, though in another powerful essay Joseph Pugliese argues that it’s often not possible to speak of the corporeal at all in the face of such catastrophic violence: ‘The moment of lethal violence transmutes flesh into unidentifiable biological substance that is violently compelled geobiomorphologically to assume the topographical contours of the debris field’ ( ‘Death by Metadata: The bioinformationalisation of life and the transliteration of algorithms to flesh’, in Holly Randell-Moon and Ryan Tippet (eds) Security, race, biopower: essays on technology and corporeality (London: Palgrave, 2016) 3-20).

So here is May describing the strike on a pick-up truck in the early evening as it ground its way along a rough road through the Pech Valley; inside the cabin were the driver, three women and four young children, while seven men were crammed into the back along with sacks of flour they had bought to take back to their village.  There were a couple of miles from home, Gambir, when five missiles hit the truck in a 20-minute period.  Minutes later a second truck – which had been racing to catch up with the first – arrived close to the scene.  The driver (Mohibullah) scrambled up a small hill with a local villager:

[T]hey saw the husk of the pickup, strafed and lit up in flames. They hurried toward the fire.

When Mohibullah arrived at the blast site, he saw that of the 17 bags of flour he had helped load onto the truck, just two were intact. The rest had splayed open. There was a sick beauty to the scene — white powder over blood-red carnage.  These were men and women Mohibullah had grown up with, but he couldn’t recognize any of them. Their mangled body parts made it difficult to ascertain where one person ended and another began: spilled brains over severed limbs over ground flesh…

At first, it was just Mohibullah, another driver named Hamish Gul, and three villagers from Quroo who came to help. Most people in the area knew to stay away. The ghanghai [drones] often attacked again. Even so, the five of them worked at untangling the dead bodies — among them Aisha’s mother, father, grandmother, and little brother — and stacking them in neat rows atop the bed of Mohibullah’s truck.

Astonishingly, there was one survivor, but she too had been brutalised beyond recognition:

Mohibullah did not recognize the girl — her face had been “scrambled, she didn’t have her nose.” She still had both of her legs, but he wasn’t sure if her torso was connecting them to the rest of her body. It wasn’t until she asked in a frail voice — “Where is my father? Where is my mother?” — that he understood her to be his 4-year-old niece Aisha

A neighbor named Nasir held Aisha together for the drive back to Gambir. During the 2-mile journey, Aisha did not make a sound. Life seemed to be slipping away from her. Nasir assumed she would be buried. But when they arrived in Gambir, Aisha turned her head and asked for water. Her voice was so full of intent that they decided to rush her to a hospital in Asadabad.

Read those paragraphs again to see what Pugliese means.

Now the second issue starts to come into focus.  They reached Asadabad Provincial Hospital at 10 p.m., but the duty nurse could do little for Aisha:

Her stomach was missing, as were parts of her face and her left arm. He registered her into the hospital database, writing “acute abdominal injuries” next to her name, treated her with basic first aid, and sent her to the nearest hospital in Jalalabad, 57 miles away.

Aisha reached Jalalabad Public Health Hospital shortly after midnight, where her burns were dressed.  But here too there was little the surgeon could do; she had multiple head injuries, had lost one of her hands, and had major internal injuries.  A helicopter was called to take her to Kabul but it couldn’t land; a second helicopter arrived at midnight – 24 hours after she had reached Jalalabad – and ferried her to the French military hospital at Kabul Airport.

That hospital was a NATO Role 3 hospital, which had been run by the French since July 2009; by the summer of 2013 43 per cent of the procedures carried out by its staff had involved orthopaedic surgery.  Half of these were emergency surgeries; just 17 per cent of the patients were French military personnel and another 17 per cent were Afghan National Army or other ISAF soldiers,  while 47 per cent were Afghan (adult) civilians and 17 per cent were children.

Like other Role 3 hospitals, the facility was tasked with ‘damage-control’, for which it could call on three surgical teams rotation with a general surgeon, (abdominal, chest or vascular surgery) and an orthopedic surgeon as well as an ophthalmologist,  a neurosurgeon and an ENT or maxillofacial surgeon (I’ve taken these details from O. Barbier and others, ‘French surgical experience in the Role 3 Medical Treatment Facility of KaIA (Kabul International Airport…’, Orthopaedics and Traumataology: Surgery & Research 100 (6) (2014) 681-5; see also Christine Joubert and others, ‘Military neurosurgery in operation’, Acta Neurochir 158 (8) (2016) 1453-63).

While Aisha was being treated the hospital was visited by Afghan President Hamid Karzai.  Here is May again:

There, Karzai was confronted with a girl who had lost her sight, her nose, her lower lip, the skin on her forehead, the skin on her torso, her left hand, and nine members of her family, including her grandmother, her uncles, her aunts, her cousin, her mother, her father, and her baby brother.

“I cannot describe what I saw there,” Rangin Spanta, who served as national security adviser under Karzai and accompanied him to the hospital that day, told me from his home in Kabul. We were sitting on a rattan set on his front porch. In telling this story, Spanta covered his face and wept. “Still I have my trauma.” Spanta had lost five family members in the war, but the sight of Aisha, a girl who had been reduced to a “piece of biological construct,” gave him “the feeling that this was a kind of a nightmare.” Spanta, who had seen the guts of suicide bombers splattered across his car window and has visited double, triple, and quadruple amputees, said Aisha was the “most shocking thing I’ve seen in this war.” Karzai asked the attending doctor why her face was covered. “Because there is nothing there” was the answer.

That a high proportion of patients the military hospital were Afghan civilians was by no means unusual for a Role 3 facility, but as I’ve noted before ISAF had strict Rules of Medical Eligibility.  Afghan civilians who were injured during military operations and/or needed ‘life, limb or eyesight saving care’ – both of which applied to Aisha – could be admitted to the international medical system.  But as soon as possible, Afghans were to be treated by Afghans and so, after surgical intervention, they had to be transferred to the local healthcare system.



That system was – is – often rudimentary, which is why Aisha was passed from Asadabad to Jalalabad before reaching Kabul.  And returning someone in her post-operative condition to that system was obviously fraught with danger.  Here is Emily Mayhew in A Heavy Reckoning describing the dilemma for doctors at the Role 3 hospital at Camp Bastion in Helmand province:

Some of the most difficult decisions taken by the Deployed Medical Director related to local patients, Afghans civilians, their families and others. Locals made up the majority (probably as much as 80 per cent) of the patients cared for during the lifetime of the hospital. During the war there were no Afghan hospitals with the technology or capability to ventilate patients with severe chest wounds, therefore leaving Bastion meant death. So anyone intubated who could not be returned to Britain had to stay at Bastion until they could breathe unaided, which sometimes took days or weeks. They were discharged only when it was certain they could survive away from Bastion: probably in a local hospital that was under severe stress, and which could only provide medical care for two or three hours a day, where the rest of the time they would be looked after by their families.

I’ll return to this in a later post, because in some cases those local hospitals have been supplemented and even supplanted by more advanced medical facilities operated or supported by international NGOs like Emergency or MSF.

But what is extraordinary in Aisha’s case is that her pathway did not follow any of these routes.  Karzai had asked both the French and the Germans to help, but they deferred to the Americans who insisted that she be taken to the United States for further treatment.  ‘Twelve days after the strike,’ May reports, ‘Aisha was gone’: but nobody ever told her relatives what had happened to her.  Every attempt they made to find out was rebuffed.

