Trauma Geographies online

My Antipode Lecture on Trauma Geographies is now available online via YouTube.

(If you wonder why I’m hunched over my laptop, the microphone was fixed to the podium….).  Since I’m now turning this into an essay, I’d welcome any questions, comments or suggestions.

You can find more details  including open access to a series of related articles – at the Antipode Foundation website here.

Mass Murder in Slow Motion (II): Siege Economies

This is the second in a series of posts on East Ghouta (Damascus); the first, providing essential background, is here.

The logic of the siege warfare pursued by Syria and its allies has been to cordon off areas under rebel control; to restrict, disrupt and ultimately prevent movement across the siege lines (including food, fuel and medical supplies); to subject the besieged population to sustained and intensifying military violence from aircraft, ground ordnance (artillery, missiles and mortars) and sniper fire; and to outlaw the provision of medical aid to those inside the besieged areas and limit the evacuation of the sick and wounded.

You can find more on the reincarnation of siege warfare as a tactic of counterinsurgency in later modern war herehere, here and here.

Precarious lines and precarious lives

In this post I examine the siege economies that emerged in East Ghouta from 2012 and their transformation over the next six years (to March 2018).

The restrictions on movement imposed on the besieged population varied in time and space.  This map from the New York Times plots incidents between the Syrian Arab Army and various rebel groups from September to November 2012:

As the clashes intensified the Syrian Arab Army (SAA) and its allies established a series of checkpoints in November-December to regulate the movement of people and supplies between Damascus and East Ghouta, though Amnesty International reported that anyone crossing ‘ran the risk of being detained or shot by government snipers’ and there were also reports of goods being confiscated or pilfered.  Access to those crossing points was also controlled from within the besieged area by armed opposition groups whose actions affected both entrance and exit.

The restrictions increased, along with the dangers, until in August 2013 the two crossing points at al-Mleha and Douma were closed by the SAA.  One woman recalled how she ‘didn’t understand’ what was happening when the road out of Ghouta was first blocked::

What did it mean that we were trapped? Then stores’ shelves gradually went empty. Food, fuel, the most basic essentials … everything began to vanish.

But some trucks were still allowed through a third crossing point at al-Wafideen, and the ensuing geography of closure was intricate.

A series of semi-clandestine routes was established between East Ghouta and the suburban towns of al-Qaboun and Barzeh on the other side of the Damascus-Homs highway; an uneasy truce was concluded with rebels in those two towns in January and February 2014, and these routes became vital conduits for smuggling goods into East Ghouta.

People in al-Qaboun and Barzeh relied on conditional access to regime-controlled neighbourhoods beyond the checkpoints.  ‘The residents of al-Qaboun and Barzeh live as though they are trapped in a limbo,’ wrote Rafia Salameh, ‘at the mercy of checkpoints.’

The ʻmoodʼ of these checkpoints is measured in the distance between the guards’ pockets – as they are hungry and poor – and their strict application of the law within the presence of superior officers, punishing those who try to smuggle past them simple materials for survival…

Lighters, batteries, light bulbs and any other electrical devices are forbidden. Salt and citric acid, which may be used in the manufacture of explosives, are also forbidden. Gas, milk bottles, and diapers are allowed through if the family carries around the proper documentation in which checkpoint transits are recorded by date, to prove they are not smugglers. However, all these regulations frequently fell silent by paying a bribe at the Barzeh checkpoint.

Salim, a 13-year-old young merchant of sugar says: “They beat us and chase us when the main officer is present.” He went on to explain how his sales decisions are driven by what he can or cannot afford to pay at the checkpoint. His profit per kilogram of sugar is 100 Syrian pounds (SYP), or $0.20 on the black market. He can carry eight kilograms of sugar, and he dips into his profits to purchase a pack of cigarettes for the security officers to allow him through their inspection. The cigarette pack costs 300 SYP, or $0.60. That means he ends the day with less than 500 SYP of profit, which amounts to one US dollar.

Some of these goods ultimately found their way through the tunnels into East Ghouta, but the price differentials between Damascus (which was not without economic problems of its own) and the Ghouta were stark.  Aron Lund posted this chart for March 2015 (prices are all in Syrian Pounds):

On 17 February 2017 the Syrian Arab Army backed by the Russian Air Force opened a new offensive against al-Qaboun (below) and Barzeh and eventually sealed them off from the Ghouta.

The only route that remained open was the al-Wafideen crossing; it had been subjected to intermittent, temporary closures, but on 21 March 2017 it too was finally sealed.  The siege of East Ghouta immediately became absolute until the cordon was breached by the renewed SAA offensive in February 2018 and, the following month, by evacuation corridors for the besieged population.

The closure of al-Wafideen had a catastrophic effect.  Here is a second price comparison, this time for May 2017 (when the exchange rate was 500 SYP to $1):

Such price comparisons are inevitably difficult and shot through with all sorts of difficulties, but similar data on food security from the World Food Programme makes it clear that price inflation on this scale made life immensely precarious for those inside the besieged areas – lives then made even more precarious by the escalation of military and paramilitary violence (my next post) and the disruption of medical provision (my final post in this series).  According to the WFP in October 2017:

Since the Al-Wafideen crossing closed in September, all food supply routes to eastern Ghouta have been completely closed. Food prices have soared as a consequence, with particularly grave consequences for the poorest and most vulnerable people. During the WFP market assessment conducted in Kafr Batna (in eastern Ghouta) at the end of October, the remaining food stock was found to be very limited, with severe shortages of staple foods such as rice, pulses, sugar and oil.

Based on the market assessment data, the cost of the standard food basket in October 2017 reached SYP327,000, which is 204 percent higher than in September and more than five times higher than in August 2017 (before the crossing closed). The eastern Ghouta food basket currently is almost ten times more expensive than the national average.

According to key informants, the only available cooking fuel in eastern Ghouta is liquid melted plastic, which costs SYP 3,500/litre – ten times more than the national average price of diesel. Some households also reported burning animal remains and even used diapers to boil vegetables.

A bundle of bread in Kafr Batna is being sold at SYP2,000, which is more than 35 times the average price in accessible markets.

Food security is likely to deteriorate rapidly in the coming weeks if the siege continues. It is estimated that food stocks will be totally depleted by end November 2017.

Local resources and improvisations

Faced with the shortages and high prices imposed by the siege, the people of East Ghouta had limited resources to fall back on (see my previous post here), and these contracted sharply after the Syrian Arab Army finally seized control of the rich agricultural lands in the south of the Ghouta (the Marj) in May 2016, near the start of the harvest season.  People throughout the besieged area were forced to improvise and to devise ever more exacting economies.

The survival strategies listed by the WFP included reducing the number of meals, reducing portion size and limiting adult consumption, but once the siege became absolute – crossings closed, tunnels blown – many were reduced to far worse than those.  The designation of East Ghouta as one of four ‘de-escalation zones’ during the summer of 2017 only opened what Reuters called ‘the doors of starvation’:

‘When people in the Ghouta learned of the deal and thought it would bring relief, many began using up their food reserves at home, said Khalil Aybour, head of the local council in the town of Douma. “After they saw it was all rumors,” he said, “the misery grew immensely.”

Here is a report from November 2017:

The sight of a woman weeping as she drags her malnourished children into a clinic is not rare in eastern Ghouta…. But when one mother told Abdel Hamid, a doctor, that she had fed her four starving children newspaper cutouts softened with water to stop them from screaming into the night, even he was stunned.  “I could try to describe to you how terrible the conditions are in which we are living, but the reality would still be worse,” [he] said.

Another young widow described how she rationed food between her three young daughters:

My girls take turns eating now. We barely have any food so each one eats one meal every three days. It breaks my heart because they go to bed hungry and wake up with no energy.

Stories like these are what lie behind the distanced prose of an interagency assessment of food security conducted for the World Food Programme that same month, which reported:

Due to the lack of available food and the high food needs, a food basket meant to support a five member household for a month [supplied by the UN] is being shared among six different households (approximately 30 people).

Due to lack of staple food commodities and severe shortfall of cooking fuel (firewood, diesel and gas) in addition to their high prices, residents have been reduced to subsist on raw vegetables such as maize corn, cabbage and cauliflower with no more than one meal per day. In many households with multiple mouths to feed, priority is given to children with adults often skipping entire days without eating. Some households are even resorting to rotation strategies whereby the children who ate yesterday would not eat today and vice-versa.

Cases of severe acute malnutrition among children were identified by the UNICEF team…

Three months later, once the offensive started in deadly earnest, the situation deteriorated still further.  By March 2018, when thousands of people were huddled in basements and cellars sheltering from the incessant bombing and artillery fire, some of those that could find food were reluctant to eat in front of other people in the face of such widespread hunger.  Others shared what little they had.

In fact food was the central concern throughout the siege.  In the beginning some residents started to grow vegetables on their roofs to supplement local production and avoid the soaring prices in local markets:

“The blockade has forced us to find alternatives, especially in towns like al-Buwaidah, hijjera, and al-Sbeneh, where all the surrounding farming lands were destroyed, and many farmers were killed,” said Ahmad Abu Farouq, a 19-year-old who lives in Ghouta with his family of nine.

Ahmad said he and his family have turned their 1,600-square-foot (150 sq meter) rooftop into a year-round farm, planting zucchini and pumpkin in the winter, and lettuce and parsley in the summer [see the image below]. “I throw in a mix of eggplant, peppers and cucumbers when I can,” he added.

Eastern Ghouta is frequently and heavily hit by government airstrikes. To protect themselves and their crops, according to Ahmad, most people who have chosen to take up alternative farming find ways to hide their box planters so as not to make them entirely visible from up above.

This proved to be a short-term solution: when the Assad regime cut electricity supply to the Ghouta it had serious spill-over effects, and ‘on rooftops, as in the agricultural fields, the [consequent] lack of an irrigation system providing clean water caused the end of this semi-autonomous way of surviving the siege.’

So fuel was a second major concern, but there too there were improvisations. Mark Hanrahan and Bhassam Khabieh described an elaborate scheme in Douma to convert plastic waste into fuel.  Using methods he learned from YouTube videos, Abu Kassem and his family collected plastic bottles, rubble from damaged buildings, plastic cooking utensils, even plastic water and sewage pipes; they burned them all in a makeshift refinery, and sold the gas for domestic and commercial use or condensed the gas and refined the liquid into fuel for generators and vehicles.

At its height the workshop was running 15 hours a day six days a week; on an average day it burned 800 – 1,000 kg of plastic waste to produce around 850 litres of fuel. This was a dangerous, noxious business:

“Working here is very tiring, but we feel that we are providing a great service to people. I have been working here for a short time and have begun to adapt to the atmosphere here,” said Abu Ahmed, 28, [one] of the workers.

And the products were snapped up:

“When the siege began on eastern Ghouta at the end of 2013 fuel prices rose madly and we were no longer able to water crops as in the past,” Abu Firas, 33, an agricultural worker in the district told Reuters. “When we started producing local fuel, and water engines could be powered by this fuel, … life returned to agricultural land.”

