Cities under siege (II)

In this second post on Cities under siege I provide a back-story to the re-intensification of military and paramilitary violence against civilians in Syria I described here.  But it’s also a back-story to the stunning image above, ‘Deluge’ by Imranovi: people were evacuated to what eventually became nominally ‘de-escalation zones’ from besieged cities like Aleppo, but many more continued to flee Syria altogether – like Imranovi himself (more on Imranovi here and here).  It’s worth pausing over his artwork: every time we see video of those perilous boats crammed with desperate refugees we ought to reflect on the oceans of bloody rubble strewn across their land and the millions of other displaced people in their wake.

There is a close connection between internal displacement and cities under siege.  Here is the UN’s estimate of the displaced population in December 2016:

They are concentrated in towns and cities.  Many people have managed to escape areas under siege, risking their lives to do so, but many others have sought refuge in towns and cities that have themselves come under siege.  Here, for example, is Siege Watch‘s description of Eastern Ghouta in mid-2016:

The capture of besieged towns on the south and eastern sides of Eastern Ghouta had a negative impact on conditions throughout the entire besieged region. IDPs from the frontline areas fled into host communities that have also been subjected to the same long-term siege and lack the infrastructure and resources to support the newly displaced families. There is now a higher concentration of people living in temporary shelters or sleeping on the streets.

The UN defines a besieged area as ‘an area surrounded by armed actors with the sustained effect that humanitarian assistance cannot regularly enter, and civilians, the sick and wounded cannot regularly exit the area.’  

But the definition  and its application turn out to be as problematic as perhaps you would expect.  Here is Annie Sparrow:

Estimates of the number of Syrians currently living under siege vary widely, according to who is doing the reporting. For example, last December [2015], the United Nations Office for the Coordination of Humanitarian Affairs (OCHA) in Damascus communicated back to the UN secretary-general’s office that 393,700 civilians were besieged. For the same period, Siege Watch estimated that the real figure was more than one million…

From its base at the five-star Four Seasons Hotel in Damascus, OCHA decided that an area is merely “hard to reach” rather than besieged if it has received an aid convoy in the last three months, regardless of whether the supplies are sufficient for one month, let alone three.

One doesn’t need to travel far from Damascus to see how little a distinction there often is between a “hard to reach” and a “besieged” area.

I’ll return to that last, vital point, but here are two of those OCHA maps.  The first shows the situation in January 2016 and the second in April 2017:

Even those attenuated maps are alarming enough, but the Syrian American Medical Society (SAMS) also believes that the OCHA reports systematically under-report the magnitude of the crisis, and in Slow Death: Life and Dearth in Syrian communities under siege (March 2015) they provided a more sensitive three-tier classification.

These are, of course, heterogeneous communities – none of the reports I have cited (nor those I will draw on later) conceals the presence of armed groups of various stripes within them, often jostling for control – but siege warfare renders them as homogeneous.  The presence of civilians, for the most part desperately struggling to survive in the midst of chaos and conflict, is erased; this begins as a discursive strategy but rapidly becomes a visceral reality.  In short, siege warfare becomes a version of enemy-centric counterinsurgency and counterterrorism, the Syrian government less invested in ‘performing the state’ through the provision of services than in denying services to the entire population in these areas.  By these means the Assad regime has pursued a strategy that mimics the Islamic State’s determination to ‘extinguish the grey zone‘:

Like Annie, I have been impressed by the work of Siege Watch and so I’ll start with their regular reports that have provided a series of powerful insights into the effects of sieges on everyday life.  In their first report they identified characteristics shared by all communities besieged by the Syrian government.  When that report was compiled almost 50 communities were besieged; only two of them were under siege by forces other than the Syrian government and a third was besieged on one side by the Syrian government and on the other by Islamic State.

There are three characteristics that I want to emphasise:

Deprivation:

  • ‘Civilians in the besieged areas struggle to survive. Electricity and running water are usually cut off, and there is limited (if any) access to food, fuel, and medical care. In many of these areas, civilians have died from malnutrition due to the severity with which the blockades are enforced. In all of these areas, civilians with diseases, chronic conditions, and injuries have died as a result of the lack of access to medical care. Other recorded causes of siege-related deaths include hypothermia due to the lack of heating oil in the winter, and poisoning after eating something toxic while scavenging for food. Poor sanitation conditions in the besieged areas have resulted in frequent outbreaks of infectious diseases.’

Extortion and economic development:

  • ‘The pre-war economies in all of the government-besieged areas have collapsed. They have been replaced with siege economies that depend on smuggling, bribery, and local production; and because they are nearly-closed economic systems they experience extreme price volatility. Unemployment levels in besieged areas are high, reaching 100% in some of the worst Tier 1 communities such as Jobar. The Syrian government profits off of the sieges by allowing a few pro-government traders to sell goods – sometimes expired – through the checkpoints at tremendously inflated prices and taking a cut of the profits. Sometimes civilians can pay extremely high bribes to government forces or smugglers to escape the besieged areas, although both methods entail tremendous personal risk. These extortive practices have drained the areas under long-term siege of their financial resources.’

An improvised fuel stand in besieged Eastern Ghouta, February 2017

Violence:

  • ‘Most of these besieged areas are targeted with violent attacks by the Syrian armed forces and its allies. In addition to sniping and the use of explosive weapons with wide area effects in populated areas, there have also been confirmed uses of internationally banned weapons such as landmines, cluster munitions, and chemical weapons….  Most of the communities also contain AOGs [Armed Opposition Groups] which defend the the areas against incursion by pro-government forces, launch offensive attacks against the Syrian military and its allies, and coordinate with the Local Councils to varying degrees. Many Siege Watch survey respondents noted that AOGs were present only around the periphery of their communities, and a few respondents from towns in the interior of the Eastern Ghouta said that AOGs were not active in their areas at all.… [In addition] both Syrian government forces and extremists compete to recruit recruit men and boys from besieged communities using threats, blackmail, fear, propaganda, and indoctrination.’  

