‘The Bomb and Siege Routine’

I’ve been on the road – I’m in London now for more archival work at the Wellcome, after a wonderful conference on “Drone imaginaries” at Odense – but I hope to post the next essay in my series on siege warfare in Syria shortly.  It will address medical care under siege – a continuation and extension of my wider work on ‘surgical strikes’ on hospitals and medical facilities (see for example here: more under the GUIDE tab) – but in the interim here is a short post from Jonathan Whittall at Médecins Sans Frontières (MSF Analysis; also at al Jazeera here) on the ‘bomb and siege routine’:

Medicine and medical workers have also been sucked into the violence. This can be seen in the attempts by the Syrian government to control the provision of healthcare in opposition-held areas by denying humanitarian access, threatening or arresting medical staff, and damaging or destroying medical infrastructure.

Early on in the conflict, medical facilities went underground, forming the beginning of a network of field hospitals such as the ones I visited in Homs. The international backers of the Syrian armed opposition on their part imposed stringent sanctions on the Syrian government which contributed to the decline of the government healthcare system.

As the war raged on, we saw indiscriminate bombing and shelling that did not differentiate between civilian and military targets. In some cases, civilians were considered military targets based on the fact that they had remained in areas controlled by groups designated as “terrorist”.

Hospitals have regularly been hit. This is the new norm. We no longer know if they are struck accidentally or intentionally or destroyed as part of a general rampage of violence. Either way, the infrastructure that sustains life is being eliminated….

From Syria to Iraq and from Yemen to Gaza, the armies and their backers use the trump card of the “fight against terrorism” as the ultimate justification for any atrocities committed against civilian populations under siege.

Indiscriminate bombing is never acceptable, no matter who the enemy is. Nor is targeting civilians and civilian infrastructure. Humanitarian supplies must always be exempt from the military tactic of siege.

The wounded and civilians wishing to escape the violence must always be allowed safe passage. The civilians who stay behind do not become legitimate targets. Providing treatment to patients – both civilians and wounded combatants alike – is never an act of “terrorism”, nor is it a form of support for “terrorism”. It is a legally protected act of humanity.

Bombs, bunkers and borders

Here is the first of a series of updates on Syria, this one identifying recent work on attacks on hospitals and health care which I’ve been reading while I turn my previous posts into a long-form essay (see ‘Your turn, doctor‘ and ‘The Death of the Clinic‘).

First, some context.  Human Rights Watch has joined a chorus of NGOs documenting attacks on hospitals and health care around the world.  On 24 May HRW issued this bleak statement:

Deadly attacks on hospitals and medical workers in conflicts around the world remain uninvestigated and unpunished a year after the United Nations Security Council called for greater action, Human Rights Watch said today.

On May 25, 2017, UN Secretary-General Antonio Guterres is scheduled to brief the Security Council on the implementation of Resolution 2286, which condemned wartime attacks on health facilities and urged governments to act against those responsible. Guterres should commit to alerting the Security Council of all future attacks on healthcare facilities on an ongoing rather than annual basis.

“Attacks on hospitals challenge the very foundation of the laws of war, and are unlikely to stop as long as those responsible for the attacks can get away with them,” said Bruno Stagno-Ugarte, deputy executive director for advocacy at Human Rights Watch. “Attacks on hospitals are especially insidious, because when you destroy a hospital and kill its health workers, you’re also risking the lives of those who will need their care in the future.”

The statement continues:

International humanitarian law, also known as the laws of war, prohibits attacks on health facilities and medical workers. To assess accountability measures undertaken for such attacks, Human Rights Watch reviewed 25 major attacks on health facilities between 2013 and 2016 in 10 countries [see map above]. For 20 of the incidents, no publicly available information indicates that investigations took place. In many cases, authorities did not respond to requests for information about the status of investigations. Investigations into the remaining five were seriously flawed…

No one appears to have faced criminal charges for their role in any of these attacks, at least 16 of which may have constituted war crimes. The attacks involved military forces or armed groups from Afghanistan, Central African Republic, Iraq, Israel, Libya, Russia, Saudi Arabia, South Sudan, Sudan, Syria, Ukraine, and the United States.

More here.

The World Health Organisation reached similar conclusions in its report of 17 May 2017:

Alexandra Sifferlin‘s commentary for Time drew attention to the importance of attacks on medical facilities in Syria:

In a 48-hour period in November, warplanes bombed five hospitals in Syria, leaving Aleppo’s rebel-controlled section without a functioning hospital. The loss of the Aleppo facilities — which had been handling more than 1,500 major surgeries each month — was just one hit in a series of escalating attacks on health care workers in 2016, the World Health Organization (WHO) reported on Friday.