Abu Talal had the same idea:

“We get plastic materials from areas and buildings that are deserted after being shelled by the regime forces. We collect all the plastic we find, such as water tanks and drainage pipes.”

After Talal and his team gather the plastic, they cut it into smaller pieces and put 50 kilograms in each barrel, along with 20 meters of piping to cool the water that runs in and out of the barrel. They contain narrower tubes, which contain the fumes that come from the burned plastic. Then they light a fire.

“It takes two to three hours to extract as much as possible from one batch of plastic,” he says. “In the last stage, we get the temperature to 100 to 115 degrees to extract a kind of diesel. The temperature must be accurate for the diesel to come out and for it to burn well, so it can be used in cars and motorcycles.”

Ammar al-Bushy described a similar operation at Erbin here.  ‘People are aware that the fuel extracted from burning plastic [is of a lower] quality than that extracted from oil,’ he reported, and it ’causes long-term problems for engines, but it meets the purpose for people living in a dire situation, in addition to the lower cost than fuel extracted from oil.’

The economics of the operation were explained by Abu Hassan:

“Gasoline reached the price of 4000-4200 Syrian Pounds ($20-$21), and the amounts available were minimal. However, we found a substitute by heating plastic and extracting methane, gasoline, and diesel.

“The price of diesel was 3200-3500 Syrian Pounds ($16-$18.50) per liter, which is considered very expensiv. So people were no longer able to purchase it, but after we started operating on plastic and started extracting diesel from it, the price decreased to 1200-1500 SP and it became more available.”

There were other manufactories too: there is a remarkably detailed analysis of the manufacture of weapons by Jaish al-Islam here, including improvised mortars, rockets, grenades and rifles.

But my focus here is on those resources basic to civilian survival in the besieged area. There were all sorts of other substitution strategies in East Ghouta  – I’ll deal with the improvisation of medical supplies and anaesthetics in the final post in this series – but the two examples I’ve provided show concerted attempts to devise solutions to the supply shortages and high prices that were the immediate products of the tightening siege.

Those economic conditions were also affected by cross-cordon transactions: by merchants who were allowed to bring goods in through the al-Wafideen checkpoint, and by smugglers who (until the offensives against Barzeh and al-Qaboun) operated a series of clandestine tunnels that gave access to markets on the suburban fringe.  I’ll consider each in turn, but in both cases there was an elaborate administration of precarity: an apparatus of permissions and permits, exactions and kick-backs, through which the local economy was manipulated and political and (para)military relations were managed.

There was another set of cross-border transactions: these were non-commercial flows of humanitarian aid.  The Syrian government put in place an intensely bureaucratic system  to regulate aid convoys which was also part of the administration of precarity.  It proved to be (and was intended to be) so restrictive that these flows had precious little sustained impact on economic conditions in Ghouta.  But, as I’ll show, these transactions were entangled in a wider and intrinsically partisan geography of precarity that magnified the marginality of Ghouta and effectively enlarged the power of the regime to dictate the terms of its ‘surrender or starve‘ strategy.

Merchants and the Million Checkpoint

One of Amnesty International‘s informants described how the importation of food into East Ghouta was slowly restricted:

By April  2013, you were not allowed to take any food into Eastern Ghouta. Security forces would beat women and men when they found bread or vegetables hidden in the boot of the car or under clothes. As I passed by a checkpoint, I remember seeing food piled up and people being beaten up or humiliated. The Syrian authorities did not allow any bread, vegetables, fruits, pasta, sugar or eggs to enter.

As individual transactions were banned, so selected merchants were allowed to organise much larger shipments. The al-Wafideen crossing became the most important external source of food and fuel for East Ghouta – often described as the ‘lung’ through which the Ghouta breathed – and the central figure in commercial transactions through the checkpoint was Mohyeddin al-Manfoush (‘Abu Ayman’), one of what the Economist called ‘Syria’s new war millionaires’: the ‘dairy godfather’.

Before the war Manfoush lived in Mesraba near Douma, where he owned a small herd of cows and a cheese factory, and traded as al-Marai al-Dimashqiya (Damascus Pastures).  Once the siege began he quickly struck a deal with the Syrian government.  The Economist again:

He began to bring cheap milk from rebel territory in Eastern Ghouta to regime-held Damascus, where he could sell it for double the price. The regime received a cut of the profit. Mr Manfoush reinvested his share. He snapped up the region’s best cows and dairy machinery from farmers and businessmen whose livelihoods had been hammered by the siege. As the business evolved, the trucks that left Ghouta with milk and cheese came back laden with the barley and wheat he needed to feed his growing dairy herd there and run the bakeries he bought.

It was immensely profitable; with a captive market of 400,000 people and runaway prices Manfoush not only expanded his business (under the umbrella Manfoush Trading Company) but also moved to a new house in Damascus and even established his own private militia.

Others profited too.  The security forces controlling the crossing (above, in February 2018) received ‘extra payments’ from Manfoush; there have been reports that they charged 200-300 Syrian pounds ($1 – $1.40) and sometimes as much as 750 Syrian pounds for each kilogram of goods passing through the checkpoint.  Local people came to refer to al-Wafideen as ‘the Million Crossing’ because it supposedly generated one million Syrian pounds per hour in bribes for its soldiers and security officers.  In March 2015 researchers were told a fee of one million Syrian pounds allowed a vehicle to pass through the checkpoint.  And Manfoush dispatched convoys not single trucks:

But the kickbacks almost certainly went much higher than those operating the checkpoint.  Roger Asfar has claimed that Manfoush’s web of companies is linked to the business empire of President Assad’s brother, Maher al-Assad (who also usefully heads the Republican Guard).  Be that as it may, the regime had more than a commercial interest in Manfoush’s transactions because it was able to leverage its control over al-Wafideen and ‘exploit its ability to turn trade on and off in order to sow enmity among [different] rebel [groups].’

The state’s ability to goad its enemies in this way depended not only on the rivalries between different rebel groups, however, but also on those groups’ own stakes in the siege economy.  These derived, in part, from the revenues generated through their ancillary checkpoints.  Many informants testified that another set of ‘fees’ were exacted there, though what eventually became the major rebel group in Douma, Jaish al-Islam [JAI], denied having any stake in Manfoush’s operations at al-Wafideen:

“Manfoush does not serve the Islam Army [JAI], he serves the Ghouta in its entirety,” said the Islam Army official Mohammed Bayraqdar. “Our interests are in harmony with the interests of the people and our relationship is merely that of facilitating his services. If there were another person [who performed the same function], we would provide the same services to him in return for his services to the people of the Ghouta.”

Those ‘facilitations’ and ‘services’ involved granting Manfoush’s convoys safe passage into East Ghouta, and it seems highly unlikely that this was a purely philanthropic gesture.  In June 2015 one of Amnesty International‘s informants explained:

Since the end of 2014, the Army of Islam [JAI] has controlled the supply route from al- Wafedine camp and Ajnad al-Sham, the underground tunnels in Harasta. The Army of Islam is responsible for regulating the prices. During the winter, the Army of Islam collects most of the food supplies from the market, increasing the prices threefold. You sleep one night and wake up the next day to find there is no food and prices are high.  The Army of Islam in collaboration with suppliers store food and non-food items in [its] warehouses. 

Siege Watch was even more blunt in its assessment for May-July 2017: ‘the corrupt trading monopoly run by al-Manfoush at the al-Wafideen checkpoint lined the pockets of the Syrian miilltary and JAI’.

There is no doubt that Jamash al-Islam’s provision of ‘services’, whether corrupt or not, was far from disinterested: facilitating the importation of food, fuel and other supplies gave it leverage over the besieged population. It was able to extend its control over the local labour market in Douma – determining which shops were allowed to open, for example – and gave those on its payroll privileged access to imported goods from its own warehouses. JAI was not the only group to take advantage of the siege economy.  In Harasta, Fajr al-Umma reportedly ‘gave away free food and a tank of propane … in [an] attempt to strengthen its popularity in the area.’  In short, food and fuel became vital currencies not only for the counterinsurgency but also for the insurgency.  ‘Joining one of the armed groups can provide a monthly salary of an average of USD 50,’ Rim Turkmani and her collaborators in the LSE’s ‘Security in Transition’ programme (including Mary Kaldor) found, ‘in addition to food parcels.’  And at times, they continued, ‘fighters are only paid in food.’

Putting all this together, Rim produced this diagram which traces the journey of a loaf of bread from Damascus into East Ghouta and shows how extensive was the system of exchange whose fulcrum was al-Wafideen:

Underground economies

In his detailed analysis of the tunnels excavated and operated by the armed opposition groups in the Ghouta, Aron Lund explains:

Apart from the Wafideen Crossing, the Eastern Ghouta has been supplied through a system of secret tunnels and semi-informal frontline crossings. While the crossings can bring in a far greater volume of trade, the tunnels serve to import goods that are restricted or banned by the government (including fuel, medical supplies, and arms), to move people in and out of the enclave, and to challenge and undercut food prices set by the Wafideen monopolists.

Digging the tunnels was difficult and dangerous work – but in a place where the economy was collapsing, where there were so few jobs to be had, and where some rebel groups resorted to more directly coercive methods of recruitment the work proceeded apace:

Men of Douma work in three shifts a day to finish their job, using primitive tools. “Each worker has one meal – either breakfast with an egg and a piece of bread, or lunch with rice and bread. The digging never stops. When we hit a large rock or anything like it, we turn on the generator and use a jackhammer,” said Abdullah, a tunnel digger. When asked about the reason that men take this job and whether it pays well, Abdullah said: “Many have lost their job because of the ongoing war, so we have no means to earn money to buy food. Prices are also very high because of the prolonged siege. They pay around 1,000 Syrian pounds per worker, which covers the price of a kilo of flour….”

“When we first started digging tunnels, we faced many difficulties; however, we found solutions and continued the operation. For example, we pumped oxygen at certain points inside the tunnels, which is very important for the workers. We also set up pillars inside the tunnel to prevent them from collapsing over the workers, which had happened often earlier, and killed and trapped many workers for many hours before we could rescue them,” said Abu Mahmoud.

There were five main tunnels (I’ve taken most of these details and the maps from a report by Enab Baladi‘s Investigative Unit on ‘The economic map of Ghouta‘).  

The first (the Zahteh or Central Tunnel) ran 800 metres from Harasta under the Damascus–Homs highway to Qaboun; construction was started by Fajr al-Umma towards the end of 2013, and the tunnel opened the following summer.  It soon emerged as ‘the primary [clandestine] artery for the Eastern Ghouta’s siege economy’.

In January 2015 Jaish al-Umma opened a second, parallel tunnel, but Fajr al-Umma soon controlled this route too:

In May 2015 two other rebel groups, Failaq al-Rahman and al-Liwan al-Awwal, dug the so-called ‘Mercy Tunnel’ from Arbin to Qaboun; this was much longer than the previous two (2,800 metres) and wide enough to allow the passage of cars and even Kia 2400 trucks.