Months later her uncle was informed that she was at Walter Reed hospital in Maryland; she had been sponsored by an American organisation, Solace for the Children.  According to its website:

Each Summer Solace for the Children Summer Medical Program brings children from areas affected by war to the United States so they may receive medical care unavailable to them in their country. We currently focus our efforts on children in Afghanistan. Each fall, applications are accepted for treatment. Our office in Afghanistan typically receives more than 50 applications they must review and qualify. Youth are qualified for services based on need and health condition. They are then placed with a host family for approximately 6 weeks while receiving the medical care they require. After care, youth return to Afghanistan with a better quality of life, brighter future and hope for peace.

While ‘there was no official relationship between the U.S. military and Solace,’ May was told by the charity’s director Patsy Wilson, ‘individual members of the military often reached out to Solace, which had been the case for Aisha.’

“We just get calls. We get calls from the military all over Afghanistan,” she said. She repeatedly deferred to the military, stating, “I am sure they don’t say we kidnap children.” Wilson also expressed doubts that Aisha had been injured in a drone strike, despite the claims of scores of villagers interviewed by The Intercept. “We do not necessarily believe Aisha was in a drone strike, but I know that is one of the stories,” she said. When pressed for details, she said, “I have been told not to discuss that,” adding, “We have no facts. There are no facts.”

Those last sentences are becoming all too familiar, but in this case ISAF not only acknowledged the ‘IM [international military] aerial attack’ but carried out its own investigation into the civilian casualties.  It has never been declassified.

New depths

I’m still working on the (very) long-form version of ‘The Death of the Clinic’; in a previous post I described the attacks on hospitals in Syria and, in particular, the the construction – and destruction – of the underground Cave Hospital in Hama, Syria (see also my update on ‘Bombs, bunkers and borders’ here).  You can find videos and photographs from Jake Godin here.  The hospital has provided trauma surgery and paediatric care, treatment for major illnesses, and emergency treatment for victims of gas attacks (below):

Th hospital opened in late 2015; it suffered series of devastating air strikes in October 2016 (see here).

I have just received this bleak news:

A few hours ago, at 12:15 pm Damascus time [on 1 February], the Al Maghara (Dr. Hassan Al Araj) Cave Hospital in Kafr Zita, Hama was hit by five missiles from an airstrike. The hospital, built under 60 feet of rock, suffered extensive damage.

The pharmacy was destroyed and there was extensive damage to the emergency department, which UOSSM supports, and ambulances. There were minor injuries and no casualties reported. The facility was put out of service. The hospital serves a population of 50,000 people, has 7,000 beneficiaries a month and performs roughly 150 major surgeries a month.

The hospital was previously hit by three airstrikes in 2018; on January 30, January 5, January 2. The hospital was built under 60 ft. of rock to protect it from airstrikes and is considered one of the most structurally fortified hospitals in all of Syria. Damaging the structure to this extent is only possible through advanced weapons/ bunker buster missiles.

Cities and War

This week the Guardian launched a new series on Cities and War:

War is urbanising. No longer fought on beaches or battlefields, conflict has come to the doors of millions living in densely populated areas, killing thousands of civilians, destroying historic centres and devastating infrastructure for generations to come.

Last year, the world watched the Middle East as Mosul, Raqqa, Sana’a and Aleppo were razed to the ground. Across Europe, brutal attacks stunned urban populations in Paris, London and Berlin, while gang warfare tore apart the fabric of cities in central and south America.

In 2018, Guardian Cities will explore the reality of war in cities today – not merely how it is fought, but how citizens struggle to adapt, and to rebuild stronger than ever.

The series opened on Monday with a photographic gallery illustrating ‘a century of cities at war’; some of the images will be familiar, but many will not.  When I was working on ‘Modern War and Dead Cities‘ (which you can download under the TEACHING tab), for example, I thought I had seen most of the dramatic images of the Blitz, but I had missed this one:

It’s an arresting portfolio, and inevitably selective: there is a good discussion below the line on what other cities should have made the cut.

The first written contribution is an extended essay from Jason Burke, ‘Cities and terror: an indivisible and brutal relationship‘, which adds a welcome historical depth and geographical range to a discussion that all too readily contracts around recent attacks on cities in Europe and North America, and suggests an intimate link between cities and terrorism:

[I]t was around the time of the Paddington station attack [by Fenians in 1883]  that the strategy of using violence to sway public opinion though fear became widespread among actors such as the anarchists, leftists and nationalists looking to bring about dramatic social and political change.

This strategy depended on two developments which mark the modern age: democracy and communications. Without the media, developing apace through the 19th century as literacy rates soared and cheap news publications began to achieve mass circulations, impact would be small. Without democracy, there was no point in trying to frighten a population and thus influence policymakers. Absolutist rulers, like subsequent dictators, could simply ignore the pressure from the terrified masses. Of course, a third great development of this period was conditions in the modern city itself.

Could the terrorism which is so terribly familiar to us today have evolved without the development of the metropolis as we now know it? This seems almost impossible to imagine. Even the terror of the French revolution – Le Terreur – which gives us the modern term terrorism, was most obvious in the centre of Paris where the guillotine sliced heads from a relatively small number of aristocrats in order to strike fear into a much larger number of people.

The history of terrorism is thus the history of our cities. The history of our cities, at least over the last 150 years or so, is in part the history of terrorism. This is a deadly, inextricable link that is unlikely to be broken anytime soon.

Today Saskia Sassen issued her ‘Welcome to a new kind of war: the rise of endless urban conflict‘.  She begins with an observation that is scarcely novel:

The traditional security paradigm in our western-style democracies fails to accommodate a key feature of today’s wars: when our major powers go to war, the enemies they now encounter are irregular combatants. Not troops, organised into armies; but “freedom” fighters, guerrillas, terrorists. Some are as easily grouped by common purpose as they are disbanded. Others engage in wars with no end in sight.

What such irregular combatants tend to share is that they urbanise war. Cities are the space where they have a fighting chance, and where they can leave a mark likely to be picked up by the global media. This is to the disadvantage of cities – but also to the typical military apparatus of today’s major powers.

The main difference between today’s conflicts and the first and second world wars is the sharp misalignment between the war space of traditional militaries compared to that of irregular combatants.

Irregular combatants are at their most effective in cities. They cannot easily shoot down planes, nor fight tanks in open fields. Instead, they draw the enemy into cities, and undermine the key advantage of today’s major powers, whose mechanised weapons are of little use in dense and narrow urban spaces.

Advanced militaries know this very well, of course, and urban warfare is now a central medium in military training.  Saskia continues:

We have gone from wars commanded by hegemonic powers that sought control over sea, air, and land, to wars fought in cities – either inside the war zone, or enacted in cities far away. The space for action can involve “the war”, or simply specific local issues; each attack has its own grievances and aims, seeking global projection or not. Localised actions by local armed groups, mostly acting independently from other such groups, let alone from actors in the war zone – this fragmented isolation has become a new kind of multi-sited war.

This is, in part, what I tried to capture in my early essay on ‘The everywhere war’, and I’m now busily re-thinking it for my new book.  More on this in due course, but it’s worth noting that the Trump maladministration’s National Defense Strategy, while recognising the continuing importance of counter-terrorism and counterinsurgency, has returned the Pentagon’s sights to wars between major powers – notably China and Russia (see also here)– though it concedes that these may well be fought (indeed, are being fought) in part through unconventional means in digital domains.  In short, I think later modern war is much more complex than Saskia acknowledges; it has many modalities (which is why I become endlessly frustrated at the critical preoccupation with drones to the exclusion of other vectors of military and paramilitary violence), and these co-exist with – or give a new inflection to – older modalities of violence (I’m thinking of the siege warfare waged by Israel against Gaza or Syria against its own people).