Violent attacks on hospitals and health workers “continue with alarming frequency,” the WHO said in its new report. In 2016, there were 302 violent attacks, which is about an 18% increase from the prior year, according to new data. The violence — 74% was in the form of bombings — occurred in 20 countries, but it was driven by relentless strikes on health facilities in Syria, which the WHO has previously condemned. Across the globe, the 302 attacks last year resulted in 372 deaths and 491 injuries…

After the spate of attacks on Syrian hospitals last November, the WHO reported that three of the bombed hospitals in Aleppo had been providing over 10,000 consultations every month. Two other bombed hospitals in the city of Idleb were providing similar levels of care, including 600 infant deliveries. One of the two hospitals in Idleb was a primary referral hospital for emergency childbirth care.

“The attack…is an outrage that puts many more lives in danger in Syria and deprives the most vulnerable – including children and pregnant women – of their right to health services, just at the time when they need them most,” the WHO said.

The WHO has also provided a series of reports on attacks on hospitals and health care in Syria; here is its summary for last month:

But the WHO’s role in the conflict in Syria has been sharply criticised by Annie Sparrow, who has accused it of becoming a de facto apologist for the Assad regime.  Writing in Middle East Eye earlier this year, she said:

For years now, the World Health Organisation (WHO) has been fiddling while Syria burns, bleeds and starves. Despite WHO Syria having spent hundreds of millions of dollars since the conflict began in March 2011, public health in Syria has gone from troubling in 2011 to catastrophic now…

Yet WHO Syria has been anything but an impartial agency serving the needy. As can be seen by a speech made by Elizabeth Hoff, WHO’s representative to Syria, to the UN Security Council (UNSC) on 19 November 2016, WHO has prioritised warm relations with the Syrian government over meeting the most acute needs of the Syrian people.

Annie singles out three particularly problematic issues.

  • She claims that the WHO parrots the Assad regime’s claim that before the conflict its vaccination programmes had covered 95 per cent of the population (or better), whereas she insists that vaccinations had been withheld from children ‘in areas considered politically unsympathetic, such as the provinces of Idlib, western Aleppo, and Deir Ezzor.’  On her reading, in consequence, the re-emergence of (for example) polio ‘is consistent with pre-existing low immunisation rates and the vulnerability of Syrian children living in government-shunned areas.’
  • It was not until 2016 that the WHO reported attacks on hospitals at all, and when its representative condemned ‘repeated attacks on healthcare facilities in Syria’ she failed to note that the vast majority of those attacks were carried out by the Syrian Arab Air Force and its Russian ally.  The geography of deprivation was erased: ‘It is only in opposition-held areas that healthcare is compromised because of the damage and destruction resulting from air strikes by pro-government forces.’
  • Those corpo-materialities – an elemental human geography, so to say – did emerge when the WHO accused the Assad regime of of ‘withholding approval for the delivery of surgical and medical supplies to “hard-to-reach” and “besieged” locations.’  But Annie objects to these ‘politically neutral terms’ because they are ‘euphemisms for opposition-controlled territory, and so [avoid] highlighting the political dimension of the aid blockages, or the responsibility of the government for 98 percent of the more than one million people forced to live in an area under siege.’

You can read WHO’s (I think highly selective) response here.

Earlier this month 13 Syrian medical organisations combined with the Syria Campaign to document how attacks on hospitals have driven hospitals and health facilities underground (I described this process – and the attacks on the Cave Hospital and the underground M10 hospital in Aleppo – in ‘Your turn, doctor‘).  In Saving Lives Underground, they write:

Health facilities in Syria are systematically targeted on a scale unprecedented in modern history.

There have been over 454 attacks on hospitals in the last six years, with 91% of the attacks perpetrated by the Assad government and Russia. During the last six months of 2016, the rate of attacks on healthcare increased dramatically. Most recently, in April 2017 alone, there were 25 attacks on medical facilities, or one attack every 29 hours.

While the international community fails to protect Syrian medics from systematic aerial attacks on their hospitals, Syrians have developed an entire underground system to help protect patients and medical colleagues as best they can. The fortification of medical facilities is now considered a standard practice in Syria. Field hospitals have been driven underground, into basements, fortified with sandbags and cement walls, and into caves. These facilities have saved the lives of countless health workers and patients, preserved critical donor-funded equipment, and helped prevent displacement by providing communities with emergency care.

But all this comes at a cost:

Donors often see the reinforcement and building of underground medical facilities exclusively as long-term aid, or development work. However, as the Syria crisis is classified as a protracted emergency conflict, medical organizations do not currently have access to such long-term funds.

Budget lines for the emergency funding they receive can include “protection” work, but infrastructure building, even for protective purposes, often falls outside of their mandate. The divide between emergency humanitarian and development funding is creating a gap for projects that bridge the two, like protective measures for hospitals in Syria.