In June 2015 Jaish al-Islam constructed a 3km tunnel from Arbin and Zamalka to Qaboun; it too was wide enough to accommodate small trucks.

In September 2015 Falaq al-Rahman joined with Jabhat al-Nusra in Qaboun to establish a third tunnel under its control, the ‘Nour [Light] Tunnel’, from Arbin to Qaboun for foot traffic only.

These were the main tunnels, but several smaller tunnels were dug between the Ghouta and Jobar, and others were dug primarily for (para)military purposes to move personnel, ammunition and armaments.  Other tunnels were dug within the Ghouta as defences against air strikes; they served multiple purposes, not least connecting the dispersed facilities of underground field hospitals (more on this in a later post).  One SAA informant described to Robert Fisk what he saw when he entered Douma in March 2018:

I have never seen so many tunnels. They had built tunnels everywhere. They were deep and they ran beneath shops and mosques and hospitals and homes and apartment blocks and roads and fields. I went into one with full electric lighting, the lamps strung out for hundreds of yards. I walked half a mile through it. They were safe there. So were the civilians who hid in the same tunnels.

The main cross-line tunnels were used for multiple purposes too: but commercial traffic was always an important consideration.

I describe this as commercial not only because the goods were sold at stores inside Ghouta but also because the tunnels provided the groups that controlled them (often through nominally civilian front organisations or ‘foundations’) with income and resources.  This caused considerable jockeying between them;  Aron Lund provides a superbly detailed analysis of the rivalries, deals and counter-deals that ensued.

The tunnels were considerable undertakings.  The director of the organisation set up to operate the Mercy Tunnel told Enab Baladi that it cost 30,000,000 Syrian Pounds each month to cover ‘the expenses of nine Kia 2400 trucks that work between 3 p.m. and 6 a.m. and the salaries of 450 employees, including drivers, workers, administrators, officials and custodians, in addition to security officials.’

There were three streams of commercial transactions.  The first involved the passage of civilians and, like all movement through the tunnels, was closely controlled by the rebel groups.  One of Enab Baladi‘s informants outlined the rules:

Those passing through the tunnels must be born before 1970, since the factions are in need of young fighters.

The person passing must provide clearance from the Unified Judiciary, to prove that there are no cases outstanding against him or her, and a clearance from the Housing Bureau.

Fighters must provide an official permit  (below) from their faction.

All documents must be submitted to the Crossing Office, which will assign the person a date to pass.

Medical emergencies are exempted from the waiting period, but must provide a report from the Unified Medical Bureau.

Under no circumstances are weapons allowed to leave Ghouta.

No goods other than clothes and basic supplies are allowed (not to exceed two bags).

Abu Ali described how he and his family made their escape:

The process of applying to use the tunnel, he said, was strangely bureaucratic for such a risky method of escape: He submitted an official request at a Jaish al-Islam office and was informed two weeks later that it had been granted… [He] and three other families granted access to the tunnel started their journey on a bus from the city of Hamouriyya.

“The bus took us to the city of Arbin. In Arbin, the bus took side streets, so that we wouldn’t be noticed. We finally arrived at a house where our identification cards were checked, and our luggage was searched. We were told that we had to be very careful, so no one would discover where the tunnel was,” he said.

The tunnel “was very tight – there was barely enough room for two people to walk side by side and it was about two meters in height. In addition to lights, the tunnel had turbines for ventilation purposes.”

These rules were never set in stone, still less once the co-operation implied by the ‘Unified Medical Bureau’ and the ‘Unified Judiciary’ [established in the summer of 2014] broke down and in-fighting between the groups controlling the tunnels became commonplace.  Despite the age restrictions, some of them were willing to allow young people to pay for a permit: the cost varied between 100,000 and 200,000 Syrian pounds.  If they wished to escape Qaboun or Barzeh, they would then pay further bribes to the soldiers and security officers controlling the regime’s checkpoints into Damascus.

There was one constant: the rules allowed for the evacuation of medical emergencies but no medical staff – doctors, nurses, pharmacists – were permitted to leave.  In fact it seems unlikely that many serious medical cases were evacuated through the tunnels either. They would not have found better treatment in Barzeh or Qaboun, but during the early stages of the truce some patients were allowed to cross from those besieged districts into Damascus.   Dr Immad al-Kabbani testified that ‘for a period beginning in September 2014 we were able to evacuate a minimum of 20 patients and their families each week’ through the tunnels (and even ‘to send biopsies from cancer patients to cooperative labs in Damascus for diagnosis’) but by March 2016 the clandestine system was already failing. One cancer patient was allowed to leave for radiation therapy which was unavailable at the Dar al-Rahma Center for Cancer in Ghouta, but her journey turned out to be fruitless:

 I received no care at hospitals [in Damascus] so I relapsed and the tumour returned to its previous status. I decided to go back to Eastern Ghouta through the same tunnels to have the chemical doses.

That same month patients were travelling in the opposite direction.  A doctor from the Syrian-American Medical Society testified:

Now, as access to Damascus has been cut off, the 35,000 civilians inside Barzeh have extremely limited access to healthcare, and must travel to East Ghouta to obtain treatment. Even the dialysis patients in Barzeh are traveling to East Ghouta [via the tunnels] to obtain treatment with the extremely limited supplies.

For a time the tunnels were a two-way street of sorts for cancer patients: those who needed chemotherapy were treated at the Dar al-Rahma Center in Ghouta, using medical supplies smuggled through the tunnels [below], while those needing radiotherapy were taken through the tunnels to al-Nawawi hospital in Damascus.  According to the director of the Dar al-Rahma, ‘after the closure of the tunnels, there is no possibility of providing either of the treatments.’

By the time the tunnels were closed in February 2017 the UN estimated that around 80 patients out of 700 estimated to be in need of urgent treatment had been evacuated from East Ghouta through the tunnels.  Some were transferred because there were no specialists available inside the besieged area, others because clinics there had been denied the medicines and equipment needed to treat them.  But the numbers were small when set against the extensive record of seriously injured or ill patients being placed on evacuation lists from the Ghouta only to have their doctors’ requests refused or ignored by the Syrian government.  Once the tunnels were closed ‘all movement of patients was halted.’

The second stream of traffic involved everyday supplies of all kinds, including food and fuel.  Some rebel groups limited their dealings to particular merchants but in every case a tunnel ‘tax’ was levied.  The usual fee seems to have been 10 per cent but there were times when 25 per cent and even 45 per cent of the value of the goods was levied.  The ‘tax’ was paid in cash or in kind: the different factions maintained their own warehouses and usually gave their own fighters and supporters privileged access to the supplies they skimmed from the shipments.  During the first two months that the Mercy Tunnel was in operation, for example, Falaq al-Rahman allegedly ‘filled its warehouses with more than 12 tons of goods, claiming that it had to secure its fighters first.’  As this implies, the totals involved were small – they paled into insignificance alongside the commercial shipments through al-Wafideen – but they provided the armed opposition groups with significant financial gains.  Enab Baladi again, citing one of the directors of the Mercy Foundation:

“Everyone finds in the tunnel the perfect opportunity to make money. Since the very first tunnel was completed, Fajr al-Umma, the faction that had dug the tunnel, took control of all incoming goods and sold them for extremely high prices. In 2014, for example, 1kg of sugar was sold for 60-70 Syrian pounds [around 30 cents] in Damascus, but Fajr al-Umma sold it for 3, 500 Syrian pounds [more than $16] within Ghouta.”

These exactions – and the subterranean monopolies that underwrote them – prompted endless negotiations (and worse) between the groups over shared access.  Kholoud al-Shami suggested that Jabhat al-Nusra planned the Nour Tunnel explicitly to undercut its rivals, bring prices down, and so boost its support among the besieged population.  One local resident told her:

It appears that Nusra’s goal is to reduce the suffering of the besieged residents, who had begun cursing the revolution and the rebels because of Falaq al-Rahman and Fajar al-Umma keeping prices high. All factions want to build up their popular support, which is what Nusra is doing… Local residents have viewed the drastic drop in prices positively and stood in solidarity with Jabhat a-Nusra when Falaq al-Rahman prevented them from selling gasoline at reduced prices when they were still sharing a tunnel.

Similarly, Jaish al-Islam apparently pressured Fajar al-Ummah to lower its prices. It was an intricate and constantly changing story, but running through all these deals was the imbrication of the political with the economic.  The attempts to lower prices were all about more than the high-minded desire to ‘reduce suffering’: they were also aimed at boosting support for one faction over another.

The third stream of traffic consisted of medical supplies.  I have separated these from other supplies because they were categorically barred from the al-Wafidden crossing; even UN convoys with the appropriate authorisations had them removed at the checkpoint.  Yet they were vital.  Inside Ghouta doctors were struggling with often catastrophic injuries from shelling and bombing, and doing their best to treat seriously ill patients with chronic conditions (how often we forget that people still get sick in war zones).  With no provision possible through the overland crossings, doctors had to use the tunnels.  A team from the Union of Free Syrian Doctors worked around the clock in Barzeh to obtain vital medical supplies for hospitals and clinics in Ghouta, but by the time they had paid Syrian Arab Army soldiers controlling checkpoints on the highway and then the tunnel tax – medicines were not exempt but were charged ‘only’ 5 per cent – the costs of even routine medications had soared.  Students from the Columbia School of Journalism reported:

By the time all the fees are paid, the price of medical supplies in Eastern Ghouta “is three times higher, sometimes as much as five times, than what’s in the north or south of Syria,” said [Mahmoud] al-Sheikh [director of the Unified Revolutionary Medical Bureau in Eastern Ghouta]. A liter of serum, which is used to help the body replenish lost blood, goes for about $1 in regime-controlled areas (one liter is about one fluid quart). But health workers say they’ve paid anywhere from $3.50 to $10 for one liter of serum brought in from Barzeh.

[Osama] Abu Zayd [a medical equipment engineer with the Union of Free Syrian Doctors] estimates that Ghouta, with its many neighborhoods, needs about 10,000 liters (more than 2,600 gallons) of serum per month.

Whatever came through the tunnels, it was never enough, and all three traffic streams came to a juddering halt as the offensive against Barzeh and Qaboun was renewed.  During the winter of 2016-17 the regime sought to amend the terms of the truce, stipulating that the smuggling trade had to stop; then in February 2017 it peremptorily closed the checkpoints so that supplies from Damascus dried up, and within days nothing was moving through the tunnels to Ghouta.

The fighting that followed was protracted and bloody, and thousands fled through the tunnels to find refuge in East Ghouta.  But by the end of February the Syrian Arab Army occupied the warehouse concealing the portal to the Zahteh Tunnel, and by the middle of May, when the remaining opposition fighters in Barzeh and Qaboun had surrendered and the population was forcibly evacuated, all the major tunnels had been breached.  

State media published videos showing the army cutting the tunnels and carrying out controlled explosions.  The ultimate objective was not only to take down Barzeh and Qaboun but ‘to strangle the Ghouta … by closing off the crossings and tunnels,’ a spokesman for Jaish al-Islam explained.  ‘Trade through the tunnels has completely stopped.’