The two contributions I’ve singled out are both broad-brush essays, but Ghaith Abdul-Ahad has contributed a two-part essay on Mosul under Islamic State that is truly brilliant: Part I describes how IS ran the city (‘The Bureaucracy of Evil‘) and Part II how the people of Mosul resisted the reign of terror (‘The Fall‘).

Mosul fell to IS in July 2014, and here is part of Ghaith’s report, where he tells the story of Wassan, a newly graduated doctor:

Like many other diwans (ministries) that Isis established in Mosul, as part of their broader effort to turn an insurgency into a fully functioning administrative state, the Diwan al-Siha (ministry of health) operated a two-tier system.There was one set of rules for “brothers” – those who gave allegiance to Isis – and another for the awam, or commoners.

“We had two systems in the hospitals,” Wassan said. “IS members and their families were given the best treatment and complete access to medicine, while the normal people, the awam, were forced to buy their own medicine from the black market.

“We started hating our work. As a doctor, I am supposed to treat all people equally, but they would force us to treat their own patients only. I felt disgusted with myself.”

(Those who openly resisted faced death, but as IS came under increasing military pressure at least one doctor was spared by a judge when he refused to treat a jihadist before a civilian: “They had so few doctors, they couldn’t afford to punish me. They needed me in the hospital.”)

Wassan’s radical solution was to develop her own, secret hospital:

“Before the start of military operations, medicines begun to run out,” she said. “So I started collecting whatever I could get my hands on at home. I built a network with pharmacists I could trust. I started collecting equipment from doctors and medics, until I had a full surgery kit at home. I could even perform operations with full anaesthesia.”

Word of mouth spread about her secret hospital.

“Some people started coming from the other side of Mosul, and whatever medicine I had was running out,” she said. “I knew there was plenty of medicine in our hospital, but the storage rooms were controlled by Isis.

“Eventually, I began to use the pretext of treating one of their patients to siphon medicine from their own storage. If their patient needed one dose, I would take five. After a while they must have realised, because they stopped allowing doctors to go into the storage.”

The punishment for theft is losing a hand. Running a free hospital from her home would have been sedition, punishable by death…

When Wassan’s hospital was appropriated by Isis fighters [this was a common IS tactic – see the image below and the Human Rights Watch report here; the hospital was later virtually destroyed by US air strikes] her secret house-hospital proved essential. More than a dozen births were performed on her dining table; she kicked both brothers out of their rooms to convert them into operating theatres; her mother, an elderly nurse, became her assistant.

As the siege of Mosul by the Iraqi Army ground on, some of the sick and injured managed to run (or stumble) the gauntlet to find medical aid in rudimentary field hospitals beyond the faltering grip of IS, while others managed to make it to major trauma centres like West Irbil.

But for many in Mosul Wassan’s secret hospital was a lifeline (for a parallel story about another woman doctor running a secret clinic under the noses of IS, see here).

Yet there is a vicious sting in the tail:

For Wassan, the ending of Isis rule in Mosul is bittersweet. After many attempts to reach Baghdad to write her board exams for medical school, she was told her work in the hospital for the past three years did not count as “active service”, and she was disqualified.

“The ministry said they won’t give me security clearance because I had worked under Isis administration,” she said.

This, too, is one of the modalities of later modern war – the weaponisation of health care, through selectively withdrawing it from some sections of the population while privileging the access and quality for others.  ‘Health care,’ writes Omar Dewachi, ‘has become not only a target but also a tactic of war.’  (If you want to know more about the faltering provision of healthcare and the fractured social fabric of life in post-IS Mosul, I recommend an interactive report from Michael Bachelard and Kate Geraghty under the bleak but accurate title ‘The war has just started‘). 

The weaponisation of health care has happened before, of course, and it takes many forms. In 2006, at the height of sectarian violence in occupied Baghdad, Muqtada al-Sadr’s Shi’a militia controlled the Health Ministry and manipulated the delivery of healthcare in order to marginalise and even exclude the Sunni population.  As Amit Paley reported:

 ‘In a city with few real refuges from sectarian violence – not government offices, not military bases, not even mosques – one place always emerged as a safe haven: hospitals…

‘In Baghdad these days, not even the hospitals are safe. In growing numbers, sick and wounded Sunnis have been abducted from public hospitals operated by Iraq’s Shiite-run Health Ministry and later killed, according to patients, families of victims, doctors and government officials.

‘As a result, more and more Iraqis are avoiding hospitals, making it even harder to preserve life in a city where death is seemingly everywhere. Gunshot victims are now being treated by nurses in makeshift emergency rooms set up in homes. Women giving birth are smuggled out of Baghdad and into clinics in safer provinces.’

He described hospitals as ‘Iraq’s new killing fields’, but in Syria the weaponisation of health care has been radicalised and explicitly authorized by the state.

You may think I’ve strayed too far from where I started this post; but I’ve barely moved.  For towards the end of her essay Saskia wonders why military and paramilitary violence in cities in so shocking – why it attracts so much more public attention than the millions murdered in the killing fields of the Congo.  And she suggests that the answer may lie in its visceral defilement of one of humanity’s greatest potential achievements:

Is it because the city is something we’ve made together, a collective construction across time and space? Is it because at the heart of the city are commerce and the civic, not war?

Lewis Mumford had some interesting things to say about that.  I commented on this in ACME several years ago, and while I’d want to flesh out those skeletal remarks considerably now, they do intersect with Saskia’s poignant question about the war on the civic:

In The Culture of Cities, published just one year before the Second World War broke out, Mumford included ‘A brief outline of hell’ in which he turned the Angelus towards the future to confront the terrible prospect of total war. Raging against what he called the ‘war-ceremonies’ staged in the ‘imperial metropolis’ (‘from Washington to Tokyo, from Berlin to Rome’: where was London, I wonder? Moscow?), Mumford fastened on the anticipatory dread of air war. The city was no longer the place where (so he claimed) security triumphed over predation, and he saw in advance of war not peace but another version of war. Thus the rehearsals for defence (the gas-masks, the shelters, the drills) were ‘the materialization of a skillfully evoked nightmare’ in which fear consumed the ideal of a civilized, cultivated life before the first bombs fell. The ‘war-metropolis’, he concluded, was a ‘non-city’.

After the war, Mumford revisited the necropolis, what he described as ‘the ruins and graveyards’ of the urban, and concluded that his original sketch could not be incorporated into his revised account, The City in History, simply ‘because all its anticipations were abundantly verified.’ He gazed out over the charnel-house of war from the air — Warsaw and Rotterdam, London and Tokyo, Hamburg and Hiroshima — and noted that ‘[b]esides the millions of people — six million Jews alone — killed by the Germans in their suburban extermination camps, by starvation and cremation, whole cities were turned into extermination camps by the demoralized strategists of democracy.’

I’m not saying that we can accept Mumford without qualification, still less extrapolate his claims into our own present, but I do think his principled arc, at once historical and geographical, is immensely important. In now confronting what Stephen Graham calls ‘the new military urbanism’ we need to recover its genealogy — to interrogate the claims to novelty registered by both its proponents and its critics — as a way of illuminating the historical geography of our own present.

It’s about more than aerial violence – though that is one of the signature modalities of modern war – and we surely need to register the heterogeneity and hybridity of contemporary conflicts.  But we also need to recognise that they are often not only wars in cities but also wars on cities.

Bombs, bunkers and borders

Here is the first of a series of updates on Syria, this one identifying recent work on attacks on hospitals and health care which I’ve been reading while I turn my previous posts into a long-form essay (see ‘Your turn, doctor‘ and ‘The Death of the Clinic‘).

