Trauma Geographies

I’ve been invited to give the Antipode lecture at the RGS/IBG conference on 29 August.  Here’s the abstract:

Trauma Geographies: broken bodies and lethal landscapes  

Elaine Scarry reminds us that even though ‘the main purpose and outcome of war is injuring’ this ‘massive fact can nevertheless ‘disappear from view along many separate paths.’ This presentation traces some of those paths, exploring the treatment and evacuation of the injured and sick in three war zones: the Western Front in the First World War, Afghanistan 2001-2018, and Syria 2012-2018. The movement of casualties from the Western Front inaugurated the modern military-medical machine; it was overwhelmingly concerned with the treatment of combatants, for whom the journey – by stretcher, ambulance, train and boat – was always precarious and painful. Its parts constituted a ‘machine’ in all sorts of ways, but its operation was far from smooth. The contrast with the aerial evacuation and en route treatment of US/UK casualties in Afghanistan is instructive, and at first sight these liquid geographies confirm Stephen Pinker’s progressivist theses about ‘the better angels of our nature’ [see also here]. But this impression has to be radically revised once Afghan casualties are taken into account – both combatant and civilian – and it is dispelled altogether by the fate of the sick and wounded in rebel-controlled areas of Syria. For most of them treatment was dangerous, almost always improvised and ever more precarious as hospitals and clinics were routinely targeted and medical supplies disrupted, and evacuation impossible as multiple sieges brutally and aggressively tightened. Later modern war has many modalities, and the broken bodies that are moved – or immobilised – in its lethal landscapes reveal that the ‘therapeutic geographies’ mapped so carefully by Omar Dewachi and others [see here and here] continue to be haunted by the ghosts of cruelty and suffering that stalked the battlefield of the American Civil War in the years following Lincoln’s original appeal to those ‘better angels’.

The presentation will tie together several strands I’ve laid out in posts on Geographical Imaginations; the next installment of my analysis of siege warfare and geographies of precarity in Syria will appear shortly.

Losing sight

May Jeong – whose excellent investigation of the US air strike on the MSF Trauma Centre at Kunduz I’ve commended before – has a new, equally enthralling extended report over at the Intercept on the sole survivor of a US drone strike in Kunar province in eastern Afghanistan on 7 September 2013: ‘Losing Sight‘.

It’s a long, rich read, but there are two issues I want to highlight.

First, May captures the stark, bio-physical horror of an air strike with an economy and force I’ve rarely seen equalled.  As I’ve noted before (see here and here), many critical analyses emphasise the bio-convergences that animate what happens behind the digital screens of the kill-chain and say remarkably little about those that lie on the other side.  It’s all too easy to lose sight of the embodied nature of remote warfare, though in another powerful essay Joseph Pugliese argues that it’s often not possible to speak of the corporeal at all in the face of such catastrophic violence: ‘The moment of lethal violence transmutes flesh into unidentifiable biological substance that is violently compelled geobiomorphologically to assume the topographical contours of the debris field’ ( ‘Death by Metadata: The bioinformationalisation of life and the transliteration of algorithms to flesh’, in Holly Randell-Moon and Ryan Tippet (eds) Security, race, biopower: essays on technology and corporeality (London: Palgrave, 2016) 3-20).

So here is May describing the strike on a pick-up truck in the early evening as it ground its way along a rough road through the Pech Valley; inside the cabin were the driver, three women and four young children, while seven men were crammed into the back along with sacks of flour they had bought to take back to their village.  There were a couple of miles from home, Gambir, when five missiles hit the truck in a 20-minute period.  Minutes later a second truck – which had been racing to catch up with the first – arrived close to the scene.  The driver (Mohibullah) scrambled up a small hill with a local villager:

[T]hey saw the husk of the pickup, strafed and lit up in flames. They hurried toward the fire.