For this reason, as Emma Beals reported in the Guardian, many projects have resorted to crowdfunding:

The latest underground medical project seeking crowdfunding to complete building works is the Avicenna women and children’s hospital in Idlib City, championed by Khaled al-Milaji, head of the Sustainable International Medical Relief Organisation.

Al-Milaji is working to raise money with colleagues from Brown University in the US, where he studied until extreme security vetting – the Trump administration’s “Muslim ban” – prevented him re-entering the country after a holiday in Turkey.

He has instead turned his attention to building reinforced underground levels of the hospital, sourcing private donations to meet the shortfall between donor funding and actual costs…

Crowdfunding was an essential part of building the children’s Hope hospital, near Jarabulus in northern Syria. The project is run by doctors from eastern Aleppo, who were evacuated from the city in December after it was besieged for nearly six months amid a heavy military campaign. Doctors worked with the People’s Convoy, which transported vital medical supplies from London to southern Turkey as well as raising funds to build the hospital, which opened in April. More than 4,800 single donations raised the building costs, with enough left over to run the hospital for six months.

Saving Lives Underground distinguishes basement hospitals (the most common response to aerial attack by aircraft or shelling: 66 per cent of fortified hospitals fall into this category; the average cost is usually around $80–175,000, though more elaborate rehabilitation and repurposing can run up to $1 million); cave hospitals (‘the more effective protection model’ – though there are no guarantees – which accounts for around 4 per cent of fortified hospitals and which typically cost around $200–800,000) and purpose-built underground hospitals (two per cent of the total; these can cost from $800,000 to $1,500,000).

It’s chilling to think that hospitals have to be fortified and concealed in these ways: but even more disturbing, the report finds that 47 per cent of hospitals in these vulnerable areas have no fortification at all.

Seriously ill or wounded patients trapped inside besieged areas have few choices: medical facilities are degraded and often makeshift; access to vital medical supplies continues to be capriciously controlled and often denied; and attempts to evacuate them depend on short-lived ceasefires and deals (or bribes).  In Aleppo control of the Castello Road determined whether ambulances could successfully run the gauntlet from eastern Aleppo either west to hospitals in Reyhanli in Turkey or out to the Bab-al Salama Hospital in northern Aleppo and then across the border to state-run hospitals in Kilis: but in the absence of a formal agreement this was often a journey of last resort.

A victim of a barrel bomb attack in Aleppo is helped into a Turkish ambulance on call at the Bab al Salama Hospital near the Turkish border.

In October 2016 there were repeated attempts to broker medical evacuations from eastern Aleppo; eventually an agreement was reached, but the planned evacuations were stalled and then abandoned.  In December a new ‘humanitarian pause’ agreed with Russia and the Syrian government allowed more than 100 ambulances to be deployed by the Red Cross and the Red Crescent from Turkey; 200 critical patients were ferried from eastern Aleppo to hospitals in rural Aleppo, Idlib or Turkey – but the mission was abruptly terminated 24 hours after it had started.

The sick and injured have continued to make precarious journeys to hospitals in Turkey (Bab al-Hawa, Kilis, Reyhanli and other towns along the  border: see here, here and here), and also Jordan (in Ramtha and Amman, and in the Zaatari refugee camp: see here and here), Lebanon (in Beirut, Tripoli and clinics in the Bekaa Valley), and even Israel (trekking across the Golan Heights into Northern Israel: see here, herehere and especially here).

But there are no guarantees; travelling within Syria is dangerous and debilitating for patients, and access to hospitals outside Syria is frequently disrupted by border closures (which in turn can thrust the desperate into the hands of smugglers).  In March 2016, for example, Amnesty International reported:

 Since 2012 Jordan has imposed increasing restrictions on access for Syrians attempting to enter the country through formal and informal border crossings. It has made an exception for Syrians with war-related injuries.  However, Amnesty International has gathered information from humanitarian workers and family members of Syrian refugees with critical injuries being denied entry to Jordan for medical care, suggesting the exceptional criteria for entry on emergency medical grounds is inconsistently applied. This has led to refugees with critical injuries being returned to field hospitals in Syria, which are under attack on a regular basis, and to some people dying at the border.

In June Jordan closed the border, after an IS car bomb killed seven of its soldiers, and by December MSF had been forced to close its clinic at the Zaatari camp, which had provided post-operative care for casualties brought in from Dara’a.

Tens of thousands of refugees are now trapped in a vast, informal encampment (see image above) between two desert berms in a sort of ‘no man’s land‘ between Syria and Jordan.  From there Jordanian troops transport selected patients to a UN clinic, located across the border in a sealed military zone – ‘and then take them back again to the checkpoint after they are treated.’