Siege Watch notes how, in consequence, ordinary people have ‘adjusted’ to these new, bleak realities: ‘Creative survival tactics such as rooftop gardening [below: eastern Aleppo], burning plastic to extract oil derivatives, and the local production of some basic medical supplies have become more common over time, and people have begun to acclimatise to a more primitive lifestyle’ [see also here].

That sentence gestures towards a sharper point made by José Ciro Martinez and Brent Eng (‘Struggling to perform the state: the politics of bread in the Syrian civil war’, International political sociology 11 (2) (2017) 130-47):

‘Most accounts [of the war in Syria] choose to privilege bellicose affairs over the humdrum concerns of daily life, which are deemed humanitarian issues separate from the violent battles and geopolitical struggles said to comprise the “actual” politics of war. This portrayal of conflict is illusory: it disregards the majority of interactions that shape both life and politics in contemporary war zones, where “most people most of the time are interacting in non-violent ways” (Tilly 2003, 12). One result of prevalent depictions of civil war is that civilians are frequently rendered powerless. If they do appear, it is as pawns in a conflict fought by armed groups autonomous from the societies they struggle to control.’

That’s an important qualification, but it plainly doesn’t erase the struggles of civilians either – which makes ‘acclimatisation’ a remarkably weak term to describe the multiple, extraordinary ways in which civilians have been forced to adjust to a new, terrifyingly abnormal ‘normal’ in order to survive.  Here, for example, is a doctor in Homs describing ‘Siege Medicine’ [more here]:The Center for Civilians in Conflict has also provided a report on civilian survival strategies that lists a series of other extraordinary, collective measures (and the title, Waiting for No One, says it all).  These strategies include the provision of makeshift early warning systems against incoming air attacks (spotter networks, radios and sirens); the provision and protection of medical infrastructure (in part through improvised field hospitals and the construction of underground hospitals); and the development of local aid and rescue teams (including the Syrian Civil Defence or White Helmets); protection from unexploded ordnance (‘the armed groups typically harvest them for their own makeshift weapons’ but the White Helmets and other groups have sought to render them harmless).

But Siege Watch – and José and Brent – have in mind something more: something in addition to strategies that are necessarily but none the less intimately related to direct, explosive and often catastrophic violence.  They also want to emphasise the ways in which otherwise ordinary, everyday activities have been compromised and ultimately transformed by siege warfare.

Here I focus on food (in)security.  Here is Annia Ciezadlo reporting from Yarmouk in Damascus:

In a dark kitchen, by the flickering light of a single safety candle, two men bundled in hats and jackets against the cold put on an impromptu video satire: live from Yarmouk, at the southernmost edge of Damascus, a cooking show for people under siege.

“This is the new dish in the camp of Yarmouk. It hasn’t even hit the market yet,” said the man on the right, 40-year-old Firas Naji, the blunt and humorous host.

He picked up a foot-long paddle of sobara, Arabic for prickly pear cactus. Holding it carefully by one end to avoid thorns, he displayed first one side and then the other for the camera.

“In the U.S., they get Kentucky [Fried Chicken], hot dogs. In Italy, spaghetti and pizza,” he said, his raspy voice caressing the names of unattainable foods. “Here in Yarmouk, we get sobara.

“It’s not enough we have checkpoints in the streets and shelling,” he added, laying the cactus back on the counter with a sad laugh. “Even our cooking has thorns.”

 

Yarmouk was established in 1957 as a refugee camp for Palestinians but gradually it had absorbed more and more Syrians displaced by drought, famine and eventually fighting.  As the war intensified, so the siege tightened:

The government checkpoints in and out of Yarmouk would close for four days, then five, then six. Soldiers would confiscate any amount of food over a kilo…. On July 21, 2013, the regime closed the main checkpoint into Yarmouk for good. The siege was total: Nobody could leave, and nothing could enter except what the soldiers permitted.

Over the next six months, the price of everything went up. A single radish reached $1.50 at one point; a kilo of rice was $100.

And so the inhabitants turned to gardening:

Between buildings, in abandoned lots and on rooftops, the siege gardeners of Yarmouk have been cultivating everything from eggplants to mulukhiyeh, a jute plant whose glossy leaves make a rich green stew. Come harvest time, they bag the produce into 1-kilo portions, hang the bags on the handlebars of beat-up bicycles and pedal around the camp distributing the food to their neighbors. They focus on those most in danger of starving: children, poor people and the elderly.

But the situation was much bleaker than the picture conjured up by that paragraph; the siege waxed and waned, and UNRWA was occasionally granted permission to deliver emergency relief, but the image below – of residents queuing for food supplies – shows how desperate the situation became.

Here is a woman in September 2014 describing the horrors of the siege to Jonathan Steele:

There was no anger or hysteria in her voice, just a calm recollection of facts. “You couldn’t buy bread. At the worst point a kilo of rice cost 12,000 Syrian pounds (£41), now it is 800 pounds (£2.75) compared to 100 Syrian pounds (34p) in central Damascus. It was 900 pounds (£3.10) for a kilo of tomatoes, compared to 100 here,” Reem recalled. “We had some stocks but when they gave out we used to eat wild plants. We picked and cooked them. In every family there was hepatitis because of a lack of sugar. The water was dirty. People had fevers. Your joints and bones felt stiff. My middle daughter had brucellosis and there was no medication,” she said. In October 2013, in a sign of how bad things had become, the imam of Yarmouk’s largest mosque issued a fatwa that permitted people to eat cats, dogs and donkeys.

