Digital Militarisms

Posted on July 20, 2016 by Derek Gregory

News from Lucy Suchman of a special issue of Catalyst: Feminism, Theory, and Technoscience on Digital Militarisms. Here is a list of the articles plus abstracts; all are available for download here (open access).

Configuring the Other: Sensing War through Immersive Simulation – Lucy Suchman

This paper draws on archival materials to read two demonstrations of FlatWorld, an immersive military training simulation developed between 2001 and 2007 at the University of Southern California’s Institute for Creative Technologies. The first demonstration is a video recording of a guided tour of the system, staged by its designers in 2005. The second is a documentary created by the US Public Broadcasting Service as part of their “embedded” media coverage of the system while it was installed at California’s Camp Pendleton in 2007. I critically attend to the imaginaries that are realized in the simulation’s figurations of places and (raced, gendered) bodies, as well as its storylines. This is part of a wider project of understanding how distinctions between the real and the virtual are effectively elided in technoscientific military discourses, in the interest of recognizing real/virtual entanglements while also reclaiming the differences that matter.

***

Military Utopias of Mind and Machine – Emily Cohen Ibañez

The central locus of my study is southern California, at the nexus of the Hollywood entertainment industry, the rapidly growing game design world, and military training medical R&D. My research focuses on the rise of military utopic visions of mind that involve the creation of virtual worlds and hyper-real simulations in military psychiatry. In this paper, I employ ethnography to examine a broader turn to the senses within military psychology and psychiatry that involve changes in the ways some are coming to understand war trauma, PTSD, and what is now being called “psychological resilience.” In the article, I critique assumptions that are made when what is being called “a sense of presence” and “immersion” are given privileged attention in military therapeutic contexts, diminishing the subjectivity of soldiers and reducing meaning to biometric readings on the surface of the body. I argue that the military’s recent preoccupation with that which can be described as “immersive” and possessing a sense of presence signals a concentrated effort aimed at what might be described as a colonization of the senses – a digital Manifest Destiny that envisions the mind as capital, a condition I am calling military utopias of mind and machine. Military utopias of mind and machine aspire to have all the warfare without the trauma by instrumentalizing the senses within a closed system. In the paper, I argue that such utopias of control and containment are fragile and volatile fantasies that suffer from the potential repudiation of their very aims. I turn to storytelling, listening, and conversations as avenues towards healing, allowing people to ascribe meaning to difficult life experiences, affirm social relationships, and escape containment within a closed language system.

***
Simulated War: Remediating Trauma Narratives in Military Psychotherapy – Marisa Renee Brandt

How have the politics of therapy been reconfigured during the so-called Global War on Terror? What role have the new virtual reality therapies that so resemble other forms of military simulation played in this reconfiguration? In this article, I draw upon feminist science and technology’s (STS) theorization of human-machine interaction into order to interrogate how contemporary therapies for treating post-traumatic stress disorder (PTSD) reconfigure agency in the practice of healing. Analyzing trauma therapy as a site of reconfiguration, I show how new exposure-based therapies for PTSD—both with and without virtual reality—configure aspects of human subjectivity, such as memory, affect, and behavior, as objects for technological intervention. Through comparative analysis of different modalities of PTSD treatment, I show that the politics of therapy is especially enacted through the therapeutic remediation of trauma narratives: the mediational practices through which a traumatic memory is made available for therapeutic reworking. Therapeutic remediation practices configure therapists, patients, and nonhuman actants as subjects and objects with different forms of agency.