The loss of the tunnels triggered panic buying in Ghouta, driving prices still higher, and triggered a new round of fighting between the two major blocs of rebel fighters (Jaish al-Islam based in Douma and Falaq al-Rahman in fractious and as it turned out temporary alliance with Hay’at Tahrir a-Sham, which later became Jabhat al-Nusra, which were based in the so-called ‘Central Section’ to the south and the west).

Residents of the Ghouta demonstrated against the infighting – and, in a displaced and horrifying repetition of the tactics employed by regime’s security forces, Jaish al-Islam opened fire on the crowd – and the deepening tension served only to aggravate the economic crisis.  In July 2017 Alaa Nassar reported:

Dozens of recently erected checkpoints and berms split the suburbs [of East Ghouta] in half. For residents trapped inside the Central Section, this means a lack of access to the Wafideen crossing and, therefore, to outside resources.

By September 2017 the Syrian-American Medical Society‘s report on the siege of East Ghouta described a truly dreadful predicament:

In a report for the Middle East Institute, ‘Sieges in Syria: Profiteering from misery‘ (2016) Will Todman summarises the two sets of cross-cordon transactions I’ve described so far – overt commercial transactions through al-Wafideen and clandestine transactions through the tunnels – like this:

It’s an effective summary but, as I now need to show, the bottom line (sic), in which UN convoys are described as ‘an effective means to get goods to civilians at a lower price,’ is problematic.

Aid convoys

Like the commercial convoys of merchandise that were allowed in to East Ghouta, humanitarian aid came in through al-Wafideen (above).  Unlike the commercial flows, however, humanitarian aid was rigorously policed, strictly limited and utterly spasmodic. In Douma, for example, which had been under siege since 2013, the first UN interagency aid convoy did not arrive until 10 June 2016 (below). Its 36 trucks provided emergency food, wheat flour, and nutrition supplies for only 17 per cent of the population.  Those stocks were supposed to last for one month, but the next convoy did not arrive until 19 October 2016, with 44 trucks carrying food supplies for 24 per cent of the population (baby milk had been removed at the checkpoint).  Those supplies were also intended to last for one month, and a third convoy duly arrived at al-Wafideen with supplies for 49 per cent of the population on 17 November 2016.  But the mission was aborted because ‘it lacked specific approval needed to proceed without dog searches and unsealing of the trucks.’  The next UN convoy arrived on 30 October 2017.

I have extracted most of these details from a report prepared by Elise Baker for Physicians for Human Rights with the dismally appropriate title Access Denied.  The report describes a system of deliberate obstruction of humanitarian aid by the Assad regime that imposed – by design, remember – ‘slow, painful death by starvation’ on populations in areas besieged by its forces: what the report also calls ‘murder by siege’.

There have been two main modalities of obstruction.  The first has involved a byzantine process through which UN agencies have been required to obtain formal permission from the government to deliver humanitarian aid.  Following the establishment of a joint working group to facilitate (sic) the process in 2014, it was agreed that each convoy would need approval from the Ministry of Foreign Affairs and ‘facilitation letters’ from the Ministry of Social Affairs, the Syrian Arab Crescent and (in the case of medical supplies) the Ministry of Health.  The process was described by the UN Humanitarian Coordinator as ‘extremely complex and time-consuming’, and matters were not improved by the introduction of additional clearance requirements from the High Relief Committee and the National Security Office.

After repeated protests from the UN the Syrian government finally agreed to ‘simplified procedures for the approval of interagency convoys across conflict lines‘ in March 2016, that should have reduced an eight-step process to a two-step process, with all approvals (or refusals) being issued within seven working days.  In practice, the two-step became a ten– or even eleven-step process.  In January 2017 the UN Security Council was advised of ‘subsequent administrative delays on the part of the government, including in the approval of facilitation letters, approval by local governors and security committees, as well as broader restrictions by all parties [that] continue to hamper our efforts’ to deliver humanitarian aid to besieged populations.  Even with approvals from the authorities in Damascus, protocols were routinely violated at checkpoints.   Stephen O’Brien elaborated:

We continue to be blocked at every turn, by lack of approvals at central and local levels, disagreements on access routes, and by the violation of agreed procedures at checkpoints by parties to the conflict. Are these important? Yes. We can’t – and if I may quote – “just plough on” or “just get on with it” as I’ve heard one member sitting around this say table to me. Because if one brave aid worker drives through the checkpoint without the facilitation letter and the command transmitted down the line, the check-point guard or their sniper takes the shot.

In a statement two months later he bluntly declared: ‘The current bureaucratic architecture is at best excessive and at its worst, deliberately intended to prevent convoys from proceeding.’

The second modality of obstruction was to withhold permission altogether.  The chart below was compiled for PHR’s Access denied; notice the substantial differences between the populations for whom the UN requested access and the populations for whom access was approved, a difference that was the product of both outright rejection and a calculated failure to respond.

Notice too the still smaller population eventually reached by the aid convoys:

From May through December 2016, on average, Syrian authorities authorized UN interagency convoys to deliver aid to approximately two thirds of the besieged and hard-to-reach populations that UN authorities requested access to each month – a figure which, in itself, represents a fraction of the entire besieged and hard-to-reach population. However, UN convoys only reached 38 percent of that smaller approved population, due to additional approval procedures and other delays imposed overwhelmingly by government officials…  At worst, this pattern reflects an effort by Syrian authorities to appear cooperative while still ensuring that access to besieged areas remained blocked.

The approval process allowed the authorities not only to veto the populations permitted to receive humanitarian aid but also to restrict the amount and composition of that aid.  In November 2017, for example, a UN convoy of 24 trucks was allowed in to Douma – the first since August – with food for an estimated 21,500 people (the original request had been for supplies for 107,500); medical supplies had been removed from the convoy.  In March 2018 another, much delayed convoy reached Douma with food for 27,500 people (below); deliveries were interrupted by renewed shelling and 10 of the 46 trucks were forced to return with their loads.  Marwa Awad, who accompanied the convoy with the World Food Programme, described what she found:

Volunteers gathered to help offload the aid from the trucks, including WFP’s wheat flour which the men were offloading into underground cellars. Speaking with the local council, we learned that there were more than 200,000 people in Douma, many of them displaced from nearby villages and other areas within Eastern Ghouta, and all of them needing food and medicine….

Leaving the devastation above, we took a long and narrow staircase deep into Douma’s underworld: a network of basements that has become fertile ground for disease and infection.  Many residents are forced to live underground, crammed together in packed spaces to avoid airstrikes…

There we met Mustafa, a man in his twenties.

“The food aid trickles in very slowly, drop by drop. Many families here are struggling. I hope whoever is hungry gets help,” he said. Because of the increasing demand for food and limited quantities allowed inside, residents of Douma have had to split the food assistance WFP delivered during an earlier convoy in order to reach as many people as possible.

The convoy took place at the height of the final military offensive against the Ghouta: yet the World Health Organisation said that Syrian government officials had ordered the removal of 70 percent of the medical supplies it had prepared for the convoy, including all trauma kits, surgical supplies, dialysis equipment and insulin.

The control exercised by the Assad regime over humanitarian aid derived not only from formal procedures, or the subsequent ‘deletions’ and on occasion, even contamination of supplies at checkpoints; it also depended on the system of clandestine intelligence built in to the architecture of the authoritarian state. The head of one UN agency working out of Damascus told one US/UK investigation team:

We were spied on, followed, our computer traffic was monitored, our notebooks stolen, they knew what we were doing. I’m not sure anyone appreciates how hard all of this was . . . the daily grind of getting a tiny concession of access or movements of goods. The SARC [Syrian Arab Red Crescent] were used as a proxy to control and spy on us and contain us.

So many controls.  And yet UN Security Council resolutions 2139 (2014), 2165 (2014), 2191 (2014) and 2258 (2015) authorized the unconditional delivery of humanitarian assistance, including medical assistance, to besieged and hard-to-reach communities countrywide.  The emphasis is mine; the wording is the UN’s.  But the Assad regime clearly called the shots and imposed the most exacting conditions on the delivery of humanitarian aid to besieged areas like the Ghouta.  The UN even deferred to the Syrian government over the identification of what constituted a siege; its mappings of besieged and ‘hard-to-reach’ areas were far more restrictive than those conducted by Siege Watch or the Syrian-American Medical Society.  Its in-country contracts had to be approved by the government, and not surprisingly many of them – individually worth tens of millions of dollars for accommodation, trucks, fuel, and cellphone service – were with businesses closely tied to the Assad regime.   As Reinoud Leenders put it, ‘the Syrian regime’s aggressive assertions of state sovereignty have locked UN aid agencies into a disturbingly submissive role.’

A report from the Syria CampaignTaking Sides – found that humanitarian aid delivered under the auspices of the UN was disproportionately directed towards areas under the direct control of the Assad regime.  Here is the distribution of aid through the World Food Programme – the largest UN agency handling food aid – shortly after the passage of UNSC 2139, revealing what John Hudson described as ‘Assad’s starvation campaign’:

The following month (April 2014) 75 per cent of food aid delivered from inside Syria went into government-controlled areas.  Two years later (April 2016) 88 per cent of food aid delivered from inside Syria went into government-controlled territory; once cross-border deliveries from Iraq, Jordan, Lebanon and Turkey were taken into account – now authorised by further UN Security Council resolutions – the (dis)proportion going into government-controlled territories fell to 72 per cent.  But by April 2017 it had increased to 82 per cent.  

Still, these raw figures conceal as much as they reveal; humanitarian aid for government-controlled areas has not been subject to the same restrictions, deletions and delays as aid for areas outside the regime’s direct control.  Convoys were far more frequent, loads were larger, and medical supplies were not removed.  The Assad regime frequently represented aid to areas under its control as both a gift from the government (through granting access to international agencies) and a gift of the government: at its highest levels, the Syrian Arab Red Crescent (a central and compulsory actor in these deliveries) is a de facto arm of the state.  There was and continues to be an undoubted need for aid throughout Syria, but according to the UN’s own figures 54 per cent of the population in need lived in government-controlled areas in 2016.  Accordingly, Taking Sides argues that 

The effective subsidy of government areas releases resources that are likely used by the government in its war effort. The UN has enabled one side in the conflict to shift more of its resources away from providing for the needs of its people and into its military campaign.

The official position was always that the UN had to comply with the Assad regime’s predilections and stipulations as a necessary price for access to the besieged areas, but David Miliband (President of the International Rescue Committee) countered that ‘the Assad regime can’t afford to kick the UN out of Damascus [because] the UN is feeding so many of [Assad’s] own people.’  