Control of Yarmouk see-sawed between the Syrian Arab Army, Al-Nusrah and Islamic State, with thousands of civilians trapped behind the siege lines so that time and time again the community was thrown back on its own, desperately strained resources to survive.

Here is how Mamoon Yalabasi described a second satirical video from Yarmouk, made shortly after IS over-ran the camp, in April 2015:

“We are in the Yarmouk camp, the camp of plentifulness…  Take a look at the floor,” said the man as the camera shows water in the street. “This is not water. This is an excess of cooking [flooding the streets].”

The youth then moved on to mockingly give his viewers advice on how to lose weight.

“Would you like to lose weight? Green tea won’t work, nor will ginger … just come to Yarmouk camp for five months, in each month you’ll lose 9kg,” he said, adding the Arabic proverb: “Ask someone with experience instead of asking a doctor.”  …  “We ask the troublesome channels that claim Yarmouk camp is under siege to stop reporting that. It is ‘absolutely’ [said in English] not true,” one said.  “It’s true that my grandmother died of hunger but not because the camp was under siege but because my grandfather was so stingy – he never allowed her near the fridge,” he added.

Perhaps you think all this extreme, even exceptional, comforted by those images of rooftop gardens, and believe that those who bravely tended them could somehow perform their own green revolution.  So here are Zeinat Akhras and her brother describing how they survived during the siege of Homs:

The examples can be multiplied many times over, but in a way this last testimony is exceptional – amongst those on which I’m drawing, at any rate – because it only became available once the siege had been lifted.  Those videos from Yarmouk point towards something different: the possibility of breaching siege lines through digital media.

So let me turn to Madaya, a town in the Qalamoun Mountains 45 km north-west of Damascus and once famous for its fruits and vegetables.  It came under siege from the Syrian Arab Army and Hezbollah militias in July 2015: the town was encircled by 65 sniper-controlled checkpoints (below) and its surrounding countryside sown with thousands of landmines.

In January 2016 the UN still classified Madaya as a ‘hard-to-reach area’, so listen to one local resident describing conditions to Amnesty International that same month:

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.

I’ve described that field hospital before, but Mohammad‘s testimony reminds us that war produces not only catastrophic injuries; it also produces and intensifies chronic illnesses that a protracted siege eventually renders untreatable.  (The Syrian American Medical Society issued a report, Madaya: Starvation under Siege, which you can read here).

Two days later there were reports of a different digital satire: one that denied the existence of a siege in Madaya and mocked its victims.

A hashtag has swept Facebook and Twitter,  #متضامن_مع_حصار_مضايا , which translates to “in solidarity with the siege on Madaya”, where individuals have posted pictures of food or skeletons, mocking those in Madaya. While many believe that the siege is a myth, some appear to be genuinely mocking the suffering of innocent people…’

The posts were subsequently removed, but here is one I captured:

Fortunately a different digital economy was already at work.  Rym Momtaz, a producer with ABC News, had started a text exchange with a young mother of five children in Madaya:

We communicate through secure messaging apps over the phones, over the internet really. So the way we went about finding her was to go through a wide network of sources that we’ve cultivated over the years of covering the war in Syria. We had to work for a few weeks, I have to say, to identify the right person and then to get in touch with her and to gain her trust in order for her to feel comfortable enough to engage in this conversation with us because she felt and her family felt that it might put her in danger.

‘‘She would text me from the moment she woke up, which was very, very, early, like 5 a.m.,’ Rym explained, ‘and then she would text me truly throughout the day.’  And that same month – January 2016 – ABC started publishing those precious despatches from Madaya.  ‘They can’t get out of Madaya – and we can’t get in,’ ABC News’ Foreign Editor emphasised, but ‘they can tell their story to the world.’

Working with Marvel Comics, ABC transformed her story into a free digital comic: Madaya Mom.

For Dalibor Talajic, the Marvel Comics illustrator who worked on the project,

The most striking parts is for me the most intimate ones as she – for instance, she decides to even though they are – they’re all starving, she decides to stop eating herself because this little amounts of supplies and food that she has, she distributes it to her children and of course husband. And she herself just stopped eating. And it’s not like a dramatic decision. It’s, like, a logical thing to do. These are the moments that stick with me most.

And it is through the assault on the intimacies of everyday life – on something as vital as feeding one’s family – that siege warfare is at its most vicious.

In case you are wondering how the family managed to charge their phones, not at all incidentally, here is the answer:

After protracted negotiations aid convoys were allowed in from time to time, but the situation remained grave.  An aid worker who accompanied a UNICEF convoy into Madaya in September 2016 described the stories told by patients who flocked to a makeshift medical clinic:

Parents whose children had stopped eating because their bodies could no longer tolerate only rice and beans. Children who could no longer walk straight because of the lack of Vitamin D and micronutrients that had riddled their bones with rickets, or who had stopped growing entirely, stunted from lack of essential vitamins. One mother showed us her baby’s bottle filled with rice water – the teat so worn it had to be sewn back to together. “Look at what I am feeding my child” she said.

Almost everyone we spoke to asked for protein – meat, eggs, milk, vegetables – something more to sustain themselves than the dry goods that were available. One mother explained that every time her child now smells boiled burgal, she starts to cry.

The doctor reported an increase in miscarriages, 10 cases in the last 6 months, because of the nutritional status of mothers. Over the last year alone, he has had to perform over 60 caesarian sections. This number was unheard of before the crisis, she told us  But women no longer have the strength for childbirth, and many pregnancies go over term, again because of the poor health of pregnant women.

