Buses and tanks on the street

At a wonderful conference earlier this year in Roskilde I heard a stunning presentation about cross-cultural encounters and everyday racism on board Bus 5A in Copenhagen:

‘With more than 65,000 passengers a day, bus 5A is the busiest route in Copenhagen and the Nordic countries. Day and night, the bus cuts through the streets and connects different parts of the city. Bus 5A is iconic and loved, but also hated among bus drivers who have named it ‘the suicidal’ route and in everyday language refer to it as ‘Slamsugeren’ (suction vehicle) because it transports all kinds of people and connects many different places in the city. The bus starts in the suburb (Husum) and connects the multicultural part of Copenhagen (Nørrebro) with the more gentri ed inner city and the outskirts of Copenhagen, ending at the airport.’

The paper, by Lasse Koefoed, Mathilde Dissing Christensen and Kirsten Simonsen – which has been published in Mobilities (and from where I’ve borrowed these quotations) – describes a series of tactics pursued by passengers (and drivers) on the bus; for example:

‘… the dominant picture of the bus more often involves what we could call ‘the little racism’. A Pakistani immigrant describes this to us with a strong use of body language. He looks askance and moves a bit away from an imagined person next to him, wrinkles up his nose and says,‘Ashh’, in this way performing distanciation. Another respondent confirms this impression by telling: ‘You can feel it on the Danes, in particular when it is crowded’. She has difficulties finding words but talks about discomfort and anger. She is aware that she cannot rule herself out from the feeling:

I can see that I actually do it a bit myself. When a group of young immigrants enters the bus, then I strengthen my hold on my backpack or my bag. (Charlotte, passenger)

She recognises that it must be an unpleasant experience for the young men and feels a bit guilty, but she ‘tries to do it a little discreet[ly]’. What is at stake here is a sensing of an affective space, the more passive side of emotional experience, where emotions such as fear, discomfort, anger and disgust are circulating in the intense atmosphere of the crowded bus. This affective space is also at work as a background when young boys, asked about visions for the future, develop a utopia of a bus without racism.’

It’s a stimulating and provocative read, and it’s been on my mind for months since.  But it’s given a startling immediacy today by the new that Amnesty International has plastered a tank on the side of a Copenhagen bus.  Adweek reports:

The wrap makes a city bus look like a tank prowling the streets. “This is everyday life in Aleppo,” says the headline on the side, referring to the Syrian city devastated by the country’s civil war….

The idea is to remind people that while the Islamic State has left Aleppo [that’s a sentence that requires a good deal of qualification: to attribute the horrors of the siege of Aleppo to IS is not so much shorthand as sleight of hand], the Syrian war continues. The ad is also designed to raise awareness of refugees’ right to security from war and persecution.

“Everyone has the right to safety—also refugees,” says Claus Juul, legal consultant for Amnesty International. “It can be difficult to imagine what it is like to be human in a city, where one daily fears for one’s own and loved ones lives. Therefore, we have brought the everyday life of Aleppo to Copenhagen’s summer cityscape, so we, Danes, have the opportunity to face Syria’s brutal conflict.”

You need to see the short animation here or here to get the effect.

Fortunately the route is the 26 not the 5A…

Conflict Urbanism

I’m in Copenhagen – and still bleary-eyed – for a symposium organised by my good friends Kirsten Simonsen and Lasse Koefoed at Roskilde on their current project  ‘Paradoxical spaces: Encountering the other in public space‘.  I’ll be talking about the war in Syria, drawing on my previous work on attacks on hospitals, healthcare workers and patients (see ‘Your turn, doctor‘) – which I’ve now considerably extended as I work on turning all this into  a longform essay: I’ll post some updates as soon as I can – but now adding a detailed discussion of siege warfare in Syria.  More on that in my next post; but for now I wanted to share some remarkable work on Aleppo by Laura Kurgan and her students at the Center for Spatial Research at Columbia:

Conflict Urbanism: Aleppo is a project in two stages.

First, we have built an open-source, interactive, layered map of Aleppo, at the neighborhood scale. Users can navigate the city, with the aid of high resolution satellite imagery from before and during the current civil war, and explore geo-located data about cultural sites, neighborhoods, and urban damage.

Second, the map is a platform for storytelling with data. We are inviting collaborators and students to bring new perspectives and analyses into the map to broaden our understanding of what’s happening in Aleppo. Case studies will document and narrate urban damage — at the infrastructural, neighborhood, building, social, and cultural scales — and will be added to the website over time.

We invite ideas and propositions, and hope to build on the data we have compiled here to create an active archive of the memory of destruction in Aleppo through investigation and interpretation, up close and from a distance.

That last phrase is an echo of Laura’s book, Close Up at a Distance: Mapping, Technology and Politics, published by MIT in 2013.  The new project emerged out of a seminar taught by Laura in 2016:

Students worked collaboratively to develop a series of case studies using a map developed by the Center for Spatial Research, specifically designed to research urban damage in Aleppo during the ongoing civil war. Their work incorporates a range of disciplines, methods and results. Each student was asked to create case studies and add layers to the existing map. The results — spatializing youtube video, interior borders between fighting factions, imagining urban survival during wartime, imaging escape routes, audio memory maps, roads, water, hospitals, informal neighborhoods, religion, communications infrastructure, and refugee camps at the borders — are [available online here].

I’m particularly taken by ‘Spatializing the YouTube War’.   One of the challenges for those of us who follow these events ‘at a distance’ is precisely how to get ‘close up’; digital media and the rise of citizen journalism have clearly transformed our knowledge of many of today’s conflict zones – think, for example, of the ways in which Forensic Architecture has used online videos to narrate and corroborate Russian and Syrian Arab Air Force attacks on hospitals in rebel-held areas Syria; similarly, Airwars has used uploaded videos for its painstaking analysis of US and coalition airstrikes and civilian casualties (see this really good backgrounder by Greg Jaffe on Kinder Haddad, one of the Airwars team, ‘How a woman in England tracks civilian deaths in Syria, one bomb at a time) – and I’ve used similar sources to explore the effects of siege warfare on Aleppo, Homs and Madaya.