Conversely, the carefully calibrated restrictions placed by the regime on flows of goods through al-Wafideen into the Ghouta amounted to an assertion of continued control over the besieged population.  Esther Meinghaus [‘Humanitarianism in intra-state conflict: aid inequality and local governance in government and opposition-controlled areas in the Syrian war’, Third World Quarterly 37 (8) (2016) 1454-82] argues that in those areas where the regime was not able to maintain military control it exercised effective ‘humanitarian control’ by continuing to dictate the parameters within which the population lived (and died).  In consequence, like Esther, José Ciro Martinez and Brett Eng [‘The unintended consequences of emergency food aid: neutrality, sovereignty and politics in the Syrian civil war, 2012-15’, International Affairs 92 (1) (2016) 153-73; also available here] describe besieged areas like the Ghouta as spaces of exception.  They reveal a persistent attempt by the Assad regime to separate those ‘included in a juridical order and those stripped of juridical-political protections – a separation between life that is politically qualified and one that is “bare” or naked.’  But as José and Brett emphasise, actors inside the Ghouta (and outside) have repeatedly called into question the actions of the Syrian government and its allies and sought to confound them.   The political salience of those counter-strategies is itself compromised, they insist, by treating humanitarian aid as a ‘neutral’ and essentially technical matter of alleviating physical distress and deprivation – the register within which UN agencies conceive their interventions – because that is to become complicit in the reduction of besieged populations to ‘bare life’: ‘Those receiving assistance are valued strictly in terms of their biological life not their political voice’ (p. 165).

The administration of precarity

Throughout this essay I’ve written about ‘the administration of precarity’ because – following David Nally‘s wonderful example – the siege economy was administered by multiple actors whose regulations and restrictions made them responsible for delivering precarity to the besieged population.  That the Assad regime and its allies had a direct interest in doing so followed directly from their strategy of ‘surrender or starve’, and there was an elaborate web of exactions and extortions reaching from the highest levels of the state down to the foot soldiers who controlled the checkpoints and crossings.  The rebel groups were involved too, but they had a more direct interest in the subterranean smuggling economy, levying fees in cash or in kind on flows through the tunnels to boost their coffers and secure their own supporters.  But the United Nations and its agencies were also culpable in acceding to the demands of the Assad regime, allowing it to funnel most humanitarian aid to areas under its control and condemning the civilian populations in besieged areas to half-chance lives of ever increasing precarity.

Yet precarity does not mean passivity, and a ‘siege economy’ is always more than a political economy: it is also and always what E.P. Thompson would have called a moral economy.  The rebel groups in the Ghouta were chronically incapable (or uninterested) in finding common ground, and their support amongst the besieged population was uneven and variable.  As the siege wore on, protests against their exactions and impositions – and the infighting amongst them – multiplied.  For all that, many (and probably most) civilians remained opposed to the Assad regime, and we should remember too that the war emerged out of the violent response of the state to peaceful protests by ordinary people in the Ghouta and elsewhere calling for democratic reforms.  This matters because as I worked on this essay – watching the videos, reading the reports, unearthing the testimonies – I became aware of an extraordinary resilience and communal solidarity forged within the population.  I think of the ingenuity of the rooftop farmers, the fuel distillers, and the makers of gauze and medicines; the dedication of the doctors, nurses, ambulance drivers and rescue workers faced with so many grievously wounded and seriously ill people; the courage of mothers sharing blankets and what little food they had and singing songs and sharing stories as they huddled with their children in the crowded basements sheltering from the bombs and missiles (see here).

I wrote those words last night; this morning I read this moving letter from the Syria Campaign on ‘Leaving Ghouta‘:

Over the past five years, Ghouta has faced terrible violence including the sarin gas chemical attack that took the lives of hundreds in their sleep. And despite it all they have taught the world a lesson in courage and resilience. When the regime lost control of Ghouta its people built new forms of local governance and held free elections for the first time in Syria’s history. When the bombs started falling on neighbourhoods its teachers and doctors took schools and hospitals underground and ordinary residents put on white helmets and rushed to rescue their friends and neighbours. The people of Ghouta launched inspiring civil society projects, often women-led. They created new media platforms and produced award-winning photojournalism. They created alternative energy resources and introduced new farming techniques.

But after this latest, relentless onslaught, people were truly left with no choice. If they remained in Ghouta they risked being detained and tortured as the Syrian regime closed in, particularly the ones who decided to teach, treat the wounded, or post updates to Facebook. So now many are leaving behind everything they’ve ever known to go to a place that isn’t that much safer. The province of Idlib, home to more than two million, is also being struck from the air by the Syrian regime and its Russian ally.

If only the ‘international community’ had been even half the community created by these brave men and women.

To be continued

Cities under siege (I)

This is the first of a two-part post, in which I return (at last!) to a promissory note I issued last year about siege warfare in Syria.  My return is prompted by a series of reports about the catastrophic situation in Eastern Ghouta (a suburb of Damascus) and Idlib.

First, Eastern Ghouta, which has been under siege by the Syrian Arab Army and its allies since April 2013.  Most of Eastern Ghoutta was designated as one of four ‘de-escalation zones’ (see map above) under an agreement reached in May 2017, in which aerial violence and all other hostilities would be suspended for six months and humanitarian aid would be allowed across the siege lines.

But the agreement turned out to be primarily a way of killing time.  Aron Lund writes:

In September, just as the Eastern Ghouta’s de-escalation zone was finalized, the situation abruptly worsened. After ordering a halt to the already heavily restricted commercial traffic through the Wafideen crossing [see map below: more here and here], the Syrian government refused to permit any more UN aid missions.

It was a transparent attempt to stoke the humanitarian emergency in Eastern Ghouta, but this time the effect was more severe than during previous rounds of food cuts. With the rebel trading tunnels out of commission for half a year, smuggling could no longer compensate for the shortfall or bring in medicine or basic necessities like fuel, which has not entered the Ghouta since February.

Food stockpiles dwindled quickly and triggered a scramble for whatever remained available on the market, the panicky mood inflamed by suspicions that rebel-connected businessmen were hoarding goods for speculation purposes. From August to October, the already high prices inside Eastern Ghouta increased fivefold, far beyond any other region of Syria.

Air strikes (above) and artillery bombardment resumed in November and have continued, and urgent medical evacuations were denied.  Here is UN Senior Adviser Jan Egelan in December 2017:

Six months ago a very detailed evacuation plan was delivered to the government for needy cases of evacuation, on medical grounds from eastern Ghouta.  Since then, names have been added regularly and it is now, we now have a revised list of 494 names. There are among them 282 cases that need] specialized surgery, specialized treatment, specialized investigations that [they] cannot get inside. There are 73 severe cancer cases, 25 kidney failure cases and 97 heart disease cases [that are] very concerning, five acutely malnourished children that need to be evacuated, six acute mental health cases etc.

The list had to be revised because 12 patients had died while waiting for ‘a half an hour drive to hospitals in Damascus and elsewhere that stand ready to help and save lives.’  Egelan explained that ‘231 of the cases are female, 137 are children, 61 are over 65 years old.  So these are civilians, in the midst of this horrific war.’

He added:  ‘Civilians, children, no one can be a bargaining chip in some kind of tug of war, where many things are negotiated at the same time. These have a right to be evacuated and we have an obligation to evacuate them.’

Siege warfare involves not only closure of movement across the lines for those inside; it also involves opening the zone to violence from the outside.  The assault on Eastern Ghouta has provided ample evidence, but the second case is even more instructive.

And so, second, what was supposed to be the ‘de-escalation’ zone of Idlib has been converted into a ‘kill box’ (for a discussion of the term in relation to remote warfare, see here and here).  Here is Martin Chulov and Kareem Shaheen writing in the Guardian:

Russian and Syrian jets bombed towns and villages across north-west Syria on Monday, devastating civilian areas and forcing fresh waves of refugees to flee to open ground in the biggest aerial blitz on opposition-held areas since the fall of Aleppo more than a year ago.  Monitoring groups said as many as 150 airstrikes were recorded in Idlib province by Monday, with dozens more pounding up to 18 towns across the region by nightfall.  Residential areas bore the brunt of the strikes, which severely damaged at least two major hospitals, and levelled dozens of buildings in which panicked locals had taken shelter.

Refugees and locals say they fear that Idlib has been transformed into a kill box, with the international community paying scant regard to their fate, as regional powers, Russia, Turkey and Iran all vie for influence in a vital corner of the country.

These strikes were in retaliation for the downing of a Russian aircraft – in this spectacularly asymmetric war, only air-to-ground attacks are acceptable – but aerial violence against civilian infrastructure in Idlib precedes that incident.  Owdai (al Hisan) hospital in Saraqab City was hit by air strikes on 21 and 29 January, for example, and has now closed indefinitely  MSF reports that the loss of the hospital is all the more devastating because ‘medical needs in the area are expected to increase due to the massive displacement of Syrians fleeing fresh violence in Idlib’s eastern countryside and northeast Hama.’

Since then, the strikes intensified:

“The Russians are on a frenzy. They’re going mad. The shelling is ongoing throughout the day and night. The warplanes are hitting residential areas,” Hadi Abdullah, a local journalist, told Al Jazeera by phone from the town of Kafr Nabl in the northwestern Syrian province bordering Turkey…

The main hospital in Maaret al-Numan [above: this was the largest hospital in Idlib], east of Kafr Nabl, has stopped working after it was hit by air strikes, according to the civil defence – also known as the White Helmets.  “About 10 air raids hit the hospital. It was a disaster,” said Hadi, who had rushed to the scene.”The most difficult and heartbreaking scene was when the volunteers were quickly pulling the babies out of the hospital. I can’t get the image out of my head,” he recalled with a trembling voice.

‘De-escalation’ has become a prelude to its inverse.  “There is a misperception that the de-escalation areas have resulted in peace and stability,’ UN assistant secretary-general Panos Moumtsiz said today. “If anything, these have been serious escalation areas.”

With all these horrors in mind, in my second post I’ll turn to the back-story.  You can find other dimensions to the critique of siege warfare in Susan Power, ‘Siege warfare in Syria: prosecuting the starvation of civilians’, Amsterdam Law Forum 8: 2 (2016) 1-22 here or Will Todman, ‘Isolating dissent, punishing the masses: siege warfare as counterinsurgency’, Syria Studies 9 (1) (2017) 1-32.

There’s also a series of important quarterly reports from Siege Watch; these started in February 2016, and the most recent covers August-September 2017 and includes a detailed analysis of both Eastern Ghouta and Idlib.

I plan to approach the issue through one of my favourite books, Steve Graham‘s Cities under siege.  Steve’s object was what he called ‘the new military urbanism’ but the situation in Syria – and elsewhere: think Mosul in Iraq (see, for example, here: scroll down) or Israel’s endless sieges of Gaza (see, for example, here) – demonstrate the extraordinary capacity of later modern war to combine cutting-edge technology (never has that adjective been more dismally appropriate) with medieval cruelty.  There is another difference; for all Steve’s analytical passion – and empathy – the voices of those inside the cities under siege are largely silent, yet in Syria (again: and elsewhere) digital media allow us to listen to them and to witness their suffering.  More soon.