Six months later life in Madaya remained precarious in the extreme:

Throughout the siege there were accusations of profiteering, but these ran in both directions (it is partly through them that Hezbollah elected to acknowledge the suffering of the city – only to point the fingers of blame at the rebels inside).  According to Avi Asher-Schapiro for VICE News, who spoke to the local leader of Ahrar al-Sham, Abdulrahman, via Skype in January 2016:

Hezbollah media outlets are accusing Abudlrahman and his men of confiscating food in Madaya, holding the population hostage, and profiteering during the crisis. In early January, a video surfaced of a woman from Madaya condemning rebels for hoarding food among themselves. The rebels are “only traders in people’s blood,” she told a scrum of reporters who gathered at the barricades outside Madaya. “They only care about securing food supplies for their families.”

That video [above] was aired around the world by Reuters and Al Jazeera. The accusations enraged Abdulrahman. “When Madaya goes hungry, we go hungry,” he says. “These are vicious lies.” VICE News spoke with another woman who claimed to be at the barricades that day. Although it was impossible to verify her claims, she said that Hezbollah fighters — who can be seen in the video frame — told women to condemn the rebels and praise Assad in exchange for food and safe passage from the town.

In a press release from early January, Hezbollah also accused Abdulrahman of profiteering. “Armed groups in Madaya control food supplies within the town and sell to whoever can afford it,” the statement read, “Thus, starvation is widespread among poor civilians.” VICE News spoke to a Hezbollah commander stationed outside Madaya who repeated these claims, and said that Hezbollah has been sending food inside the town. The rebels, he said, are keeping it for themselves. He also strongly denied that Hezbollah was trading food for propaganda.

VICE News also spoke with aid workers at the Doctors Without Borders-affiliated field hospital in Madaya, who reported no interference from Abdulrahman’s men in the dispensation of aid.

For further, still more shocking twists on the story, see here and a response here.  It’s difficult to adjudicate these competing claims in the face of skilfully organised propaganda campaigns (in which the alt.left is often as grotesque as the alt.right), but wherever the truth lies, it is clear that food has been consistently transformed into a weapon of war (‘surrender or starve‘) – a crime expressly forbidden by international humanitarian law (see also here) – and that 40,000 civilians inside Madaya were trapped in the midst of the battle.

In my previous post on this subject, I described all this as the back-story to the carnage now taking place in Idlib, in eastern Ghouta and elsewhere, but it is of course only one back-story: there are many more.  Still, on 14 April 2017 under the ‘Four Towns Agreement’ a fleet of sixty buses transported several thousand people, rebels and civilians, from Madaya – to Idlib.

Only 2,200 out of 40,000 people signed up to go, and ‘Madaya Mom’ expressed the catch-22 facing the besieged population perfectly:

If we leave, we’re labeled terrorists and we go to Idlib where the chemical attack happened last week; and if we stay we don’t know how the government will treat us.

At first, those who left were relieved and even heartened.  Deutsche Welle spoke with one young evacuee from Madaya soon after he arrived in Idlib:

I was surprised. I saw markets [below, June 2017], people walking in the streets; there is electricity, internet, ice cream and food – things we did not have in Madaya. Madaya and Zabadani are destroyed. In Idlib, the destruction is not too bad. There are a lot of cars and I was really surprised to see cars. I felt like the little children that came from Madaya to Idlib: they were surprised when they saw a banana, a cherry, biscuits or chocolate. They have never seen that before. It sounds stupid, but I felt a little bit the same when I saw cars again.

I can eat everything. The first thing I ate was fried chicken and it was great. And I have had a lot of chocolate, too.

But as the interview progressed, his elation was punctured by a growing realisation of the  bleak future ahead:

But in general, Idlib is a poor city… I started to search for jobs, but there are almost no jobs here. Idlib is like a big prison. It’s like Gaza. It’s like Madaya, but a big Madaya. So we are imprisoned here.

We know what horrors lay in wait, and we know something of what is happening in Idlib now.  But what of Madaya?  Here are extracts from a report (‘community profile’) for September 2017 (you can find more from SIRF/REACH here):

  • Movement was unrestricted within Madaya. For movement in and out of the area, two access points have been used since the implementation of the Four Towns Agreement. In September, 26-50% of the population were reportedly able to use formal access points providing they showed identi cation. However, men reportedly did not feel safe using the access points, fearing conscription and detention when crossing, while both men and women reported verbal harassment.
  • Since May 2017, commercial vehicle access has been permitted to the area. However, access restrictions on vehicle entry continued to be reported in September and included documentation requirements, confiscation of loads, required fees and limited entry depending on the day or time.
  • Humanitarian vehicle entry has reportedly not been permitted for the past six months.
  • The cost of a standard food basket in Madaya has remained stable since May 2017, with the average cost around 12% more expensive than nearby communities not classi ed as besieged or hard-to-reach.
  • Water continued to be insufficient and some residents reportedly reallocated money intended for other things to purchase water. Meanwhile, access to generators remained stable at 4-8 hours a day in all areas of the community.

I’m conscious of how much I haven’t been able to address in this post.  In particular, I’ve chosen to focus on the ‘silent violence’ of hunger and malnutrition rather than the explosive violence of mortars, missiles and bombs.  The two coincide in all sorts of ways – think, for example, of the air strikes on bakeries, what Anna Ciezadlo called ‘the war on bread‘, and on hospitals and clinics – but the contrast is really my point.  As one resident of Aleppo told Amnesty,

You need months before you die of starvation. The air strike attacks were a different story. You could die from a piece of shrapnel in a fraction of a second. Nobody was protected from the air strikes and shelling. Civilians, rebels, buildings, cars, bridges, trees, gardens etc. were all a target.