When Mohibullah arrived at the blast site, he saw that of the 17 bags of flour he had helped load onto the truck, just two were intact. The rest had splayed open. There was a sick beauty to the scene — white powder over blood-red carnage.  These were men and women Mohibullah had grown up with, but he couldn’t recognize any of them. Their mangled body parts made it difficult to ascertain where one person ended and another began: spilled brains over severed limbs over ground flesh…

At first, it was just Mohibullah, another driver named Hamish Gul, and three villagers from Quroo who came to help. Most people in the area knew to stay away. The ghanghai [drones] often attacked again. Even so, the five of them worked at untangling the dead bodies — among them Aisha’s mother, father, grandmother, and little brother — and stacking them in neat rows atop the bed of Mohibullah’s truck.

Astonishingly, there was one survivor, but she too had been brutalised beyond recognition:

Mohibullah did not recognize the girl — her face had been “scrambled, she didn’t have her nose.” She still had both of her legs, but he wasn’t sure if her torso was connecting them to the rest of her body. It wasn’t until she asked in a frail voice — “Where is my father? Where is my mother?” — that he understood her to be his 4-year-old niece Aisha

A neighbor named Nasir held Aisha together for the drive back to Gambir. During the 2-mile journey, Aisha did not make a sound. Life seemed to be slipping away from her. Nasir assumed she would be buried. But when they arrived in Gambir, Aisha turned her head and asked for water. Her voice was so full of intent that they decided to rush her to a hospital in Asadabad.

Read those paragraphs again to see what Pugliese means.

Now the second issue starts to come into focus.  They reached Asadabad Provincial Hospital at 10 p.m., but the duty nurse could do little for Aisha:

Her stomach was missing, as were parts of her face and her left arm. He registered her into the hospital database, writing “acute abdominal injuries” next to her name, treated her with basic first aid, and sent her to the nearest hospital in Jalalabad, 57 miles away.

Aisha reached Jalalabad Public Health Hospital shortly after midnight, where her burns were dressed.  But here too there was little the surgeon could do; she had multiple head injuries, had lost one of her hands, and had major internal injuries.  A helicopter was called to take her to Kabul but it couldn’t land; a second helicopter arrived at midnight – 24 hours after she had reached Jalalabad – and ferried her to the French military hospital at Kabul Airport.

That hospital was a NATO Role 3 hospital, which had been run by the French since July 2009; by the summer of 2013 43 per cent of the procedures carried out by its staff had involved orthopaedic surgery.  Half of these were emergency surgeries; just 17 per cent of the patients were French military personnel and another 17 per cent were Afghan National Army or other ISAF soldiers,  while 47 per cent were Afghan (adult) civilians and 17 per cent were children.

Like other Role 3 hospitals, the facility was tasked with ‘damage-control’, for which it could call on three surgical teams rotation with a general surgeon, (abdominal, chest or vascular surgery) and an orthopedic surgeon as well as an ophthalmologist,  a neurosurgeon and an ENT or maxillofacial surgeon (I’ve taken these details from O. Barbier and others, ‘French surgical experience in the Role 3 Medical Treatment Facility of KaIA (Kabul International Airport…’, Orthopaedics and Traumataology: Surgery & Research 100 (6) (2014) 681-5; see also Christine Joubert and others, ‘Military neurosurgery in operation’, Acta Neurochir 158 (8) (2016) 1453-63).

While Aisha was being treated the hospital was visited by Afghan President Hamid Karzai.  Here is May again:

There, Karzai was confronted with a girl who had lost her sight, her nose, her lower lip, the skin on her forehead, the skin on her torso, her left hand, and nine members of her family, including her grandmother, her uncles, her aunts, her cousin, her mother, her father, and her baby brother.

“I cannot describe what I saw there,” Rangin Spanta, who served as national security adviser under Karzai and accompanied him to the hospital that day, told me from his home in Kabul. We were sitting on a rattan set on his front porch. In telling this story, Spanta covered his face and wept. “Still I have my trauma.” Spanta had lost five family members in the war, but the sight of Aisha, a girl who had been reduced to a “piece of biological construct,” gave him “the feeling that this was a kind of a nightmare.” Spanta, who had seen the guts of suicide bombers splattered across his car window and has visited double, triple, and quadruple amputees, said Aisha was the “most shocking thing I’ve seen in this war.” Karzai asked the attending doctor why her face was covered. “Because there is nothing there” was the answer.