Here is how Laura and her students – in this case, Nadine Fattaleh, Michael James Storm and Violet Whitney describe their contribution:

The civil war in Syria has shown how profoundly the rise of cellphones with video-cameras, as well as online video-hosting and emergent citizen journalism, has changed the landscape of war documentation. YouTube has become one of the largest sources (and archives) of information about events on the ground in Syria: since January 2012 over a million videos of the conflict there have been uploaded, with hundreds of millions of views to date. Major news agencies have come to rely on YouTube as a primary source for their reporting, and human rights organizations often cite videos as part of their advocacy and documentation efforts. This independently reported footage has created a new powerful archive, but opens up crucial questions of credibility, verification, and bias. As with all data, every video comes to us bearing the traces of the situation and intentions that motivated its production. This does not disqualify it – quite to the contrary – but it does demand that we approach everything critically and carefully.

We set out to investigate YouTube as archive of the Syrian uprising and to develop a method for organizing that archive spatially. We used the frameworks that we had developed for the Conflict Urbanism Aleppo interactive map, together with a naming convention used by Syrian civic media organizations, in order to sort and geolocate YouTube videos from multiple sources. We then produced a searchable interactive interface for three of the most highly cited YouTube channels, the Halab News Network, the Aleppo Media Center, and the Syrian Civil Defense. We encourage journalists, researchers, and others to use this specifically spatial tool in sorting and searching through the YouTube dataset.

The Halab News Network [above] shows a wide distribution of videos across the city, including the city center and government-held Western side of the city. The Eastern half of the city — in particular the Northeastern neighborhoods of ash-Sha’ar (الشعار), Hanano (هنانو), and Ayn at-Tal (عين التينة) – is the best-documented.

In contrast:

The videos published by the Aleppo Media Center [above] roughly follow the formerly rebel-held Eastern side of the city, with a small number of videos from the central and Western areas. The highest number of videos is in the neighborhood of ash-Sha’ar (الشعار). Particular spots include ash-Sha’ar (الشعار), coverage of which is shared with the Syrian Civil Defense. Another notable concentration are two neighborhoods in the Southwest, Bustan al-Qaser (بستان القصر) and al-Fardos (الفردوس).

They also analyse the video geography produced by the White Helmets [below]: ‘The Syrian Civil Defense, also known as the White Helmets, have uploaded videos primarily in the formerly rebel-held Eastern and Southern areas of Aleppo. Only the Western area of ash-Shuhada’ (الشهداء) falls outside of this trend.’

This, like the other collaborative projects under the ‘Conflict Urbanism’ umbrella, is brilliant, essential work, and we are all in their debt.

You can read more about the project in a short essay by Laura, ‘Conflict Urbanism, Aleppo: Mapping Urban Damage’, in Architectural Design 87 (1) (2017) 72-77, and in another essay she has written with Jose Francisco Salarriaga and Dare Brawley, ‘Visualizing conflict: possibilities for urban research’, open access download via Urban Planning 2 (1) (2017) here [this includes notice of a parallel project in Colombia].

Aleppo in London and Berlin

A common response to mass violence elsewhere is to imagine its impact transferred to our own lives and places.  It’s a problematic device in all sorts of ways.  After Hiroshima and Nagasaki US media became obsessed with imagining the impact of a nuclear attack on US cities – though, as I’ve also noted elsewhere, there were multiple ironies in conjuring up ‘Hiroshima, USA’ – and in the wake of the US-led invasion of Iraq there were several artistic projects that mapped the violence in Baghdad onto (for example) Boston, New York or San Francisco (I discussed some of them in the closing sections of ‘War and Peace’: DOWNLOADS tab).

This may be one way to ‘bring the war home’, as Martha Rosler‘s mesmerising work has shown, and even constitute a counter-mapping of sorts, but sometimes it can devolve into a critical narcissism: rather than being moved by the suffering of others, we place ourselves in the centre of the frame.  To forestall any misunderstanding about Rosler’s own work, let me repeat what I wrote in ‘War and Peace’:

Domestic critics have frequently noted the interchange between security regimes inside and outside the United States; they insist that the ‘war on terror’ ruptures the divide between inside and outside, and draw attention to its impact not only ‘there’ but also ‘here’. But Rosler’s sharper point is to goad her audience beyond what sometimes trembles on the edge of a critical narcissism (‘we are vulnerable too’) to recognise how often ‘our’ wars violate ‘their’ space: her work compels us to see that what she makes seem so shocking in ‘our’ space is all too terrifyingly normal in ‘theirs’.

So it’s with somewhat mixed feelings that I record Hans Hack‘s attempt to transfer violence in Aleppo to London and Berlin.

He explains his Reprojected Destruction like this:

The United Nations Institute for Training and Research (UNITAR) has recently published a map which “illustrates the percentage of buildings damaged in the city of Aleppo” based on satellite imagery analysis. The map shows the levels of destruction in each of Aleppo’s districts. For this project “Reprojected Destruction” information from that map has been reprojected onto figure-ground maps of Berlin and London. As a geographical reference point, the historical center of Aleppo (The Citadel of Aleppo) has been superimposed on that of Berlin (Museum Island) and London (The Tower of London). The reprojected destruction is indicated by randomly selected buildings marked in red. To make it more representative, the distribution of the reprojected destruction has also been mapped with respect to Aleppo’s administrative borders provided by OCHA. The overall aim of the exercise is to help viewers imagine the extent of destruction that might have been visited upon the UK and German capitals had these cities stood at the centre of Syria’s current conflict.

Hans told Reuters:

For me it’s hard to understand in the news what it means, how strongly Aleppo was destroyed. I wanted to take this information and project it onto something I know personally that I can have some reference to. So I chose Berlin and London.

But the key question for me is simply this: why is it so hard?

Breaking Aleppo

screen-shot-2017-02-13-at-10-37-53The Atlantic Council has issued a new report, Breaking Aleppo, which uses satellite imagery, CCTV clips, social media and video from the Russian Ministry of Defence and the RT network to explore the siege of eastern Aleppo and in particular attacks on civilian targets and infrastructure.

It includes an analysis by Forensic Architecture of the bombing of the ‘M2’ hospital in the Maadi district of Aleppo on 16 July 2016.

