War and demise

Tanisha Fazal has an important article in the latest International Security: ‘Dead wrong? Battle deaths, military medicine and exaggerated reports of war’s demise.’

It is, in part, an artful response to what must surely seem the increasingly astonishing claim that we live in a time of unprecedented peace.  It depends, in part, on who ‘we’ are, of course, but the general thesis has been shouted from the rooftops by (for example) Joshua Goldstein‘s Winning the war on war (2011) and Steven Pinker‘s The better angels of our nature (2011).  Pinker’s thesis is the more general, to be sure: he claims a decline in ‘violence’ in general, not only in military and paramilitary violence.

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Tanisha’s argument hinges on the reliance on ‘battle deaths’ as an index of the incidence of war; these statistics are a minefield of their own, though they are used by most of the major databases, but Tanisha argues that many contemporary wars have been distinguished by a diminution in battle deaths and a marked increase in the numbers of wounded who now survive injuries that would previously have killed them.

She identifies four key changes.  The first two are pre-emptive: soldiers in advanced militaries are now healthier, and so they  can survive disease and injury much better than in the past, and they are equipped with protective equipment that reduces their vulnerability (she’s thinking here not only of MRAPs but more particularly of personal equipment that affords the head and trunk some protection against blast injuries).

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The second two are reactive, and their emphasis on military medicine and evacuation chains intersects directly with my present research on combat casualty care 1914-2014 (see here and here).  From Tanisha’s summary over at Political violence @ a Glance:

‘… battlefield medicine itself has improved via the availability of anesthetics and antibiotics, which make for more effective surgeries as well as a greater likelihood of avoiding or surviving post-operative infections. Similarly, the return of the tourniquet as part of a general focus on hemostatics appears to have dramatically reduced the percentage of soldiers dying from preventable blood loss.

‘… military evacuation practices have gone from soldiers laying on the ground for weeks waiting for transport by stretchers to mechanized ambulances to medevac helicopters. States invest heavily in military transport for this purpose today; NGOs like the ICRC, however, were at the vanguard of this particular shift.’

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That last sentence raises a series of other, crucial questions that I’m also trying to address in my own project: not only the involvement of civilian/humanitarian organisations (and here I’m presently exploring the role of the Friends Ambulance Service on the Western Front in the First World War and in the Western Desert in the Second) but also the part played by militaries in caring for civilian casualties.  How far have they enjoyed the benefits of improved military medicine and trauma care, and how far down the evacuation chain do they move before they are diverted to (often less advanced) civilian hospitals and clinics?

MAP and the meat-grinder

I’ve updated my previous posts on the medical geographies of Gaza several times (see herehere and here), and I’ve drawn on the testimony of Dr Mads Gilbert in extenso, but this testimony from another brave volunteer doctor deserves its own notice.

I met Ghassan Abu Sitta at a wonderful workshop in Paris in December 2012 on War and Medicine, and I learned so much from that one meeting (from everyone there: see my note about War and therapeutic geographies) that I was inspired to develop my own research project on the medical evacuation of casualties from war zones, 1914-2014.

Ghassan Abu Sitta

Ghassan is a reconstructive surgeon who used to work at Great Ormond Street in London but is now based in Beirut.  He’s recently returned from Gaza where he worked as a Medical Aid for Palestinians (MAP) volunteer at al Shifa hospital carrying out five, six and sometimes seven surgeries a day.

You can read some of the background in this excellent report by Robert Tait for Britain’s Telegraph, published ten days ago and from which I’ve borrowed the photograph above, but Ghassan has just been interviewed in depth by Yazan al-Saadi for Al Akhbar; you can read the full version here.

Ghassan says the attack on Gaza was like ‘a meat-grinder’, which he attributes to:

The amount of ordinance that the Israelis fired, the indiscriminate use of these bombs that are capable of bringing down whole buildings, the use of artillery shelling which is indiscriminate because the shell will hit the first thing it reaches, the fact that they were attacking from the air, from the sea, and by land with artillery at the same time. And there was a night they were doing this and then they lit all of Gaza’s sky with these flares just so people will know that this is what’s happening.

He also provides compelling testimony of his experience at al-Shifa, the main trauma centre for Gaza, that adds important detail to the accounts I’ve noted previously:

‘It looked like a refugee camp. The campus of the hospital has a lot of the families that escaped the bombing or lost their houses and they were living inside the walls of the hospital. Everywhere you go you see makeshift dwellings made out of laundry lines and bed sheeting turned into tents. And the hospital was completely full. Single rooms had four beds in them. In some wards we had two patients per bed.

‘The difference between this conflict and the one before is that nobody was allowing the patients out. So you had 7,000 injured – at the time I was there it was 6,000 and by the time the conflict ended the injured were 10,000. An overwhelming majority have still not been able to get out of Gaza. There have been some numbers, but not significant numbers to break the back of this problem….

‘The contingency plans were that all diesel was kept for the al-Shifa Hospital, so people did not have electricity at home, they would donate the diesel to the hospital. The wells that supply Shifa, like the rest of the water in Gaza, had become so contaminated with sea water, it’s salty. People do the best with what they have….

‘… the majority of the killing was happening because they were dropping ammunition designed to penetrate mountain caves. [The Israelis] were dropping them on civilian dwellings made out of breeze block. And so these four or five storey buildings were being pulverized by these one-ton bombs. That was what was wiping out whole families. And in Gaza, because land is so much in shortage, people come along and build their house, they build enough foundations that when their kids grow up, they can build a floor on top. So when you take out a four storey building, you take out four generations of a family. That was what happened to, I think, 60 families that have been completely wiped out…

The graphic below shows 26 members of just one extended family, the Abu Jame family, killed at home in Bani Suheila on 20 July; it comes from a sequence that is shockingly far too large to reproduce here, compiled by B’Tselem and available here. The infographic lists ‘members of families killed in their homes in 59 incidents of bombing or shelling’ in which 458 people were killed, including 108 women under the age of 60, 214 minors, and 18 people over the age of 60.  If you follow the link, you can hover over each image for the names and ages of those killed.

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Ghassan continues:

‘… they started inventing these humanitarian ceasefires, where people would go out and they would start killing them. We had this on the day of Eid, they said there was a humanitarian ceasefire and the kids went out to a local fair ground and they bombed them. The other time was in al-Shujayeh market, there was a humanitarian ceasefire, they got them into the market, they killed them, then they waited for the ambulances to get there, and then they shelled the ambulances again.

‘So the issue isn’t the type of weapons, but the intent to kill. The amount of ordinance they used and the tonnage of the bombs they used were intended to wipe out whole neighborhoods. That’s what they have done. They have completely wiped out Shejayeh, they wiped out Khuza’a, they wiped out a big part of Rafah, a big part of Khan Younes, and parts of Beit Hanoun….

‘ All the areas around the hospital were being bombed all the time. You would hear it. We heard something we knew it was close, but didn’t know how close it was. We then got a call to the emergency room and we were told that the administration and the out patients building had been hit – a lot of families had taken refuge in that area – so we had to go and help.’

Asked directly whether Hamas or other factions were firing rockets from the vicinity of the hospital, Ghassan is unequivocal:

‘Around Shifa? No, no, no. But in other places you would see them in the sky or hear them. You would learn to distinguish the whoosh of the rocket. Gaza is so small and so flat, I mean you are not going to hide them in the mountains or the jungle because there are no mountains or jungle. People are literally on top of each other. It’s going to happen. But around the hospital there were none.’