The Geographies of Sixty Minutes

One of the cardinal principles informing modern casualty evacuation is the Golden Hour.  In 1975 R. Adams Cowley, founder of Baltimore’s Shock Trauma Institute, argued that ‘the first hour after injury will largely determine a critically injured person’s chances for survival.’  It’s not a straightforward metric, and combat medical care and evacuation has been transformed since it was first proposed, but the rule of thumb is that the chances of survival are maximised if the time between traumatic injury and definitive care is kept to 60 minutes or less.

Following a fire-storm of criticism on 15 June 2009 US Secretary of Defense Robert Gates required the standard time between a call for evacuation and treatment of the critically injured to be 60 minutes or less.  For US military personnel in the Second World War the average time was 10 hours; in Korea that had been cut to 5 hours (the result of using helicopters for speedy evacuation); and in Vietnam it was already down to one hour.  The reason for Gates’s intervention was that in Afghanistan the aim was two hours…

U.S. Air Force Sgt. Daniel Fye serving on a tour in the Kandahar province of Afghanistan in April 2011. (Courtesy of Daniel Fye)

U.S. Air Force Sgt. Daniel Fye serving on a tour in the Kandahar province of Afghanistan in April 2011. (Courtesy of Daniel Fye)

The importance of those time-critical sixty minutes was no secret to the troops in the line of fire.  Here is a scene from Brian Castner‘s truly brilliant All the ways we die and kill which imagines the thoughts running through one soldier’s head – Air Force Technical Sergeant Dan Fye on his third tour of duty with Explosive Ordnance Disposal (above) – after he stepped on an IED during a clearance operation in Mushan (Panjwayi) on 27 May 2011:

They worked on Fye a long time, and the longer they worked, the more anxious Fye got about the precious minutes slipping away. “I don’t hear the bird,” he said, over and over. They wrote the time of the tourniquet application on the white headband Fye wore under his helmet. Hopkins pushed morphine into his veins.

Eventually, an eon since Hopkins arrived but only twenty-five minutes after the blast, the hyperactive thump of helo blades cutting air slowly emerged in the distance.

Fye thought it was the most wonderful sound he had ever heard. They were at the extreme limit of the NATO footprint, and so it was a sixty-kilometer flight to the main hospital at Kandahar [see map below]. If they moved quickly, Fye would just make it in the magic golden hour.

1-FO0625_KandaharMap

Castner writes that as Fye was bleeding out in the back of the helicopter, he was

‘clinging to one thought and one thought only, running in a continuous Times Square news ticker across the front of his oxygen-starved brain: One hour. If I can get back to Kandahar in one hour, I’ll live. One hour, and I’ll live. That’s what they say. You’ll make it if you can get back to the hospital in one hour.’

He made it.  The new, modernised and expanded Role 3 NATO hospital at Kandahar had opened a year earlier, and its executive officer claimed that ‘They hit our doors, they live.’

Kandahar new Role 3 2010

But Fye was lucky.  Later he learned why it had taken so long for the helicopter to arrive, and why he very nearly never made it to Kandahar at all:

Over multiple radio calls between Hopkins’s platoon and the rescue operations center, his report of “bilateral amputation” had been converted, telephone-game style, into “bilateral lacerations.” The medical operations center had actually turned the rescue mission off; helos don’t fly for scraped knees. The bird that eventually picked up Fye wasn’t even a real medevac bird. That’s why the robotic flight crew ignored him, didn’t treat his wounds as they went. They weren’t medics. The helo pilots had just been in the air and happened to overhear the radio traffic, including the original call for help. They understood the mistake and had disobeyed orders to go get Fye. If the human pilot of that bird had been less stubborn, the golden hour would have been long past by the time Fye made it to KAF, and he could well have been one of the 1 percent.

(More from Brian on medical evacuation here and here).

Even without miscommunication the logistical challenges were formidable.  In 2007, two years before Gates’ intervention, ISAF produced this map showing the medevac coverage – what Fye called the ‘NATO footprint’ – that supported that two-hour standard (I have taken this map and the following one from a report prepared by Col Dr Ingo Hartenstein for NATO/ISAF in December 2008 which is available here; scroll down):

ISAF Medevac coverage 2 hours

Like Vietnam, Afghanistan was a ‘war without fronts’ with a battlefield geometry that imposed a radically different evacuation model from the classical line of evacuation that had been established during the First World War.  Here is how Brian Turner puts it in My life as another country:

We won’t hear the battle in progress and work our way toward it as baggage trains of wounded, exhausted soldiers and civilians carrying their lives on their backs travel in the opposite direction. Our battle space – and perhaps it’s a cliché now – will occur in a 360-degree, three-dimensional environment.

More technically, here is Brigadier Martin Bricknell, who served (among many other roles) as Medical Adviser to ISAF’s Regional Command South in Kandahar in 2010:

The tactical geometry for the current operating environment is based upon security forces holding areas of ground and securing this space from opposition activity. This converts the battlefield from the conventional force-on-force linear geometry with an identifiable confrontation line to an area battlefield with multiple nodes of contested space. Thus the MEDEVAC mission is converted from a linear flow to area support, hence MEDEVAC planning is based upon a ‘range ring’ coverage with a radius of 40–60 nautical miles.

Given the available resources, a second map showed how those ‘range rings’ would contract if the Golden Hour were to be imposed over the evacuation grid:

ISAF MEDEVAC coverage allowing 1 hr from POI to surgery HARTENSTEIN

In practice, the situation was more variable than these maps imply – not least because there was a significant difference between the ways in which American and British contingents organised medical evacuation.

The US military, drawing on their experience in Vietnam, used Blackhawk or Pavehawk helicopters to get paramedics or combat medical technicians to the casualty as fast as possible:

DUST OFF Afghanistan.001

DUST OFF Afghanistan.002

The British used larger Chinook helicopters to dispatch a Medical Emergency Response Team (MERT) with a trauma surgeon onboard to the casualty close to the point of injury (POI):

MERT Afghanistan.001

The response time was usually longer but the MERT enabled advanced trauma care to begin as soon as the patient was onboard.

There has been considerable debate and disagreement about the robustness of the ‘Golden Hour’ in military trauma care and its relation to evacuation pathways: see, for example,  Jonathan Clarke and Peter Davis, ‘Medical evacuation and triage of combat casualties in Helmand Province, Afghanistan: October 2010-April 2011’, Military Medicine 171 (11) (2012) 1261-6.  But a research team has now calibrated the effects of reduced evacuation time on US casualty fatality rates (CFR) in Afghanistan between 2001 and 2014 [Russ Kotwal et al, ‘The effect of a Golden Hour policy on the morbidity and mortality of combat casualties’, JAMA Surgery 151 (1) (2016) 15-24; see also here]:

KOTWAL Case fatality rate and transport time

For 4,500 cases of US military casualties with detailed data the study showed a substantial change in the CFR following the Secretary of Defense’s mandate to evacuate casualties within 60 minutes: as the median evacuation time fell from 90 minutes to 43 minutes the CFR fell from 13.7 to 7.6; before the mandate 25 per cent of casualty evacuation missions fell within the Golden Hour, after the mandate the proportion soared to 75 per cent.

The interpretive field is a complicated one – while a significant number of casualties who would previously have died from their wounds now survived, a proportion of those who would previously have been recorded as ‘killed in action’ (KIA) none the less now ‘died of wounds’ (DOW) – and the reasons for the improvement in survival rates are also multivariate:

‘Secondary effects resulting from the mandate that contributed to achieving the mandated time included stream-lined authority and helicopter launch procedures, increased number and dispersion of Army helicopters, and the addition of Air Force helicopters to assist with the Army prehospital transport mission. As decreased time from critical injury to treatment capability was the underlying goal, personnel with increased expertise (blood transfusion protocol-trained basic medics, critical care paramedics, and critical care nurses) were trained and assigned to prehospital flights more routinely, resulting in earlier availability of blood products and other advanced care.

In addition, an increase in the number and dispersion of small but mobile forward surgical teams across the battle-field brought major surgical capability even closer to the point of injury and provided an alternative to transporting patients longer distances to large, but less mobile, civilian trauma center–equivalent [Combat Support Hospitals].’

GoldenHourFig1

These findings – together with the experience of the British MERTs – intersect with a recalibration of the Golden Hour.  The US Combat Casualty Care Research Program (CCCRP) has proposed an ‘evolved concept’ (see the figure above) that moves from a location-based protocol to a physiological one:

The program must be willing to turn the doctrine of fixed or traditional echelons of care on its side and innovate for scenarios in which Level II and III care is performed aboard transport vehicles (land-, air- or sea-based) or within local structures of opportunity. In such circumstances, field care may be prolonged, lasting for days or even weeks. Combat casualty care research with these complex scenarios in mind promises to enhance resuscitative capability for injured service personnel regardless of environment, leveraging communications networks (i.e., telementoring) and targeted resupplies of materials. In the future, CCCRP must focus on transforming the concept of the golden hour into one bound not by the time to reach traditional echelons of care or fixed facilities, but the time until enhanced resuscitative capability can be delivered to the injured troop, regardless of location or need for transport.

There are two riders to add.  First, embedded within the Golden Hour are ‘the platinum ten minutes’: the imperative to stop bleeding (which has led to the re-emergence and re-engineering of the tourniquet) and to control the casualty’s airway within 10 minutes of wounding.

Combat Medical Technician and Platinum 10 minutes.001

The second is that the speed of treatment and trauma care available to American and British soldiers is radically different from that available to Afghan soldiers and police officers.  Previously, they could rely on aeromedical evacuation by their allies.  But now most of their medical evacuations take place by land, over difficult and dangerous roads.  Last September Josh Smith reported:

Under the dim light of a single bulb, a local Afghan policeman lay severely injured, slipping in and out of consciousness. A military doctor reported to an Afghan army brigade commander that the man was unlikely to live through the night.

Injured Afghan policeman examined by Afghan Army doctor August 2015

Despite the doctor’s pleas, the commander stood firm. The army could not spare any soldiers or ambulances [below] to make the five-hour drive to a better hospital at that late hour through territory teeming with Taliban ambushes and roadside bombs.

, Nangarhar province, August 2015

The lack of speedy evacuation is a tragically common problem for the rising number of Afghan police and soldiers being injured on the battlefields of Afghanistan. U.S. advisers have worked to help close the capability gap, but mostly behind the scenes, far from the battlefields where many Afghan troops say they increasingly feel alone.

Although the American forces still stationed in the country have conducted more than 200 airstrikes since their combat mission was declared over at the end of 2014, as of July, U.S. military aircraft had not flown a single conventional medical evacuation mission, according to data released by the U.S. Air Force Central Command.

U.S. military officials say they haven’t flown evacuation missions because they haven’t been asked. Also, there are far fewer American resources available for such missions now.

The difference shows up in the ratios of those killed and those who survived their wounds.

About 2,363 Americans have died in Afghanistan, with a little more than 20,000 wounded, a ratio of roughly 1-to-10.  In the first half of 2015 alone, 4,302 Afghan soldiers and police were killed in action and 8,009 more were wounded, a ratio of about 1-to-2.