Here is part of that analysis employing Forensic Architecture’s signature methodology:

One strike [on M2] was reported on July 14; on July 16, another attack was reported, again with CCTV footage showing the moment of the attack from multiple angles. In this incident, photographs and videos from the attack allowed locations in the photographs to be firmly identified, allowing analysts to confirm that the locations featured were indeed M2 Hospital. To begin this process, a photograph taken outside the hospital after the attack, showing debris and damaged vehicles, was geolocated.

forensic-architecture-analysis-of-attack-on-m2-hospital

A video published by the Aleppo Media Center (AMC) showed the aftermath of the attack, with patients being evacuated to another medical center. During the video, a sequence showed one patient being transported through the building into an ambulance waiting outside the building. It was possible to match the balcony visible in the geolocated photograph to a balcony in the background of the exterior shot in the Aleppo Media Center video.

By following the journey of the patient in the AMC video back to its starting point inside the hospital building, it was then possible to match the route to CCTV footage showing the moment of the attack, also posted on YouTube by AMC.

This CCTV footage, from the same cameras that captured the June 24 bombing, clearly shows that the building was damaged on July 16; parts of the video show the explosion throwing debris through the air with civilians, sta , and patients caught in the attack. The images show the moment a civilian is hit by a large piece of material flung through the air by the explosive force of the attack….

Taken together, these images from multiple sources over a period of several months confirm that the M2 hospital was repeatedly struck between June and December 2016.

But this doesn’t do justice to Forensic Architecture’s analysis of the strikes on M2; for that, you can go here and also watch the video here (its privacy settings prevent me from embedding it):

From June to December 2016, according to the Syrian American Medical Society (SAMS), the Omar Bin Abdul Aziz Hospital, also known as M2, has been subject to 14 strikes by pro-government forces. The strikes have been predominantly by air to surface missiles, but also included illegal cluster munitions, barrel bombs, naval mines, and artillery. The hospital sustained significant damage in this 6 month period which has put it out of service numerous times.

Photographs and videos taken in and around the hospital allow us to analyze some of the consequences of the strikes. Each piece of footage captures only a small part of the building, but composing and cross referencing them allows us to reconstruct the architecture of the building as a 3D model and locate the images of the bombings and their damage.The model becomes the medium through which we can navigate between the different images and videos of the incidents.

There are a number of CCTV cameras in the hospital that are continuously on, capturing every strike. We locate each camera and its orientation in the building. We integrate footage from the CCTV cameras, handheld videos, and photographs within virtual space. Locating each video clip in space provides a tangible link between them, verifying their place and constructing their relation to each other.

One essential video which moves from inside-outside becomes a hinge to the geolocation of the hospital. By analyzing what we can see in the video we can demonstrate a common disposition of the built environment in satellite imagery. Due to the spatial link we created, we are able to anchor all footage to this exact location. We therefore establish the location and multiplicity of strikes and as a result raise questions about intent.

fa-analysis-of-m2

The video embeds a series of video clips and CCTV footage within the model of the hospital.  It concludes with a grim roll call of the strikes on M2 – 14 strikes in six months.  Remember that this was just one hospital attacked repeatedly – and as the map from Breaking Aleppo below shows, it was but one of many hospitals targeted.

The report takes the scale and systematicity of the attacks together with the Assad government’s ‘intimate knowledge of the terrain’ and its regular confiscation of medical supplies from humanitarian aid convoys to opposition-controlled areas across Syria as evidence that hospitals were being deliberately targeted ‘as part of a strategy intended to break the will and infrastructure of the resistance.’

You can find a version of the report with video embeds here.

Here is its key summary:

According to the Syrian Network for Human Rights (SNHR), Aleppo was hit by 4,045 barrel bombs in 2016, with 225 falling in December alone. A record of attacks compiled by the first responder organization Syrian Civil Defence, known as the ‘White Helmets’, covering the period from September 19, 2016 until the evacuation in mid-December showed 823 distinct reported incidents, ranging from cluster-munition attacks to barrel bombs. By comparing satellite images of the east of the city taken on October 18 with those taken on September 19, HRW was able to identify 950 new distinct impact sites—an average of more than one blast an hour, day and night, for a month.

Over the course of the year, the SNHR recorded 506 civilian fatalities from barrel bomb attacks, including 140 children and 63 women. Separately, the Violations Documentation Center recorded the death by military action of 3,497 civilians in Aleppo from June to mid-December 2016.

This evidence was gathered by multiple, independent witnesses using a variety of sources, from on-the-ground contacts up to satellite photographs. The sources reinforce and corroborate one another. They reveal a collage of thousands of mostly indiscriminate attacks, and their devastating impact on life and death in Aleppo during the siege.

The scale of attacks on Aleppo makes it almost impossible to compile a robust and verified record of every attack on the city. But drawing on a broad range of information, it is possible to see that an extensive aerial campaign was waged in Aleppo, and that a high proportion of the munitions deployed against the city and its population were indiscriminate.

The indiscriminate strikes were not one-sided: armed opposition groups also engaged in rocket attacks on civilians in western, government-held Aleppo. Casualty numbers are more difficult to find, but the SNHR reported sixty-four civilian deaths during the period from April 20 to April 29, 2016, and the Syrian Observatory for Human Rights recorded seventy-four civilian deaths during the opposition offensive to break the siege of Aleppo in late October 2016. The indiscriminate nature of the attacks is equally disturbing, and subject to analysis and judgement under the same international laws as any other attack on civilians in the conflict. However, there is little equivalence between the two sides when considering the scale and resources employed in the conflict.

aleppo-hospitals-bombed-3-june-to-14-december-2016

The report insists that

Aleppo was not broken in the darkness. Numerous witnesses provided evidence, some of it conflicting but much of it consistent, to substantiate claims of chemical attacks, barrel bombs, air strikes on hospitals and schools, and the deaths of thousands of civilians.

Its authors summarise an extraordinary campaign of disinformation that has three prongs: ‘denying the deeds’; ‘militarizing the victims’; and ‘attacking the witnesses’. I was astonished at the extent – and the mendacity – of this ‘campaign against the evidence’, as Breaking Aleppo calls it, when I first encountered it while analysing attacks on hospitals and medical workers in Syria.  It was (is) by no means confined to the alt.right and the devotees of Trump’s ‘alternative facts’ but reaches across to the far left, including an uncomfortable number of academics who have been willing to forego any critical understanding in order to absolve Russia and Syria of any and all culpability.