Destructive Edge

In a previous post on ‘The Death Zone‘, I suggested readers compare Israel’s extended ‘buffer zone’ in Gaza by following the line of the main highway, Saladin Street.  Hugh Naylor has followed that route on the ground – what he calls ‘Desolation Road’ – and his report is accompanied by an interactive map showing some of the vast panorama of destruction:

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I’ll have more to say about the caption – about the Israeli military’s targeting in Gaza – shortly.  The Guardian has just published a graphic by Nadja Popovich showing the UNRWA-run schools sheltering refugees (many of them from the expanded ‘buffer zone’) that were struck by the Israeli military:

Gaza schools hit by Israeli military

 Amnesty International reports growing evidence that health facilities and workers were deliberately targeted by the Israeli military:

Testimonies from doctors, nurses, and ambulance workers who have spoken to Amnesty International paint a disturbing picture of hospitals and health professionals coming under attack by the Israeli army in the Gaza Strip, where at least six medics have been killed. There is growing evidence that health facilities or professionals have been targeted in some cases.

Since Israel launched Operation “Protective Edge” on 8 July, the Gaza Strip has been under intensive bombardment from the air, land and sea, severely affecting the civilian population there. As of 5 August, according to the UN Office for the Coordination of Humanitarian Affairs, 1,814 Palestinians had been killed in the Gaza Strip, 86 per cent of them civilians. More than 9,400 people have been injured, many of them seriously. An estimated 485,000 people across the Gaza Strip have been displaced, and many of them are taking refuge in hospitals and schools.

Amnesty International has received reports that the Israeli army has repeatedly fired at clearly marked ambulances with flashing emergency lights and paramedics wearing recognizable fluorescent vests while carrying out their duties. According to the Palestinian Ministry of Health, at least six ambulance workers, and at least 13 other aid workers, have been killed as they attempted to rescue the wounded and collect the dead. At least 49 doctors, nurses and paramedics have been injured by such attacks; at least 33 other aid workers were also injured. At least five hospitals and 34 clinics have been forced to shut down due to damage from Israeli fire or continuing hostilities in the immediate area.

Hospitals across the Gaza Strip suffer from fuel and power shortages (worsened by the Israeli attack on Gaza’s only power plant on 29 July), inadequate water supply, and shortages of essential drugs and medical equipment. The situation was acute before the current hostilities, due to Israel’s seven-year blockade of Gaza, but have been seriously exacerbated since…

Amnesty International is aware of reports that Palestinian armed groups have fired indiscriminate rockets from near hospitals or health facilities, or otherwise used these facilities or areas for military purposes. Amnesty International has not been able to confirm any of these reports. While the use of medical facilities for military purposes is a severe violation of international humanitarian law, hospitals, ambulances and medical facilities are protected and their civilian status must be presumed. Israeli attacks near such facilities – like all other attacks during the hostilities – must comply with all relevant rules of international humanitarian law, including the obligation to distinguish between civilians and civilian objects and military targets, the obligation that attacks must be proportional and the obligation to give effective warning. Hospitals and medical facilities must never be forced to evacuate patients under fire.

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The report includes detailed testimony from Palestinian paramedics and ambulance crews who describe the extraordinary difficulty and danger they faced in attending to casualties from Israeli shelling (see also my post on ‘Gaza 101‘, the emergency number for Gaza, and the update here).  Not surprisingly, Israel has rejected Amnesty’s claims and denied targeting hospitals, but when Netanyahu’s spokesperson, Mark Regev, explained that ‘What we’ve had to do on a number of occasions is to hit terrorist targets in the immediate vicinity of hospitals and things like that, where they’ve abused them,’ he failed to address the violations of international law summarised in the last paragraph above.

There’s more.  B’Tselem, now back on line, is also providing detailed testimony from Gaza, including (so far) two ambulance drivers, Rami ‘Abd al-Haj ‘Ali and Ahmad Sabah.  Here is an extract from the first statement (all testimonies are linked to B’Tselem’s interactive map):

B'Tselem map Beit HanounOn Friday afternoon, 25 July 2014, I was working at the medical emergency call center in Beit Hanoun. At around 4:30 P.M., we received a call reporting injured people in al-Masriyin Street in Beit Hanoun. We asked the International Red Cross to coordinate our going there. About 15 minutes after we received the call, we got authorization and an ambulance headed over there with paramedics ‘Aaed al-Bura’i, 25, Hatem Shahin, 38, and driver Jawad Bdeir, 52. The team didn’t make it to the wounded people. Soon after they reached the street, they reported back that a tank had fired at them and they were injured. They asked for another team to come and rescue them.

The call center coordinated the arrival of another team with the International Red Cross and got authorization to go rescue the injured team. I drove the second ambulance, and there were two medics with me – Muhammad Harb, 31, and Yusri al-Masri, 54. The street is only about 200-300 meters from the call center, so we were there within minutes. When we reached the entrance to the street, we were surprised to see three tanks and a military bulldozer in the street, about 100 meters away.

Suddenly, with no warning, they opened heavy machine-gun fire at us. The bullets penetrated the ambulance. I tried to turn the ambulance around to get out of there, but the steering wheel must have been hit. Suddenly, I felt sharp pain in my leg and realized I’d been hit by a bullet or shrapnel. Then the windshield shattered. Because I couldn’t turn the ambulance around, I decided to try reversing. They kept firing as I backed up, until we got far enough away. When they stopped, I managed to turn us around and head back to the center.

On the way there we met Hatem Shahin, one of the paramedics from the first ambulance. He’d been hit by shrapnel in his shoulder and leg. He told us that a shell fired from a tank had hit the front part of the ambulance. He said he’d managed to get away but the other paramedic, ‘Aaed, had been hit. He told us that after he ran away from there, he saw the tank fire another shell at the ambulance, completely destroying it. He thought ‘Aaed must have been killed, but we didn’t know for sure.

The next day, on Saturday, a ceasefire was declared from 8:00 A.M. to 8:00 P.M. An ambulance team went to the spot and found ‘Aaed’s body in the burnt ambulance.

To put all of this in context, the BBC has mapped the deaths of 1,890 Palestinians – ‘mostly civilians’, as its accompanying chart shows – killed during the Israeli offensive to 6 August.  As you can see, Palestinians were killed ‘right across Gaza’ – not only in the expanded buffer zone shown on the map, though the carnage in Beit Hanoun and Shejaiya is clearly visible – with high concentrations also produced in the killing grounds of Gaza City and Khan Younis:

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Finally, in case you’re puzzled by the title for this post: Israel’s attack on Gaza is codenamed Tzuk Eitan in Hebrew, meaning ‘Firm Cliff’ or ‘Resolute Cliff’.  According to Yagiv Levy, ‘The operation’s name signals the power, commitment and resilience of the Israeli people.’  But the official English-language version, ‘Protective Edge’, was changed ‘to give it a more defensive connotation’ (really). As Steven Poole explains, ‘the bombing was supposedly “protective”, though not of those bombed’. All of this is of course in line with the designation of the Israeli military as the ‘Israeli Defence Forces’.

I decided I’d prefer to use a version that provides a more accurate rendering of what has happened – in Hebrew, English or Arabic.

Scoping Afghanistan

BOIJ Tracking drone strikes in AfghanistanThe marvellous Bureau of Investigative Journalism has just published a preliminary report on its new study  of drone strikes in Afghanistan, ‘the most heavily drone-bombed country in the world.’  The study, carried out with the support of the Remote Control Project, has been prompted by analyses which show that ISAF has persistently under-estimated civilian casualties from its strikes (‘“We only count that which we see… You can do a tremendous amount of forensics … [but] seldom do we see the actual bodies.”)