That a high proportion of patients the military hospital were Afghan civilians was by no means unusual for a Role 3 facility, but as I’ve noted before ISAF had strict Rules of Medical Eligibility.  Afghan civilians who were injured during military operations and/or needed ‘life, limb or eyesight saving care’ – both of which applied to Aisha – could be admitted to the international medical system.  But as soon as possible, Afghans were to be treated by Afghans and so, after surgical intervention, they had to be transferred to the local healthcare system.



That system was – is – often rudimentary, which is why Aisha was passed from Asadabad to Jalalabad before reaching Kabul.  And returning someone in her post-operative condition to that system was obviously fraught with danger.  Here is Emily Mayhew in A Heavy Reckoning describing the dilemma for doctors at the Role 3 hospital at Camp Bastion in Helmand province:

Some of the most difficult decisions taken by the Deployed Medical Director related to local patients, Afghans civilians, their families and others. Locals made up the majority (probably as much as 80 per cent) of the patients cared for during the lifetime of the hospital. During the war there were no Afghan hospitals with the technology or capability to ventilate patients with severe chest wounds, therefore leaving Bastion meant death. So anyone intubated who could not be returned to Britain had to stay at Bastion until they could breathe unaided, which sometimes took days or weeks. They were discharged only when it was certain they could survive away from Bastion: probably in a local hospital that was under severe stress, and which could only provide medical care for two or three hours a day, where the rest of the time they would be looked after by their families.

I’ll return to this in a later post, because in some cases those local hospitals have been supplemented and even supplanted by more advanced medical facilities operated or supported by international NGOs like Emergency or MSF.

But what is extraordinary in Aisha’s case is that her pathway did not follow any of these routes.  Karzai had asked both the French and the Germans to help, but they deferred to the Americans who insisted that she be taken to the United States for further treatment.  ‘Twelve days after the strike,’ May reports, ‘Aisha was gone’: but nobody ever told her relatives what had happened to her.  Every attempt they made to find out was rebuffed.

Months later her uncle was informed that she was at Walter Reed hospital in Maryland; she had been sponsored by an American organisation, Solace for the Children.  According to its website:

Each Summer Solace for the Children Summer Medical Program brings children from areas affected by war to the United States so they may receive medical care unavailable to them in their country. We currently focus our efforts on children in Afghanistan. Each fall, applications are accepted for treatment. Our office in Afghanistan typically receives more than 50 applications they must review and qualify. Youth are qualified for services based on need and health condition. They are then placed with a host family for approximately 6 weeks while receiving the medical care they require. After care, youth return to Afghanistan with a better quality of life, brighter future and hope for peace.

While ‘there was no official relationship between the U.S. military and Solace,’ May was told by the charity’s director Patsy Wilson, ‘individual members of the military often reached out to Solace, which had been the case for Aisha.’

“We just get calls. We get calls from the military all over Afghanistan,” she said. She repeatedly deferred to the military, stating, “I am sure they don’t say we kidnap children.” Wilson also expressed doubts that Aisha had been injured in a drone strike, despite the claims of scores of villagers interviewed by The Intercept. “We do not necessarily believe Aisha was in a drone strike, but I know that is one of the stories,” she said. When pressed for details, she said, “I have been told not to discuss that,” adding, “We have no facts. There are no facts.”

Those last sentences are becoming all too familiar, but in this case ISAF not only acknowledged the ‘IM [international military] aerial attack’ but carried out its own investigation into the civilian casualties.  It has never been declassified.

War Stories

The video from our War Stories event in Vancouver last month – including Farah Nosh‘s narration of her wonderful photographs, a superb capsule genealogy of PTSD from Ann Jones, my discussion of casualty evacuation over the last hundred years, a drama staged by veterans from Afghanistan and directed by George Belliveau, Contact! Unload!, and a lively Q&A with the audience moderated by Peter Klein is now available here.

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My lecture, Precarious journeys, has also been carved out for the Peter Wall Institute website here. The idea behind the event was, in large measure, to think through the multiple ways in which modern war is narrated, which is why we had such a rich and diverse portfolio of performers and why I take the turns I do…  Regular readers will probably recognize that the arc of my presentation draws on my current research on evacuation from the Western Front in the First World War, on evacuation from Afghanistan today, and on my admiration for Harry Parker‘s Anatomy of a Soldier (see my ‘Object lessons’ here and the slides available under the DOWNLOADS tab).