***
Weaponizing Affect: A Film Phenomenology of 3D Military Training Simulations during the Iraq War – D. Andy Rice

This article critically considers the relation between simulation design and human experience through the analysis of three-dimensional military training simulation scenarios developed between 2003 and 2012 at the Fort Irwin National Training Center in the Mojave Desert of California. Following news reports of torture at Abu Ghraib, the US military began to implement “cultural awareness” training for all troops set to deploy to the Middle East. The military contracted with Hollywood special-effects studios to develop a series of counterinsurgency warfare immersive-training simulations, including hiring Iraqi-American and Afghan-American citizens to play villagers, mayors, and insurgents in scenarios. My primary question centers on the military technoscience of treating human bodies as variables in a reiterative simulation scenario. I analyze interviews with soldiers and actors, my own experiences videotaping training simulations at the fort, and the accounts of many other visiting journalists and filmmakers across time. From this, I contend that the stories participants tell about simulation experiences constitute one key outcome of the simulation itself, blunting dissent and aiding the fort’s long-term efforts to retain clout and funding in the face of wars whose intensity fluctuates. I treat the ongoing cinematic performances on the fort as a kind of “simulation body” unbounded by skin, a theoretical framework drawn from Vivian Sobchack’s (1992) film phenomenological concept of the “film body” and affect theory grounded in the work of Kara Keeling (2007), as well as Eve Sedgwick (2003), Sedgwick and Adam Frank (1995), and Lisa Cartwright (2008), by way of American behavioral psychoanalyst Silvan Tomkins (2008).

***

Tactical Tactility: Warfare, Gender, and Cultural Intelligence – Isra Ali

The participation of women in the landscape of warfare is increasingly visible; nowhere is this more evident than in the US military’s global endeavors. The US military’s reliance on cultural intelligence in its conceptualization of engagement strategies has resulted in the articulation of specific gendered roles in warfare. Women are thought to be particularly well suited to non-violent tactile engagements with civilians in war zones in Iraq and Afghanistan because of gender segregation in public and private spaces. Women in the military have consequently been able to argue for recognition of their combat service by framing this work in the war zone as work only women can do. Women reporters have been able to develop profiles as media producers, commentators, and experts on foreign policy, women, and the military by producing intimate stories about the lives of civilians only they can access. The work soldiers and reporters do is located in the warzone, but in the realms of the domestic and social, in the periods between bursts of violent engagement. These women are deployed as mediators between civilian populations in Afghanistan and Iraq and occupying forces for different but related purposes. Soldiers do the auxiliary work of combat in these encounters, reporters produce knowledge that undergirds the military project. Their work in combat zones emphasizes the interpersonal and relational as forms of tactile engagement. In these roles, they are also often mediating between the “temporary” infrastructure of the war zone and occupation, and the “permanent” infrastructure of nation state, local government, and community. The work women do as soldiers and reporters operates effectively with the narrative of militarism as a means for liberating women, reinforcing the perception of the military as an institution that is increasingly progressive in its attitudes towards membership, and in its military strategies. When US military strategy focuses on cultural practice in Arab and Muslim societies, commanders operationalize women soldiers in the tactics of militarism, the liberation of Muslim women becomes central in news and governmental discourses alike, and the notion of “feminism” is drawn into the project of US militarism in Afghanistan and Iraq in complex ways that elucidate how gender, equality, and difference, can be deployed in service of warfare.

***
A Drone Manifesto: Re-forming the Partial Politics of Targeted Killing –Katherine Fehr Chandler

Debates about today’s unmanned systems explain their operation using binary distinctions to delimit “us” and “them,” “here” and “there,” and “human” and “machine.” Yet the networked actions of drone aircraft persistently undo these oppositions. I show that unmanned systems are dissociative, not dualistic. I turn to Haraway’s “A Cyborg Manifesto” (1991) to reflect on how drones rework limits ranging from the scale of bodies to geopolitical territories, as well as the political challenges they entail. The analysis has two parts. The first considers how Cold War drones fit into cybernetic discourse. I examine the Firebee, a pilotless target built in the aftermath of World War II, and explore how the system acts as if it were guided by machine responses even though human control remains integral to its operation. The second part considers how contemporary discussions of drone aircraft, both for and against the systems, rely on this dissociative logic. Rather than critiquing unmanned aircraft as dehumanizing, I argue that responses to drones must address the interconnections they produce and call for a politics that puts together the dissociations on which unmanned systems rely.

***
Introduction to Attachments to War: Violence and the Production of Biomedical Knowledge in Twenty-first Century America – Jennifer Terry

This is an excerpt from Jennifer Terry’s book, Attachments to War: Violence and the Production of Biomedical Knowledge in Twenty-first Century America, forthcoming 2017.

‘Dearer to the Vultures’

Posted on June 5, 2016 by Derek Gregory

Over at the Paris Review Scott Beauchamp has a beautiful short essay that complements my own reading of Harry Parker‘s Anatomy of a Soldier: ‘Dearer to the Vultures‘.