(For the image above, and a commentary by MSF’s Jason Cone, see here).

For patients who do manage to make it across any of these borders, it’s far from easy for doctors to recover their medical history – as the note below, pinned to an unconscious patient who was admitted to the Ziv Medical Center in Safed implies – and in the case of Syria (as in Iraq) everything is further complicated by a fraught politics of the wound.

Here, for example, is Professor Ghassan Abu-Sitta, head of plastic and reconstructive surgery at the medical centre in Beirut, talking earlier this month with Robert Fisk:

In Iraq, patients wounded in Saddam’s wars were initially treated as heroes – they had fought for their country against non-Arab Iran.  But after the US invasion of 2003, they became an embarrassment.  “The value of their wounds’ ‘capital’ changes from hero to zero,” Abu-Sitta says.  “And this means that their ability to access medical care also changes.  We are now reading the history of the region through the wounds.  War’s wounds carry with them the narrative of the wounding which becomes political capital.”

In the bleak wars that have scarred Syria, and which continue to open up divisions and divides there too, the same considerations come into play with equal force.

‘Your turn, doctor’

This is the fourth in a new series of posts on military violence against hospitals and medical personnel in conflict zones.  It follows from my analysis of air strikes on base hospitals on the coast of France in 1918 here, and of the US air strike on the MSF Trauma Centre in Kunduz, Afghanistan in 2015 here and here.  This post, together with the next in the series, is about Syria.  They all derive from a new presentation – still in active development – called ‘The Death of the Clinic: surgical strikes and spaces of exception’ that will eventually become an essay in my next book, so I would appreciate any comments or suggestions.

The eye of the storm 

Syria’s civil war has multiple origins, but one of the most incendiary incidents took place on 16 February 2011 in the city of Dara’a 80 km south of Damascus near the Jordanian border.  Inspired by the spread of the Arab uprisings east across the Maghreb from Tunisia, and the threat they posed to a succession of autocratic regimes, a group of local teenagers decided to daub slogans on the wall of their high school.  One of them, a brave 15-year old (who now lives with his family in Jordan), painted this:

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‘Ejak el door ya Doctor’ – ‘Your turn, doctor’.

The doctor in question was Bashar al-Assad, Syria’s president, who had trained as an opthalmologist in Damacus and London.  In the months to come, Assad would give that slogan a viciously ironic twist.

The immediate response of the security forces to the graffiti was swift and draconian; the boys were rounded up, imprisoned and tortured (see herehere and here).  When their relatives protested to the officer in charge he told them:

‘Forget your children.  Just make more children. And if you don’t know how to make more, I’ll send someone to show you.’

hrw-weve-never-seen-such-horrorLocal people took to the streets, and as the demonstrations spread on 22 March security forces entered the National Hospital in Dara’a, cleared it of all non-essential medical staff and stationed snipers on the roof who were under orders to fire on protesters.  The hospital remained until military control until May 2013; admissions were restricted and snipers continued to fire on the sick and wounded who tried to approach the hospital.  On 8 April security forces opened fire on thousands of demonstrators approaching a roadblock; ambulances were prevented from reaching the wounded, and a doctor, a nurse and an ambulance driver were killed when they tried to get through (UN Human Rights Council: ‘Assault on Medical Care in Syria’, 13 September 2013: download here; see also the Human Rights Watch report, ”We’ve never seen such horror’ here).

daraa-is-syria-in-damascus-2011

Others took up the cry, taking to the streets and chanting ‘Dara’a is Syria‘.  In many other areas the government stationed snipers, armoured personnel carriers, tanks and heavy artillery at hospitals; doctors suspected of treating protesters were arrested and tortured; security forces forcibly removed patients from hospitals, ‘claiming bullet or shrapnel wounds as evidence of participation in opposition activities’; and ambulances transporting casualties were attacked and pharmacies looted.

The UN Human Rights Council concluded:

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This was, sadly, hardly novel.  In 2006, at the height of sectarian violence in occupied Baghdad, for example, Muqtada al-Sadr‘s Shi’a militia controlled the Health Ministry and manipulated the delivery of healthcare in order to marginalise and even exclude the Sunni population.  As Amit Paley reported:

‘In a city with few real refuges from sectarian violence – not government offices, not military bases, not even mosques – one place always emerged as a safe haven: hospitals…

‘In Baghdad these days, not even the hospitals are safe. In growing numbers, sick and wounded Sunnis have been abducted from public hospitals operated by Iraq’s Shiite-run Health Ministry and later killed, according to patients, families of victims, doctors and government officials.

‘As a result, more and more Iraqis are avoiding hospitals, making it even harder to preserve life in a city where death is seemingly everywhere. Gunshot victims are now being treated by nurses in makeshift emergency rooms set up in homes. Women giving birth are smuggled out of Baghdad and into clinics in safer provinces.’