I have my doubts about the wisdom of severing ‘drone strikes’ from air strikes carried out by conventional aircraft that are networked in to ISR feeds from drones; I’ve elaborated this before, and it is a crucial part of my own work on militarised vision, where I’m working through the military investigations into air strikes in Kunduz, Sangin and Uruzgan.  I’ll start posting about this work next month.

The irony, I think, is not (quite) that we know so little about the ostensibly ‘public’ strikes in Afghanistan compared with the ‘covert’ campaigns in Pakistan, Yemen, Somalia and elsewhere: it is, rather, that we know a lot about how the USAF (though not the RAF) conducts strikes in Afghanistan but remarkably little about the victims, whereas in Pakistan we know much less about how the strikes are carried out (apart from the bureaucratisation of ‘kill lists’ in Washington) and, thanks to the work of the Bureau, much more about the victims.

It is true, though, that while the official US military investigations released through FOIA requests are often immensely informative, even in redacted form (more on this next month), there is often also a remarkable reluctance to release even basic information to the public.  Spot the difference between these two tables; the first release (on top) was subsequently overwritten by the second (below)…

Airpower statistics 2007-2012

As I say, more to come.  In the meantime, the ‘scoping study ‘ from the Bureau is here, and well worth reading.

Footnotes to Gaza 101

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Updates on Gaza 101 (at the risk of stating the obvious, the title for this post is a riff on Joe Sacco‘s brilliant Footnotes in Gaza [2009])

(1) Another powerful interview with Dr Mads Gilbert from al-Shifa Hospital, the main trauma centre in Gaza, and an excellent question:

“What would have happened if Palestinian fighters had bombed an Israeli hospital and killed five patients?  The world would have turned upside down. What is this second-hand, or even third-hand or fourth-hand citizenship in the world for the Palestinians?”

And in Gaza it’s way more than five (though that is clearly how so many governments around the world, including Canada, rank Palestinian citizenship).

Palestinian child deaths

(2)  By ‘citizenship in the world’ Gilbert is getting at the differential calculus that constitutes what Judith Butler calls ‘a grievable life’, and here Maya Mikdashi sharpens a (different) point I’ve made in relation to air strikes in the Federally Administered Tribal Areas and elsewhere: that not only the dead and injured women and children [see the map above, also available here] but also the dead and injured men are worthy of our grief.

Palestine men and women and children are one people— and they are a people living under siege and within settler colonial conditions. They should not be separated in death according to their genitalia, a separation that reproduces a hierarchy of victims and mournable deaths. Jewish Israelis (including soldiers and settlers) occupy the highest rungs of this macabre ladder, Palestinian men the lowest. This hierarchy is both racialized and gendered, a twinning that allows Palestinian womenandchildren to emerge and be publicly and internationally mourned only in spectacles of violence, or “war”—but never in the slow and muted deaths under settler colonial conditions—the temporality of the “ceasefire.” To insist on publicly mourning all of the Palestinian dead, men and women and children—at moments of military invasion and during the every day space of occupation and colonization— is to insist on their right to have been alive in the first place.

(3) Finally – if only it were the end to all this – here is the splendid Richard Falk on the chronic failure of international law to protect – let alone provide justice for – the Palestinian people.  This is how he begins:

What has been happening in Gaza cannot usefully be described as “warfare”. The daily reports of atrocities situate this latest Israeli assault on common humanity within the domain of what the great Catholic thinker and poet, Thomas Merton, caIled “the unspeakable”. Its horror exceeds our capacity to render the events through language.

Up to  a point; I said something similar but much less eloquently in ‘Gaza 101’.  Trauma ruptures language, to be sure, but these words from Ann Jones are also worth reflecting on (they come from her They were soldiers):

The worst we can say of war is that it is “unspeakable,” which in fact it is not. But we don’t speak of it because that would involve so many nasty words we don’t want to use and elicit so many things we don’t want to know, so many things we think we can’t do anything about now that the government answers only to the powerful few…

 

Gaza 101

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101 is the emergency number for Gaza and the rest of occupied Palestine.  And perhaps I should begin with that sentence: I say ‘the rest of occupied Palestine’ because, despite Israel’s ‘disengagement’ from Gaza in 2005, Israel continues to exercise effective control over the territory which means that Gaza has continued to remain under occupation.  It’s a contentious issue – like Israel’s duplicitous claim that the West Bank is not ‘occupied’ either (even by its illegal settlers) merely ‘disputed’ – and if you want the official Israeli argument you can find it in this short contribution by a former head of the IDF’s International Law Department here and here.  The value of that essay – apart from illustrating exactly what is meant by chutzpah – is its crisp explanation of why the issue matters:

‘This does not necessarily mean that Israel has no legal obligations towards the population of the Gaza Strip, but that to the extent that there are any such legal obligations, they are limited in nature and do not include the duty to actively ensure normal life for the civilian population, as would be required by the law of belligerent occupation…’

Certainly, one of the objectives of Israel’s ‘disengagement’ was to produce what its political and military apparatus saw as ‘an optimal balance between maximum control over the territory and minimum responsibility for its non-Jewish population’.  That concise formulation is Darryl Li‘s, which you can find in his excellent explication of Israel’s (de)construction of Gaza as a ‘laboratory’ for its brutal bio-political and necro-political experimentations [Journal of Palestine Studies 35 (2) (2006)]. (Another objective was to freeze the so-called ‘peace process’, as Mouin Rabbani explains in the latest London Review of Books here; his essay also provides an excellent background to the immediate precipitates of the present invasion). Still, none of this entitles Israel to evade the obligations of international law.  Here it’s necessary to recall Daniel Reisner‘s proud claim that ‘If you do something for long enough, the world will accept it… International law progresses through violations’: Reisner also once served as head of the IDF’s International Law Department, and the mantra remains an article of faith that guides IDF operations.  But as B’Tselem, the Israeli Information Center for Human Rights in the Occupied Territories, insisted in an important opinion published at the start of this year:

Even after the disengagement, Israel continues to bear legal responsibility for the consequences of its actions and omissions concerning residents of the Gaza Strip. This responsibility is unrelated to the question of whether Israel continues to be the occupier of the Gaza Strip.

But there’s more.  International humanitarian law – no deus ex machina, to be sure, and far from above the fray – not only applies during Israel’s military offensives and operations, including the present catastrophic assault on Gaza, but provides an enduring set of obligations.  For as Lisa Hajjar shows in a detailed discussion re-published by Jadaliyya last week, Israel’s attempts to make Gaza into a space of exception – ‘neither sovereign nor occupied’ but sui generis – run foul of the inconvenient fact that Gaza remains under occupation. Israel continues to control Gaza’s airspace and airwaves, its maritime border and its land borders, and determines what (and who) is allowed in or out [see my previous post and map here].  As Richard Falk argues, ‘the entrapment of the Gaza population within closed borders is part of a deliberate Israeli pattern of prolonged collective punishment’ – ‘a grave breach of Article 33 of the Fourth Geneva Convention’ – and one in which the military regime ruling Egypt is now an active and willing accomplice.