You can find my own arguments in previous posts here and here.

Human Rights Watch has also just issued a report on co-ordinated chemical attacks – illegal under international law – conducted by Syrian government forces as they advanced into eastern Aleppo between 17 November and 13 December 2016.

‘Your turn, doctor’

This is the fourth in a new series of posts on military violence against hospitals and medical personnel in conflict zones.  It follows from my analysis of air strikes on base hospitals on the coast of France in 1918 here, and of the US air strike on the MSF Trauma Centre in Kunduz, Afghanistan in 2015 here and here.  This post, together with the next in the series, is about Syria.  They all derive from a new presentation – still in active development – called ‘The Death of the Clinic: surgical strikes and spaces of exception’ that will eventually become an essay in my next book, so I would appreciate any comments or suggestions.

The eye of the storm 

Syria’s civil war has multiple origins, but one of the most incendiary incidents took place on 16 February 2011 in the city of Dara’a 80 km south of Damascus near the Jordanian border.  Inspired by the spread of the Arab uprisings east across the Maghreb from Tunisia, and the threat they posed to a succession of autocratic regimes, a group of local teenagers decided to daub slogans on the wall of their high school.  One of them, a brave 15-year old (who now lives with his family in Jordan), painted this:

your-turn-doctor

‘Ejak el door ya Doctor’ – ‘Your turn, doctor’.

The doctor in question was Bashar al-Assad, Syria’s president, who had trained as an opthalmologist in Damacus and London.  In the months to come, Assad would give that slogan a viciously ironic twist.

The immediate response of the security forces to the graffiti was swift and draconian; the boys were rounded up, imprisoned and tortured (see herehere and here).  When their relatives protested to the officer in charge he told them:

‘Forget your children.  Just make more children. And if you don’t know how to make more, I’ll send someone to show you.’

hrw-weve-never-seen-such-horrorLocal people took to the streets, and as the demonstrations spread on 22 March security forces entered the National Hospital in Dara’a, cleared it of all non-essential medical staff and stationed snipers on the roof who were under orders to fire on protesters.  The hospital remained until military control until May 2013; admissions were restricted and snipers continued to fire on the sick and wounded who tried to approach the hospital.  On 8 April security forces opened fire on thousands of demonstrators approaching a roadblock; ambulances were prevented from reaching the wounded, and a doctor, a nurse and an ambulance driver were killed when they tried to get through (UN Human Rights Council: ‘Assault on Medical Care in Syria’, 13 September 2013: download here; see also the Human Rights Watch report, ”We’ve never seen such horror’ here).

daraa-is-syria-in-damascus-2011

Others took up the cry, taking to the streets and chanting ‘Dara’a is Syria‘.  In many other areas the government stationed snipers, armoured personnel carriers, tanks and heavy artillery at hospitals; doctors suspected of treating protesters were arrested and tortured; security forces forcibly removed patients from hospitals, ‘claiming bullet or shrapnel wounds as evidence of participation in opposition activities’; and ambulances transporting casualties were attacked and pharmacies looted.

The UN Human Rights Council concluded:

healthcare-has-become-militarised-001

This was, sadly, hardly novel.  In 2006, at the height of sectarian violence in occupied Baghdad, for example, 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.

Counterterrorism and the criminalisation of health care

Doctors were systematically targeted for treating anyone who opposed the government.  In April 2012 one surgeon from Idlib told Annie Sparrow:

‘We were detained in the hospital for several days. Tanks parked out front, artillery in the wards, snipers on the roofs shooting patients who tried to come. They took our names, and summoned three of the five security branches – state, political and military. I was interrogated and forced to sign several commitments not to treat anyone not pro-regime. Of course, as soon as I was released I violated it immediately…the city was full of wounded and sick people. Soon after that a friend who worked in military security let me know I was now “wanted” [for my work], the charge being that I was the leader of a terrorist group. So I went into hiding, and moved my family to Turkey. In retaliation my brother was executed.’

shot-by-a-sniper-001

The State of Emergency that had been in force in Syria since 1962 was abruptly ended on 21 April 2012.  But on 2 July a new Counter-terrorism Law came into force that criminalised all medical aid to the opposition.  Here is Annie Sparrow again:

it-is-forbidden-to-carry-out-any-first-aid-activities-001

The parallels with the objections voiced by some members of Afghanistan’s security services against MSF’s work in Kunduz are only too clear: but in Syria they have been given explicit state sanction enforced through the law.

As Neil Macfarquhar and Hala Droubi reported for the New York Times in March 2013, doctors repeatedly found themselves in the cross-hairs.  Here, for example, is the case of Dr Mohamad Nour Maktabi:

doctors-in-the-crosshairs-001

The Counter-terrorism Law also declared that all medical facilities operating in opposition-held areas without government permission were illegal – and thereby transformed them (under Syrian law, at least) into legitimate targets of military violence.

Air wars and ‘surgical strikes’

The nature of military and paramilitary violence has changed during the course of the war; shooting and mortar-fire have increasingly been supplemented by air strikes.

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Even in the early stages of the war doctors were confronting what one trauma specialist called ‘unimaginable injuries’.  Dr Rami Kalazi, a neurosurgeon in east Aleppo, explained:

‘In the beginning, we saw new injuries that we did not know how to treat. Fortunately, at the beginning of the revolution and when we began working in field hospitals, there was more freedom of movement. In 2012 and 2013, there was no such thing as “barrel bombs” and there was no violent shelling from airplanes, so many visiting foreign doctors came…

‘But even so, they told us that they were seeing injuries that they had never seen before in books or textbooks or in the hospitals where they worked in their home countries. Unfortunately, reality forces you to learn.’

But air strikes transformed the calculus of injury.  Many more casualties resulted from each attack, and the wounds of those who survived were often far more serious.

The US-led coalition has carried out multiple airstrikes primarily in areas controlled by IS, and the campaign has caused (minimally) hundreds and probably several thousand civilian casualties – see my analysis of specific US air strikes here and here, for example –  but the Syrian Arab Air Force has concentrated its fire on areas controlled by other rebel groups (see Jeffrey White‘s analysis here).

