Bombs, bunkers and borders

Posted on May 28, 2017 by Derek Gregory

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, here, here 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 weaponisation of health care

Posted on March 16, 2017 by Derek Gregory

I’m continuing to work on attacks on hospitals and health care workers in conflict zones – see ‘The Death of the Clinic’ here for a general discussion – and I’ve just finished reading the preliminary report on the weaponisation of health care from The Lancet-American University of Beirut Commission on Syria. You can find out more on the Commission here and download the open access report here.

The authors propose the ‘weaponisation of health care’ to capture ‘the phenomenon of large-scale use of violence to restrict or deny access to care as a weapon of war’:

Weaponisation is multi-dimensional and includes practices such as attacking health-care facilities, targeting health workers, obliterating medical neutrality, and besieging medicine. Through large-scale violations of international humanitarian laws, weaponisation of health care amounts to what has been called a “war-crime strategy”. Weaponisation of health care in the Syria conflict is manifested most notably in the targeting of health workers and facilities.

They trace the targeting of health-care workers by pro-government forces in Syria back to the earliest weeks of protest against the regime, but the ‘substantial militarisation’ that followed – especially after the ‘military surge’ that began in September 2015 when Russia joined the Syrian government forces – made those attacks ever more aggressive and ever more systematic. This map, based on the work of Physicians for Human Rights, provides a minimal accounting of attacks on doctors, nurses and other healthcare workers:

Attacks on hospitals – some of which I described in detail in a previous post – became not only more systematic but even repetitive, on a scale which the authors is wholly unprecedented.

‘Examination of attacks since 2012 on health facilities has revealed a distinct pattern of weaponisation.Analysis of attacks over several years in important opposition-held areas of Aleppo, Hama, Idlib, eastern Ghouta, and Homs reveals a pattern of repeated targeting with intention to shut access to health care, whether to impede opposition forces or to force civilian displacement.’

They list the effects of these attacks on healthcare in areas outside the control of the Syrian government – ‘rebel-held areas’ – but they also sketch the situation in areas under the control of the Islamic State:

Efforts to recruit foreign doctors through social media have reportedly helped IS to develop a functioning health system with modern facilities and equipment, qualified health workers, and a medical school in Raqqa where students train for free. But this health system is exclusive to IS, and foreign doctors are only permitted to provide care for IS members. For the rest of Raqqa’s civilians, over 1 million people, there are only 33 specialist doctors including just three obstetricians and one ophthalmologist, and just two public hospitals. Anecdotal reports indicate that health workers are forced to deliver care at gunpoint while others are arrested, abducted, or even executed for refusing to deliver care. To stop the exodus of health workers, IS uses the threat of seizure of homes and clinics in case of absence from work. Gender separation in these areas means that female health providers are subject to additional stress and restrictions, being forced to abide by IS dress code and to treat only female patients.

And for the benefit of the useful idiots inside the academy who deny these predations by the Syrian government on its own people, I should add that the report also discusses the situation inside government-controlled areas:

The bulk of Syria’s remaining health workers are in government-controlled areas, where there is variability in the capacity of health facilities and personnel. Workers from these areas have also reported challenges, but of a different nature to those working in non-government- controlled areas. Indiscriminate mortar attacks from rebel areas have adversely affected daily life and the public’s sense of security. Many health workers report facing multiple security checkpoints for their daily trip to a hospital or clinic. The collapsing economy has eroded living standards and restricted school and career options for offspring of health workers. Medical students fear the military draft and the risk of being sent to the battlefield. To avoid that fate, many seek whatever residency training positions are available upon graduation, irrespective of specialty. However, with the emigration of many experienced senior academics, fewer high-quality specialists are available to supervise the training of younger doctors. Travel restrictions due to sanctions and the need for leave permits from the government leave few choices for these doctors. Some doctors in these areas have indicated that the international media pay little attention to their plight. Others report being forced to breach ethical principles under unbearable pressure.