Here’s how it begins:

My memories of war are fractured: faces disappear like smoke while literal plumes of smoke, their specific shapes and forms, linger on vividly for years. I remember the mesh netting, concrete, and dust smell of tower guard, but the events of entire months are completely gone. I remember the sound of a kid’s voice, but not anything he actually said. I guess that’s what Tim O’Brien meant when he wrote about Vietnam, “What sticks to memory, often, are those odd little fragments that have no beginning or end.”

Memories of people, too complex to carry through the years, fall apart. It’s easier to find purchase on memories of objects. The weapon I was assigned on my first deployment to Iraq was an M249 SAW, or what we would colloquially and inaccurately refer to as the “Squad Assault Weapon.” I remember the way it felt to disassemble—the slight give of the heat-shield assembly, its tiny metal pincers clinging to the barrel. I remember the sound of the feed tray snapping shut on a belt of ammunition. And I remember the tiny rust deposits on the legs of my weapon’s bipod, which would never go away, no matter how hard I scrubbed with CLP (Cleaner, Lubricant, and Protectant oil). I remember my SAW’s voice and the things it said.

During my second deployment, I served as the gunner in a Bradley Fighting Vehicle. We ran over two Soviet-era landmines that had been stacked on top of each other. Besides a few bruises and perforated eardrums, everyone in the crew was fine. When I would try to tell people the story back home, civilians would get caught up on the descriptions of objects they had never heard of, objects that were integral to understanding my experience of the event. “Were you hurt?” Not really, I’d say, but my head slammed against the ISU, and since we had the BFT mounted in a weird place, that sort of got in the way. “What’s an ISU and a BFT?”

I came to realize that the barrier in explaining my injuries to civilians wasn’t quite phenomenological so much as it was ontological. Everyone has experienced pain, fear, and frustration, but not everyone knows what an Integrated Sight Unit is or has had their face slammed into one. Even in just trying to narrate the events to family members, it seemed like any understanding of my trauma would have to come through a knowledge of the materials around me that made the trauma possible: the ISU, the Bradley Fighting Vehicle, the way the tracks moved, the type of soil underneath the tracks, how the mine mechanism worked, the radios we used to call in the explosion to base.

Harry Parker, a former British Army Captain, recently published Anatomy of a Soldier, a novel that puts forward an object-oriented ontology of war: an assertion that the material objects sharing the battleground with humans play an equal role in the composition of reality itself.

And the rest is equally worth reading, including some interesting reflections on ‘the rush from the intimate to the inanimate’ –and its limitations.

I first wrote about Anatomy of a Soldier here, followed it up with a notice of an interview with Harry Parker at the Imperial War Museum here (where I’m currently working, deep in the Research Room), and finally summarised my conference presentation on the book and its implications in San Francisco here (‘Object Lessons’: the presentation slides are available under the DOWNLOADS tab).

In the footsteps of war

Posted on May 10, 2016 by Derek Gregory

An update to my discussion of ‘The prosthetics of military violence‘: Gizmodo has published an arresting series of images from the ICRC’s rehabilitation centre in Kabul. As Jamie Condliffe notes, and as I tried to show in that extended post:

Last week, bioengineering’s most advanced prosthetics were shown off at the world’s largest orthopedics event in Germany. But in Afghanistan, things are a little different.

These photographs, from AP, show the work being carried out at the International Committee of the Red Cross’s physical rehabilitation center in Kabul, Afghanistan. There, those who have suffered the loss of a limb — whether children with birth defects or adults who’ve been injured in war — are fitted with the best prosthetics the ICRC can provide.

As you can see, they’re not quite as advanced as those shown off in Germany last week. Think less of carbon fiber and 3D printing, and more of plaster and orbital sanders.

An Afghan employee of the International Committee of the Red Cross (ICRC) works on a prosthetic leg at the ICRC physical rehabilitation center in Kabul, Afghanistan, Tuesday, May 10, 2016. Afghanistan is one of the world’s most heavily mined countries. (AP Photo/Rahmat Gul)

You can find many more remarkable photographs from the ICRC centre at Getty Images here.

‘Acceptable CIVCAS is 0’

Posted on April 29, 2016 by Derek Gregory

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).

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.

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.

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.

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.

Wounded

Posted on April 27, 2016 by Derek Gregory

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.