A favourite tactic has been the deployment of ‘barrel bombs‘ – in effect, aerial IEDs: oil drums filled with high explosive and cut rebar to act as shrapnel – dropped from helicopters (see Human Rights Watch here).  Basel al-Junaidi described witnessing their impact:

I saw the aftermath of a barrel bomb. I saw human remains scattered in the street; I heard the screaming. I’m trained as a doctor, but I was unable to act. I just stood there, petrified. The West thinks we’re used to this, but we aren’t of course. We’re like anyone else – we use computers and cars, not camels and tents…

Another doctor who worked in Syria said he kept ‘a drawing from a second grader in Aleppo, showing helicopters bombing the city, blood and destruction below.’  Chillingly, ‘the dead children are smiling while the living ones are crying.’

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From September 2015) the Russian Air Force, often acting in concert with the Syrian Arab Air Force, has also concentrated on targets in areas controlled by other opposition groups:

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Russia has routinely denied these charges, but from 30 September to 12 October 2015 its Ministry of Defence published videos of 43 airstrikes. Bellingcat, aided by crowdsourcing, identified the exact location of 36 of them and overlaid them on the ministry’s own map identifying which groups controlled what parts of the country (see the full report, ‘Distract, Deceive, Destroy’, here):

‘The result revealed inaccuracy on a grand scale: Russian officials described 30 of these videos as airstrikes on Isis positions but in only one example was the area struck in fact under the control of Isis, even according to the Russian MoD’s own map.’

The effect of these air strikes has been devastating on the population at large.  To make matters even worse, air strikes cannot target individual doctors and have instead frequently been directed against hospitals and other medical facilities.   This compromises not only trauma care for the wounded but also the treatment of chronic and infectious diseases:

chronic-diseases-and-the-syrian-civil-war-001

(You can find a discussion of the problem of infectious diseases in Sima L. Sharara and Souha S. Kanj, ‘War and infectious diseases: challenges of the Syrian Civil War’, PLOS Pathogens 10 (11) (2014) here).

Hospitals and bomb sights

Doctors and other medical staff had to adjust to a new, sickening vulnerability.  Here is one OB/GYN who was still working in a hospital in East Aleppo when she was interviewed on Public Radio International in August 2016:

Carol Hills, PRI: Doctor Farida, did I just hear a noise there? Was that some sort of attack that I just heard?
Dr Farida Almouslem: It’s attack. [Laughs]. It’s normal. It’s away from me. Not next to me. These noises are all the time.
Hills: Do you and the doctors and patients you work with feel safe inside the place where you’re working?
Dr Farida: No. It’s not safe. I work at the third floor in my hospital. And many times the wall was perforated. So every woman came to the hospital, she knows that there is a danger on her life. So they just give the delivery, or give the birth, and then go home. She escapes to home because she knows our hospital is always targeted.

Other doctors in opposition-held areas said the same.  Here is Dr Mohamed Tennari, director of an above-the-ground field hospital in Idlib:

‘When I am in the hospital, I feel like I am sitting on a bomb. It is only a matter of time until it explodes. It is wrong − a hospital should not be the most dangerous place.  I wish I could say that targeting a hospital in Syria is unique, but is not.’

In fact, it’s far from unique: Physicians for Human Rights has issued a report detailing Attacks on Doctors, Patients and Hospitals hospitals and provided a interactive map of attacks on healthcare in Syria.

In the face of these escalating attacks, hospitals in opposition-held areas have tried to conceal their locations from the Syrian government.  In contrast to the protocol adopted by the MSF Trauma Centre in Kunduz, they have been markedly reluctant to provide their GPS coordinates (and see MSF’s explicit comparison between what happened in Kunduz and the situation in Syria here):

gps-coordinates-and-surgical-strikes-001

But this has trapped them in a grim Catch-22.  Michiel Hofman of Médecins sans Frontières – which is not permitted to operate in government-controlled areas in Syria – explains:

‘Hospitals that MSF supports in Syria are bereft of the possible protection of being clearly marked as a hospital or sharing of GPS coordinates, as the Syrian government passed an anti-terrorist law in 2012 that made illegal the provision of  humanitarian assistance – including medical care – to the opposition, forcing most health structures to go underground and operate without governmental medical registration. The bombing parties can then conveniently claim they were unaware it was a hospital they hit.’

More often, the Syrian government and its allies routinely describe the bombed building as a ‘so-called hospital’.  After an air strike on an MSF-supported hospital near Maarat al-Numan in Idlib on 15 February 2016 Bashar Jaafari, Syria’s ambassador to the United Nations, made this statement:

‘The so-called hospital was installed without any prior consultation with the Syrian government by the so-called French network called MSF which is a branch of the French intelligence operating in Syria… They assume the full consequences of the act because they did not consult with the Syrian government. They did not operate with the Syrian government permission.’

The allies of the Syria government are not confined to Russia and Iran.  On 27 April 2016 the Al Quds hospital in Aleppo was hit by two air strikes that killed 55 people  – among them two specialists, including Dr Muhammad Waseem Maaz, Al Quds’s pediatrician – and severely damaged the hospital. When it partially reopened 20 days later its capacity was reduced from 34 to 12 beds.  MSF conducted a detailed review of the operations of the hospital and the circumstances of the attack:

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Here is Professor Tim Anderson on what he calls ‘The “Aleppo Hospital” Smokescreen‘ (and for reasons that will become obvious I am so tempted to put scare-quotes around the title that adorns his post; the Department of Political Economy at the University of Sydney lists him as a Senior Lecturer not a Professor, but perhaps anxiety over the appellation ‘Doctor’ is contagious):

‘…the story of Russian or Syrian air attacks on the ‘al Quds hospital’ gained prominence in the western media… CCTV showed people leaving this ‘hospital’ before an explosion.

‘The building is in the southern al-Sukkari district, which has been a stronghold of Jabhat al Nusra for some years. Many Aleppans had never heard of ‘al Quds hospital’. Dr Antaki [Aleppo Medical Association in Western Aleppo] says: “This hospital did not exist before the war. It must have been installed in a building after the war began”…. This facility was not a state-run or registered facility.’