First, some context.  Human Rights Watch has joined a chorus of NGOs documenting attacks on hospitals and health care around the world.  On 24 May HRW issued this bleak statement:

Deadly attacks on hospitals and medical workers in conflicts around the world remain uninvestigated and unpunished a year after the United Nations Security Council called for greater action, Human Rights Watch said today.

On May 25, 2017, UN Secretary-General Antonio Guterres is scheduled to brief the Security Council on the implementation of Resolution 2286, which condemned wartime attacks on health facilities and urged governments to act against those responsible. Guterres should commit to alerting the Security Council of all future attacks on healthcare facilities on an ongoing rather than annual basis.

“Attacks on hospitals challenge the very foundation of the laws of war, and are unlikely to stop as long as those responsible for the attacks can get away with them,” said Bruno Stagno-Ugarte, deputy executive director for advocacy at Human Rights Watch. “Attacks on hospitals are especially insidious, because when you destroy a hospital and kill its health workers, you’re also risking the lives of those who will need their care in the future.”

The statement continues:

International humanitarian law, also known as the laws of war, prohibits attacks on health facilities and medical workers. To assess accountability measures undertaken for such attacks, Human Rights Watch reviewed 25 major attacks on health facilities between 2013 and 2016 in 10 countries [see map above]. For 20 of the incidents, no publicly available information indicates that investigations took place. In many cases, authorities did not respond to requests for information about the status of investigations. Investigations into the remaining five were seriously flawed…

No one appears to have faced criminal charges for their role in any of these attacks, at least 16 of which may have constituted war crimes. The attacks involved military forces or armed groups from Afghanistan, Central African Republic, Iraq, Israel, Libya, Russia, Saudi Arabia, South Sudan, Sudan, Syria, Ukraine, and the United States.

More here.

The World Health Organisation reached similar conclusions in its report of 17 May 2017:

Alexandra Sifferlin‘s commentary for Time drew attention to the importance of attacks on medical facilities in Syria:

In a 48-hour period in November, warplanes bombed five hospitals in Syria, leaving Aleppo’s rebel-controlled section without a functioning hospital. The loss of the Aleppo facilities — which had been handling more than 1,500 major surgeries each month — was just one hit in a series of escalating attacks on health care workers in 2016, the World Health Organization (WHO) reported on Friday.

Violent attacks on hospitals and health workers “continue with alarming frequency,” the WHO said in its new report. In 2016, there were 302 violent attacks, which is about an 18% increase from the prior year, according to new data. The violence — 74% was in the form of bombings — occurred in 20 countries, but it was driven by relentless strikes on health facilities in Syria, which the WHO has previously condemned. Across the globe, the 302 attacks last year resulted in 372 deaths and 491 injuries…

After the spate of attacks on Syrian hospitals last November, the WHO reported that three of the bombed hospitals in Aleppo had been providing over 10,000 consultations every month. Two other bombed hospitals in the city of Idleb were providing similar levels of care, including 600 infant deliveries. One of the two hospitals in Idleb was a primary referral hospital for emergency childbirth care.

“The attack…is an outrage that puts many more lives in danger in Syria and deprives the most vulnerable – including children and pregnant women – of their right to health services, just at the time when they need them most,” the WHO said.

The WHO has also provided a series of reports on attacks on hospitals and health care in Syria; here is its summary for last month:

But the WHO’s role in the conflict in Syria has been sharply criticised by Annie Sparrow, who has accused it of becoming a de facto apologist for the Assad regime.  Writing in Middle East Eye earlier this year, she said:

For years now, the World Health Organisation (WHO) has been fiddling while Syria burns, bleeds and starves. Despite WHO Syria having spent hundreds of millions of dollars since the conflict began in March 2011, public health in Syria has gone from troubling in 2011 to catastrophic now…

Yet WHO Syria has been anything but an impartial agency serving the needy. As can be seen by a speech made by Elizabeth Hoff, WHO’s representative to Syria, to the UN Security Council (UNSC) on 19 November 2016, WHO has prioritised warm relations with the Syrian government over meeting the most acute needs of the Syrian people.

Annie singles out three particularly problematic issues.

  • She claims that the WHO parrots the Assad regime’s claim that before the conflict its vaccination programmes had covered 95 per cent of the population (or better), whereas she insists that vaccinations had been withheld from children ‘in areas considered politically unsympathetic, such as the provinces of Idlib, western Aleppo, and Deir Ezzor.’  On her reading, in consequence, the re-emergence of (for example) polio ‘is consistent with pre-existing low immunisation rates and the vulnerability of Syrian children living in government-shunned areas.’
  • It was not until 2016 that the WHO reported attacks on hospitals at all, and when its representative condemned ‘repeated attacks on healthcare facilities in Syria’ she failed to note that the vast majority of those attacks were carried out by the Syrian Arab Air Force and its Russian ally.  The geography of deprivation was erased: ‘It is only in opposition-held areas that healthcare is compromised because of the damage and destruction resulting from air strikes by pro-government forces.’
  • Those corpo-materialities – an elemental human geography, so to say – did emerge when the WHO accused the Assad regime of of ‘withholding approval for the delivery of surgical and medical supplies to “hard-to-reach” and “besieged” locations.’  But Annie objects to these ‘politically neutral terms’ because they are ‘euphemisms for opposition-controlled territory, and so [avoid] highlighting the political dimension of the aid blockages, or the responsibility of the government for 98 percent of the more than one million people forced to live in an area under siege.’

You can read WHO’s (I think highly selective) response here.

Earlier this month 13 Syrian medical organisations combined with the Syria Campaign to document how attacks on hospitals have driven hospitals and health facilities underground (I described this process – and the attacks on the Cave Hospital and the underground M10 hospital in Aleppo – in ‘Your turn, doctor‘).  In Saving Lives Underground, they write:

Health facilities in Syria are systematically targeted on a scale unprecedented in modern history.

There have been over 454 attacks on hospitals in the last six years, with 91% of the attacks perpetrated by the Assad government and Russia. During the last six months of 2016, the rate of attacks on healthcare increased dramatically. Most recently, in April 2017 alone, there were 25 attacks on medical facilities, or one attack every 29 hours.

While the international community fails to protect Syrian medics from systematic aerial attacks on their hospitals, Syrians have developed an entire underground system to help protect patients and medical colleagues as best they can. The fortification of medical facilities is now considered a standard practice in Syria. Field hospitals have been driven underground, into basements, fortified with sandbags and cement walls, and into caves. These facilities have saved the lives of countless health workers and patients, preserved critical donor-funded equipment, and helped prevent displacement by providing communities with emergency care.

But all this comes at a cost:

Donors often see the reinforcement and building of underground medical facilities exclusively as long-term aid, or development work. However, as the Syria crisis is classified as a protracted emergency conflict, medical organizations do not currently have access to such long-term funds.

Budget lines for the emergency funding they receive can include “protection” work, but infrastructure building, even for protective purposes, often falls outside of their mandate. The divide between emergency humanitarian and development funding is creating a gap for projects that bridge the two, like protective measures for hospitals in Syria.

For this reason, as Emma Beals reported in the Guardian, many projects have resorted to crowdfunding:

The latest underground medical project seeking crowdfunding to complete building works is the Avicenna women and children’s hospital in Idlib City, championed by Khaled al-Milaji, head of the Sustainable International Medical Relief Organisation.

Al-Milaji is working to raise money with colleagues from Brown University in the US, where he studied until extreme security vetting – the Trump administration’s “Muslim ban” – prevented him re-entering the country after a holiday in Turkey.