And so one final digital satire.  In April 2016 the Syrian government held elections and claimed that even opposition-held areas were enthusiastically participating.  Responding to what they called ‘the theatrics of the Assad regime’, teenagers in Madaya posted a video of their own mock hustings:The rival candidates were “Deadly Starvation”, “Deadly Illness”, and “Airstrikes”.

Bombs, bunkers and borders

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

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

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

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

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

The statement continues:

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

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

More here.

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

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

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

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

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

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

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

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

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

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

Annie singles out three particularly problematic issues.

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

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

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

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

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

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

But all this comes at a cost:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The war on Ebola

ECONOMIST The war on Ebola

We’ve been here before – ‘wars’ on this and ‘wars’ on that.  It’s strange how reluctant states are to admit that their use of military violence (especially when it doesn’t involve ‘boots on the ground‘) isn’t really war at all – ‘overseas contingency operations’ is what the Pentagon once preferred, but I’ve lost count of how many linguistic somersaults they’ve performed since then to camouflage their campaigns – and yet how eager they are to declare everything else a war.

These tricks are double-edged.  While advanced militaries and their paymasters go to extraordinary linguistic lengths to mask the effects of their work, medical scientists have been busily appropriating the metaphorical terrain from which modern armies are in embarrassed retreat.

Yet all metaphors take us somewhere before they break down, and the ‘war on Ebola’ takes us more or less directly to the militarisation of the global response.  In an otherwise critical commentary, Karen Greenberg draws parallels between the ‘the war on terror’ and the ‘war on Ebola’:

‘The differences between the two “wars” may seem too obvious to belabor, since Ebola is a disease with a medical etiology and scientific remedies, while ISIS is a sentient enemy. Nevertheless, Ebola does seem to mimic some of the characteristics experts long ago assigned to al-Qaeda and its various wannabe and successor outfits. It lurks in the shadows until it strikes. It threatens the safety of civilians across the United States. Its root causes lie in the poverty and squalor of distant countries. Its spread must be stopped at its region of origin — in this case, Guinea, Liberia, and Sierra Leone in West Africa — just as both the Bush and Obama administrations were convinced that the fight against al-Qaeda had to be taken militarily to the backlands of the planet from Pakistan’s tribal borderlands to Yemen’s rural areas.’

There are other parallels too, not least the endless re-descriptions of terrorism and even insurgency as life-threatening diseases, ‘cancers’ on the body politic.  And, as Josh Holmes shows, there is also an entirely parallel (geo)politics of fear in both cases (see also Rebecca Gordon on the racialization of ‘the fear machine’ here).  Given the threat supposedly posed by ‘the enemy within’, it’s not surprising that US Northern Command has already set up a 30-person ‘military rapid response team‘ for domestic Ebola cases, and that the Department of Homeland Security has been issuing Biosurveillance Event Reports on the Ebola outbreak in West Africa from the National Biosurveillance Integration Center.

National Biosurveillance EBOLA DHS 1 Oct 2014

But as I’ve said, Karen’s is a critical commentary and so, before the military metaphors carry us away,  her conclusion bears repeating:

The United States is about to be tested by a disease in ways that could dovetail remarkably well with the war on terror. In this context, think of Ebola as the universe’s unfair challenge to everything that war bred in our governmental system. As it happens, those things that the U.S. did, often ineffectively and counterproductively, to thwart its enemies, potential enemies, and even its own citizenry will not be an antidote to this “enemy” either. It, too, may be transnational, originate in fragile states, and affect those who come in contact with it, but it cannot be stopped by the methods of the national security state.

To make sense of all this, I think we need to stand back and start with four general observations:

(1) Modern military medicine has long involved more than evacuating and treating the wounded from the field of battle.  It has always had a substantial public health component.  Until the early twentieth century, ‘infectious diseases unrelated to trauma were responsible for a much greater proportion of the deaths during war than battle-related injuries‘.  As militaries started to pay much closer attention to hygiene and disease prevention, Matthew Smallman-Raynor and Andrew Cliff estimate that the ratio of ‘battle deaths’ to deaths from disease amongst the military population fell from 1:0.4 in the First World War to 1:0.1 in the Second World War; then it rose to 1:0.13 in the Vietnam War but in the first US-led Gulf War (1991) it fell to 1:0.01.

Beyond Anthrax(2) Modern militaries are no strangers to biowarfare either.  Both sides in the First World War experimented with chemical weapons, and although the US Army’s explicitly offensive Biological Warfare Weapons Laboratories closed in 1969 the commitment to ‘bio-defense’ and bio-security has ensured a continuing military investment in the weaponisation of infectious diseases (see right).  I don’t subscribe to the view that the Ebola epidemic in West Africa is the result of a rogue US biowarfare program – see for example the claims made by ‘Robert Wenzel’ here: and if you want to know why his name is in scare-quotes, appropriately enough, read Chris Becker‘s takedown here –  nor to the fear that what Scientific American calls ‘weaponised Ebola’ is poised to become a ‘bio-terror threat’.  But I do think it worth noting the work of the US Army Medical Research Institute of Infectious Diseases which has had field teams on the ground in West Africa since 2006, and the importance placed on surveillance and monitoring.

(3) I also think it’s necessary to think through the biopolitics of public health in relation to military and paramilitary violence.  This takes multiple forms.  It’s become dismally apparent that in many conflict zones hospitals, doctors and other health-care workers have become targets: in Gaza, to be sure, but in Syria and elsewhere too.  The treatment of disease has also become a tactical vector: think of the CIA’s use of polio vaccination campaigns as a cover for its intelligence operations and – the conjunction is imperative – the Taliban’s manipulation of polio vaccinations in Pakistan’s Federally Administered Tribal Areas.  Think, too, of the way in which the Assad regime has inflicted a resurgent, even counterinsurgent geography of polio on the Syrian people.  As Annie Sparrow shows (see also here):

‘This man-made outbreak is a consequence of the way that Syrian President Bashar al-Assad has chosen to fight the war—a war crime of truly epidemic proportions. Even before the uprising, in areas considered politically unsympathetic like Deir Ezzor, the government stopped maintaining sanitation and safe-water services, and began withholding routine immunizations for preventable childhood diseases. Once the war began, the government started ruthless attacks on civilians in opposition-held areas, forcing millions to seek refuge in filthy, crowded, and cold conditions. Compounding the problem are Assad’s ongoing attacks on doctors and the health care system, his besieging of cities, his obstruction of humanitarian aid, and his channeling of vaccines and other relief to pro-regime territory.