More in an interview with Charlie Smith from the Georgia Straight here.

Wounded

Somme medical dispositions.001

This summer London’s Science Museum is staging an exhibition that is of direct relevance to my current research on casualty evacuation from war zones over the last hundred years:  Wounded: Conflict, Casualties and Care.  It opens on 29 June and is designed to commemorate the centenary of the Battle of the Somme:

57,000 casualties were sustained by British Forces on 1 July 1916, the first day of the Battle of the Somme, creating huge and unprecedented medical challenges. Wounded: Conflict, Casualties and Care, a new exhibition opening at the Science Museum on 29 June, will commemorate the 100th anniversary of this battle and the remarkable innovations in medical practices and technologies that developed as a result of this new kind of industrialised warfare.

During the First World War ten million combatants were killed, but double that number were wounded and millions were left disabled, disfigured or traumatised by their experiences. The challenges were immense. For medical personnel near the front line treating blood loss and infection was the immediate priority in order to save lives. However medics also encountered new forms of physical and mental wounding on a scale that had never been seen before, creating huge numbers of veterans returning home with serious long term care needs.

At the centre of the exhibition will be a remarkable collection of historic objects from the Science Museum’s First World War medical collections, illustrating the stories of the wounded and those who cared for them. From stretchers adapted for use in narrow trenches to made-to-measure artificial arms fitted back in British hospitals, medical technologies, techniques and strategies were pioneered or adapted throughout the war to help the wounded along each stage of rescue and treatment. Visitors will also see unique lucky charms and improvised personal protective items carried by soldiers on the frontline alongside examples of official frontline medical equipment.

I’m looking forward to seeing this over the summer.  The organisers note that:

 Warfare has changed dramatically over the last one hundred years, but similarities remain with the military medical challenges faced today, both through the experiences of the wounded and in their treatment and care. The Wounded exhibition team has worked closely with two UK charities that were formed during the First World War, Combat Stress and Blind Veterans UK, to draw out these parallels and share the personal experiences of soldiers wounded in more recent conflicts.

You can find some of my preliminary thoughts on casualty evacuation from the Western Front here and here, and on twenty-first century casualty evacuation in Afghanistan here and here.  Some of the differences between the two systems are summarised in this slide from a presentation on the project I gave in 2014.

WOUNDS OF WAR Vancouver Jan 2014.001

Much  more to come!

Bodies on the line

The more I think about corpography (see also ‘Corpographies under the DOWNLOADS tab) – especially as part of my project on casualty evacuation from war zones – the more I wonder about Grégoire Chamayou‘s otherwise artful claim that with the advent of armed drones the ‘body becomes the battlefield’.  He means something very particular by this, of course, as I’ve explained before (see also here).

But let me describe the journey I’ve been taking in the last week or so that has prompted this post. Later this month I’m speaking on ‘Wounds of war, 1914-2014‘, where I plan to sketch a series of comparisons between casualty evacuation on the Western Front (1914-18) and casualty evacuation from Afghanistan.  I’ve already put in a lot of work on the first of these, which will appear on these pages in the weeks and months ahead, but it was time to find out more about the second.

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En route I belatedly discovered the truly brilliant work of David Cotterrell who is, among many other things, an installation artist and Professor of Fine Art at Sheffield Hallam University.  He became interested in documenting the British military casualty evacuation chain from Afghanistan, and in 2007 secured access to the Joint Medical Forces’ operations at Camp Bastion in Helmand.  He underwent basic training, a course in even more basic battlefield first-aid, and then found himself on an RAF transport plane to Bastion.  The Role 3 Hospital was, as he notes, a staging-ground. ‘Field hospitals are islands between contrasting environments,’ he wrote in his diary, ‘between the danger and dirt of the Forward Operating Bases and the order and convention of civilian healthcare.’  You can read a long, illustrated extract from the diary (3 – 26 November 2007) here, follow the photo-essay as a slideshow here, and explore David’s many other projects on his own website here.

