Surgical strike

Kunduz Trauma Center (Andrew Quilty)

An update to my post (which I’ve updated several times) on the US air strike on the hospital in Kunduz early last month: MSF has released an internal review of the events that took place that night.  It’s only a preliminary report – the inquiry is ongoing – but it makes for grim reading.

MSF opened its Kunduz Trauma Center in August 2011, providing free, high-quality surgical care to all those who needed it (for more on MSF and other medical charities in Afghanistan, see my post on ‘The prosthetics of military violence’ here).

By the end of September 2015 the original 92 beds had grown to 140 as the numbers being treated grew:

Case load Kunduz Trauma Center 2011-2015 (MSF)

MSF is an experienced, highly regarded relief organisation and so it comes as no surprise to learn that it was fully aware of the cardinal principle of medical neutrality and took all possible steps to secure the legal and military foundations on which it operated:

MSF activities in Kunduz were based on a thorough process to reach an agreement with all parties to the conflict to respect the neutrality of our medical facility. In Afghanistan, agreements were reached with the health authorities of both the government of Afghanistan and health authorities affiliated with the relevant armed opposition groups. These agreements contain specific reference to the applicable sections of International Humanitarian Law including:

  • –  Guaranteeing the right to treat all wounded and sick without discrimination
  • –  Protection of patients and staff guaranteeing non-harassment whilst under medical care
  • –  Immunity from prosecution for performing their medical duties for our staff
  • –  Respect for medical and patient confidentiality
  • –  Respect of a ‘no-weapon’ policy within the hospital compound

The report makes it clear that this had been clearly endorsed by all the military and paramilitary parties to the conflict.

Fighting intensified in the week before the air strike.  Most of those treated since the Trauma Center opened had been from the Afghan government side, but from Monday 28 September ‘this shifted to primarily wounded Taliban combatants.’  The Afghan government speedily arranged the transfer of all its patients (apart from the most severely wounded cases) to another hospital.  By that night the Taliban announced that it was in control of the district.

The next day, as the numbers seeking treatment increased yet again, MSF reconfirmed the GPS co-ordinates of the Trauma Center with both the Afghan authorities and the US military.

On Thursday 1 October MSF was asked by Carter Malkasian, a a special adviser to the Chairman of the Joint Chiefs of Staff, whether the hospital ‘had a large number of Taliban “holed up” and enquired about the safety of [MSF] staff’ and was told that its staff ‘were working at full capacity’ and that the hospital ‘was full of patients including wounded Taliban combatants’.  And because the Taliban were hors de combat they were not a legitimate military target: there is absolutely no ambiguity about this.

That same day a UN civilian/military liason ‘advised MSF to remain within the GPS coordinates provided to all parties to the conflict as “bombing is ongoing in Kunduz.”’

On Friday 2 October two large MSF flags were placed on the roof of the hospital.  That night the hospital was calm, there was no fighting taking place within the vicinity and MSF insists that there were no armed combatants in the buildings or the grounds of the hospital.

The air strikes began soon after 2 a.m. on Saturday 3 October, and throughout the attack – which lasted for over an hour – MSF made repeated attempts to stop the assault:

MSF Kunduz phone log

And yet, despite everything the US military had been told in advance and despite these repeated attempts to stop the air strikes, an AC-130 gunship made five repeated passes:

A series of multiple, precise and sustained airstrikes targeted the main hospital building, leaving the rest of the buildings in the MSF compound comparatively untouched. This specific building of the hospital correlates exactly with the GPS coordinates provided to the parties to the conflict [my emphasis].

Bombing of Kunduz Trauma Center

As MSF’s Director concludes,

‘The question remains as to whether our hospital lost its protected status in the eyes of the military forces engaged in this attack – and if so, why. The answer does not lie within the MSF hospital. Those responsible for requesting, ordering and approving the airstrikes hold these answers’.

And, as the report notes, this is the view from the inside: ‘What we lack is the view from outside the hospital – what happened within the military chains of command.’

So far, controlled leaks from the US military investigation have suggested that an Afghan ‘rapid reaction force’ requested the attack, that it had been rushed to Kunduz from elsewhere in Afghanistan, arriving ‘just days before the air strike’, and that it had no experience in working with the US ground troops from the Third Special Forces Group who relayed the request for ‘aerial fires’ to the Joint Operations Center at Kunduz airfield.  The Green Berets ‘were aware it was a functioning hospital,’ AP reported, ‘but believed it was under Taliban control.’  The report continues:

The Green Berets had asked for Air Force intelligence-gathering flights over the hospital, and both Green Berets and Air Force personnel were aware it was a protected medical facility, the records show, according to the two people who have seen the documents.

The analysts’ dossier included maps with the hospital circled, along with indications that intelligence agencies were tracking the location of [an] … operative [from Pakistan’s Inter-Services Intelligence directorate who was allegedly co-ordinating Taliban operations in the area] and activity reports based on overhead surveillance, according to a former intelligence official who is familiar with some of the documents. The intelligence suggested the hospital was being used as a Taliban command and control center and may have housed heavy weapons.

According to the Washington Post,

… the crew of the AC-130, call sign Hammer, verified their permission to fire twice before engaging the hospital. AC-130Us carry a crew of 14, often including a special forces liaison officer responsible for communicating with ground units.

And the US troops remained in contact with the AC-130 gunship throughout the attacks.

So even if you accept all these unverified claims about the intelligence (or lack of it) behind the air strikes, you surely have to wonder about the studied lack of response to the repeated calls to have the attacks stopped.  Bear in mind, too, that the AC-130 has a sophisticated sensor suite on board, including IR and low-light cameras, that the hospital kept its lights on throughout the night (it was one of the few buildings in the city whose electricity was still working), and that MSF staff were advised to remain inside the co-ordinate grid they had given to the military: which turned out to be the very co-ordinates used for the attack.  It seems dismally clear that the trauma center was precisely targeted and that it could not have been mistaken for any other building.

Regular readers will know that the US military has repeatedly relied on an elaborate bio-medical discourse to legitimise its actions (for a brilliant recent discussion, see Elke Schwarz‘s ‘Prescription drones: on the techno-biopolitical regimes of contemporary ‘ethical killing’’, online early at Security Dialogue); the most familiar version, hideously ironic given the events in Kunduz, is the claim that the US military has an unprecedented ability to carry out ‘surgical strikes’…

UPDATE:  For an excellent analysis, see Kate Clark at the Afghan Analysts Network here

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.