Karam abu Salem crossing

So: Gaza 101.  Medical equipment and supplies are exempt from the blockade and are allowed through the Karam Abu Salem crossing (after protracted and expensive security checks) but the siege economy of Gaza has been so cruelly and deliberately weakened by Israel that it has been extremely difficult for authorities to pay for them.  Their precarious financial position is made worse by direct Israeli intervention in the supply of pharmaceuticals.  Corporate Watch reports that

When health services in Gaza purchase drugs from the international market they come into Israel through the port of Ashdod but are not permitted to travel the 35km to Karam Abu Salem directly. Instead they are transported to the Bitunia checkpoint into the West Bank and stored in Ramallah, where a permit is applied for to transport them to Gaza, significantly increasing the length and expense of the journey.

There’s more – much more: you can download the briefing here – but all this explains why Gaza depends so much on humanitarian aid (and, in the past, on medical supplies smuggled in through the tunnels).  Earlier this summer Gaza’s medical facilities were facing major shortfalls; 28 per cent of essential drugs and 54 per cent of medical disposables were at zero stock.

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Medical care involves more than bringing in vital supplies and maintaining infrastructure (the map of medical facilities above is taken from the UN’s humanitarian atlas and shows the situation in December 2011; the WHO’s summary of the situation in 2012 is here).  Medical care also involves unrestricted access to electricity and clean water; both are compromised in Gaza, and on 1 January 2014 B’Tselem reported a grave deterioration in health care as a result:

‘The siege that Israel has imposed on the Gaza Strip since Hamas took over control of the security apparatus there in June 2007 has greatly harmed Gaza’s health system, which had not functioned well beforehand…. The reduction, and sometimes total stoppage, of the supply of fuel to Gaza for days at a time has led to a decrease in the quality of medical services, reduced use of ambulances, and serious harm to elements needed for proper health, such as clean drinking water and regular removal of solid waste. Currently, some 30 percent of the Gaza Strip’s residents do not receive water on a regular basis.’

WHO Right to healthIn-bound transfers are tightly constrained, but so too are out-bound movements.  Seriously ill patients requiring advanced treatment had their access to specialists and hospitals outside Gaza restricted:

‘Israel has cut back on issuing permits to enter the country for the hundreds of patients each month who need immediate life-saving treatment and urgent, advanced treatment unavailable in Gaza. The only crossing open to patients is Erez Crossing, through which Israel allows some of these patients to cross to go to hospitals inside Israel [principally in East Jerusalem], and to treatment facilities in the West Bank, Egypt, and Jordan. Some patients not allowed to cross have referrals to Israeli hospitals or other hospitals. Since Hamas took over control of the Gaza Strip, the number of patients forbidden to leave Gaza “for security reasons” has steadily increased.’

As in the West Bank, Israel has established a labyrinthine system to regulate and limit the mobility of Palestinians even for medical treatment.  Last month the World Health Organization explained the system and its consequences (you can find a detailed report with case studies here):

‘In Gaza, patients must submit a permit application at least 10 days in advance of their hospital appointment to allow for Israeli processing. Documents are reviewed first by the health coordinator but final decisions are made by security officials. Permits can be denied for reasons of security, without explanation; decisions are often delayed. In 2013, 40 patients were denied and 1,616 were delayed travel through Erez crossing to access hospitals in East Jerusalem, Israel, the West Bank and Jordan past the time of their scheduled appointment. If a patient loses an appointment they must begin the application process again. Delays interrupt the continuity of medical care and can result in deterioration of patient health. Companions (mandatory for children) must also apply for permits. A parent accompanying a child is sometimes denied a permit, and often both parents, and the family must arrange for a substitute, a process which delays the child’s treatment.’

On 17 June Al-Shifa Hospital, the main medical facility in Gaza City (see map below), had already been forced to cancel all elective surgeries and concentrate on emergency treatment.  On 3 July it had to restrict treatment to life-saving emergency surgery to conserve its dwindling supplies. All of this, remember, was before the latest Israeli offensive.  People have not stopped getting sick or needing urgent treatment for chronic conditions, so the situation has deteriorated dramatically.  The care of these patients has been further compromised by the new, desperately urgent imperative to prioritise the treatment of those suffering life-threatening injuries from Israel’s military violence.

al-Shifa and Shuja'iyeh map

Trauma surgeons emphasise the importance of the ‘golden hour’: the need to provide advanced medical care within 60 minutes of being injured.  Before the IDF launched its ground invasion, there were three main sources of injury: blast wounds from missiles, penetrating wounds from artillery grenades and compression injuries from buildings collapsing.  But this is only a typology; many patients have multiple injuries. ‘We are not just getting patients with one injury that needs attending,’ said the head of surgery at Al-Shifa, ‘we are getting a patient with his brain coming out of his skull, his chest crushed, and his limbs missing.’  All of these injuries are time-critical and require rapid intervention. Ambulance control centre central GazaAnd yet the Ministry of Health reckons that Gaza’s ambulance service is running at 50 per cent capacity as a result of fuel shortages.  That figure must have been reduced still further by the number of ambulances that have been hit by Israeli fire (for more on paramedics in Gaza, and the extraordinary risks they run making 20-30 trips or more every day, see here and this report from the Telegraph‘s David Blair here).  When CNN reporters visited the dispatch centre at Jerusalem Hospital in Gaza City last Tuesday, they watched a a screen with illuminated numbers recording 193 killed and 1,481 injured and the director of emergency services dispatching available ambulances to the site of the latest air strike (by then, there had already been over 1,000 of them).  But the system only works effectively when there is electricity…

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Power supplies were spasmodic at the best of times (whenever those were); they have been even more seriously disrupted by the air campaign, and since the start of the ground assault Gaza has lost around 90 per cent of its power generating capacity.  Nasouh Nazzal reports that many hospitals have been forced to switch to out-dated generators to light buildings and power equipment:

“The power generators in Gaza hospitals are not trusted at all and they can go down any moment. If power goes out, medical services will be basically terminated,” [Dr Nasser Al Qaedrah] said. He stressed that the old-fashioned types of power generators available in Gaza consume huge quantities of diesel, a rare product in the coastal enclave.

On occasion, Norwegian ER surgeon Mads Gilbert told reporters, if the lights go out in the middle of an operation ‘[surgeons] pick up their phones, and they use the light from the screen to illuminate the operation field.’ (He had brought head-lamps with him from Bergen but found they were on Israel’s banned list of ‘dual-use’ goods). As the number of casualties rises, the vast majority of them civilians, so hospitals have been stretched to the limit and beyond.  According to Jessica Purkiss, the situation was already desperate a week ago:

“The number of injuries is huge compared to the hospitals’ capacity,” said Fikr Shalltoot, the Gaza program director for Medical Aid for Palestinians, an organization desperately trying to raise funds to procure more supplies. “There are 1,000 hospital beds in the whole of Gaza. An average of 200 injuries are coming to them every day.”