He described hospitals as ‘Iraq’s new killing fields’, but in Syria the weaponisation of health care has been radicalised and explicitly authorized by the state.

Counterterrorism and the criminalisation of health care

Doctors were systematically targeted for treating anyone who opposed the government.  In April 2012 one surgeon from Idlib told Annie Sparrow:

‘We were detained in the hospital for several days. Tanks parked out front, artillery in the wards, snipers on the roofs shooting patients who tried to come. They took our names, and summoned three of the five security branches – state, political and military. I was interrogated and forced to sign several commitments not to treat anyone not pro-regime. Of course, as soon as I was released I violated it immediately…the city was full of wounded and sick people. Soon after that a friend who worked in military security let me know I was now “wanted” [for my work], the charge being that I was the leader of a terrorist group. So I went into hiding, and moved my family to Turkey. In retaliation my brother was executed.’

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The State of Emergency that had been in force in Syria since 1962 was abruptly ended on 21 April 2012.  But on 2 July a new Counter-terrorism Law came into force that criminalised all medical aid to the opposition.  Here is Annie Sparrow again:

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The parallels with the objections voiced by some members of Afghanistan’s security services against MSF’s work in Kunduz are only too clear: but in Syria they have been given explicit state sanction enforced through the law.

As Neil Macfarquhar and Hala Droubi reported for the New York Times in March 2013, doctors repeatedly found themselves in the cross-hairs.  Here, for example, is the case of Dr Mohamad Nour Maktabi:

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The Counter-terrorism Law also declared that all medical facilities operating in opposition-held areas without government permission were illegal – and thereby transformed them (under Syrian law, at least) into legitimate targets of military violence.

Air wars and ‘surgical strikes’

The nature of military and paramilitary violence has changed during the course of the war; shooting and mortar-fire have increasingly been supplemented by air strikes.

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Even in the early stages of the war doctors were confronting what one trauma specialist called ‘unimaginable injuries’.  Dr Rami Kalazi, a neurosurgeon in east Aleppo, explained:

‘In the beginning, we saw new injuries that we did not know how to treat. Fortunately, at the beginning of the revolution and when we began working in field hospitals, there was more freedom of movement. In 2012 and 2013, there was no such thing as “barrel bombs” and there was no violent shelling from airplanes, so many visiting foreign doctors came…

‘But even so, they told us that they were seeing injuries that they had never seen before in books or textbooks or in the hospitals where they worked in their home countries. Unfortunately, reality forces you to learn.’

But air strikes transformed the calculus of injury.  Many more casualties resulted from each attack, and the wounds of those who survived were often far more serious.

The US-led coalition has carried out multiple airstrikes primarily in areas controlled by IS, and the campaign has caused (minimally) hundreds and probably several thousand civilian casualties – see my analysis of specific US air strikes here and here, for example –  but the Syrian Arab Air Force has concentrated its fire on areas controlled by other rebel groups (see Jeffrey White‘s analysis here).

A favourite tactic has been the deployment of ‘barrel bombs‘ – in effect, aerial IEDs: oil drums filled with high explosive and cut rebar to act as shrapnel – dropped from helicopters (see Human Rights Watch here).  Basel al-Junaidi described witnessing their impact:

I saw the aftermath of a barrel bomb. I saw human remains scattered in the street; I heard the screaming. I’m trained as a doctor, but I was unable to act. I just stood there, petrified. The West thinks we’re used to this, but we aren’t of course. We’re like anyone else – we use computers and cars, not camels and tents…

Another doctor who worked in Syria said he kept ‘a drawing from a second grader in Aleppo, showing helicopters bombing the city, blood and destruction below.’  Chillingly, ‘the dead children are smiling while the living ones are crying.’

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From September 2015) the Russian Air Force, often acting in concert with the Syrian Arab Air Force, has also concentrated on targets in areas controlled by other opposition groups:

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Russia has routinely denied these charges, but from 30 September to 12 October 2015 its Ministry of Defence published videos of 43 airstrikes. Bellingcat, aided by crowdsourcing, identified the exact location of 36 of them and overlaid them on the ministry’s own map identifying which groups controlled what parts of the country (see the full report, ‘Distract, Deceive, Destroy’, here):

‘The result revealed inaccuracy on a grand scale: Russian officials described 30 of these videos as airstrikes on Isis positions but in only one example was the area struck in fact under the control of Isis, even according to the Russian MoD’s own map.’