He has instead turned his attention to building reinforced underground levels of the hospital, sourcing private donations to meet the shortfall between donor funding and actual costs…

Crowdfunding was an essential part of building the children’s Hope hospital, near Jarabulus in northern Syria. The project is run by doctors from eastern Aleppo, who were evacuated from the city in December after it was besieged for nearly six months amid a heavy military campaign. Doctors worked with the People’s Convoy, which transported vital medical supplies from London to southern Turkey as well as raising funds to build the hospital, which opened in April. More than 4,800 single donations raised the building costs, with enough left over to run the hospital for six months.

Saving Lives Underground distinguishes basement hospitals (the most common response to aerial attack by aircraft or shelling: 66 per cent of fortified hospitals fall into this category; the average cost is usually around $80–175,000, though more elaborate rehabilitation and repurposing can run up to $1 million); cave hospitals (‘the more effective protection model’ – though there are no guarantees – which accounts for around 4 per cent of fortified hospitals and which typically cost around $200–800,000) and purpose-built underground hospitals (two per cent of the total; these can cost from $800,000 to $1,500,000).

It’s chilling to think that hospitals have to be fortified and concealed in these ways: but even more disturbing, the report finds that 47 per cent of hospitals in these vulnerable areas have no fortification at all.

Seriously ill or wounded patients trapped inside besieged areas have few choices: medical facilities are degraded and often makeshift; access to vital medical supplies continues to be capriciously controlled and often denied; and attempts to evacuate them depend on short-lived ceasefires and deals (or bribes).  In Aleppo control of the Castello Road determined whether ambulances could successfully run the gauntlet from eastern Aleppo either west to hospitals in Reyhanli in Turkey or out to the Bab-al Salama Hospital in northern Aleppo and then across the border to state-run hospitals in Kilis: but in the absence of a formal agreement this was often a journey of last resort.

A victim of a barrel bomb attack in Aleppo is helped into a Turkish ambulance on call at the Bab al Salama Hospital near the Turkish border.

In October 2016 there were repeated attempts to broker medical evacuations from eastern Aleppo; eventually an agreement was reached, but the planned evacuations were stalled and then abandoned.  In December a new ‘humanitarian pause’ agreed with Russia and the Syrian government allowed more than 100 ambulances to be deployed by the Red Cross and the Red Crescent from Turkey; 200 critical patients were ferried from eastern Aleppo to hospitals in rural Aleppo, Idlib or Turkey – but the mission was abruptly terminated 24 hours after it had started.

The sick and injured have continued to make precarious journeys to hospitals in Turkey (Bab al-Hawa, Kilis, Reyhanli and other towns along the  border: see here, here and here), and also Jordan (in Ramtha and Amman, and in the Zaatari refugee camp: see here and here), Lebanon (in Beirut, Tripoli and clinics in the Bekaa Valley), and even Israel (trekking across the Golan Heights into Northern Israel: see here, herehere and especially here).

But there are no guarantees; travelling within Syria is dangerous and debilitating for patients, and access to hospitals outside Syria is frequently disrupted by border closures (which in turn can thrust the desperate into the hands of smugglers).  In March 2016, for example, Amnesty International reported:

 Since 2012 Jordan has imposed increasing restrictions on access for Syrians attempting to enter the country through formal and informal border crossings. It has made an exception for Syrians with war-related injuries.  However, Amnesty International has gathered information from humanitarian workers and family members of Syrian refugees with critical injuries being denied entry to Jordan for medical care, suggesting the exceptional criteria for entry on emergency medical grounds is inconsistently applied. This has led to refugees with critical injuries being returned to field hospitals in Syria, which are under attack on a regular basis, and to some people dying at the border.

In June Jordan closed the border, after an IS car bomb killed seven of its soldiers, and by December MSF had been forced to close its clinic at the Zaatari camp, which had provided post-operative care for casualties brought in from Dara’a.

Tens of thousands of refugees are now trapped in a vast, informal encampment (see image above) between two desert berms in a sort of ‘no man’s land‘ between Syria and Jordan.  From there Jordanian troops transport selected patients to a UN clinic, located across the border in a sealed military zone – ‘and then take them back again to the checkpoint after they are treated.’

(For the image above, and a commentary by MSF’s Jason Cone, see here).

For patients who do manage to make it across any of these borders, it’s far from easy for doctors to recover their medical history – as the note below, pinned to an unconscious patient who was admitted to the Ziv Medical Center in Safed implies – and in the case of Syria (as in Iraq) everything is further complicated by a fraught politics of the wound.

Here, for example, is Professor Ghassan Abu-Sitta, head of plastic and reconstructive surgery at the medical centre in Beirut, talking earlier this month with Robert Fisk:

In Iraq, patients wounded in Saddam’s wars were initially treated as heroes – they had fought for their country against non-Arab Iran.  But after the US invasion of 2003, they became an embarrassment.  “The value of their wounds’ ‘capital’ changes from hero to zero,” Abu-Sitta says.  “And this means that their ability to access medical care also changes.  We are now reading the history of the region through the wounds.  War’s wounds carry with them the narrative of the wounding which becomes political capital.”

In the bleak wars that have scarred Syria, and which continue to open up divisions and divides there too, the same considerations come into play with equal force.

Anatomy of another soldier

I’ve drawn attention to Harry Parker‘s Anatomy of a soldier before: see here and here (and especially ‘Object lessons’: DOWNLOADS tab).  Most of the reviews of the novel were highly favourable, applauding Parker’s experimental attempt to tell the story of a soldier seriously wounded by an IED in Afghanistan through the objects with which he becomess entangled.

But writing in The Spectator Louis Amis saw it as an object lesson in ‘How not to tell a soldier’s story‘.  He complained that Parker’s device produced a narrative

‘as if the war were composed only of its inanimate processes, either accidental or inevitable. It’s a different planet to the bloody, profane, outlaw Iraq of [Phil] Klay’s Redeployment, radiating shame, PTSD and suicide, and the unbearable awkwardness of transmitting such truths to an alienated civilian world.

Parker’s device gestures aptly towards a spreading out of consciousness, a transmutation, the scattering of the individual along some plane at the threshold of death; the sensations of depersonalisation and hyper-perceptivity associated with traumatic experience; and the soothing quiddity of simple objects, as opposed to abstract thought, for a recovering victim. But it is also a method of averting the gaze from a war’s futility and waste, and worse — and probably, therefore, too, from the true nature of any saving grace.’

I do think Parker’s narrative accomplishes more than Amis allows. It succeeds in making the war in Afghanistan at once strange and familiar; and its strangeness comes not from the people of Afghanistan, that ‘exotic tableau of queerness’ exhibited in so many conventional accounts, but through the activation of objects saturated with the soldier’s sweat, blood and flesh.  It’s also instructive to read the novel alongside Jane Bennett‘s Vibrant matter: a political ecology of things or Robert Esposito‘s Persons and things, as I’ve done elsewhere, and to think through the corpo-materialities of modern war and its production of the battle space as an object-space: but neither of these has much to say about how their suggestive ideas might be turned to substantive account.

Still, Amis’s point remains a sharp one; Scottt Beauchamp says something very similar:

Harry Parker goes further than [Tim] O’Brien [in The things they carried] in giving equal narrative play to nonhuman things. Not only do they make the plot of Parker’s novel possible, they also bear semiconscious witness to our shared reality, corroborating it. Their inability to pass moral judgment comes off as a silent accusation. If this ontological shift toward objects is the most honest way we have of talking about war, it’s still limiting: it turned its weakness—its inability to fully articulate the moral significance of war—into a defining characteristic.