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Late this summer she provided this update:

‘… nearly all the cases of polio have occurred in areas of northern Syria under rebel control, where the government is seemingly doing everything in its power to prevent vaccination. The Syrian government has appealed to the UN for hundreds of medicines for areas of the country it controls, while largely ignoring the far more dire needs of opposition-held areas. Many children, especially newborns, still do not have access to polio immunization. Daily government airstrikes target the very health facilities that should be the foundation of vaccination efforts, as well as the children who should be protected from polio, measles, and other preventable childhood diseases. As Dr. Ammar, a doctor from Aleppo, said to me bitterly after an April 30 airstrike killed twenty-two schoolgirls, “The government’s polio control strategy for children is to kill them before they can get polio.”’

(4) Finally, biopolitics threads its way from the sub-national and the national to the trans-national and so to what Sara Davies calls, in a vitally important essay, ‘securitizing infectious disease‘. (The link will take you to an open access version, which was originally published in International affairs 84 (2008) 295-313; see also her ‘The international politics of disease reporting: towards post-Westphalianism?‘, International politics 49 (2012) 591-613, and the collection she has edited with Jeremy Youde, The politics of surveillance and response to disease outbreaks: the new frontier for states and non-state actors – due out next year).

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In her original essay, Sara shows how powerful states in the global North joined forces with the World Health Organisation to construct infectious disease as an existential security threat that demanded new rules and protocols for its effective containment.  Crucially:

‘The outcome of this has been the development of international health cooperation mechanisms that place western fears of an outbreak reaching them above the prevention of such outbreaks in the first place. In turn, the desire of the WHO to assert its authority in the project of disease surveillance and containment has led it to develop global health mechanisms that primarily prioritizes the protection of western states from disease contagion.’

This has a genealogy as well as a geography (or what Alan Ingram once called a ‘geopolitics of disease’).  Peter Dörrie notes that on 18 September 2014 the U.N. Security Council declared the current Ebola outbreak in West Africa ‘a threat to international peace and security’, and that this was ‘the first time the U.N. had taken this step in a public health crisis‘ (in fact the Council had previously expressed similar concerns about the impact of HIV/AIDS on ‘stability and security’).  Under Chapter VII of the UN Charter this declaration has significant legal implications, as Jens David Ohlin notes here, but what most concerns Peter is how long it took for the Security Council to stir itself.  It issued its statement 180 days after the WHO confirmed the outbreak, and over a month after the WHO had declared Ebola a ‘Public Health Emergency of International Concern’, and in his eyes the international system ‘ignored the problem until it was too big for any solution other than full-scale military intervention.’   But I’ve already suggested, it’s wrong to treat the militarisation of epidemic disease as somehow new.  Of direct relevance to the present ‘war on Ebola’ is this passage from Sara’s essay:

The United States has been a keen participant in disease surveillance and response since the mid-1990s. The United States Department of Defense (US DoD) has had overseas infectious disease research laboratories located in over 20 countries for nearly ten years. The Global Emerging Infectious Surveillance and Response System (DoD-GEIS) mobile laboratories were set up for the purpose of ‘responding to outbreaks of epidemic, endemic and emergent diseases’, and their location in the DoD, as opposed to the United States Agency for International Development (USAID) or Centre for Disease Control (CDC) demonstrates how seriously the United States views the response to infectious disease as a key national security strategy.

So, four observations about the military-medical-security nexus that provide a context for the ‘war on Ebola’.  There are two other issues that should also be on the table before proceeding.

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The first involves the imaginative geographies circulating in the global North that (mis)inform public response to the epidemic.  Many of them can be traced back to colonial descriptions of the coast of nineteenth-century West Africa (and Sierra Leone in particular) as ‘the white man’s grave’, a form of what in a different context Dan Clayton calls a ‘militant tropically’.  The contemporary reactivation of these tropes is clearly a serious concern because it corrodes an effective political response.  As geographer Kerrie Thornhill writes,

African and diaspora scholars, already accustomed to the ‘thousand tiny paper cuts’ of casual racism, demonstrate how these (metaphorical) cuts escalate into real fatalities. Writers such as Nanjala Nyabola and Lola Okolosie point out the abundance of racist tropes depicting West African societies as inherently unclean, chaotic, uncooperative, ungrateful, and childlike. This racism reinforces a global culture of disregard for black African lives, and the perception that they are a source of social and biological contamination.

You can find much more on this in Cultural Anthropology‘s brilliant Ebola in Perspective series.

Health care systems in West Africa Economist

The second is the precarious condition of health care systems in West Africa (Ebola in Perspective is good on this too).  Brice de la Vigne, the operations director of MSF, reminds us that ‘both Sierra Leone and Liberia were at war ten years ago and all the infrastructure was destroyed. It’s the worst place on earth to have these epidemics.’  Other critics suggest that these uncivil wars were not the only culprits.  In their view, it was the neoliberal economic model forced on West Africa by the global North that was primarily responsible for gutting public health systems:

While years of war played a role in weakening public systems, it is the “war against people, driven by international financial institutions” that is largely responsible for decimating the public health care system, eroding wages and conditions for health care workers, and fueling the crisis sweeping West Africa today, says [Emira] Woods. “Over the past six months to a year there have been rolling health care worker strikes in country after country—Nigeria, Sierra Leone, and Liberia,” said Woods. “Nurses and doctors are risking and losing their lives but don’t have protective gear needed to serve patients and save their own lives. They are on the front lines and have not had their voices heard.”