THEY-WERE-SOLDIERS_by-Ann-Jones_72The diary is immensely interesting and informative in its own right, not least about the exceptional personal and professional difficulties involved in documenting the evacuation process.  Here there’s a helpful comparison to be made with journalist Ann Jones‘s no less brilliant They were soldiers: how the wounded return from America’s wars (more on this in a later post), which starts at the US military’s own Level III Trauma Center, the Craig Joint Theater Hospital at Bagram, and moves via Landstuhl Regional Medical Center in Germany, the largest US hospital outside the United States, to the Walter Reed Army Medical Center in Washington DC.

David’s visual record is even more compelling, as you would expect from a visual artist, not only in its documentary dimension but also in the installations that have been derived from it.  In Serial Loop, for example, we are confronted with a looped film showing the endless arrival of casualties at Bastion: ‘The sound of a continuously arriving and departing Chinook helicopter accompanies images of a bleak and wasted landscape; the banality of the film’s fixed perspective masks the dramas that unfold within the ambulances as they travel to triage.’

9-liner explores what David calls ‘the abstraction of experience within conflict’:

9-Liner explores the dislocation between the parallel experiences of casualties within theatre. It is a quiet study of a dramatic event: the attempt to bring an injured soldier to the tented entrance of the desert field hospital. The screens show apparently unrelated information. JCHAT – a silent scrolling codified message – runs on a central screen. Our interpretation of it is enabled through its relationship between one of two radically different but equally accurate views of the same event. To the left we see the Watchkeeper – a soldier manning phones and reading computer screens in a crowded office. On the right we view the MERT flight – the journey of the Medical Emergency Response Team in a Chinook helicopter.

SHU’s REF submission includes this summary of David’s work (one of the very few useful things to come out of that otherwise absurdist exercise):

The research made clear that soldiers recovering from life-changing injuries had limited means of reconstructing the narrative of their transformative experiences. From the time of wounding through to secondary operations in the UK, many soldiers remained sedated or unconscious for a period of up to five days. The radical physical transformation that had occurred during this period was not adequately reconciled through medical notes, and the embargo on photographic documentation of incident and subsequent medical procedures served further to obscure this period of lost memory.

A culture of secrecy meant that medical professionals were unable to access documentation of the expanded care pathway with which they, and their colleagues, were engaged. This fragmentation of experience and understanding within the process of evacuation, treatment and rehabilitation meant that the assessment of the contradictions and disorientation experienced by casualties and medical practitioners was denied to front-line staff.

Family members, colleagues and members of the public outside the immediate environment of the military were unable to visualise or understand the transformative effects of conflict on directly affected civilians and soldiers. Partly as a result, the scope for public debate to engage meaningfully with the longer term societal cost of contemporary conflict was limited.

The submission goes on to list an impressive series of debriefings, presentations to military and medical professionals, major exhibitions, and follow-through research in Birmingham.

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And it’s one of those follow-throughs that prompted me to think some more about corpographies.  I’d noted the connection between corpography and choreography in my original post, but David’s extraordinary collaboration with choreographer Rosie Kay and her dance company gives that a much sharper edge.  Again, there’s a comparison to be drawn – this time with Owen Sheers‘s impressively researched and executed body of work, not only the astonishing Pink Mist but also The Two Worlds of Charlie F (2012)which was a stage play based on the experiences of wounded soldiers who also made up the majority of the cast (see my discussion of these two projects here).

5 Soldiers started life as a stage presentation in 2010 (watch some extracts here):

A dance theatre work with 5 dancers, it looks at how the human body is essential to, and used in, warfare. 5 SOLDIERS explores the physical training that prepares you for war, as well as the possible effects on the body, and the injury caused by warfare.

Featuring Kay’s trademark intense physicality and athleticism, 5 SOLDIERS weaves a journey of physical transformation, helping us understand how soldiers are made and how war affects them.

5 SOLDIERS is a unique collaboration between award-winning choreographer Rosie Kay, visual artist David Cotterrell and theatre director Walter Meierjohann. It follows an intense period of research, where Rosie learnt battle training with The 4th Battalion The Rifles and David spent time in Helmand Province with the Joint Forces Medical Group.