As in so many other contemporary conflicts – Iraq, Libya, Syria – hospitals themselves had already become targets for military violence.  For eleven days Al-Wafa Hospital in Shuja’iyeh in eastern Gaza City (see the map above), the only rehabilitation centre serving the occupied territories, was receiving phone calls from the IDF warning them that the building was about to be bombed.  [In case you’re impressed by the consideration, think about Paul Woodward‘s observation: ‘I grew up in Britain during the era when the Provisional IRA was conducting a bombing campaign in Northern Ireland and on the mainland. I don’t remember the Provos ever being praised for the fact that they would typically phone the police to issue a warning before their bombs detonated. No one ever dubbed them the most humane terrorist organization in the world.’] The staff refused to evacuate the hospital because their patients were paralysed or unconscious. The Executive Director, Dr Basman Alashi, explained:

‘We’ve been in this place since 1996. We are known to the Israeli government. We are known to the Israeli Health Center and Health Ministry. They have transferred several patients to our hospital for rehabilitations. And we have many success stories of people come for rehabilitation. They come crawling or in a wheelchair; they go out of the hospital walking, and they go back to Israel saying that al-Wafa has done miracle to them. So we are known to them, who we are, what we are. And we are not too far from their border. Our building is not too small. It’s big. It’s about 2,000 square meters. If I stand on the window, I can see the Israelis, and they can see me. So we are not hiding anything in the building. They can see me, and I can see them. And we’ve been here for the last 12 or 15 years, neighbors, next to each other. We have not done any harm to anybody, but we try to save life, to give life, to better life to either an Arab Palestinian or an Israeli Jew.’

el-Wafa.03

But just after 9 p.m. on 17 July shells started falling:

‘… the fourth floor, third floor, second floor. Smoke, fire, dust all over. We lost electricity… luckily, nobody got hurt. Only burning building, smoke inside, dust, ceiling falling, wall broke, electricity cutoff, water is leaking everywhere. So, the hospital became [uninhabitable].’

Seventeen patients were evacuated and transferred to the Sahaba Medical Complex in Gaza City. Sharif Abdel Kouddos takes up the story:

‘The electricity went out, all the windows shattered, the hospital was full of dust, we couldn’t see anything,’ says Aya Abdan, a 16-year-old patient at the hospital who is paraplegic and has cancer in her spinal cord. She is one of the few who can speak.

It is, of course, literally unspeakable.  But this was not an isolated incident – still less ‘a mistake’ – and other hospitals have been bombed or shelled.  According to the Ministry of Health, 25 health facilities in Gaza have been partially or totally destroyed. Just this morning it was reported that Israeli tanks shelled the al-Aqsa Hospital in Deir al-Balah in central Gaza, killing five and injuring 70 staff and patients. The Guardian reports that ambulances which tried to evacuate patients were forced to turn back by continued shelling.  According to Peter Beaumont:

‘”People can’t believe this is happening – that a medical hospital was shelled without the briefest warning. It was already full with patients,” said Fikr Shalltoot, director of programmes at Medical Aid for Palestinians in Gaza city.’

mads-gilbert-at-al-shifa-hospital

The hospitals that remain in operation are overwhelmed, with doctors making heart-wrenching decisions about who to treat and who to send away, refusing ‘moderately injured patients they normally would have admitted in order to make room for the more seriously wounded.’  Mads Gilbert (centre in the image above) again:

Oh NO! not one more load of tens of maimed and bleeding, we still have lakes of blood on the floor in the ER, piles of dripping, blood-soaked bandages to clear out – oh – the cleaners, everywhere, swiftly shovelling the blood and discarded tissues, hair, clothes,cannulas – the leftovers from death – all taken away…to be prepared again, to be repeated all over. More then 100 cases came to Shifa last 24 hrs. enough for a large well trained hospital with everything, but here – almost nothing: electricity, water, disposables, drugs, OR-tables, instruments, monitors – all rusted and  as if taken from museums of yesterdays hospitals.

Al-Shifa, where he is working round the clock, has only 11 beds in its ER and just six Operating Rooms.  On Saturday night, when the Israeli army devastated the suburb of Shuja’ieyh, its ‘tank shells falling like hot raindrops‘, al-Shifa had to deal with more than 400 injured patients. Al-Shifa is Gaza’s main trauma centre but in other sense Gaza’s trauma is not ‘centred’ at all but is everywhere within its iron walls.  Commentators repeatedly describe Gaza as the world’s largest open-air prison – though, given the cruelly calculated deprivation of the means of normal life, concentration camp would be more accurate – but it is also one where the guards routinely kill, wound and hurt the prisoners. The medical geography I’ve sketched here is another way of reading Israel’s bloody ‘map of pain‘. I am sickened by the endless calls for ‘balance’, for ‘both sides’ to do x and y and z, as though this is something other than a desperately unequal struggle: as though every day, month and year the Palestinians have not been losing their land, their lives and their liberties to a brutal, calculating and manipulative occupier.  I started this post with an image of a Palestinian ambulance; the photograph below was taken in Shuja’ieyh at the weekend.  It too is an image of a Palestinian ambulance.

Shujaiyeh.01
For updates see here; I fear there will be more to come. In addition to the links in the post above, this short post is also relevant (I’ve received an e-mail asking me if I realised what the initial letters spelled…. Duh.)

Behind the lines

I’m sorry for the long silence – I’ve been in the UK, giving a new presentation on the Uruzgan air strike of February 2010, and learning much en route in Lancaster, Lincoln and Bristol.  I’ll try to post extracts from the (developing) presentation in the next several weeks as I think about turning it into an essay, but I’ll still be on the road – or, more accurately, on vacation, so things will be irregular for some time to come.  I expect regular postings to resume in early July, when I’ll be back in Vancouver.

POPERINGE railhead

I’ve also spent several days in Flanders, visiting some of the major sites associated with the First World War.  We based ourselves in Poperinge, which was sufficiently far from the devastated and levelled town of Ypres to serve as a major staging post for munitions, supplies and men arriving at its station [see the image above], and for casualties being shipped back to the coast or to Britain (a slower and much more difficult journey).  It was also the place (known to the British as “Pop”, supposedly the Paris of the Front, at least around Ypres) where soldiers on leave from the Ypres Salient went to have as good a time as possible, in the shops, bars, restaurants and brothels.

Poperinge Tommy Supply

All of this has made me start to explore even more closely the military-civilian interactions behind the lines.  There’s surprisingly little work on this, but waiting for me at home is a new book by Craig Gibson, Behind the Front: British soldiers and French civilians 1914-1918 (Cambridge University Press, 2014), which despite the subtitle appears to include the war in Flanders too:

Until now scholars have looked for the source of the indomitable Tommy morale on the Western Front in innate British bloody-mindedness and irony, not to mention material concerns such as leave, food, rum, brothels, regimental pride, and male bonding. However, re-examining previously used sources alongside never-before consulted archives, Craig Gibson shifts the focus away from battle and the trenches to times behind the front, where the British intermingled with a vast population of allied civilians, whom Lord Kitchener had instructed the troops to ‘avoid’. Besides providing a comprehensive examination of soldiers’ encounters with local French and Belgian inhabitants which were not only unavoidable but also challenging, symbiotic and uplifting in equal measure, Gibson contends that such relationships were crucial to how the war was fought on the Western Front and, ultimately, to British victory in 1918. What emerges is a novel interpretation of the British and Dominion soldier at war.

GIBSON Behind the FrontThe Contents List is topical and – to my regret – doesn’t seem to include anything on the overlapping and sometimes confounding geographies of military and civilian medical care, but it still looks like an excellent survey:

Part I. Mobile Warfare, 1914:
1. The first campaign
Part II. Trench Warfare, 1914–1917:
2. Land
3. Administration
4. Billet
5. Communication
6. Friction
7. Farms
8. Damages
9. Money
10. Discipline
11. Sex
Part III. Mobile Warfare, 1918:
12. The final campaign

And while I’m on the subject of medical-military machines, Britain’s Arts & Humanities Research Council has a new website, Beyond the Trenches, which is devoted to recent research on the First World War.  One of its opening (short) essays is by Jessica Meyer on The long trip home: medical evacuations from the Front, which coincides with the first phase of my new research project.  It’s a skeletal account of the casualty chain, or rather chains, and doesn’t flesh out these precarious journeys like Emily Mayhew‘s marvellous social history, Wounded: from battlefield to Blighty, 1914-1918 (see here).  But it’s an interesting introduction to some of the logistical issues.