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So – back to the front lines.  Despite the geopolitical-military-security back story, it was Médecins Sans Frontières that made the first public call (on 2 September) for military assistance in combatting Ebola.

‘States with biological-disaster response capacity, including civilian and military medical capability, must immediately dispatch assets and personnel to West Africa… 

‘Many countries possess biological threat response mechanisms. They can deploy trained civilian or military medical teams in a matter of days, in an organised fashion, and with a chain of command to assure high standards of safety and efficiency to support the affected countries…

‘In the immediate term, field hospitals with isolation wards must be scaled up, trained personnel must be dispatched, mobile laboratories must be deployed to improve diagnostics, air bridges must be established to move personnel and material to and within West Africa, and a regional network of field hospitals must be established to treat medical personnel with suspected or actual infections.’

MSF call 2 Sept 2014

Ten days later Peter Piot, the Director of the London School of Tropical Medicine and Hygiene and the microbiologist who helped identify the Ebola virus in 1976, also called for a ‘quasi-military intervention’.  Although he spoke about a ‘state of emergency’, he too wanted to reverse the response prefigured by Giorgio Agamben in such situations and contract the spaces of exception that were multiplying across West Africa.  He had in mind ‘beds, ambulances and trucks as well as an army of clinicians, doctors and nurses.’

What materialised was rather different.

Africom_emblemOn 16 September President Obama flew to the Centers for Disease Control and Prevention in Atlanta to announce Operation United Assistance.  He committed 3-4,000 US troops and $750 million in defence funding to the mission, which is being orchestrated by US Africa Command (AFRICOM) through US Army Africa in concert with USAID.  The focus of the US military-medical mission is Liberia. There are close historical connections between the US and Liberia, which originally offered to host AFRICOM’s headquarters in the capital Monrovia; now a Joint Force Command has been set up there.  You can find the 75-page AFRICOM operational order here, dated 15 October 2014, from which I’ve taken the ‘common operating picture’ below.  The title puzzles me – the only ‘Operation United Shield’ (singular) I’ve been able to find was a multinational operation to evacuate peacekeeping forces from Somalia in 1995.  Appendix B is particularly worth reading, incidentally, because it identifies ‘the enemy’: ‘Ebola Virus Disease is the enemy, aided by poor preventive medicine practices in areas where EVD cases are prevalent and difficulties in identifying and treating EVD patients.’

USAFRICOM-EbolaResponseOPORD (dragged)

The US deployment is complemented by the deployment of UK forces to Sierra Leone (Operation Gritrock)and French forces to Guinea.  In both cases there are also close, colonial connections, and the British-led International Military Advisory Training Team Sierra Leone has been on the ground since 2000 (since last year this has been re-tasked as the International Security Advisory Team Sierra Leone).

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(The map above is borrowed from the BBC; in addition, the Guardian has an interactive map tracing the historical geography of Ebola from the first known case in the Democratic Republic of Congo in 1976 to the present epidemic in West Africa here).

These forces differ in more than geographical deployment; their capabilities differ significantly too.  The UK is sending 750 troops, including contingents from the Royal Army Medical Corps (notably 22 Field Hospital), who will construct treatment centres (the aim is to add 700 beds to triple Sierra Leone’s existing capacity) and treat doctors and other health-care workers who contract the disease; they are supported by the Royal Navy’s ‘Primary Casualty Receiving Ship’ RFA Argus (which will provide a further 100 beds), and by another 780 volunteer health care staff.

AFRICOM update 29

The US has mobilised troops from the 101st Airborne, whose primary mission is to set up 17 Ebola Treatment Units (each with 100 beds); meanwhile the US Air Force’s 633rd Medical Group is establishing a 25-bed Expeditionary Medical Support System field hospital for doctors and other health care workers who contract the disease (below).  The US Army has also fielded three mobile laboratories to test samples for the virus, reducing the time to diagnosis from days to hours. According to Pardis Sabeti, who leads viral-genome research at the Broad Institute of M.I.T. and Harvard, ‘the faster you can get a diagnosis of Ebola, the faster you can stop it.’

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‘Our enemy is a disease’, declared Lt Col Brian De Santis, echoing AFRICOM’s operational order – but it was quickly made clear that the vast majority of troops will not come into contact with the enemy or any of its victims at all.  This is just as well; most of the soldiers have minimal medical training – just four hours from the US Army Medical Research Institute of Infectious Disease – and the Pentagon’s Press Secretary Rear Admiral John Kirby explained that there is ‘no intention right now that [troops] will interact with patients or be in areas where they would necessarily come into contact with patients’:

‘They’re not doctors. They’re not nurses. They’re not trained for that and not equipped for that. That’s not part of the mission. They will be kept in locations where they can do their jobs without coming into contact with patients.’

Andrew Bacevich thinks all this absurd:

‘It’s like the city that spends all its money to raise up a formidable police force only to discover that what it really needs is a bigger sewage treatment plant. Of course, you can always put cops to work burning human excrement but there are better — that is, more effective and cheaper — ways to solve the problem.’