Rosie explained her commitment to the project (and her training with The Rifles) like this:

“I wanted to look at how the physicality of a soldier’s job defines them –like a dancer, the soldier is drilled, trained, their responses becoming automatic, but can anything prepare you for the realities of war? It is young soldiers and their bodies that are the ultimate weapon in war – their strength and weaknesses may win or lose a battle, their ability to harm or injure others is key to victory. While war is surrounded with weaponry, uniforms, history and ceremony, the real business is human, dirty, messy, painful and happening right now.”

(She is, not coincidentally, an affiliate of the School of Anthropology at Oxford).

5 Soldiers installation PNG

And now there’s a film version that works as a multi-screen installation (screen shot above).

Instead of just creating a short film, the team wanted the web user to get a truly interactive way to watch dance, and actually feel that they can go inside the minds and the body of the work. The 80-minute work was cut to just 10 minutes long, and the company spent one week filming in a huge aircraft hangar at Coventry Airport…

Using a variety of cutting edge filming techniques, the collaborative team have created a 13 angle edit that takes you into the heart of the work, follows each of the dancers, and zooms out so that the performers appear to be like ants in a huge empty landscape.

You can see the interactive, multi-perspectival version here.  This relied on helmetcams, and there’s a fine, more general commentary on this in Kevin McSorley‘s ‘Helmetcams, militarized sensation and “somatic war”‘ here.  But here’s the short, ‘director’s cut’ version:

And look at the tag-line: ‘The body is the frontline’.  It’s not only drones that make it so.

Journeys from No Man’s Land

Stretcher-bearers

I’ve agreed to join a panel organised by Noam Leshem on Remnants of No Man’s Land: history, theory and excess at the Annual Meeting of the Association of American Geographers in Chicago next April (I imagine this is a follow-up to the session at the RGS/IBG in September).

The no-man’s lands of the First World War were never limited to the killing fields between the trenches. Their impact was never fully confined by the time and space of the battles: it lingered on the bodies of soldiers, in contaminated ecologies and in the radically altered post-war intellectual landscape. The violence that is unleashed in the no-man’s land and the destruction it wrought does not result in emptiness, in a terra nullius, but in excess that can never be fully contained.

This session invites additional reflections on the excessive quality of no-man’s land: its materialities, ecologies, cultural expressions and political-ideological articulations. It aims to deepen the theoretical import and conceptual power of ‘no-man’s land’, and move beyond its use as merely a convenient colloquialism. Similarly, we seek to engagements with other histories of no-man’s lands that are not solely confined to the Western Front during WWI.

LOBLEY Dugouts in the embankment near Le Cateau

Despite that last sentence, this is what I’ve come up with; these abstracts are always promissory notes, of course, written so far in advance that they can provide little real indication of what eventually transpires.  Fortunately we are now no longer lumbered with the Yellow Pages-style book of abstracts so I doubt anybody will actually read this on the day.  But here goes:

Journeys From No Man’s Land, 1914-1918

During the First World War on the Western Front a central logistical preoccupation of military planners was the deployment of troops to the front line and the evacuation of casualties from the battlefield. These priorities were closely connected – the aim was to provide medical treatment as close to the site of the wound as possible so that troops could be returned expeditiously to the line – but they also often confounded one another as hospital trains headed for the coast were shunted into sidings to allow troop trains to move up. In this presentation I address three questions. First, what it was possible to know about the ‘lie of the land’, particularly in the deadly spaces between the front-line trenches? Here I focus on the connections between aerial reconnaissance, night patrols and trench maps. A second question concerns the arrangements made in advance of major offensives – the disposition of stretcher bearers and aid posts, field ambulances and casualty clearing stations – and the ways in which these visible geometries of the medical-military machine affected the sensibilities of soldiers waiting to go ‘over the top’. Finally, how did the wounded apprehend and navigate No Man’s Land, and how did they make what Emily Mayhew calls their precarious journeys away from the fighting?

There’ll be more posts on this as I circle in towards the presentation.  It’s part of my new research project which explores military-medical machines and the casualties of war 1914-2014, but which is now widening to include other aspects of medical care in contemporary conflict zones like Gaza and Iraq/Syria and the militarisation of medical intervention in West Africa.