Much more to come!

The Geographies of Sixty Minutes

Posted on April 14, 2016 by Derek Gregory

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)

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.

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.’

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):

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:

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:

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):

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]:

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].’

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.

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.

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.

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.

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)

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.

Trauma Central

Posted on April 13, 2016 by Derek Gregory

To more than supplement my notes on the US air attack on the MSF hospital in Kunduz last October, two first-hand accounts have just been published. The first is by Dr Evangeline Cua, a Philippina surgeon who was on duty in the Trauma Centre when the attack started. She describes, in extraordinary detail, her work before the attack and then the nightmare (that keeps returning to haunt her, long after she has left Afghanistan):

We were like two headless chickens running in total darkness — me and the surgeon who assisted me in an operation. The nurses who were with us a moment ago had run outside the building, braving the volley of gunshots coming from above. I was coughing, half-choked by dust swirling around the area. Behind my surgical mask, my mouth was gritty, as if somebody forced me to eat sand. I could hear my breath rasping in and out. Layers of smoke coming from a nearby room made it hard to see where we were. Blinking around, I caught sight of a glow, from a man’s hand holding a phone. He seemed mortally wounded but was still trying to send a message…perhaps to a loved one?

I stood transfixed, not knowing where to turn or what to do. All around us, bombing continued in regular intervals, shaking the ground, sending debris sweeping and flying. One. Two. Three. I tried to count but there seems to be no abatement to the explosions. I stopped counting at eight and silently prayed that we could get out of there alive.
Fire licked at the roof at one end of the building, dancing and sparkling in the dark, reaching towards the branches of the trees nearby. The ICU was burning.

The second is by Dr Kathleen Thomas, an Australian doctor who was in charge of both the ICU and the ER (more from her here):

Dr Osmani [below] was the senior doctor in the unit the night the fighting started and decided to stay with us, camping out in the hospital throughout the week. He had nothing with him except the clothes on his back, not even a toothbrush. His family were extremely worried for his welfare. He had a constant flow of phone calls checking on him, probably asking him to leave. We all knew that at times, our hospital was in the middle of the rapidly changing front line – we could feel it. When the fighting was close – the shooting and explosions vibrated the walls. I was scared – we were all scared. When a loud “BOOM” would sound a bit closer to the hospital, we would all drop to the floor away from the large windows that lined the ICU walls. We also tried to move the patients and large (flammable) oxygen bottles away all from the windows, but the layout of the ICU prohibited doing this effectively. I worried constantly about the exposure from those windows – yet never thought to worry about the exposure from the roof.

By the end of the week we were physically, mentally and emotionally exhausted. There were moments when a sense of hopelessness overwhelmed us. Dr Osmani expressed these sentiments on the final day, following a tragic incident where a family trying to escape Kunduz was caught in crossfire, killing several children at the scene, then two more dying in our ER and OT. The remaining children were being treated with severe injuries, he stated: “the people are being reduced to blood and dust. They are in pieces.”

She continues:

When the US military’s aircraft attacked our hospital, its first strike was on the ICU. With the exception of one three-year-old, all the patients in the unit died. The caretakers with the patients died. Dr Osmani died. The ICU nurses Zia and Strongman Naseer died. The ICU cleaner Nasir died. I hope with all my heart that the three sedated patients in ICU, including our ER nurse Lal Mohammad, were deep enough to be unaware of their deaths – but this is unlikely. They were trapped in their beds, engulfed in flames.

The plane hit with alarming precision. Our ER nurse Mohibulla died. Our ER cleaner Najibulla died. Dr Amin suffered major injuries but managed to escape the main building, only to then die an hour later in the arms of his colleaguesas we desperately tried to save his life in the makeshift operating theatre set up in the kitchen. The OT nurse Abdul Salam [below] died. The strikes tore through the outpatients department, which had become a sleeping area for staff. Dr Satar died. The medical records officer Abdul Maqsood died. Our pharmacist Tahseel was lethally injured. He also made it to safety in the morning meeting room, only to die soon after. He bled to death. Two of the watchmen, Zabib and Shafiq, also died.