The effect of these air strikes has been devastating on the population at large.  To make matters even worse, air strikes cannot target individual doctors and have instead frequently been directed against hospitals and other medical facilities.   This compromises not only trauma care for the wounded but also the treatment of chronic and infectious diseases:

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(You can find a discussion of the problem of infectious diseases in Sima L. Sharara and Souha S. Kanj, ‘War and infectious diseases: challenges of the Syrian Civil War’, PLOS Pathogens 10 (11) (2014) here).

Hospitals and bomb sights

Doctors and other medical staff had to adjust to a new, sickening vulnerability.  Here is one OB/GYN who was still working in a hospital in East Aleppo when she was interviewed on Public Radio International in August 2016:

Carol Hills, PRI: Doctor Farida, did I just hear a noise there? Was that some sort of attack that I just heard?
Dr Farida Almouslem: It’s attack. [Laughs]. It’s normal. It’s away from me. Not next to me. These noises are all the time.
Hills: Do you and the doctors and patients you work with feel safe inside the place where you’re working?
Dr Farida: No. It’s not safe. I work at the third floor in my hospital. And many times the wall was perforated. So every woman came to the hospital, she knows that there is a danger on her life. So they just give the delivery, or give the birth, and then go home. She escapes to home because she knows our hospital is always targeted.

Other doctors in opposition-held areas said the same.  Here is Dr Mohamed Tennari, director of an above-the-ground field hospital in Idlib:

‘When I am in the hospital, I feel like I am sitting on a bomb. It is only a matter of time until it explodes. It is wrong − a hospital should not be the most dangerous place.  I wish I could say that targeting a hospital in Syria is unique, but is not.’

In fact, it’s far from unique: Physicians for Human Rights has issued a report detailing Attacks on Doctors, Patients and Hospitals hospitals and provided a interactive map of attacks on healthcare in Syria.

In the face of these escalating attacks, hospitals in opposition-held areas have tried to conceal their locations from the Syrian government.  In contrast to the protocol adopted by the MSF Trauma Centre in Kunduz, they have been markedly reluctant to provide their GPS coordinates (and see MSF’s explicit comparison between what happened in Kunduz and the situation in Syria here):

gps-coordinates-and-surgical-strikes-001

But this has trapped them in a grim Catch-22.  Michiel Hofman of Médecins sans Frontières – which is not permitted to operate in government-controlled areas in Syria – explains:

‘Hospitals that MSF supports in Syria are bereft of the possible protection of being clearly marked as a hospital or sharing of GPS coordinates, as the Syrian government passed an anti-terrorist law in 2012 that made illegal the provision of  humanitarian assistance – including medical care – to the opposition, forcing most health structures to go underground and operate without governmental medical registration. The bombing parties can then conveniently claim they were unaware it was a hospital they hit.’

More often, the Syrian government and its allies routinely describe the bombed building as a ‘so-called hospital’.  After an air strike on an MSF-supported hospital near Maarat al-Numan in Idlib on 15 February 2016 Bashar Jaafari, Syria’s ambassador to the United Nations, made this statement:

‘The so-called hospital was installed without any prior consultation with the Syrian government by the so-called French network called MSF which is a branch of the French intelligence operating in Syria… They assume the full consequences of the act because they did not consult with the Syrian government. They did not operate with the Syrian government permission.’

The allies of the Syria government are not confined to Russia and Iran.  On 27 April 2016 the Al Quds hospital in Aleppo was hit by two air strikes that killed 55 people  – among them two specialists, including Dr Muhammad Waseem Maaz, Al Quds’s pediatrician – and severely damaged the hospital. When it partially reopened 20 days later its capacity was reduced from 34 to 12 beds.  MSF conducted a detailed review of the operations of the hospital and the circumstances of the attack:

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Here is Professor Tim Anderson on what he calls ‘The “Aleppo Hospital” Smokescreen‘ (and for reasons that will become obvious I am so tempted to put scare-quotes around the title that adorns his post; the Department of Political Economy at the University of Sydney lists him as a Senior Lecturer not a Professor, but perhaps anxiety over the appellation ‘Doctor’ is contagious):

‘…the story of Russian or Syrian air attacks on the ‘al Quds hospital’ gained prominence in the western media… CCTV showed people leaving this ‘hospital’ before an explosion.

‘The building is in the southern al-Sukkari district, which has been a stronghold of Jabhat al Nusra for some years. Many Aleppans had never heard of ‘al Quds hospital’. Dr Antaki [Aleppo Medical Association in Western Aleppo] says: “This hospital did not exist before the war. It must have been installed in a building after the war began”…. This facility was not a state-run or registered facility.’

Anderson is joined in his disinformation effort by Eva Bartlett writing in the ‘OffGuardian’:

Dr. Zahar Buttal, Chairman of the Aleppo Medical Association … said: “The media says the only pediatrician in Aleppo was killed in a hospital called Quds. In reality, it was a field hospital, not registered.”