Diagram-of-evacuation-plan-Messine

The essay has been prompted by a new BBC drama series, The Crimson Field, set in a British field hospital, which in its turn was apparently inspired by Ellen Newbold La Motte‘s first-hand account of a French field hospital, The backwash of war: The Human Wreckage of the Battlefield as Witnessed by an American Hospital Nurse (1916).  This is now sitting on my Kindle (and you can also download it free from Project Gutenberg here): its ‘warts-and-all’ portrayal was so vivid that it was banned by the American government when the United States entered the war in 1917.  La Motte worked under Mary Borden, incidentally, who recorded her own experiences in The forbidden zone (more on the two women here, you can read the book here, and there is a helpful essay by Ariela Freedman, ‘Mary Borden’s Forbidden Zone: women’s writing from No Man’s Land’ in Modernism/modernity 9 (1) (2002) 109-124).

unloading-the-wounded-mary-borden

The book is organised in 14 vignettes, which were published regularly in the Atlantic Monthly, and at one point La Motte includes this observation:

“These Belgians!” said a French soldier. “How prosperous they will be after the war! How much money they will make from the Americans, and from the others who come to see the ruins!”

Having just returned from doing just that, I have to say that I saw remarkably few signs of crass commercialisation or opportunism: I was struck again and again by the dignified way in which the hideous events of those years have been recovered and commemorated.  There was refreshingly little jingoism too: just a quiet sense of the enormity of it all. One of the most poignant exhibits I saw was a photograph of families visiting the war graves shortly after the Armistice, trying to find the site where a husband, a brother or a son was buried or, failing that, the place where he had been killed (since the graves of countless thousands were unknown).  By then, the graves were being systematised and the cemeteries organised (see here), but the surroundings were still hauntingly raw: there had been no time for the ravaged landscape to recover, the blasted stumps to be torn out, and the trenches to be ploughed over.  It was sobering to imagine families, already burdened with grief, seeing for themselves a landscape which must have revealed, at least in part, something of the horror of the war that had been for so long hidden from them.

lillegatecem

Casualties of war

As most readers will know, there has been a lively debate – at once profoundly philosophical and intensely practical – about what counts as a ‘grievable’ (and indeed survivable) life after military and paramilitary violence, and on the calculus of war-time casualties.

Two reports released yesterday conclude that recording and analysing data on the casualties of conflict and armed violence (both those killed and those who survive their wounds) can improve the protection of civilians and save lives.  The first, by Action on Armed Violence, is called Counting the Cost and surveys ‘casualty recording practices and realities around the world’:

Counting the costThe AOAV report shows that transparent and comprehensive information on deaths and injuries can protect civilians and save lives. The numbers of casualties have always been a contentious issue, generally dominated by secretive counting criteria, and public numbers that have been dictated more by political agendas than evidence. In other cases, the arguments have been dictated simply by the use of different estimating techniques. An example in this sense has been the debate on the total number of people that were killed during the Iraq War between Iraq Body Count and a survey published in the Lancet medical journal. The Lancet estimated over 650,000 deaths due to the war, more than 10 times the number of deaths estimated by the Iraq Body Count for the same period. A series of articles arguing for one or the other have highlighted how different systems to estimate number of deaths can lead to very different end results.

What the AOAV new report confirms is that when transparency both in the numbers produced as well as the techniques used to record them are clear and public, the debates around these numbers can be overcome. For Serena Olgiati, report co-author, “transparency makes it clear that this data is not a political weapon used to accuse opponents, but rather a practical tool that allows states to recognise the rights of the victims of violence.”

I have a more reserved view about a ‘transparent’ space somehow empty of politics – and we all know what the first casualty of war is – but the report is more artful than the press release suggests: it begins by invoking Walter Benjamin on Klee’s Angel of History:

“There is a painting by Klee called Angelus Novus. It shows an angel who seems about to move away from something he stares at. His eyes are wide, his mouth is open, his wings are spread. This is how the angel of history must look. His face is turned toward the past. Where a chain of events appears before us, he sees on single catastrophe, which keeps piling wreckage upon wreckage and hurls it at his feet. The angel would like to stay, awaken the dead, and make whole what has been smashed. But a storm is blowing from Paradise and has got caught in his wings; it is so strong that the angel can no longer close them. This storm drives him irresistibly into the future to which his back is turned, while the pile of debris before him grows toward the sky. What we call progress is this storm1.

The philosopher Walter Benjamin wrote these words in 1940 as he saw Europe engulf in flames. Within the year he had taken his own life on the French-Spanish border, the threat of deportation to a Jewish concentration camp seemingly too great for him to bear.

They are words that resonate as much today as they did then. Syria is engulfed in flames, Iraq descends back into the abyss and gun violence takes thousands of lives a week. The single catastrophe the Angelus Novus sees in the 21st century has to be the terrible harm caused by armed violence, a harm estimated to take over half a million lives a year.

Seeing this harm in its entirety is a gruelling task. Recording the true toll of armed violence reveals hard truths: it tells of underlying prejudices, of racism, of sexism: humanity’s ugliness. But only by turning behind us and calculating how many people have died and have been injured in a conflict, in a slum area, in a city in the grip of violence, can we ever begin to address the impact that armed violence has.

The report provided an analytical overview and a series of case studies (Colombia, Thailand and the Phillipines).

Counting the Cost Infographic

The second report is from the Oxford Research Group and is part of its Every Casualty program (see my post here).  In this report the ORG reviews the United Nations and Casualty Recording:

ORG-UN-and-CR Cover_1It concludes that when the UN systematically records the direct civilian casualties of violent conflict, and acts effectively on this information, this can help save civilian lives. However, casualty recording is not currently a widespread practice within the UN system.

The report recommends that the advancement of casualty-recording practice by the UN in conflict-affected countries should be pursued, as this would have clear benefits to the work of a range of UN entities, and so to the people that they serve.

This report looks at experiences of, and attitudes towards, casualty recording from the perspectives of UN staff based in New York and Geneva that we interviewed. It includes a case study of UN civilian casualty recording by the UN Assistance Mission in Afghanistan’s Human Rights unit. Finally, the report discusses challenges to UN casualty recording, and how these might be met.

War and therapeutic geographies

Tall Rifat hospital near Aleppo attacked by helicopter gunships June 2012

I previously noted the problems of providing medical care to those fleeing the war in Syria – and to those who’ve been left behind – and an article by Thanassis Cambanis in the Boston Globe (‘Medical care is now a tool of war’) reinforces the importance of the issue:

 The medical students disappeared on a run to the Aleppo suburbs. It was 2011, the first year of the Syrian uprising, and they were taking bandages and medicine to communities that had rebelled against the brutal Assad regime. A few days later, the students’ bodies, bruised and broken, were dumped on their parents’ doorsteps.

Dr. Fouad M. Fouad, a surgeon and prominent figure in Syrian public health, knew some of the students who had been killed. And he knew what their deaths meant. The laws of war—in which medical personnel are allowed to treat everybody equally, combatants and civilians from any side—no longer applied in Syria.

“The message was clear: Even taking medicine to civilians in opposition areas was a crime,” he recalled.

As the war accelerated, Syria’s medical system was dragged further into the conflict. Government officials ordered Fouad and his colleagues to withhold treatment from people who supported the opposition, even if they weren’t combatants. The regime canceled polio vaccinations in opposition areas, allowing a preventable disease to take hold. And it wasn’t just the regime: Opposition fighters found doctors and their families a soft target for kidnapping; doctors always had some cash and tended not to have special protection like other wealthy Syrians.