Anderson is joined in his disinformation effort by Eva Bartlett writing in the ‘OffGuardian’:

Dr. Zahar Buttal, Chairman of the Aleppo Medical Association … said: “The media says the only pediatrician in Aleppo was killed in a hospital called Quds. In reality, it was a field hospital, not registered.”

As for the pediatrician, “We checked the name of the doctor and didn’t find him registered in Aleppo Medical Association records.”…

… central to the lies were the bias and propaganda of the very partial, corporate-financed Médecins Sans Frontières (MSF), which supports areas in Syria controlled by terrorists, specifically Jabhat al-Nusra…’

To repeat: the Syrian government has refused to register or recognise any hospitals operating in areas outside its control – hence the snide reference to ‘so-called hospitals’ and Anderson’s meretricious scare-quotes – and it does not permit MSF to operate in areas under its control (despite repeated requests).  As for the disappearance of Dr Muhammad Waseem Maaz from the Syrian government’s registry (though I have no doubt he was on other lists maintained by the regime) the director of the Children’s Hospital in Aleppo provides a graceful tribute to him here.  And here is the doctor whose death these commentators dismiss so lightly (if you have the stomach for it, you can see his last moments caught on CCTV here):

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What, apart from the grotesque stipulations of the Syrian state, makes them think it proper to withdraw medical care from those living – surviving – in rebel-held areas?  International humanitarian law is unequivocal: they are entitled to medical treatment and to be protected whilst it is provided to them.

In rebel-held areas medical care has increasingly moved outside what were once established hospitals into the clandestine ‘field hospitals’ referred to above, which have been given numbered code-names to conceal their locations.  Some, like those established by MSF, follow strict medical protocols and, according to a study of one operating in Jabal al-Akrad by Miguel Trelles and his colleagues, they have (for a time) been able to provide high-quality medical care with remarkable survival rates (‘Providing surgery in a war-torn context: the Médecins Sans Frontières experience in Syria’, Conflict and Health (December 2015)).  As the attacks on them have increased and qualified personnel and medical supplies have become scarce, however, many have become exercises in improvisation:

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Some of these hospitals have literally gone underground.  ‘‘In our worst dreams – in our worst nightmares – we never thought we would have to fortify hospitals,’ declared Dr Zaidoun al-Zoabi of the Union of Medical Care and Relief Organizations. ‘It’s not humane. It’s impossible to comprehend.’

Subterranean locations have been used not only to protect the hospitals but also to protect local populations.  Charles Davis reported that

‘whether it’s a vehicle or a building, anything that’s identifiable as providing medical care is ripe for an airstrike, so that staff have now taken to covering up any distinguishing characteristics. Even so, [Dr Abdulaziz Adel, a surgeon in East Aleppo, admits that] local residents are “always begging us to go away, take your hospital away from us or otherwise we’ll be a target.”‘

When the Syrian-American Medical Society proposed to build a hospital in Hama in 2014, local people begged them to locate it outside the city and so SAMS excavated what became the Dr Hasan al Araj Hospital, better known as ‘The Cave’:

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Supply chains and kill-chains

As the civil war ground on, even the most basic medical supplies became scarce and obtaining them ever more dangerous.  In March 2015 MSF reported that:

‘Even if it is available, many suppliers do not want to risk selling material like gauze or surgical threads when they know it is going to be sent into North Homs. Gauze is considered synonymous with war surgery, and often a supplier is not willing to take the risk of being arrested or shut down for supplying a besieged area.’

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You can read more here and here.  One doctor told MSF:

‘It is precious, dangerous, incriminating. There are secret outlets supplying us with gauze.’

At the end of last year the Guardian provided this image of one of the secret factories:

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In East Aleppo, hospitals have been forced to use tunnels to bring in medical supplies (more from Ellen Francis and her colleagues here):

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The risks are formidable and the costs have been almost prohibitive.  Ellen Francis and her colleagues at Columbia’s Graduate School of Journalism report that in January 2014 the Free Syrian Army and the Syrian Arab Army agreed an uneasy and ragged cease-fire in Barzeh, a small town on the northern edge of Damascus. There a team from the Union of Free Syrian Doctors was able to buy medical supplies from merchants who travelled out from the capital.

The merchants paid a 20 per cent ‘customs fee’ to Syrian Army soldiers; the agents for the doctors then paid a ‘tax’ to get the supplies through the Harasta checkpoint on the Army-controlled highway, and then a ‘toll’ to the rebels (‘tunnel lords’) who controlled the tunnels into Ghouta.

The combined fees inflated the price of medical supplies.  A litre of serum used to help the body replenish lost blood cost $1 in government-controlled areas and $3.50 to $10 via the tunnel route. Ghouta was using about 10,000 litres of serum per month.  The supply chain was subsequently severed once Barzeh itself came under siege and was cut off from Damascus.

Some humanitarian aid has crossed the lines by more conventional routes – conventional for a war zone at any rate – but medical supplies have routinely been removed from aid convoys.  On 19 May 2016 the UN Secretary-General reported to the Security Council:

‘[By May] 2016, WHO [had] submitted 21 individual requests to the Government of the Syrian Arab Republic to deliver medical supplies to 82 locations in 10 governorates. The Government approved five requests [while] 16 requests remained unanswered.

‘The removal of life-saving medicines and medical supplies continued, with nearly 47,459 treatments removed from convoys in April intended for locations in Homs, Aleppo and Rif Dimashq governorates. Removed items included surgical supplies, emergency kits, trauma kits, mental health medicines, burn kits and multivitamins. Removals extended to basic items, such as antibacterial soap, which was removed from midwifery kits. Items were also removed from other kits, notably surgical tools…’

Even then, aid convoys are not safe.  Four months later to the day a UNICEF aid convoy delivering supplies to a Syrian Red Crescent warehouse at Urum al-Kubra in Aleppo was attacked from the air, killing at least 18 people and destroying 18 of the 31 trucks.  Most analysts have concluded that the Russian Air Force was responsible, perhaps acting in concert with the Syrian Arab Air Force – see for example here and here– but the Russian Ministry of Defence and the usual suspects have variously blamed spontaneous combustion, a ground attack by rebels and a US drone attack.