As for the pediatrician, “We checked the name of the doctor and didn’t find him registered in Aleppo Medical Association records.”…

… central to the lies were the bias and propaganda of the very partial, corporate-financed Médecins Sans Frontières (MSF), which supports areas in Syria controlled by terrorists, specifically Jabhat al-Nusra…’

To repeat: the Syrian government has refused to register or recognise any hospitals operating in areas outside its control – hence the snide reference to ‘so-called hospitals’ and Anderson’s meretricious scare-quotes – and it does not permit MSF to operate in areas under its control (despite repeated requests).  As for the disappearance of Dr Muhammad Waseem Maaz from the Syrian government’s registry (though I have no doubt he was on other lists maintained by the regime) the director of the Children’s Hospital in Aleppo provides a graceful tribute to him here.  And here is the doctor whose death these commentators dismiss so lightly (if you have the stomach for it, you can see his last moments caught on CCTV here):

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What, apart from the grotesque stipulations of the Syrian state, makes them think it proper to withdraw medical care from those living – surviving – in rebel-held areas?  International humanitarian law is unequivocal: they are entitled to medical treatment and to be protected whilst it is provided to them.

In rebel-held areas medical care has increasingly moved outside what were once established hospitals into the clandestine ‘field hospitals’ referred to above, which have been given numbered code-names to conceal their locations.  Some, like those established by MSF, follow strict medical protocols and, according to a study of one operating in Jabal al-Akrad by Miguel Trelles and his colleagues, they have (for a time) been able to provide high-quality medical care with remarkable survival rates (‘Providing surgery in a war-torn context: the Médecins Sans Frontières experience in Syria’, Conflict and Health (December 2015)).  As the attacks on them have increased and qualified personnel and medical supplies have become scarce, however, many have become exercises in improvisation:

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Some of these hospitals have literally gone underground.  ‘‘In our worst dreams – in our worst nightmares – we never thought we would have to fortify hospitals,’ declared Dr Zaidoun al-Zoabi of the Union of Medical Care and Relief Organizations. ‘It’s not humane. It’s impossible to comprehend.’

Subterranean locations have been used not only to protect the hospitals but also to protect local populations.  Charles Davis reported that

‘whether it’s a vehicle or a building, anything that’s identifiable as providing medical care is ripe for an airstrike, so that staff have now taken to covering up any distinguishing characteristics. Even so, [Dr Abdulaziz Adel, a surgeon in East Aleppo, admits that] local residents are “always begging us to go away, take your hospital away from us or otherwise we’ll be a target.”‘

When the Syrian-American Medical Society proposed to build a hospital in Hama in 2014, local people begged them to locate it outside the city and so SAMS excavated what became the Dr Hasan al Araj Hospital, better known as ‘The Cave’:

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Supply chains and kill-chains

As the civil war ground on, even the most basic medical supplies became scarce and obtaining them ever more dangerous.  In March 2015 MSF reported that:

‘Even if it is available, many suppliers do not want to risk selling material like gauze or surgical threads when they know it is going to be sent into North Homs. Gauze is considered synonymous with war surgery, and often a supplier is not willing to take the risk of being arrested or shut down for supplying a besieged area.’

bloody-supply-chains-001

You can read more here and here.  One doctor told MSF:

‘It is precious, dangerous, incriminating. There are secret outlets supplying us with gauze.’

At the end of last year the Guardian provided this image of one of the secret factories:

gauze-factory-001

In East Ghouta, hospitals have been forced to use tunnels to bring in medical supplies (more from Ellen Francis and her colleagues here):

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The risks are formidable and the costs have been almost prohibitive.  Ellen Francis and her colleagues at Columbia’s Graduate School of Journalism report that in January 2014 the Free Syrian Army and the Syrian Arab Army agreed an uneasy and ragged cease-fire in Barzeh, a small town on the northern edge of Damascus. There a team from the Union of Free Syrian Doctors was able to buy medical supplies from merchants who travelled out from the capital.

The merchants paid a 20 per cent ‘customs fee’ to Syrian Army soldiers; the agents for the doctors then paid a ‘tax’ to get the supplies through the Harasta checkpoint on the Army-controlled highway, and then a ‘toll’ to the rebels (‘tunnel lords’) who controlled the tunnels into Ghouta.

The combined fees inflated the price of medical supplies.  A litre of serum used to help the body replenish lost blood cost $1 in government-controlled areas and $3.50 to $10 via the tunnel route. Ghouta was using about 10,000 litres of serum per month.  The supply chain was subsequently severed once Barzeh itself came under siege and was cut off from Damascus.