But I haven’t been able to let Parker’s experiment go.  So, for one of my presentations in Durham last month – on the parallels and differences between combat medical care and casualty evacuation on the Western Front in the First World War and Afghanistan a century later – I sketched out an Anatomy of another soldier.  It’s based on my ongoing archival work; earlier in the presentation I had used diaries, letters, memoirs, sketches and photographs to describe what Emily Mayhew calls the ‘precarious journey’ of British and colonial troops through the evacuation chain – you can see a preliminary version in ‘Divisions of life’ here – so this experiment was a supplement not a substitute.  But I wanted to see where it would take me.

So here are the slides; they ought to be self-explanatory – or at any rate, sufficiently clear – but I’ve added some additional notes.  I should probably also explain that in each case the object in question appeared on the slide at the end of its associated narrative.

***

I discuss aerial photography and trench mapping on the Western Front – and the difficulty of navigating the shattered landscapes of trench warfare – in ‘Gabriel’s map: cartography and corpography in modern war’ (DOWNLOADS tab).

You can find a short account of the synchronisation of officers’ watches on the Western Front in ‘Homogeneous (war) time’ here.

A shortage of cotton (combined with its relatively high cost) together with the extraordinary demand for wound dressings prompted the War Office to use sphagnum moss – the British were years behind the Germans and the French in appreciating its antiseptic and absorbent qualities, which also required dressings to be changed less often.  You can get the full story from Peter Ayres, ‘Wound dressing in World War I: the kindly sphagnum moss’, Field Bryology 110 (2013) 27-34 here.

But one RAMC veteran [in ‘Field Ambulance Sketches’, published in 1919] insisted on the restorative power of the white bandage, administered not by regimental stretcher bearers but by the experts of the Royal Army Medical Corps’s Field Ambulance:

The brown first field dressing, admirable as it is from a scientific point of view, always looks a desperate measure; and if it slips, as it generally does on a leg wound, it becomes for the patient merely a depressing reminder of his plight. A clean white dressing, though it may not be nearly so satisfactory in the surgeon’s eyes, seems to reassure a wounded man strangely. It makes him feel that he is being taken care of, gives him a kind of status, and stimulates his sense of personal responsibility. With a white bandage wound in a neat spiral round his leg, he will walk a distance which five minutes earlier, under the dismal suggestion of a first field dressing, he has declared to be utterly beyond his powers.

I borrowed the white maggots (and some of the other details of the wounds) from John Stafford‘s extraordinary, detailed recollection of being wounded on the Somme in August 1916 available here.

Carrying a stretcher across a mud-splattered, shell-blasted landscape was immensely tiring and it was all too easy to lose one’s bearings.  From ‘A stretcher-Bearer’s Diary’, 17 September 1916:

‘The shell fire, and the mud, are simply beyond description, and it is a miracle that any escape being hit. We have to carry the wounded shoulder high, the only way it can be done, because of the mud. Our shoulders are made raw by the chafing of the stretcher handles, although we wear folded sandbags under our shoulder straps. Sweat runs into our eyes, until we can hardly see. When a barrage comes we must keep on and take no notice, as even if we could find cover, there is none for the man on the stretcher….

‘…The rain has made the ground a sea of mud, and we have to carry the wounded three miles to the Dressing Stations, as the wheeled stretchers cannot be used at all. Two men using stretcher slings could not carry a man thirty yards, and I have seen four bearers up to their knees in mud, unable to move without further assistance.

By the time of the 3rd Battle of Ypres, it could take eight men to carry a stretcher half a mile to an aid post – and it could take them two hours to do it.

Even in ideal circumstances, manoeuvering a stretcher down a narrow, crowded trench was extremely difficult, ‘like trying to move a piano down an avenue of turnstiles.’  During major offensives a one-way system was in operation, and stretcher bearers were supposed to use only the ‘down’ trenches.  From the Aid Posts the RAMC stretcher-bearers of the Field Ambulance would take over from the regimental stretcher-bearers.  Here is one young novice, Private A.F. Young with the 2n3/4th London Field Ambulance:

Step by step we picked our way over the duckboards. It is useless to try and maintain the regulation broken step to avoid swaying the stretcher. Slowly we wind our way along the trenches, our only guide our feet, forcing ourselves through the black wall of night and helped occasionally by the flash of the torch in front. Soon our arms begin to grow tired and the whole weight is thrown on to the slings, which begin to bite into our shoulders; our shoulders sag forward, the sling finds its way on to the back of our necks; we feel half-suffocated. A twelve-stone man, rolled up in several blankets on a stretcher, is no mean load to carry, and on that very first trip we found that the job had little to do with the disciplined stretcher-bearing we had spent so many weary hours practising. We are automatons wound up and propelled by one fixed idea, the necessity of struggling forward. The form on the stretcher makes not a sound; the jolts, the shakings seem to have no effect on him. An injection of morphine has drawn the veil. Lucky for him.  

Stretcher-bearers changed – they worked in relays close to the front – but the stretcher remained the same.  Ideally the wounded soldier would remain on his stretcher only as far as the Casualty Clearing Station, from where used stretchers would be returned to dressing stations and aid posts by now empty ambulances.  

Twelve stretchers were supposed to be kept at every Regimental Aid Post, but supplies could easily run out.  When Major Sidney Greenfield was wounded, he remembered:

… the call ‘stretcher-bearers’, ‘stretcher-bearers’, the reply ‘No stretchers’. ‘Find one, it’s an officer.’

And it was not uncommon for those evacuated ‘in a rush’ to remain on their stretcher until the base hospital; and since ambulance trains heading to the coast were less urgent than troop trains and supply trains heading in the opposite direction the journey was usually a slow one.  If the nearest hospital turned out to be full, a not uncommon occurrence, the train would be sent on to the next available one, thus prolonging the journey still more.    

H.G. Hartnett recalled the sheer pleasure of finally being put to bed at the base hospital at Wimereux:

After being washed and changed into clean pyjamas I was lifted off the stretcher on which I had lain for five days and nights into a soft bed—between sheets.

The contrast, of course, was not only with the canvas stretcher but with sleeping in the trenches wrapped in a groundsheet.

Before the widespread introduction of the Thomas splint (above), ordinary or even improvised splints were used.  Here is Sister Kate Luard on board an ambulance train in October 1914:

The compound-fractured femurs were put up with rifles and pick-handles for splints, padded with bits of kilts and straw; nearly all the men had more than one wound – some had ten; one man with a huge compound fracture above the elbow had tied on a bit of string with a bullet in it as a tourniquet above the wound himself.

A fractured femur would turn out to be one of the most common injuries, described by Robert Jones as ‘the tragedy of the war’: if fractures were not properly splinted the soldier would arrive at the Casualty Clearing Station in a state of shock caused by excessive blood loss and pain:

‘These men required radical surgery to save their limbs and lives… Entry and exit wounds would have to be extended widely, removing all dead skin and fat… The bone ends of the femur at the fracture site would then have to be pulled out of the wound and be inspected directly [for loose fragments of bone, clothing and debris]… Wounded soldiers arriving at casualty clearing stations with a weak pulse and low blood pressure secondary to excess blood loss due to inadequately splinted fractures would be unlikely to survive the major procedure’ – let alone the amputations that were often administered.

Mortality rates in such circumstances were around 50 per cent. The Thomas splint was specifically designed to immobilise a fractured femur, and by April/May 1917 its use during the battle of Arras had reduced the mortality rate to 15 per cent, and far fewer men lost their legs: see Thomas Scotland, ‘Developments in orthopaedic surgery’, in Thomas Scotland and Stephen Heys (eds) War surgery 1914-1918.