Our colleagues didn’t die peacefully like in the movies. They died painfully, slowly, some of them screaming out for help that never came, alone and terrified, knowing the extent of their own injuries and aware of their impending death. Countless other staff and patients were injured; limbs blown off, shrapnel rocketed through them, burns, pressure-wave injuries of the lungs, eyes and ears. Many of these injures have left permanent disability. It was a scene of nightmarish horror that will be forever etched in my mind.

More details on the MSF employees killed in the strike can be found here. There is still no sign of the US’s internal investigation into the attack being released.

Earlier this month, six months after the attack, MSF confirmed that it had still not decided whether to reopen the Trauma Centre:

We first need to obtain clear reassurances from all parties to the conflict that our staff, patients and medical facilities will be safe from attack. We need to know that the work of our doctors, nurses and other staff will be fully respected in Kunduz and in all places where we work in Afghanistan. We require assurances that we can work according to our core principles and to international humanitarian law: namely, that we can safely treat all people in need, no matter who they are, or for which side they may fight. Our ability to operate hospitals on the frontline in Afghanistan and in conflict zones everywhere depends on the reaffirmation of these fundamental principles.

Anatomy of a soldier

Posted on March 30, 2016 by Derek Gregory

I’ve drawn attention to Harry Parker‘s spellbinding Anatomy of a Soldier in an earlier post; here at the AAG in San Francisco I may even be speaking about it tomorow – we’ll see. (I’m supposed to be speaking about something else altogether but it’s in a session on’ Objects of security and war’, so I’m half-way through a new presentation, ‘Object lessons’).

Channel Four has posted an interview with the author at the Imperial War Museum on YouTube:

And there’s another interview with the BBC here.

Red Cross-Fire

Posted on March 15, 2016 by Derek Gregory

Yet more on violations of medical neutrality in contemporary conflicts (see my posts here, here, here and here). Over at Afghan Analysts Network Kate Clark provides a grim review of (un)developments in Afghanistan, Clinics under fire? Health workers caught up in the Afghan conflict.

Those providing health care in contested areas in Afghanistan say they are feeling under increasing pressure from all sides in the war. There have been two egregious attacks on medical facilities in the last six months: the summary execution of two patients and a carer taken from a clinic in Wardak by Afghan special forces in mid-February – a clear war crime – and the United States bombing of the Médecins Sans Frontières (MSF) hospital in Kunduz in October 2015, which left dozens dead and injured – an alleged war crime. Health professionals have told AAN of other violations, by both pro and anti-government forces. Perhaps most worryingly, reports AAN Country Director Kate Clark, have been comments by government officials, backing or defending the attacks on the MSF hospital and Wardak clinic [see image below].

So, for example:

Afghan government reactions to the news of the Wardak killings [at Tangi Sedan during the night of 17/18 February 2016; see also here] came largely at the provincial level, from officials who saw no problem in those they believed were Taleban – wounded or otherwise – being taken from a clinic and summarily executed. Head of the provincial council, Akhtar Muhammad Tahiri, was widely quoted, saying: “The Afghan security forces raided the hospital as the members of the Taliban group were being treated there.” Spokesperson for the provincial governor, Toryalay Hemat, said, “They were not patients, but Taliban,” and “The main target of the special forces was the Taliban fighters, not the hospital.” Spokesman for Wardak’s police chief, Abdul Wali Noorzai, said “Those killed in the hospital were all terrorists,” adding he was “happy that they were killed.”

Yet, the killings were a clear war crime. The Laws of Armed Conflict, also known as International Humanitarian Law, give special protection to medical facilities, staff and patients during war time – indeed, this is the oldest part of the Geneva Conventions. The Afghan special forces’ actions in Wardak involved numerous breaches: forcibly entering a medical clinic, harming and detaining staff and killing patients. The two boys and the man who were summarily executed were, in any case, protected either as civilians (the caretaker clearly, the two patients possibly – they had claimed to have been injured in a motorbike accident) or as fighters who were hors d’combat (literally ‘out of the fight’) because they were wounded and also then detained. Anyone who is hors d’combat is a protected person under International Humanitarian Law and cannot be harmed, the rationale being that they can no longer defend themselves. It is worth noting that, for the staff at the clinic to have refused to treat wounded Taleban would also have been a breach of medical neutrality: International Humanitarian Law demands that medical staff treat everyone according to medical need only.