Doctors began to flee Syria, Fouad among them. He left for Beirut in 2012. By last year, according to a United Nations working group, the number of doctors in Aleppo, Syria’s largest city, had plummeted from more than 5,000 to just 36.

Since then, Fouad has joined a small but growing group of doctors trying to persuade global policy makers—starting with the world’s public health community—to pay more urgent attention to how profoundly new types of war are transforming medicine and public health.

It is grotesquely ironic that ‘global policy-makers’ should have to be persuaded of the new linkages between war, medicine and public health, given how often later modern war is described (and, by implication, legitimated) through medical metaphors: see in particular Colleen Bell, ‘War and the allegory of medical intervention: why metaphors matter’, International Political Sociology 6: 3 (2012) 325-28 and ‘Hybrid warfare and its metaphors’, Humanity 3 (2) (2012) 225-47.

AI Health Crisis in SyriaBut there are, as Fouad emphasises, quite other, densely material biopolitics attached to contemporary military and paramilitary violence, including not only the targeting of medical staff, as he says, but also their patients.

“In Syria today, wounded patients and doctors are pursued and risk torture and arrest at the hands of the security services,” said Marie-Pierre Allié, president of [Médecins san Frontières’]. “Medicine is being used as a weapon of persecution.”

In October 2011 Amnesty International described the partisan abuse of the wounded in hospitals in Damascus and Homs, and the denial of medical care in detention facilities, in chilling detail.

At least then (and there) there were hospitals.  Linking only too directly to my previous post on Aleppo, Cambanis concludes:

Today, Fouad’s former home of Aleppo is largely a ghost town, its population displaced to safer parts of Syria or across the border to Turkey and Lebanon. The city’s former residents carry the medical consequences of war to their new homes, Fouad said—not just injuries, but effects as varied as smoking rates, untreated cancer, and scabies. Wars like those in Syria and Iraq don’t follow the old rules, and their effects don’t stop at the border.

I first became aware of these issues at a conference on War and medicine in Paris in December 2012, which prompted my current interest in the casualties of war, combatant and civilian, and the formation of modern medical-military machines.  Several friends from the Paris meeting (Omar Dewachi, Vinh-Kim Nguyen and  Ghassan Abu Sitta) have since joined with other colleagues to produce a preliminary review published this month in The Lancet: ‘Changing therapeutic geographies of the Iraqi and Syrian wars’.  They write:

War is a global health problem. The repercussions of war go beyond death, injury, and morbidity. The effects of war are long term, reshaping the everyday lives and survival of entire populations.

In this report,we assess the long-term and transnational dimensions of two conflicts: the US-led occupation of Iraq in 2003 and the ongoing armed conflict in Syria, which erupted in 2011. Our aim is to show that, although these conflicts differ in their geopolitical contexts and timelines, they share similarities in terms of the effects on health and health care. We analyse the implications of two intertwined processes—the militarisation and regionalisation of health care.  In both Syria and Iraq,boundaries between civilian and combatant spaces have been blurred. Consequently,hospitals and clinics are no longer safe havens. The targeting and misappropriation of health-care facilities have become part of the tactics of warfare. Simultaneously, the conflicts in Iraq and Syria have caused large-scale internal and external displacement of populations. This displacement has created huge challenges for neighbouring countries that are struggling to absorb the health-care needs of millions of people.

They emphasise ‘the targeting and implication of medicine in warfare’ and note that ‘the militarisation of health care follows the larger trends of the war on terror, where the boundaries between civilian and combatant spaces are broadly disrespected.’  They have in mind ‘not only the problem of violence against health care, but also [the ways in which] health care itself has become an instrument of violence, with health professionals participating (or being forced to participate) in torture, the withholding of care, or preferential treatment of soldiers.’

And they describe a largely unplanned dispersal of medical care across the region that blurs other – national – boundaries, requiring careful analysis of the ‘therapeutic geographies‘ which trace the precarious and shifting journeys through which people obtain medical treatment in and beyond the war zone.  They insist that ‘migrants seeking refuge from violence cannot be framed and presented as mere victims but as people using various strategies to acquire health care and remake their lives.’ The manuscript version of the report included the map below, which illustrates the scale of the problem:

Therapeutic geographies

My own work addresses similar issues through four case studies over a longer time-span, to try to capture the dynamics of these medical-military constellations: the Western Front in 1914-18, the Western Desert in the Second World War, Vietnam, and Afghanistan 2001-2014 (see ‘Medical-military machines’, DOWNLOADS tab).

msf-afghanistan-report-finaToday Médecins sans Frontières published an important report, Between rhetoric and reality:  the ongoing struggle to access healthcare in Afghanistan, that speaks directly to these concerns.  Like the Lancet team, the report explores the ways in which war affects not only the provision of healthcare for those wounded by its violences but also access to healthcare for those in the war zone who suffer from other, often chronic and life-threatening illnesses: ‘The conflict creates dramatic barriers that people must overcome to reach basic or life- saving medical assistance. It also directly causes death, injury or suffering that increase medical needs.’  Releasing their findings, MSF explained:

After more than a decade of international aid and investment, access to basic and emergency medical care in Afghanistan remains severely limited and sorely ill-adapted to meet growing needs created by the ongoing conflict…  While healthcare is often held up as an achievement of international state-building efforts in Afghanistan, the situation is far from being a simple success story. Although progress has been made in healthcare provision since 2002, the report … reveals the serious and often deadly risks that people are forced to take to seek both basic and emergency care.

The research – conducted over six months in 2013 with more than 800 patients in the hospitals where MSF works in Helmand, Kabul, Khost and Kunduz provinces – makes it clear that the upbeat rhetoric about the gains in healthcare risks overlooking the suffering of Afghans who struggle without access to adequate medical assistance.

“One in every five of the patients we interviewed had a family member or close friend who had died within the last year due to a lack of access to medical care,” said Christopher Stokes, MSF general director. “For those who reached our hospitals, 40 per cent of them told us they faced fighting, landmines, checkpoints or harassment on their journey.”

The patients’ testimonies expose a wide gap between what exists on paper in terms of healthcare and what actually functions. The majority said that they had to bypass their closest public health facility during a recent illness, pushing them to travel greater distances – at significant cost and risk – to seek care.

MSF provides a photoessay describing some of these precarious journeys (‘Long and dangerous roads’) here, from which I’ve taken the photograph below, showing an inured man being led by a relative into the Kunduz Trauma Centre.

MSB5652

A mile in these shoes

I’m just back from Beirut, and trying to catch up.  Every day I went for a walk along the Corniche, and on the second morning a young Syrian boy asked if he could clean my shoes.  I was wearing trainers, but told him that I’d pay him anyway and he could clean my shoes next time I came out; he refused to take the money until I had agreed where and when I would present myself for the service.  Heart-warming and hear-breaking, and I can’t get him out of my mind.  So here is a quick up-date on the situation (see also my previous posts here and here).

Syria civil war casualties

First, this week Foreign Policy published this sobering animated map of casualties from the civil war in Syria based on data from the Human Rights Data Analysis Group:

It visualizes the approximately 74,000 people who died from March 2011 to November 2013. Every flare represents the death of one or more people, the most common causes being shooting, shelling, and field execution. The brighter a flare is, the more people died in that specific time and place. The data used are drawn from the Violations Documentation Center (VDC), the documentation arm of the Local Coordination Committees in Syria which has been one of the eight sources on which HRDAG has based its count. In a June 2013 report, HRDAG cited VDC as the most thorough accounting of casualties in Syria, though the dataset has been found to contain some inconsistencies…

What the map demonstrates is the escalation of the conflict — with data from March 2011 through the VDC’s Nov. 21, 2013 report — and its quick descent from being a smattering of violence to a multi-front war with militias challenging the military (and other militias) almost everywhere at once. What it can’t show, of course, is the horror and destruction of this war.