Stretcher bearers were trained to apply the splint in the field, as in this case, but one senior officer made it clear that in any event it had to be applied no later than the Regimental Aid Post:

The Thomas thigh splint should be applied with the boot and trousers on, the latter being cut at the seam to enable the wound to be dressed. The method of obtaining extension by means of a triangular bandage has been sketched and circulated to all MOs in the Divn. After the splint is adjusted it should be suspended both at the foot and at the ring by two tapes at either end tied to the iron supports one of which is fitted to the stretcher opposite the foot and one opposite the hip.

More information on this truly vital innovation: P.M. Robinson and M. J. O’Meara, ‘The Thomas splint: its origins and use in trauma’, Journal of bone and joint surgery 91 (2009) 540-3: never in my wildest dreams did I imagine reading or referencing such a journal – but it is an excellent and thoroughly accessible account.  See for yourself here.

It was vital not to leave a tourniquet on for long.  Here is one RAMC officer, Captain Maberly Esler, recalling his service on the Somme in June 1915:

If a limb had been virtually shot off and they were bleeding profusely you could stop the whole thing by putting a tourniquet on, but you couldn’t keep it on longer than an hour without them losing the leg altogether. So it was necessary to get the field ambulance as soon as possible so they could ligature the vessels, and the quicker that was done the better.

Lt Col Henderson‘s pencilled notes on the treatment of the wounded (1916-16) urged stretcher bearers to make every effort to stop bleeding with a compress or bandage: ‘ A tourniquet should only be applied if this response fails and where a tourniquet is applied the [Regimental Medical Officer] should be at once informed on the arrival of the case at the [Regimental Aid Post].’  By May 1916 Medical Officers were being warned ‘against too frequent use of the tourniquet, on the grounds that the dreaded gas bacillus (perfringens) is most likely to thrive in closed tissues.’

A tourniquet could aggravate damaged tissues and did indeed increase the risk of gangrene; 80 per cent of those whose limbs had a tourniquet applied for more than three hours required amputation.

This was a major responsibility; sometimes the card was filled in at a Dressing Station, sometimes at the Casualty Clearing Station.  George Carter‘s diary entry for 31 August 1915 explains its importance:

‘My work consists of nailing every patient and getting his number, rank, name, initial, service, service in France, age, religion, battalion and company. That is usually fairly plain sailing, I find, but entails a certain amount of searching [extracting paybook or diary, for example] when a patient is too ill to be bothered with questions. Then I have to find out what is the matter with him, what treatment he has had, and what is going to be done with him… The reason for taking these particulars and making out forms is to prevent any man being lost sight of, whatever happens to him. If he finishes in England after taking a week on the journey, he has got all his partics on him, everywhere he has stopped, the RAMC have been able to see at a glance all about him and can turn up all about him if called on.’

But things could easily go awry.  Here is one young soldier, Henry Ogle:

I think it must have been here [at the CCS] that orderlies tied Casualty Labels on our top tunic buttons, and got mine wrong, though it may have been at Louvencourt or even Hébuterne. Wherever it had happened, it was here that I first noticed it and called the attention of an orderly to it. I had been wounded in the right calf by part of a rifle bullet which penetrated deeply and remained in but I had been labelled for superficial something or other, while Frank Wallsgrove was GSW for gunshot wound. I said, ‘Mine’s wrong, for we two were hit by the same bullet.’ ‘Can’t alter your label, chum. Anyhow it doesn’t matter. It’ll get proper attention.’ We were already being packed into a train so nothing could be done and I didn’t worry about it.

At the base hospital he tried again:

An orderly came along (it was then dark night) and threw a nightgown and a towel at me. ‘Bathroom. Down that passage. On the right. Any of them.’ ‘Don’t think I can get there. Can’t walk.’ ‘Let’s see your label.’ ‘Label’s wrong.’ ‘What do you know about that? Go on.’ ‘I know a bloody sight more about it than you do, chum, but I’ll see what I can do.’ It was not easy as the leg was quite out of action and my orderly friend had no time to watch…  On crawling back I found Frank tucked into bed. Our case-sheets were clipped to boards which hung on the wall behind our beds and, so far, the items from our tunic labels had been copied out on the case-sheets. The next morning the customary round of visits was made by the Medical Officer on duty with Matron and Sister of Ward and an orderly or two. I tried to explain that my label was wrong and Frank backed me up but we were simply ignored. My wound was dressed as a surface wound.

It was only after the swelling of his leg alarmed Matron that Henry was shipped off for an X-ray that revealed the need for an operation to remove the bullet.

‘T’ for anti-tetanus serum.  In the first weeks of the war tetanus threatened to become a serious problem: on 19 October 1915 Sister Kate Luard recorded ‘a great many deaths from tetanus’ in her diary, but two months later she was able to note ‘The anti-tetanus serum injection that every wounded man gets with his first dressing has done a great deal to keep the tetanus under.’  In A Surgeon in Khaki, published in 1915, Arthur Andersen Martin confirmed that ‘every man wounded in France or Flanders today gets an injection of this serum within twenty-four hours of the receipt of the wound’ – at least, if he had been recovered in that time – and ‘no deaths from tetanus have occurred since these measures were adopted.’

More information: Peter Cornelis Wever and Leo van Bergen, ‘Prevention of tetanus during the First World War’, Medical Humanities 38 (2012) 78-82.

Morphine was administered for pain relief, but it still awaits its medical-military historian (unless I’ve missed something).

This was Boyle’s anaesthetic apparatus, but before the widespread availability of these machines a variety of systems was in use and, in the heat of the moment, the administration of anaesthesia was often far removed from the clinical, calibrated procedures the machine made possible. Here is a chaplain who served at No 44 Casualty Clearing Station:

I spent most of my time giving anaesthetics. I had no right to be doing this, of course, but we were simply so rushed. We couldn’t get the wounded into the hospital quickly enough, and the journey from the battlefield was terrible for these poor lads. It was a question of operating as quickly as possible. If they had had to wait their turn in the normal way, until the surgeon was able to perform an operation with another doctor giving the anaesthetic, it would have been too late for many of them. As it was, many died.

The most fortunate patients were those who had little or no recollection of the procedure.  Here is H.G. Hartnett on his experience at No 15 Casualty Clearing Station (the second occasion he was wounded):

 I was destined for surgery and lay in agony on my stretcher until near 9.00 pm, when orderlies carried me into a brilliantly lit operating theatre. I was placed on the centre one of three operating tables where I lay watching doctors and nurses completing an operation on another patient only a few feet from where I lay. When my turn came my wound was uncovered and a doctor placed a mask over my face. Then he asked me the name of the colonel of my battalion as he administered the anaesthetic. I remember no more about the operation or the theatre. When I returned to brief consciousness about 4.00 am the next morning I was lying on a stretcher on the ground in a large canvas marquee, in the third position on my side of it. Others had been carried in during the night, all from the operating theatre. The fumes of the anaesthetic from their clothes and blankets continued to put us off to sleep again. The day was well advanced when I finally returned to full consciousness.  

In the early years of the war anaesthesia was not a recognised speciality – and chloroform was the most widely used agent – but as the tide of wounded surged, operative care became more demanding and Casualty Clearing Stations assumed an increasing operative load so it became necessary to refine both its application and the skills of those who administered it.   In the British Army advances in anaesthesia were pioneered by Captain Geoffrey Marshall at No 17 Casualty Clearing Station at Remy Siding near Ypres from 1915.  By then nitrous oxide and oxygen were commonly used for short operations (which did not mean they were minor: they included guillotine amputations) but longer procedures typically relied on chloroform and ether.  A crucial disadvantage of chloroform was that it lowered blood pressure in patients who had often already lost a lot of blood.  ‘If chloroform be used,’ Marshall warned, ‘the patient’s condition will deteriorate during the administration, and he will not rally afterwards.’  And while ether would often produce an improvement during the operation, this was typically temporary: ‘the after-collapse [would be] more profound and more often fatal.’   His achievement was to show that a combination of nitrous oxide, oxygen and ether significantly improved survival rates for complex procedures – from 10 per cent to 75 per cent for leg amputations – and to have a machine made to regulate the combination of the three agents.  His design was copied and modified by Captain Henry Boyle, whose name became attached to the device.  