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These shortages are threaded into dispersed and precarious siege economies that gravely affect the health of local populations.  In December 2015 an estimated 400,000 people were surviving without access to life-saving aid in 15 besieged locations across Syria; the figures gathered by Siege Watch are even higher.

Surrounded by 6,000 land-mines and 65 sniper-controlled checkpoints, Madaya’s 40,000 inhabitants have been under siege since July 2015; 32 people died of starvation and malnutrition in December 2015 alone.  One resident interviewed by Amnesty International in January 2016 described the catastrophic situation:

‘Every day I wake up and start searching for food. I lost a lot of weight, I look like a skeleton covered only in skin. Every day, I feel that I will faint and not wake up again… I have a wife and three children. We eat once every two days to make sure that whatever we buy doesn’t run out. On other days, we have water and salt and sometimes the leaves from trees. Sometimes organizations distribute food they have bought from suppliers, but they cannot cover the needs of all the people.

‘In Madaya, you see walking skeletons. The children are always crying. We have many people with chronic diseases. Some told me that they go every day to the checkpoints, asking to leave, but the government won’t allow them out. We have only one field hospital, just one room, but they don’t have any medical equipment or supplies.’

An aid convoy was allowed in four days after this interview.

There are also grave shortages of skilled medical personnel.  The doctors who remain in opposition-held areas have all had to learn new skills sometimes far beyond their original training.  In March 2015 one young surgeon working in an MSF-supported hospital east of Damascus recalled:

‘There was a pregnant woman who was trapped during the time we were under full siege. She was due to deliver soon. All negotiation attempts to get her out failed. She needed a cesarean operation, but there was no maternity hospital we could get her to, and I had never done this operation before.

A few days before the expected delivery date, I was trying to get a working internet connection to read up information on doing a C-section. The clock was ticking and my fear and stress started to peak. I wished I could stop time, but the woman’s labour started…’

In 2015 OCHA estimated that more than 40 per cent of pregnant women in these areas now scheduled C-sections to reduce the risk of an attack preventing them from obtaining care.

In some cases doctors can call on skilled overseas help via Skype from consultants on call 24/7 in the United States, Canada and the United Kingdom.  Ben Taub has written movingly of the extraordinary efforts of what he calls ‘the shadow doctors’ enlisted in ‘the underground race to spread medical knowledge as the Syrian regime erases it.’  One of the most active is Britain’s Dr David Nott:

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But not all those seeking specialist help are qualified surgeons.  In the field hospital serving the besieged town of Madaya medical care has been provided by a dentist, a dental student and a veterinarian.  Avi Asher-Schapiro reports:

‘The five-year civil war has plunged the Madaya clinicians into the deep end, forcing them to perform medical procedures that push them far beyond their training. They have treated countless gunshot victims, performed seven amputations, over a dozen C-sections, and diagnosed everything from meningitis to cancer.’

As he explains, this remarkable trio has also relied on remote medicine:

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These are all extraordinary responses to near-impossible, life-threatening situations.  But their successes have been short-lived.

The Madaya clinic was forced to close in November 2016:

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And the M10 hospital where Nott helped direct surgery – the largest trauma and ICU centre in East Aleppo – was hit by successive, catastrophic air strikes.  First, an attack on 28 September 2016 left only half the hospital operational.  On 1 October Xisco Villalonga, MSF’s Director of Operations, reported that

‘Bombs are raining from Syria-led coalition planes and the whole of east Aleppo has become a giant kill box.’

That night multiple strikes on M10 killed two people and injured ten others; the hospital had to be evacuated because one crater was so deep there were fears that the rest of the building would collapse.

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But the ordeal was not over: there were further, devastating strikes on 3 October:

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The underground hospitals have fared no better.  ‘The Cave’ – 15 metres inside a mountain, remember – was hit by two ‘bunker-buster’ bombs at 1500 on 2 October 2016. After 35 staff and patients had been evacuated a second strike occurred in the early evening involving missiles and cluster bombs. The E.R. was wrecked, ceilings collapsed, cement walls crumbled and generators, water tanks and medical equipment were destroyed (see image below).  Nobody was seriously injured but the hospital sustained critical damage and has been closed indefinitely. It used to treat 300 patients and perform 150 surgeries a month.

Cave Hospital hit by bunker-buster bombs

The exception to the exception

Once safe places under the protection of international humanitarian law – the exception to the space of exception that is the conflict zone – hospitals have become the targets of a new and extraordinarily vicious modality of modern war.  The systematic attacks on hospitals have not only threatened the lives of patients and healthcare workers; they have also made many patients reluctant to seek medical treatment at all.  In February 2015 a report from the Centre for Public Health and Human Rights at Johns Hopkins University was already warning of the consequences:

‘Unless they feel their life is in danger, many people won’t go to hospital because it is targeted for bombardment’ [Physician, Aleppo]. Two physicians reported that fear of travel and an understanding that the hospital is a target has led to a 50% decrease in clinic visits and surgery cases, even though the level of violence has not decreased.

Dr Farida, the OB/GYN in East Aleppo interviewed earlier, no longer has a hospital to work in – the last remaining hospital was reduced to rubble and closed on 18 November – and she now provides what medical care she can from a basement:

‘People know it’s a basement, but they are afraid to come here because they know any health facility is deliberately targeted by the regime. For women, they are afraid to come — but they don’t have any other option. When they don’t have a car or fuel to come here, they have to give birth at home. Women are bleeding at home and babies are born dehydrated without oxygen.’

Those that do make the precarious journey to a field hospital or other medical facility almost always now find that their care is compromised by the shortage or even the absence of doctors, nurses, medical supplies and even the most basic medical equipment.  So doctors use ordinary sewing cotton instead of surgical thread; local anaesthetic where they would normally use a general, or even home-made, improvised variants.  Dr Zaher Sahloul, who still tries to provide help to colleagues in Syria from his home in Chicago via WhatsApp, explains:

‘We operate on the mindset that they have basic things we take for granted… The reality is, they don’t have 90 percent of the things we think they have. They know better what they have and what they can do with it. These people are facing decisions we will never face in our lives. If you have 10 patients dying, who will you see first? Do you use spoiled gauze and dirty tubes at the risk of infection? It’s Hell for them.’