In effect, this is another case of the military preferring remote operations.  Here is a telling passage from Sophie Arie’s interview with MSF’s president Joanne Liu:

‘“Countries are approaching this with the mindset of going to war,” she says. “Zero risk. Zero casualties.” Liu describes the current military efforts as the equivalent, in public health terms, of airstrikes without boots on the ground. Pledges of equipment and logistical support are helpful—“The military are the only body that can be deployed in the numbers needed now and that can organise things fast.” But there is still a massive shortage of qualified and trained medical staff on the ground. “You need to send people not stuff and get hands on, not try to do this remotely,” Liu says…’

The primary areas for military operations in the ‘war on Ebola’  to date are surveillance, logistics and containment.  I’ll consider each in turn.

Last week Public Intelligence released a series of weekly Security Updates and daily Intelligence Summaries produced by AFRICOM to support Operation United Assistance.  These rely largely on WHO reporting to track the spread of the disease.

USAFRICOM Ebola Security Oct 2014

This is to work at a highly aggregate level.  Most public health experts suggest that the key to stopping the spread of the disease is contact tracing – which, in its essentials, is the same methodology used by the military and the intelligence services to track individuals through terrorist and insurgent networks – and has been used successfully in both the United States and in Nigeria (which was declared free of Ebola on 20 October).  Ezra Klein describes it as ‘almost ludicrously simple’ and ‘as low-tech as medicine gets’, and so it is in principle.

But its application in much of West Africa is immensely difficult: the UN estimates that only 16 out of 44 zones have adequate procedures and personnel in place.  And since many local people are understandably fearful of the consequences of their answers, it is unlikely that military involvement would improve the situation.  Here is Elizabeth Cohen and John Bonifield:

‘People are often uncooperative with the tracers, sometimes even throwing stones at health care workers. They fear that they or their loved ones will be put in the hospital; they’ve seen firsthand that people who go there often don’t return.

“The community perceives this as a death sentence,” [Donald Thea, an infectious disease epidemiologist] said. “Relinquishing your loved one is tantamount to death.”

And health care workers have very little to offer people as an incentive to cooperate. “With smallpox, we could offer people a vaccine, a carrot in essence to induce them to be cooperative. With Ebola, we have nothing,” Thea said.’

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Logistics is the area where the military comes into its own.  MSF had emphasised that its priorities included ‘the mass expansion of isolation centers, air bridges to move personnel and equipment to and within the most affected countries, mobile laboratories for testing and diagnosis, and building a regional network of field hospitals to treat suspected or infected medical personnel.’ Much of the military effort is currently concentrated in these areas, but the other side to mobilising medical personnel, equipment and testing and treatment facilities is, in effect, immobilising the population.

Containment runs the gamut from quarantine through curfews and lockdowns to border closures.  Most observers believe that border closures would be counter-productive: if you want to know why, see Debora MacKenzie‘s short essay here.  The other, seemingly lesser measures also have their dangers.  In its original call for assistance, MSF insisted that ‘any military assets and personnel deployed to the region should not be used for quarantine, containment, or crowd control measures’, and it emphasised that ‘forced quarantines have only bred fear and unrest, rather than stem the virus.’

But others have other ideas.  Major Matt Cavanaugh, from the US Army War College, has made an unofficial, back-of-the-envelope calculation of what a successful ‘containment strategy’ for Ebola would require.  He is adamant that only ‘boots on the ground’ could do the job, though the nature of that ‘job’ remains elusive in his account.  He talks about military logistics – the ability to ‘fix “the last mile” problem’ – but he also notes the need ‘to fill the basic state functions related to health, security, and public order in order to adequately respond to the threat.’  In case that triptych isn’t clear enough, in his subsequent ‘Ebola Manifesto‘ the major declares that ‘There is exactly one organization designed to rapidly hold and control territory and the people on it: the military.’ The figure he eventually arrives at – somewhere between 36,600 to 73,200 troops – is derived from the wars in Afghanistan and Iraq, and suggests that, for some commentators at least, the Ebola crisis is an opportunity to deepen AFRICOM’s investment in what Jan Bachmann calls ‘policing Africa’ [see his ‘Policing Africa: the US military and visions of crafting “good order”‘, Security Dialogue 45 (2) (2014) 119-36]:

‘The spectrum of [AFRICOM’s] activities can be understood most comprehensively through an analytical perspective of policing, in which the aim of establishing ‘good order’ through an expansive regulatory engagement in issues of welfare is applied to contexts of ‘fragile’ statehood and ‘ungoverned spaces’.’

This is not a uniquely American view.  The Daily Mail (where else?) reports that one of the options being considered by Britain’s Chief of the General Staff is a full-scale military lockdown of Sierra Leone:

‘From a military perspective ebola is like a biological warfare attack and should be countered accordingly. There needs to be a clampdown on human movement inside Sierra Leone and possibly to and from the country between now and late 2015 when it is hoped that an antidote will have been developed.’

ByKlg1IIEAAmBwnIt’s hard to know how much credence this should be given, of course, though the very existence of proposals like these suggests that the ‘soft power’ which Joeva Rock sees in the militarisation of Ebola conceals an iron fist.  And Niles Williamson believes that the military-medical missions are a smokescreen:

‘The main purpose of this military operation is not to halt the spread of Ebola or restore health to those that have been infected. Rather the United States is seeking to exploit the crisis to establish a firm footing on the African continent for AFRICOM.’

That may be one of the objectives, but I think it’s a bridge too far to claim it as the main purpose: as I’ve tried to show, the militarisation and securitisation of Ebola has many other geopolitical and biopolitical dimensions.  And Nick Turse has revealed that AFRICOM, far from having a ‘light footprint’, has already achieved a remarkably rapid tempo of operations across the whole continent.

Still, even in its less extreme versions, the ‘war on Ebola’ clearly raises urgent questions about the militarisation of humanitarian aid, about what Kristin Bergtora Sandvik  calls a ‘crisis of humanitarian governance’, and about the violence that is involved in the production of the humanitarian present.