More information: Geoffrey Marshall, ‘The administration of anaesthetics at the front’, in British medicine in the war, 1914-1917N.H. Metcalfe, ‘The effect of the First World War (1914-1918) on the development of British anaesthesia’, European Journal of Anaesthesiology 24 (2007) 649-57; E. Ann Robertson, ‘Anaesthesia, shock and resuscitation’, in Thomas Scotland and Steven Heys (eds) War surgery, 1914-1918.

Bovril was advertised in all these ways; the company used a sketch of the Gallipoli campaign to claim that Bovril would ‘give strength to win’ and that it was a ‘bodybuilder of astonishing power’.  In 1916 the company even published an extract from a letter purported to come from the Western Front, accompanied by an image of an RAMC Field Ambulance tending a wounded soldier: 

But for a plentiful supply of Bovril I don’t know what we should have done.  During Neuve Chapelle and other engagements we had big cauldrons going over log fires, and as we collected and brought in the wounded we gave each man a good drink of hot Bovril and I cannot tell you how grateful they were.

Oxo seems to have been less popular, and least for any supposed medicinal or restorative properties, but it was often sent to soldiers by their families at home.  One advertising campaign enjoined them to ‘be sure to send Oxo’, and in one ad a Tommy writes home to say that when he returned to his billet to find the parcel, ‘the first thing I did was to make a cup of OXO and I and my chums declared on the spot this cup of OXO was the best drink we had ever tasted.’  

The image shows a surgeon using a fluoroscope to locate the fragments of the bullet:

An early Crookes x-ray tube visible under the table emits a beam of x-rays vertically through the patient’s body. The surgeon wears a large fluoroscope on his face, a screen coated with a fluorescent chemical such as calcium tungstate which glows when x-rays strike it. The x-ray image of the patient’s body appears on the screen, with the bullet fragments appearing dark.

The ‘partner’ referred to was the Hirtz compass (visible on the left of the image).  According to one standard military-medical history:

The essential feature of the H[i]rtz compass is the possibility of adjustment of the movable legs that support the instrument, so that when resting on fixed marks on the body of the patient the foreign body will be at the center of asphere, a meridian arc of which is carried by the compass. This arc is capable of adjustment in any position about a central axis. An indicating rod passes through a slider attached to the movable arc in such a way as to coincide in all positions with a radius of the sphere, and whether it actually reaches the center or not it is always directed toward that point. If its movement to the center of the sphere is obstructed by the body of the patient, the amount it lacks of reaching the center will be the depth of the projectile in the direction indicated by the pointer.

The value of the compass lies in its wide possibility as a surgical guide, in that it does not confine the attention of  the surgeon to a single point marked on the skin, with a possible uncertainty as to the direction in which he should proceed in order to reach the projectile, but gives him a wide latitude of approach and explicit information as to depth in a direction of his own selection.

The compass built on Gaston Contremoulins‘ attempts at ‘radiographic stereotaxis’; it could usually locate foreign objects to within 1-2 mm: much more than you could possibly want here.

The reassuring scientificity of all this is tempered by a cautionary observation from a wounded officer, Major Sidney Greenfield, who was X-rayed at a Casualty Clearing Station: 

My next recollection was the x-ray machine and two young fellows who were operating it. Apparently the operator had been killed the previous night by a bomb on the site and these two were standing in with little or no experience of an x-ray machine. Their conversation was far from encouraging and was roughly like this: ‘Now we have got to find where it is … is it this knob?’ ‘No.’ ‘Try that one.’ ‘Try turning that one.’ ‘No, that doesn’t seem to be right.’ ‘Ah, There it is.’ ‘Where’s the pencil. We must mark where it is. Now we have to find out how deep it is.’ After some time they seemed to be satisfied. In my condition and knowing little about electrical machines such as x-ray I wondered whether I should be electrocuted and was more relaxed when I was taken back to bed.

Incidentally, X-rays were called Roentgen rays (after the scientist Wilhelm Roentgen who discovered them in 1895) but the British antipathy towards all things German saw them re-named ‘X-rays’ from 1915: Alexander MacDonald, ‘X-Rays during the Great War’, in Thomas Scotland and Steven Heys (eds) War surgery, 1914-1918.

In addition to these terse communications, nurses and chaplains usually wrote to relatives on behalf of their patients. It was seen as a sacred duty, but it often seemed to be a never-ending task.  On 1 August 1917 Sister Kate Luard confided in her diary: ‘I don’t see how the “break-the-news” letters are going to be written, because the moment for sitting down literally never comes from 7 a.m. to midnight.’  In the case shown here, Sister Kathleen Mary Latham had written to Lt Hopkins’s wife on 12 November 1917 from a Casualty Clearing Station to say that

‘your husband has been brought to this hospital with wounds of the legs, arms, hand and face.  He has had an operation and is going on well. Unfortunately it was found necessary to remove the left eye as it was badly damaged, but he can see with the other though the lid is swollen and he cannot use it yet.  No bones are broken.  It will not be advisable for you to write to this address as he will probably be going on to the base in a day or two.’

The telegram from the War Office is dated three days later, by which time Hopkins had reached the base hospital at Le Touquet.  Sister Latham’s earlier account of her work at Casualty Clearing Station No. 3 at Poperinghe in 1915 is here.

***

In Durham, Louise Amoore pressed me on the anthropomorphism that seems inescapable in a narrative like this; it worries me too (I’ve always been leery of Bruno Latour‘s Aramis for that very reason).  I tried removing the ‘I’ and substituting an ‘it’ but I found doing so destroyed both the operative agency of the objects and, perhaps more important, the transient, enforced intimacy between them and the soldier’s body.  That intimacy was more than physical, I think.  I’ve already cited the reassurance provided by the prick of a needle, the whiteness of a new bandage; but the mundanity of objects could also be disorientating, intensifying an already intense sur-reality.  Here, for example, is Gabriel Chevallier recalling the moment when he and his comrades went over the top:

The feeling of being suddenly naked, the feeling that there is nothing to protect you. A rumbling vastness, a dark ocean with waves of earth and fire, chemical clouds that suffocate. Through it can be seen ordinary, everyday objects, a rifle, a mess tin, ammunition belts, a fence post, inexplicable presences in this zone of unreality.

Aramis also alerted me to another, and perhaps even more debilitating dilemma: a latent functionalism in which everything that is pressed into service works to carry the soldier through the evacuation chain.  That seems unavoidable in a narrative whose telos is precisely the base hospital and Blighty beyond.  Yet we know that, for all the Taylorist efficiency that was supposed to orchestrate the evacuation system in this profoundly industrial war, in many cases the chain was broken, another life was lost or permanently, devastatingly transformed.  As you can see, I’ve tried to do something about that with some of the objects I’ve selected.

I’ll probably add more objects: this is very much a work in progress, and I’m not sure where it will go – so as always, I’d welcome any constructive comments or suggestions.  Any written version would involve longer descriptions, I think, and would probably dispense with most of the scaffolding of notes I’ve erected here (though some of it could and probably should be incorporated into the descriptions).