As I write, the Syrian Arab Army and its supporting militias are advancing into East Aleppo, where air strikes and artillery bombardments have left more than 250,000 people without access to any form of advanced medical care.  The World Health Organisation announced that ‘although some health services are still available through small clinics, residents no longer have access to trauma care, major surgeries, and other consultations for serious health conditions.’

The final irony – although in this catalogue of horrors it probably isn’t the last at all – is that the Kremlin has announced that it will send two mobile hospitals to treat patients from East Aleppo.  The Defence Ministry will operate ‘a special 100-bed clinic with trauma equipment for treating children’ and the Emergencies Ministry will provide a 50-bed clinic capable of treating 200 outpatients a day.

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While the Kremlin congratulates itself on its ‘humanity’, we need to remember that this minimalist contribution would not have been necessary at all had medical neutrality been respected and doctors and nurses, hospitals and clinics not been so ruthlessly, systematically and deliberately targeted in the first place.

UPDATE:  On 5 December the Defence Ministry’s mobile hospital (set up in West Aleppo to treat patients from East Aleppo) came under mortar fire from the crumbling opposition-held area to the east; one Russian doctor and two paramedics were killed.  It’s not clear whether the hospital was deliberately targeted – there have been accusations that the co-ordinates of the hospital must have been given to the militants for it to have been hit ‘right at the moment when it started working‘ – or whether it was caught in the indiscriminate shelling and mortar-fire that has hit other hospitals in West Aleppo.

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But I should make two things clear.  First, attacks on hospitals in West Aleppo – even though I don’t think they have exhibited anything like the scale or the systematicity of those directed against medical facilities and healthcare workers in opposition-held areas – are as reprehensible as those on hospitals in the East.  Second, the muted response from the US-led coalition to the shelling of the Russian field hospital is deeply disturbing.  The International Committee of the Red Cross announced after the attack that ‘all sides to the conflict in Syria are failing in their duties to respect and protect healthcare workers, patients, and hospitals, and to distinguish between them and military objectives.’  The Russian Ministry of Defence dismissed this as a ‘cynical’ display of indifference to the deaths of its doctors, but I don’t read it like that at all – what is cynical is the partisan appeal to medical neutrality when it suits, and its systematic violation when it doesn’t.

To be continued

50 Feet from Syria

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As I continue my work on the targeting of hospitals and ambulances, doctors and nurses, and on the precarious provision of medical care in Syria, I’ve been watching Skye Fitzgerald‘s remarkable documentary 50 Feet from Syria, which is now available on iTunes and (in some places) on Netflix:

With a suitcase full of donated stainless-steel bone implants, Syrian-American surgeon Hisham Bismar arrives at a Turkish hospital on the Syrian border, ready for anything. What he finds is horror, chaos, and an ocean of refugees in need of medical care: colleagues who perform operations without anesthesia, stories of Syrian government snipers targeting pregnant women and children, and images of 55 gallon barrels filled with shrapnel and TNT deliberately dropped on civilians.

With dull drill bits and ill-fitting bone and joint implants Bismar repairs the bodies of the wounded fortunate enough to find their way to the hospital – both civilians and fighters. Amongst this remarkable work, remarkable people abound: “M”, a ‘Turkish Schindler’ selflessly crossing the border each day to retrieve the wounded and ferry them to the care of surgeons, and “AM” a hero among his peers for his willingness to live for years in Syrian field hospitals repeatedly bombed by the Assad regime.

50 Feet From Syria is a portrait of a quiet and determined man, performing intricate acts of medical necessity undeterred by the chaos and complexity of war around him. The film serves as a snapshot in time for the current plight of Syrian refugees. It also indelibly communicates the human cost of one of the most brutal, dehumanizing conflicts in modern history that continues to destroy and displace millions of lives.

It’s a stark reminder of the circumstances in which, once you turn from killing to caring, 5,000 feet isn’t the best….

Someone who has demonstrated the variability of distance in these situations is the remarkable British surgeon David Nott, who has both worked in field hospitals inside Syria and also advised colleagues in Aleppo and elsewhere from London by Skype and whatsapp (the most intimate of remote medicines):

You can read much more on his work – and on the medical underground in Syria more generally – in Ben Taub‘s compelling account of ‘The shadow doctors’ at the New Yorker here.

I’ve drawn on these and many other accounts for my ‘Surgical strikes and modern war’: much more to come very soon.

The sense of war

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In the face – often literally so – of  attempts to render later modern war as somehow bodiless, a project that contorts itself into grotesque formations around the spectacularly contradictory vocabulary of ‘surgical strikes’ against the cancerous cells of insurgency and terrorism, I continue to be drawn to attempts to convey the  corporeality of its violence.  I started down this road in ‘The natures of war‘ and continue it in my attempts to think about what I call ‘corpographies‘ (see DOWNLOADS tab for both, and also here, here and here), and it is a constant concern in my current work on casualty evacuation from war zones.

So I was taken with a short extract from Janine di Giovanni‘s The Morning They Came for Us: Dispatches from Syria (2016) that appears in Harper‘s.  It’s called ‘The Sense of War‘ (in another register so often another oxymoron):

The morning they came for usWhat does war sound like? The whistling sound of the bombs falling can only be heard seconds before impact—enough time to know that you are about to die, but not enough time to flee.

What does the war in Aleppo smell of? It smells of carbine, of wood smoke, of unwashed bodies, of rubbish rotting, of . . . fear. The rubble on the street—the broken glass, the splintered wood that was once somebody’s home. On every corner there is a destroyed building that may or may not have bodies still buried underneath. Your old school is gone; so are the mosque, your grandmother’s house and your office. Your memories are smashed…

War is empty shell casings on the street, smoke from bombs rising up in mushroom clouds, and learning to determine which thud means what kind of bomb. Sometimes you get it right, sometimes you don’t.

War is the destruction, the skeleton and the bare bones of someone else’s life.

Anand Gopal thinks her prose is ‘overwrought’, though I don’t think that’s entirely surprising, and when Sebastian Junger says that she ‘has described war in a way that almost makes me think it never needs to be described again’, even in this short passage you can see – feel – what he means.  You can find other reviews here and here.