That the Wardak provincial officials endorsed a war crime is worrying enough, but their words echoed reactions from more senior government officials to the US military’s airstrikes on a hospital belonging to the NGO Médecins Sans Frontières on 3 October 2015. Then, ministers and other officials appeared to defend the attack by saying it had targeted Taleban whom they said were in the hospital (conveniently forgetting that, until the fall of Kunduz city became imminent when the government evacuated all of its wounded from the hospital except the critically ill, the hospital had largely treated government soldiers). The Ministry of Interior spokesman, for example, said, “10 to 15 terrorists were hiding in the hospital last night and it came under attack. Well, they are all killed. All of the terrorists were killed. But we also lost doctors. We will do everything we can to ensure doctors are safe and they can do their jobs.”

MSF denied there were any armed men in the hospital. However, even if there had been, International Humanitarian Law would still have protected patients and medical staff: they would still have had to have been evacuated and warnings given before the hospital could have been legally attacked.

Not surprisingly heads of various humanitarian agencies all reported that the situation was worsening:

“General abuses against medical staff and facilities are on the rise from all parties to the conflict,” said one head of agency, while another said, “We have a good reputation with all sides, but we have still had threats from police, army and insurgents.” The head of a medical NGO described the situation as “messy, really difficult”:

All health facilities are under pressure. We have had some unpleasant experiences, The ALP [Afghan Local Police] are not professional, not disciplined. If the ALP or Taleban take over a clinic, we rely on local elders [to try to sort out the situation]. We are between the two parties.

He described the behaviour of overstretched Afghan special forces as “quite desperate,” adding, “They are struggling, trying to be everywhere and get very excited when there’s fighting.” Most of them, he said, were northerners speaking little or no Pashto, which can make things “difficult for our clinics in the south.”

The head of another agency listed the problems his staff are facing:

“We have seen the presence of armed men in medical facilities, turning them into targets. We have seen violations by the ANSF [Afghan National Security Forces], damage done to health facilities that were taken over as bases to conceal themselves and fight [the insurgents] from. We have seen checkpoints located close to health centres. Why? So that in case of hostilities, forces can take shelter in the concrete building. We have seen looting. We have seen ANSF at checkpoints deliberately causing delays, especially in the south, including blocking patients desperately needing to get to a health facility. We can never be certain that [such a delay] was the cause of death, but we believe it has been.”

He said his medical staff had been threatened by “ANSF intervening in medical facilities at the triage stage, forcing doctors to stop the care of other patients and treat their own soldiers, in disregard of medical priorities.” Less commonly, but more dangerously for the doctors themselves, he said, was the threat of Taleban abduction. He described a gathering of surgeons in which all reported having been abducted from their homes at least once and brought to the field to attend wounded fighters “with all the dangers you can imagine along the road.” He said the surgeons were “forced to operate without proper equipment and forced to abandon their own patients in clinics because the abduction would last days.”

Locally, medical staff often try to mitigate threats from both government forces and insurgents by seeking protection first from the local community. One head of agency described their strategy:

“When we open a clinic, our first interlocutors are the elders. Everyone wants a clinic in their area, but we decide the location and make the elders responsible for the clinic… They have to give us a building – three to four rooms. All those who work in the clinic – the ambulance driver, the owner of the vehicle, everyone – come from the area. We also need the elders to deal with the parties… If the ALP or Taleban take over clinic, we always start with the elders [who negotiate with whoever has taken over the clinic].”

However, this tactic puts a burden on community elders who may not be able to negotiate if the ANSF, ALP or insurgents are also threatening them.

***

I’ve delayed following up my previous commentaries on the US airstrike on the MSF Trauma Center in Kunduz (here and here) because I had hoped the full report of the internal investigation carried out by the US military would be released: apparently it runs to 3,000-odd pages. I don’t for a minute believe that it would settle matters, but in any event nothing has emerged so far – though I’m sure it’s subject to multiple FOIA requests and, if and when it is released, will surely have been redacted.

All we have is an official statement by General John Campbell on 25 November 2015 (above), which described the airstrike as ‘a tragic, but avoidable accident caused primarily by human error’, and a brief Executive Summary of the findings of the Combined Civilian Casualty Assessment Team (made up of representatives from NATO and the Afghan government) which emphasised that those errors were ‘compounded by failures of process and procedure, and malfunctions of technical equipment.’