Even where aircraft and trained medical technicians are available, Jeff Schogol found that the Afghan capability falls well outside the Golden Hour:

The time it takes to fly patients to hospitals varies depending on the point of injury, but it can take between 90 minutes and two and a half hours to fly an aeromedical evacuation mission in a C-208, plus one hour to transfer patients from Kandahar to Kabul in a C-130.

Injured ANA soldier lifted from Afghan Air Force C-27A

And the situation for Afghan civilians – as I explored in detail in ‘The prosthetics of military violence‘ – is still worse.

This is not a problem confined to Afghanistan: think of how the possibility of the Golden Hour recedes in urban combat zones subjected to artillery fire and bombing – the difficulties faced by first responders in Gaza or in the ravaged, rubble-strewn towns and cities of Syria (see also Annie Sparrow‘s report here).

 A Syrian youth walks past a destroyed ambulance in the Saif al-Dawla district of the war-torn northern city of Aleppo on January 12, 2013. An accident and emergency centre in Aleppo uses an abandoned supermarket to conceal a fleet of 16 ambulances, just 10 of which are in working order and are driven by 22 staff members. AFP PHOTO/JM LOPEZ/ (Getty Images)


A Syrian youth walks past a destroyed ambulance in the Saif al-Dawla district of the war-torn northern city of Aleppo on January 12, 2013. An accident and emergency centre in Aleppo uses an abandoned supermarket to conceal a fleet of 16 ambulances, just 10 of which are in working order and are driven by 22 staff members. AFP PHOTO/JM LOPEZ/ (Getty Images)

And there is no guarantee of safety even once casualties reach hospital since the principle of medical neutrality is now being routinely and systematically violated.

Divisions of Life

Journeys from No Man's Land.001

My main presentation at the AAG in Chicago was part of a session organised by Noam Leshem and Alasdair Pinkerton on Remnants of No Man’s Land: history, theory and excess (more on their larger project here).  Here is an extended summary of what I had to say, together with some of my slides, but bear in mind that this all had to be done in 20 minutes so there wasn’t much room for nuance.  Neither was there time to discuss civilian entanglements, both volunteers and victims, nor the sick: the presentation focuses on the wounded, even though the problems of trench foot, ‘trench flu’, and a host of other diseases were also extremely important.  They do all receive attention in the larger project from which this is extracted.  One last, geographical qualification: my discussion is limited to the evacuation of British and imperial troops from the Western Front.

My starting-point was the strange disappearance of the wounded from the field of battle.  As John Keegan wrote in The Face of Battle, in most histories the ‘wounded apparently dematerialize as soon as they are struck down’; he was writing specifically about General Sir William Napier’s account of the battle of Albuera in 1811, but the point is a sharp one that can be enlisted as part of a more general critique of military history.

In the case of the First World War, the emphasis on those who lost their lives – on the dead not the wounded – derives not only from the sheer scale of the slaughter but also from the enduring landscape of memorialisation and commemoration.  When John McCrae‘s elegaic poem ‘In Flanders Fields’ is recited every Remembrance Day – ‘In Flanders fields the poppies grow, between the crosses, row on row’ – it is all too easy to forget that he wrote those lines not only to commemorate the death of a close friend but that he did so at Essex Farm Advanced Dressing Station:

Journeys from No Man's Land.003

Journeys from No Man's Land.004

What lies behind those haunting lines – and that medical outpost – is a vast canvas of wounded men, which Christopher Nevinson captured as ‘The Harvest of Battle’ (below).  The dead occupy the foreground, but behind them is the endless, moving panorama of the wounded whose precarious journeys took most of them far beyond ‘No Man’s Land’.

(c) IWM (Imperial War Museums); Supplied by The Public Catalogue Foundation

In fact, as Emily Mayhew reminds us, ‘being wounded was one of the most common experiences of the Great War’: on the Western Front, she writes, ‘almost every other British soldier could expect to become a casualty’.

But, perhaps not surprisingly, for the first six months of the war the British Expeditionary Force was unprepared for the scale of casualties, and even with the help of civilian volunteers and aid societies – Nevinson briefly served as a medical orderly with the Friends Ambulance Unit, for example – the remarkably long time it took to evacuate the wounded combined with the perilous nature of their improvised journeys to increase the mortality rate.

Journeys from No Man's Land.007

Journeys from No Man's Land.008

And so what Mark Harrison called the military-medical machine had to be speeded up – and moved closer to the field of battle.

Journeys from No Man's Land.016

Before every major offensive elaborate plans for medical support were prepared: casualties were ‘cleared’ down the line as far and as fast as possible to make room for the newly injured, casualty clearing hospitals moved closer to the line, ambulances and stretcher-bearers made ready, and ‘down’ trenches designated for the efficient removal of the wounded (below).

Journeys from No Man's Land.017

Soldiers wounded in ‘No Man’s Land’ – a term never recognised by the British General Staff, who insisted that they controlled the field of battle right up to the enemy front lines – were often immobilised and disoriented; some crawled into shell holes, seeking refuge below the field of fire, but it could take hours, even days before they were discovered and rescued (I’ll devote a later post to a detailed discussion of some of those cases).

Journeys from No Man's Land.022

Journeys from No Man's Land.023

Sometimes their mates came to their rescue, sometimes the regimental stretcher bearers.  But they too had to find their way through a dangerous and devastated terrain, often with no landmarks to guide them and on occasion made virtually impassable by the thick, cloying mud that was always –  disconcertingly – much more than mud.

Journeys from No Man's Land.024

By now, they were in the care of the Royal Army Medical Corps’s Field Ambulance, and their first objective was an Advanced Dressing Station.  

Journeys from No Man's Land.026

Treatment at ADS 1917

Those that needed anything beyond simple treatment or emergency surgery were sent on by horse or motor ambulance to a Casualty Clearing Station (a field hospital).

Journeys from No Man's Land.027

Journeys from No Man's Land.030

It was usually here that their first surgeries took place.  The journalist Philip Gibb was shown around a CCS at Corbie and the experience haunted him for years:

After a visit there I had to wipe cold sweat from my forehead, and found myself trembling in a queer way. It was the medical officer—a colonel—who called it that name. “This is our Butcher’s Shop,” he said, cheerily. “Come and have a look at my cases. They’re the worst possible; stomach wounds, compound fractures, and all that. We lop off limbs here all day long, and all night. You’ve no idea!”

CCS Corbie

I had no idea, but I did not wish to see its reality. The M.O. could not understand my reluctance to see his show. He put it down to my desire to save his time—and explained that he was going the rounds and would take it as a favor if I would walk with him. I yielded weakly, and cursed myself for not taking to flight. Yet, I argued, what men are brave enough to suffer I ought to have the courage to see… I saw and sickened. These were the victims of “Victory” and the red fruit of war’s harvest-fields. A new batch of “cases” had just arrived. More were being brought in on stretchers. They were laid down in rows on the floor-boards. The colonel bent down to some of them and drew their blankets back, and now and then felt a man’s pulse. Most of them were unconscious, breathing with the hard snuffle of dying men. Their skin was already darkening to the death-tint, which is not white. They were all plastered with a gray clay and this mud on their faces was, in some cases, mixed with thick clots of blood, making a hard incrustation from scalp to chin. “That fellow won’t last long,” said the M. O., rising from a stretcher. “Hardly a heart-beat left in him. Sure to die on the operating-table if he gets as far as that… Step back against the wall a minute, will you?” We flattened ourselves against the passage wall while ambulance-men brought in a line of stretchers. No sound came from most of those bundles under the blankets, but from one came a long, agonizing wail, the cry of an animal in torture. “Come through the wards,” said the colonel. “They’re pretty bright, though we could do with more space and light.” In one long, narrow room there were about thirty beds, and in each bed lay a young British soldier, or part of a young British soldier. There was not much left of one of them. Both his legs had been amputated to the thigh, and both his arms to the shoulder-blades. “Remarkable man, that,” said the colonel. “Simply refuses to die. His vitality is so tremendous that it is putting up a terrific fight against mortality… There’s another case of the same kind; one leg gone and the other going, and one arm. Deliberate refusal to give in. ‘You’re not going to kill me, doctor,’ he said. ‘I’m going to stick it through.’ What spirit, eh?”…

“Bound to come off,” said the doctor as we passed to another bed. “Gas gangrene. That’s the thing that does us down.” In bed after bed I saw men of ours, very young men, who had been lopped of limbs a few hours ago or a few minutes, some of them unconscious, some of them strangely and terribly conscious, with a look in their eyes as though staring at the death which sat near to them, and edged nearer. “Yes,” said the M. O., “they look bad, some of ’em, but youth is on their side. I dare say seventy-five per cent. will get through. If it wasn’t for gas gangrene—“

He jerked his head to a boy sitting up in bed, smiling at the nurse who felt his pulse. “Looks fairly fit after the knife, doesn’t he? But we shall have to cut higher up. The gas again. I’m afraid he’ll be dead before to-morrow. Come into the operating-theater. It’s very well equipped.”

By now the bureaucratic machine had been activated: labels had been attached to the wounded and field medical cards (‘tickets’) completed; telegrams had been sent to advise families, and nurses had often written letters home on their patients’ behalf.

Journeys from No Man's Land.035Journeys from No Man's Land.036

The next stage for the most seriously wounded was evacuation by ambulance train to  a base hospital on the French coast.  There was a considerable bureaucracy involved in planning these movements, but for all the neatness and symmetry of the organisational diagrams – part of Clausewitz‘s ‘paper war’ – there were all sorts of delays.

Journeys from No Man's Land.038

Journeys from No Man's Land.040

Priority was given to trains rushing reinforcements, supplies and ammunition to the front, and ambulance trains were frequently marooned in sidings waiting for them to pass so that journeys that might have taken hours could take days.  It was not uncommon for an ambulance train to arrive at a base hospital to find that there was little or no room for new patients and all but the most grievous cases had to travel on to the next.

Journeys from No Man's Land.041

Journeys from No Man's Land.042

Many patients were treated at the base hospitals, but those with more serious wounds were evacuated by hospital ship to Britain.  This stage of the journey was no less dangerous than the previous one: as the war continued, there was an increasing danger of mines and submarines in the Channel.

Journeys from No Man's Land.043

Journeys from No Man's Land.044

Journeys from No Man's Land.046

A distinctive  geography of the wounded emerged.  If they arrived at Southampton, the most critical cases were taken by train straight to the Royal Victoria Military Hospital at Netley, which treated as many as 50,000 patients during the war.  According to Lyn McDonald,

 ‘Those who could not be accommodated, and those who were seriously wounded but likely to survive a longer journey, were sent on by train to Birmingham, Bristol, Exeter, Leicester, Norwich and Plymouth.  But seven out of every ten hospital trains were directed to London, and during the first days of the Somme they rolled in almost every hour to Charing Cross and Paddington stations.’