You can find an elaboration of these claims in personal testimonials here, which include this:

In November 2011, Dr. Zaki [a pseudonym], a military anaesthetist, was sent to Aleppo Military Hospital. This hospital usually received injured Syrian army combatants, but from the start of 2012, it began receiving civilian patients injured by pro-government forces during the peaceful demonstrations taking place in Idleb and Aleppo. Notably there was no conflict at this time in either city. These civilian patients were interrogated and tortured — either directly through electric shocks or beatings with rubber hoses, or indirectly, by leaving gunshot wounds or open fractures untreated,. A few days prior to the visit to the hospital by the UN-Arab League Special Envoy, who insisted on visiting all patients, Dr. Zaki was ordered by his superiors to find a way to keep these patients silent. The subtext of the order, issued by three generals, the first in charge of the hospital, the second, the head of military intelligence, and the third, head of the military secret police in Aleppo, was clear: “we know exactly who your family are and your wife’s family, and they will be arrested unless you comply” Under those conditions, Dr. Zaki used a combination of anaesthetic agents to sedate over 60 patients, so their wounds and shackles could literally be covered up, and no patient would be able to describe the torture and conditions of their confinement to the Special Envoy. Shortly after this, Dr. Zaki defected and fled to Turkey, along with his entire family and his wife’s family.

I urge you to read the whole report (it’s only 11 Lancet pages).

The report describes what it calls ‘siege medicine’, and for an update you can turn to another new report, this one from Physicians for Human Rights: Access Denied: UN aid deliveries to Syria’s besieged and hard-to-reach areas.

This is how it begins:

Death by infection because security forces do not allow antibiotics through checkpoints.

Death in childbirth because relentless bombing blocks access to clinics.

Death from diabetes and kidney disease because medicines to treat chronic illnesses ran out months ago.

Death from trauma because snipers stand between injured children and functioning hospitals.

And – everywhere – slow, painful death by starvation.

This is what one million besieged people – trapped mostly by their own government – face every day in Syria.

This is the unseen suffering – hidden under the shadow of barrel bombs and car bombs – that plagues the Syrian people as they enter a seventh grim year of conflict.

This is murder by siege.

The report is limited to ‘the failure of the two-step approval process in ensuring the completion of UN interagency humanitarian convoys to besieged and hard-to-reach areas across Syria’; this excludes operations outside that approval process, but it still makes for remarkably grim reading. Here are the raw figures tabulating aid deliveries requested, approved and completed under the two-step process:

Even within these diminished envelopes there were further specific restrictions on medical supplies:

Throughout 2016, Syrian authorities specifically restricted medical aid to besieged and hard-to-reach areas, in direct violation of international humanitarian law.From February through December 2016, Syrian authorities prevented the delivery of more than 300,000 medical treatments to besieged and hard-to-reach areas.28 There is no clear definition of what constitutes a “medical treatment,” nor is there publicly available data on how much of each type of aid was removed from convoys. However, as [the examples in the tabulation below show], the disallowed medical aid included basic medicine, supplies, and equipment needed to treat traumatic, chronic, and acute conditions resulting from or aggravated by the sieges. In addition, it included medical aid speci cally meant to treat infants and children. Some of the disallowed medical aid could have been reused repeatedly to treat numerous people, thus its exclusion likely a ected large populations for prolonged periods of time.

In one particularly egregious example, Syrian government forces turned away an entire aid convoy as it was about to enter besieged Daraya in May 2016 because it contained medical aid and infant formula. Ironically, Syrian authorities in Damascus had limited the type of aid allowed on that convoy speci cally to medical aid, infant formula, and school supplies.

Breaking Aleppo

Posted on February 13, 2017 by Derek Gregory

The 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.

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.

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.

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.

Striking Syria

Posted on January 17, 2017 by Derek Gregory

The Syrian-American Medical Society (SAMS) has published a grim report documenting the pattern of attacks on healthcare in Syria following the passage of UN Security Council Resolution 2286 on 3 May 2016 condemning attacks on medical facilities and personnel in conflict zones. The Resolution was a general one; several states drew attention to Israel’s assault on medical facilities in Gaza, and to the US airstrike on the MSF Trauma Centre in Kunduz (Afghanistan) (see here and here).

The Resolution had the urgent support of a host of humanitarian NGOs; it was co-sponsored by more than 80 member states, and it was adopted unanimously by the Security Council. At the time the UN Secretary-General Ban Ki-Moon described attacks on hospitals as a war crime, and declared:

When so-called surgical strikes are hitting surgical wards, something is deeply wrong… Even wars have rules… The Council and all Member States must do more than condemn such attacks. They must use every ounce of influence to press parties to respect their obligations.