My image is just a screen grab, of course, so you need to visit the original to see the overall, devastating effect.

For more detail, I recommend Syria Deeply, a new digital platform that attempts to combine citizen journalism with professional analysis; there’s a profile of the project at start-up over at Fast Company here and a more recent commentary from its founder Lara Setrakian here. I think there are lessons to be learned here about the way publics can be created and brought to engage with conflicts, and that goes for academics as well as journalists.

Second, it’s much harder to find information about those who have been wounded in the conflict – one of my present preoccupations: see here and here – but while I was in Beirut Lebanon’s Daily Star published an interesting report on NGOs working in the borderlands to treat casualties from the war zone.  In the Bekaa Valley the International Committee of the Red Cross has treated over 700 people since 2012, while a 20-bed clinic run by Lebanon’s Ighatheyya has treated 135 people since it opened five months ago in Kamed al-Loz.  The casualties include pro- and anti-Assad fighters (according to the ICRC, ‘When we know the patients are from opposing sides we separate them by placing them on different floors … We make sure they don’t know the other is there’) and civilians alike.  Many of them are suffering from infected wounds because they were initially treated in makeshift facilities in tents or private houses, which is why the perilous journey across the border is so vitally important. Neither the ICRC nor Ighatheyya make cross-border runs.  The Star‘s reporters explain:

Many patients are lawfully retrieved from the border by the Lebanese Red Cross, who then take them to a number of cooperating hospitals across the Bekaa Valley for treatment. According to a well-informed source, the ICRC has contracted four hospitals, in Chtaura, Jib Jenin, Baalbek and Hermel, to care for war wounded Syrians.

After surgery patients are often referred to clinics run by other non-governmental organizations, such as Ighatheyya, who oversee the patients’ convalescence…. Ighatheyya is [also] in the process of building a fully equipped 30-bed hospital in the border town of Arsal, where many refugees and combatants cross into Lebanon.

Another major locus of emergency medical treatment is Tripoli, just 30 km from the border and the primary treatment centre for Syrians seeking emergency medical assistance in northern Lebanon.  Médecins Sans Frontières, which also operates from four locations in the Bekaa Valley, has been supporting local clinics and hospitals here since February 2012 (and it’s been working inside Syria since March 2011).

NGOs are not the only organisations on the field.  Last summer NBC described the operation of a new clinic set up by the Syrian National Opposition to treat opposition fighters.  It too is in the Bekaa Valley, which is for the most part controlled by Hezbollah – which is of course militantly pro-Asad.  Four days after the clinic opened a local militia aligned with Hezbollah broke into the compound and forced a rapid evacuation, and early last summer armed men attacked an ambulance transporting a patient to surgery and kidnapped him: ‘Since then, the Lebanese Red Cross has refused to transport the clinic’s patients in ambulances through certain Hezbollah-dominated areas without an army escort. And private cars carrying patients through those areas have been shot at.’

For more on the transnational ‘therapeutic geographies’ involved in the wars in Iraq and Syria, see Omar Dewachi, Mac Skelton, Vinh-Kim Nguyen, Fouad Fouad, Ghassan Abu Sitta, Zeina Maasri and Rita Giacaman, ‘The Changing Therapeutic Geographies of the Iraqi and Syrian Wars’, forthcoming in The Lancet.  And for a discussion of the regional geopolitics of all this, including a corrective to the claim that the war in Syria is simply ‘spilling over’ into Lebanon, see Bélen Fernández over at warscapes here.

Syria-Lebanon-Report-2013 (dragged)As MSF emphasises, refugees from the conflict in Syria need more than emergency treatment for war wounds: ‘The epidemiological profile of populations does not change when they cross borders; those who needed medications for chronic conditions in Syria still need them in Lebanon.’  And, clearly, they have other pressing needs too:

‘[T]the gaps in service that existed [in June 2012] have not been sufficiently addressed but have in fact widened as more people have streamed across the border. Living conditions among the majority of refugees and Lebanese returnees remain extremely precarious, particularly with winter arriving. More than 50% of those interviewed, whether they were officially registered or not, are housed in substandard structures — inadequate collective shelters, farms, garages, unfinished buildings and old schools — that provide paltry, if any, protection against the elements. The rest are renting houses, but many of those people, now separated from their lives and livelihoods, are struggling to pay the rent. The medical picture has deteriorated as well. More than half of all interviewees (52%) cannot afford treatment for chronic disease care, and nearly one-third of them have had to suspend treatment already underway because it was too expensive to continue. For those who are and are not registered alike, the costs attached to essential primary health care, ante-natal care and institutional deliveries are prohibitive. Among non-registered returnees and internally displaced Lebanese, 63% received no assistance whatsoever from any NGO.’

Here’s a recent map of Syrian refugee flows:

Syrian refugee flows to December 2013

For more detail, UNHCR’s tabulations of Syrian refugees in Lebanon can be found here, and there’s a remarkable interactive map here (again, the image below is just a screen grab).

Syrian refugees in Lebanon summer 2013

The number of registered refugees in Lebanon – and, as that MSF report indicates, registration is itself a deeply problematic process and the numbers understate the gravity of the situation – is now around one million; Lebanon’s population is four million, so one person in five is a refugee.  But wary of its experience with the Palestinian refugee camps – on which Adam Ramadan‘s work is indispensable: his book is due out later this year, but in the meantime see ‘In the ruins of Nahr al-Barid: Understanding the meaning of the camp‘, Journal of Palestine Studies 40 (1) (2010) and  ‘Spatialising the refugee camp‘, Transactions of the Institute of British Geographers 38 (1) (2013) 65-77 – Lebanon has refused to sanction camps for Syrian refugees: hence those ‘tented settlements’ on the map above (and see the image below).

24iht-m24-lebanon-refugees-articleLarge-v3

This strategy, or lack of it, is in marked contrast to Jordan, where Al- Za’atari, which opened in July 2012, will soon become the largest refugee camp in the world (below): you can find a sequence of satellite images showing its explosive growth here.

al-zataari-may-2013

But Lebanon is adamant that it will not sanction any intimations of permanence.  Norimitsu Onishi reported recently in the New York Times that

Those fears have forced the refugees to try to squeeze into pre-existing buildings and blend into the landscape. Those with means rent apartments. But hundreds of thousands are living in garages and occupying the nooks and crannies of buildings under construction. Abandoned buildings, including universities and shopping malls, have been taken over in their entirety by refugees.

Here, as usual, there are pickings to be had.  Last year Tracy McVeigh reported in the Guardian that

‘While there are widespread reports of extraordinary acts of generosity and kindness by Lebanese towards Syrian refugees, many people here are making money from Syria’s war. Landlords are getting rents for barely habitable properties, stables and outhouses. There are hefty profits to be made in the gun-running business, and refugees are easily exploited as cheap labour. The government is getting military resources from America and Europe, which are keen to see it able to protect its borders. But many others are losing out – those who are trying to house and feed large families along with their own.’

And that includes young boys looking for shoes to clean on the waterfront in Beirut.  If you want to donate more than the cost of a shoe-clean, you can reach Oxfam here, the International Rescue Committee here and UNHCR here.