Journeys from No Man's Land.047

Journeys from No Man's Land.048

This is, of course, a highly abbreviated account of the casualty evacuation chain, and in the larger project from which this is derived I provide many more details.  But I think I’ve said enough to show that the chain was, in effect, a production line with an elaborate division of labour (again, in the larger study I show how class – or more accurately, rank – gender and race segmented the chain in various ways).  Indeed, in The Politics of Wounds Ana Carden-Coyne argues that what she calls ‘the Taylorist approach in modern war’ – and remember that this was industrial war on the grand (guignol) scale – ‘was particularly evident in the assembly-line style of evacuation and triage.’

Journeys from No Man's Land.012

This prompts two concluding observations.

First, what was the instrumental logic that animated the evacuation chain?  After all, it was an expensive undertaking, as Arthur Empey (himself wounded on the Western Front) realised in this re-calculation of the chain:

It may sound heartless and inhuman, but it is a fact, nevertheless, that from a military stand-point it is better for a man to be killed than wounded.

EmpeyIf a man is killed he is buried, and the responsibility of the government ceases, excepting for the fact that his people receive a pension. But if a man is wounded it takes three men from the firing line, the wounded man and two men to carry him to the rear to the advanced first-aid post. Here he is attended by a doctor, perhaps assisted by two R.A.M.C. men. Then he is put into a motor ambulance, manned by a crew of two or three. At the field hospital, where he generally goes under an anaesthetic, either to have his wounds cleaned or to be operated on, he requires the services of about three to five persons. From this point another ambulance ride impresses more men in his service, and then at the ambulance train, another corps of doctors, R.A.M.C. men, Red Cross nurses, and the train’s crew. From the train he enters the base hospital or Casualty Clearing Station, where a good-sized corps of doctors, nurses, etc., are kept busy. Another ambulance journey is next in order — this time to the hospital ship. He crosses the Channel, arrives in Blighty — more ambulances and perhaps a ride for five hours on an English Red Cross train with its crew of Red Cross workers, and at last he reaches the hospital. Generally he stays from two to six months, or longer, in this hospital. From here he is sent to a convalescent home for six weeks.

If by wounds he is unfitted for further service, he is discharged, given a pension, or committed to a Soldiers’ Home for the rest of his life, — and still the expense piles up. When you realize that all the ambulances, trains, and ships, not to mention the man-power, used in transporting a wounded man, could be used for supplies, ammunition, and reinforcements for the troops at the front, it will not appear strange that from a strictly military standpoint, a dead man is sometimes better than a live one (if wounded).

Hence, for example, the orders recorded by A.M. Burrage:

The instructions given to stretcher-bearers are rather harsh. “ If you find two men wounded, and can take only one away, take away the one more likely to make a fit soldier again.” Therefore the one more urgently in need of attention must be left to die, because he would walk with a limp and would never again be able to carry a pack. Sound business, of course, but just a little hard.

Kate Luard captured another dimension of this when she wrote in January 1915:

‘The ambulance trains do so much bringing the British Army from the field that I hope some other  trains are busy bringing the British Army to the field, or there can’t be many left in the field…’

And Emily Mayhew provides this bleak vignette from a medical orderly that captures the seemingly insatiable drive of industrial war:

An ordinary train, similar to the one that had brought him to the front, was at one end unloading reinforcements, while at the other end it was filling up with wounded men.

The logic, then, was one of ‘salvage’; four out of every five men wounded on the Western Front were returned to the fighting, which was the over-riding objective of the military-medical machine.

Journeys from No Man's Land.055

Second, the division of labour was also a division of life: the dead from the wounded, the dying from the ‘salvageable’, and the wounded from the unwounded or yet-to-be-wounded.  The last was not the least.  For breaching that separation could have the most unsettling consequences of all:

Journeys from No Man's Land.057

Journeys from No Man's Land.058

 ***

What started me on this journey was Emily Mayhew‘s brilliantly conceived Wounded and an excellent series of articles by Martin Bricknell in the Journal of the Royal Army Medical Corps: see in particular here.

You can also find more on the casualty evacuation chain from the Western Front at Beyond the Trenches here and here, the Long, Long Trail here, the Medical Front here, and the Royal Army Medical Corps site here.

My larger project examines the evacuation of casualties, combatant and civilian, from four combat zones 1914-2014: the Western Front during the First World War, the deserts of North Africa during the Second World War, Vietnam, and Afghanistan.

Survivable life

Just back from St Andrews – the video of the Neil Smith Lecture will be available online shortly, and I’ll post a notice when it’s ready – and so much to catch up on it’s not easy to work out where to start.

THEY-WERE-SOLDIERS_by-Ann-Jones_72

But this is as good a place as any: Ann Jones‘s new book, They were soldiers: how the wounded return from America’s wars (Haymarket, 2013):

After the American invasion of Afghanistan in 2001, Ann Jones spent a good part of a decade there working with Afghan civilians—especially women—and writing about the impact of war on their lives: the subject of Kabul in Winter (2006). That book revealed the yawning chasm between America’s promises to Afghans and its actual performance in the country. Meanwhile, Jones was pondering another evident contradiction: between the U.S. military’s optimistic progress reports to Americans and its costly, clueless failures in Afghanistan as well as Iraq. In 2010-2011, she decided to see for herself what that “progress” in Afghanistan was costing American soldiers. She borrowed some body armor and embedded with U.S. troops. On forward operating bases she saw the row of photographs of “fallen” soldiers hung on the headquarters’ wall lengthen day by day.

At the trauma hospital at Bagram Air Base she watched the grievously wounded carried from medevac helicopters to the emergency room and witnessed the toll that life-saving surgeries took on the doctors who performed them. She accompanied the wounded on medevac flights from Bagram to Landstuhl Regional Medical Center in Germany, then on to Walter Reed Hospital in Washington, and finally—for those who made it—back to all-American homes where, often enough, more troubles followed: violence against wives, girlfriends, children, and fellow soldiers; Big Pharma-induced drug addiction; murder, suicide, and the terrible sorrow of caretaker moms and dads who don’t know what happened to their kids. They Were Soldiers is a powerful account of how official American promises—this time to “Support Our Troops”—fall victim to the true costs of war.

Medevac

This dovetails perfectly with what I hope will be my new research project on caring for those wounded by war – combatants and civilians – between 1914 and 2014 and their precarious journeys away from the killing zones (see DOWNLOADS tab and scroll down).  As I’ve noted before, much of the critical commentary on modern war has been preoccupied with those killed – which is of course important – but the other casualties of war have all too often been marginalised.  It’s high time to supplement inquiries into what Judith Butler calls the constitution of  a ‘grievable life’ with others into the constitution of a ‘survivable life’.

Hence the vital importance of Ann’s book.  There’s an interview with Amy Goodman at Democracy Now here, and another with Truthout here, in which she deftly rejects the lazy politics in which the left supposedly cares only for ‘their’ civilians while the right cares for ‘our’ troops:

We worry – if at all – about how vets are treated when they return because of our mistaken notion that Vietnam vets suffered mightily from not being greeted as heroes. What Vietnam veterans truly suffered from was not their reception, but the war. That fact we tend to forget. Consequently, we think we can resolve all the possible nasty consequences of war by waving flags at airports as troops return. The deeper problem is that none of these veterans of the wars of choice in Iraq and Afghanistan – not one of them – should ever have been sent to war. But without a draft that can potentially strike any family in the country, those who have no fear that a family member may be compelled to serve are free to ignore the whole political and public relations process by which leaders drag the country into war and carry it on. War can be left to a supposedly “all volunteer” standing army – those poor kids with no job options or a shot at college – which is precisely what the founding fathers warned against, believing that a standing army would be used by autocrats to destroy democracy. That volunteer army, of course, is shadowed by a larger privatized for-profit army of mercenary contractors. The standing army of the poor and patriotic is alienated from the general public and left at the mercy of the president. Our recent presidents and their cronies, who hold a nearly unblemished record of evading military service, have thrown kids into war with an enthusiasm undampened by any real knowledge of what war is, while the most influential segments of the general public, feeling both grateful and guilty that their kids are safe, make no effort to restrain those war-loving leaders.

You can read an extract from They were soldiers, with a very helpful prefatory note from Nick Turse, at TomDispatch here:

In 2010, I began to follow U.S. soldiers down a long trail of waste and sorrow that led from the battle spaces of Afghanistan to the emergency room of the trauma hospital at Bagram Air Base, where their catastrophic wounds were surgically treated and their condition stabilized.  Then I accompanied some of them by cargo plane to Ramstein Air Base in Germany for more surgeries at Landstuhl Regional Medical Center, or LRMC (pronounced Larm-See), the largest American hospital outside the United States.

Once stabilized again, those critical patients who survived would be taken by ambulance a short distance back to Ramstein, where a C-17 waited to fly them across the Atlantic to Dover Air Base in Delaware. There, tall, multilayered ambulances awaited the wounded for the last leg of their many-thousand-mile journey to Walter Reed Army Medical Center in Washington D.C. or the Naval Hospital at Bethesda, Maryland, where, depending upon their injuries, they might remain for a year or two, or more.

Now, we are in Germany, halfway home.  This evening, the ambulance from LRMC heading for the flight line at Ramstein will be full of critical-care patients, so I leave the hospital early and board the plane to watch the medical teams bring them aboard.  They’ve done this drill many times a week since the start of the Afghan War.  They are practiced, efficient, and fast, and so we are soon in the air again. This time, with a full load.

 Two rows of double bunks flank an aisle down the center of the C-17, all occupied by men tucked under homemade patchwork quilts emblazoned with flags and eagles, the handiwork of patriotic American women. Along the walls of the fuselage, on straight-backed seats of nylon mesh, sit the ambulatory casualities from the Contingency Aeromedical Staging Facility (CASF), the holding ward for noncritical patients just off the flight line at Ramstein.
At the back of the plane, slung between stanchions, are four litters with critical care patients, and there among them is the same three-man CCAT (Critical Care Air Transport) team I accompanied on the flight from Afghanistan. They’ve been back and forth to Bagram again since then, but here they are in fresh brown insulated coveralls, clean shaven, calm, cordial, the doctor busy making notes on a clipboard, the nurse and the respiratory therapist checking the monitors and machines on the SMEEDs. (A SMEED, or Special Medical Emergency Evacuation Device, is a raised aluminum table affixed to a patient’s gurney.) Designed to bridge the patient’s lower legs, a SMEED is now often used in the evacuation of soldiers who don’t have any.
Here again is Marine Sergeant Wilkins, just as he was on the flight from Afghanistan: unconscious, sedated, intubated, and encased in a vacuum spine board. The doctor tells me that the staff at LRMC removed Wilkins’s breathing tube, but they had to put it back. He remains in cold storage, like some pod-person in a sci-fi film. You can hardly see him in there, inside the black plastic pod. You can’t determine if he is alive or dead without looking at the little needles on the dials of the machines on the SMEED. Are they wavering? Hard to tell.

They were soldiers is available as an e-book if, like me, you can’t wait.