And yet this is what SAMS found in Syria:

In 2015, the rate of targeting of medical facilities and personnel was one attack every four days.
In October 2015, following Russia’s intervention in support of the Syrian government, this rate doubled to one attack every 48 hours.
In November 2016 the rate virtually doubled again to one attack every 29 hours.

SAMS estimates that there were 252 attacks on medical facilities and personnel in 2016; 199 of them took place after the passage of UNSC Resolution 2286.

Between June and December SAMS identified 172 attacks (all detailed in an appendix to the report): 168 of them were carried out by the Syrian government and its allies; one by non-state opposition forces; one by Islamic State; and two by unidentified parties. Aleppo and Idlib were the principal targets: eastern Aleppo alone received a numbing 42 per cent of all attacks.

In case you are wondering about the sources for these claims, the report explains:

SAMS maintains rigid documentation standards in collaboration with partners in the WHO Health Cluster in Turkey and the Johns Hopkins University Bloomberg School of Public Health’s Center for Health and Human Rights. Our reporters on the ground rely on rst- hand testimony and photo documentation from medical sta and record the date, time, location, damages, casualties, impact on service delivery, weapon(s) used, and perpetrator of each incident. Any other source of information is not considered.

Dr Ahmad Tarakji, President of SAMS, reaches this bleak and compelling conclusion:

The failure of the international community to hold the perpetrators of these attacks accountable sends a dangerous message: that there are no lines, no limits, and no boundaries to the atrocities that are being committed against the Syrian people.

You can find more details about the targeting of doctors and hospitals in my post on the weaponisation of healthcare in Syria here; there is also a response to the passage of UNSC Resolution 2286 and its implementation by the Safeguarding Health in Conflict coalition (in September 2016) here.

Meanwhile Chris Woods‘ Airwars team has just released its preliminary assessment of civilian casualties from air strikes carried out by the US-led coalition and by Syrian/Russian air forces:

Syria’s civilians were under constant threat from Coalition air strikes throughout 2016, with 38% more casualty events reported in Syria than Iraq over the year. This may however reflect improved local reporting by Syrian monitors.

Overall, minimum likely civilian deaths in Syrian incidents graded by Airwars as Fair or Confirmed doubled in 2016. Across 136 incidents, between 654 and 1,058 civilians were claimed killed in total. Airwars estimates that a minimum of 818 civilians were likely injured in Fair and Confirmed events in Syria alone.

There were major spikes in February, in June and July (the Manbij campaign) and November the Raqqa campaign), all of them focused on areas held by Islamic State.

As for Syrian/Russian air strikes:

Airstrikes carried out by Moscow pummeled rebel-held areas of Syria throughout 2016, with many hundreds of civilians credibly reported killed.

Overall, there were 1,452 separate claimed civilian casualty events allegedly carried out by Russia during 2016. Between 6,228 and 8,172 civilians reportedly died in these events. Many of these incidents are likely to have been the result of actions by the Assad regime. Even so, civilian deaths from Russian strikes in 2016 far outpaced those from Coalition actions.

The pattern of civilian casualties from Russian air strikes:

But at least three caveats are necessary. First, these are provisional calculations: ‘With so many allegations to assess, Airwars has a significant case backlog’, and the team has so far only completed a detailed analysis of the first four months of 2016.

Second, the report provides no separate listing of air strikes carried out by the Syrian Arab Air Force. The Airwars team concedes a ‘very high level of confusion – especially between Russia and the regime’. Here is Kinda Haddad: ‘For many incidents we have some sources blaming the regime and others Russia – and we can’t really tell who is responsible as they use similar planes and weaponry.’ One major exception to that must be the use of barrel bombs dropped by the SAAF’s helicopters.

Third, these tabulations identify immediate casualties from the strikes: one of the reasons for attacking doctors and hospitals, as I explained previously, is to multiply subsequent and distant casualties – to deny those wounded (or simply sick) life-saving medical treatment. So these casualty lists are minima – and not only as a result of the general problems of casualty accounting in conflict zones.

Red Cross-Fire

Posted on March 15, 2016 by Derek Gregory

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

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

So, for example:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

***

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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