The parallel investigations identified a series of cumulative, cascading errors and malfunctions:

(1) The crew of the AC-130 gunship that carried out the attack set out without a proper mission brief or a list of ‘no-strike’ targets; the aircraft had been diverted from its original mission, to provide close air support to ‘troops in contact’, and was unprepared for this one (which was also represented as ‘troops in contact’, a standard designation meaning that troops are under hostile fire).

(2) Communications systems on the aircraft failed, including – crucially – the provision of video feeds to ground force commanders and the transmission of electronic messages (the AC-130 has a sophisticated sensor and communications suite – or ‘battle management center’ –on board, staffed by two sensor operators, a navigator, a fire control officer, and an electronic warfare officer, and many messages are sent via classified chat rooms).

The problem was apparently a jerry-rigged antenna that was supposed to link the AC-130 to the ground. Here is how General Bradley Heithold explained it to Defense One:

“Today, we pump full-motion video into the airplane and out of the airplane. So we have a Ku-band antenna on the airplane … the U-model…. On our current legacy airplanes, the solution we used was rather scabbed on: take the overhead escape hatch out, put an antenna on, stick it back up there, move the beams around. We’ve had some issues, but we’re working with our industry partners to resolve that issue.”

He added, “99.9 percent of the time we’ve had success with it. These things aren’t perfect; they’re machines.”

Heithold said that dedicated Ku-band data transfer is now standard on later models of the AC-130, which should make data transfer much more reliable.

(3) Afghan Special Forces in Kunduz had requested close air support for a clearing operation in the vicinity of the former National Directorate of Security compound, which they believed was now a Taliban ‘command and control node’. The commander of US Special Forces on the ground agreed and provided the AC-130 crew with the co-ordinates for the NDS building. He could see neither the target nor the MSF Trauma Center from his location but this is not a requirement for authorising a strike; he was also working from a map that apparently did not mark the MSF compound as a medical facility. According to AP, he had been given the coordinates of the hospital two days before but said he didn’t recall seeing them. The targeting system onboard the AC-130 was degraded and directed the aircraft to an empty field and so the crew relied on a visual identification of the target using a description provided by Afghan Special Forces – and they continued to rely on their visual fix even when the targeting system had been re-aligned (‘the crew remained fixated on the physical description of the facility’) and, as David Cloud points out, even though there was no visible sign of ‘troops in contact’ in the vicinity of the Trauma Center (‘An AC-130 is normally equipped with infrared surveillance cameras capable of detecting gunfire on the ground’):

Sundarsan Raghaven adds that ‘Not long before the attack on the hospital, a U.S. airstrike pummeled an empty warehouse across the street from the Afghan intelligence headquarters. How U.S. personnel could have confused its location only a few hours later is not clear…’ More disturbingly, two US Special Forces troops have claimed that their Afghan counterparts told their commander that it was the Trauma Center that was being used as the ‘command and control node’, and that the Taliban ‘had already removed and ransomed the foreign doctors, and they had fired on partnered personnel from there.’

(4) The aircrew cleared the strike with senior commanders at the Joint Operations Center at Bagram and provided them with the co-ordinates of the intended target. Those commanders failed to recognise that these were the co-ordinates of the MSF hospital which was indeed on the ‘no-strike’ list; ‘this confusion was exacerbated by the lack of video and electronic communications between the headquarters and the aircraft, caused by the earlier malfunction, and a belief at the headquarters that the force on the ground required air support as a matter of immediate force protection’;

(5) The strike continued even after MSF notified all the appropriate authorities that their clinic was under attack; no explanation was offered, though the US military claims the duration was shorter (29 minutes) than the 60-minutes reported by those on the ground.

Campbell announced that those ‘most closely associated’ with the incident had been suspended from duty for violations of the Rules of Engagement – those ‘who requested the strike and those who executed it from the air did not undertake the appropriate measures to verify that the facility was a legitimate military target’ – though he gave no indication how far up the chain of command responsibility would be extended; in January it was reported that US Central Command was weighing disciplinary action against unspecified individuals. In the meantime, solatia payments had been made to the families of the killed ($6,000) and injured ($3,000).

Not surprisingly, MSF reacted angrily to Campbell’s summary: according to Christopher Stokes,

‘The U.S. version of events presented today leaves MSF with more questions than answers. The frightening catalog of errors outlined today illustrates gross negligence on the part of U.S. forces and violations of the rules of war.’

Joanne Liu, MSF’s President, subsequently offered a wider reflection on war in today’s ‘barbarian times’, prompted by further attacks on other hospitals and clinics in Afghanistan, Syria, Yemen and elsewhere:

“The unspoken thing, the elephant in the room, is the war against terrorism, it’s tainting everything,” she said. “People have real difficulty, saying: ‘Oh, you were treating Taliban in your hospital in Kunduz?’ I said we have been treating everyone who is injured, and it will have been Afghan special forces, it will have been the Taliban, yes we are treating everybody.”

She added: “People have difficulty coming around to it. It’s the core, stripped-down-medical-ethics duty as a physician. If I’m at the frontline and refuse to treat a patient, it’s considered a crime. As a physician this is my oath, I’m going to treat everyone regardless.”

Kate Clark‘s forensic response to the US investigation of the Kunduz attack is here; she insists, I think convincingly, that

‘… rather than a simple string of human errors, this seems to have been a string of reckless decisions, within a larger system that failed to provide the legally proscribed safeguards when using such firepower. There were also equipment failures that compounded the problem but, again, if the forces on the ground and in the air had followed their own rules of engagement, the attack would have been averted.’

This is what just-in-time war looks like, but it’s not enough to blame all this on what General Campbell called a ‘high operational tempo’. As a minimum, we need to be able to read the transcripts of the ground/air communications – which are recorded as a matter of course, no matter what the tempo, and which are almost always crucial in any civilian casualty incident resulting from ‘troops in contact’ (see, for another vivid example, my discussion here) – to make sense of the insensible.

The last Bastion

Posted on March 6, 2016 by Derek Gregory

In between my other projects, I’m battling my way back to my current research on casualty evacuation. Reading about the military hospital at Camp Bastion in Afghanistan – you can find a bare-bones’ (sic) summary of its development in a series of linked reports from David Vassallo here, here and here (the plans above document its expansion from 2008 to 2010) – I came across the ethnographic work of Mark de Rond:

Cornell University Press are publishing a monograph based on his work later this year – Doctors at war: an ethnographer’s account of life and death in a field hospital – though so far I’ve been unable to track down any more details of what promises to be an essential study of combat casualty care (and Mark’s key interest, ‘teamwork’ – hence his study of the Cambridge Boat Race crew).

In the meantime, you can get a sense of what he calls ‘field work beyond the comfort zone’ from an essay, ‘Soldier, surgeon, photographer, fly’ that appeared in Strategic Organization 10 (3) (2012) 256-262, available open access here:

To treat major trauma effectively requires surgeons and anaesthetists to align their efforts in a context where the margin for error is small and the stakes matters of life and death. Yet even such close cooperation does not rule out rivalry. For leave these surgeons with little or nothing to do work-wise and they may turn on each other instead. Unable to sit still, some begin to interfere in the affairs of others or to compete for work. As one of the surgeons admitted: ‘He is fighting for work. I am fighting for work, each of us hoping the other will be late.’ Sebastian Junger described the troops he embedded himself with as so bored on occasion that ‘they prayed for contact [with the enemy] as farmers pray for rain’ (Hetherington, 2010: 15). Even when work is plentiful, surgeons may compete for the most interesting jobs.

As in Junger’s Korengal Valley, in Camp Bastion’s hospital periods of great intensity follow periods of boredom in which it is however impossible to relax or to put oneself to productive use; surgeons and warriors alike intentionally objectify casualties yet can feel callous for not caring more than they do. It is here that the extremes of busyness and boredom, significance and futility can change rapidly and unpredictably, and shift the balance between altruism and selfishness, pleasure and guilt, the thrill of warfare and cowardice. ‘In this kind of war’, wrote McCullin, ‘you are on a schizophrenic trip. You cannot equate what is going on with anything else in life. . . . None of the real world judgments seem to apply. What’s peace, what’s war, what’s dead, what’s living, what’s right, what’s wrong? You don’t know the answers’ (2002: 100–1).

I’m looking forward to reading Mark’s account alongside the remarkable work of David Cotterrell that I described in ‘Bodies on the line’ here.