Some humanitarian aid has crossed the lines by more conventional routes – conventional for a war zone at any rate – but medical supplies have routinely been removed from aid convoys.  On 19 May 2016 the UN Secretary-General reported to the Security Council:

‘[By May] 2016, WHO [had] submitted 21 individual requests to the Government of the Syrian Arab Republic to deliver medical supplies to 82 locations in 10 governorates. The Government approved five requests [while] 16 requests remained unanswered.

‘The removal of life-saving medicines and medical supplies continued, with nearly 47,459 treatments removed from convoys in April intended for locations in Homs, Aleppo and Rif Dimashq governorates. Removed items included surgical supplies, emergency kits, trauma kits, mental health medicines, burn kits and multivitamins. Removals extended to basic items, such as antibacterial soap, which was removed from midwifery kits. Items were also removed from other kits, notably surgical tools…’

Even then, aid convoys are not safe.  Four months later to the day a UNICEF aid convoy delivering supplies to a Syrian Red Crescent warehouse at Urum al-Kubra in Aleppo was attacked from the air, killing at least 18 people and destroying 18 of the 31 trucks.  Most analysts have concluded that the Russian Air Force was responsible, perhaps acting in concert with the Syrian Arab Air Force – see for example here and here– but the Russian Ministry of Defence and the usual suspects have variously blamed spontaneous combustion, a ground attack by rebels and a US drone attack.

un-convoy-attacked-in-aleppo

These shortages are threaded into dispersed and precarious siege economies that gravely affect the health of local populations.  In December 2015 an estimated 400,000 people were surviving without access to life-saving aid in 15 besieged locations across Syria; the figures gathered by Siege Watch are even higher.

Surrounded by 6,000 land-mines and 65 sniper-controlled checkpoints, Madaya’s 40,000 inhabitants have been under siege since July 2015; 32 people died of starvation and malnutrition in December 2015 alone.  One resident interviewed by Amnesty International in January 2016 described the catastrophic situation:

‘Every day I wake up and start searching for food. I lost a lot of weight, I look like a skeleton covered only in skin. Every day, I feel that I will faint and not wake up again… I have a wife and three children. We eat once every two days to make sure that whatever we buy doesn’t run out. On other days, we have water and salt and sometimes the leaves from trees. Sometimes organizations distribute food they have bought from suppliers, but they cannot cover the needs of all the people.

‘In Madaya, you see walking skeletons. The children are always crying. We have many people with chronic diseases. Some told me that they go every day to the checkpoints, asking to leave, but the government won’t allow them out. We have only one field hospital, just one room, but they don’t have any medical equipment or supplies.’

An aid convoy was allowed in four days after this interview.

There are also grave shortages of skilled medical personnel.  The doctors who remain in opposition-held areas have all had to learn new skills sometimes far beyond their original training.  In March 2015 one young surgeon working in an MSF-supported hospital east of Damascus recalled:

‘There was a pregnant woman who was trapped during the time we were under full siege. She was due to deliver soon. All negotiation attempts to get her out failed. She needed a cesarean operation, but there was no maternity hospital we could get her to, and I had never done this operation before.

A few days before the expected delivery date, I was trying to get a working internet connection to read up information on doing a C-section. The clock was ticking and my fear and stress started to peak. I wished I could stop time, but the woman’s labour started…’

In 2015 OCHA estimated that more than 40 per cent of pregnant women in these areas now scheduled C-sections to reduce the risk of an attack preventing them from obtaining care.

In some cases doctors can call on skilled overseas help via Skype from consultants on call 24/7 in the United States, Canada and the United Kingdom.  Ben Taub has written movingly of the extraordinary efforts of what he calls ‘the shadow doctors’ enlisted in ‘the underground race to spread medical knowledge as the Syrian regime erases it.’  One of the most active is Britain’s Dr David Nott:

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But not all those seeking specialist help are qualified surgeons.  In the field hospital serving the besieged town of Madaya medical care has been provided by a dentist, a dental student and a veterinarian.  Avi Asher-Schapiro reports:

‘The five-year civil war has plunged the Madaya clinicians into the deep end, forcing them to perform medical procedures that push them far beyond their training. They have treated countless gunshot victims, performed seven amputations, over a dozen C-sections, and diagnosed everything from meningitis to cancer.’

As he explains, this remarkable trio has also relied on remote medicine:

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These are all extraordinary responses to near-impossible, life-threatening situations.  But their successes have been short-lived.

The Madaya clinic was forced to close in November 2016:

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And the M10 hospital where Nott helped direct surgery – the largest trauma and ICU centre in East Aleppo – was hit by successive, catastrophic air strikes.  First, an attack on 28 September 2016 left only half the hospital operational.  On 1 October Xisco Villalonga, MSF’s Director of Operations, reported that

‘Bombs are raining from Syria-led coalition planes and the whole of east Aleppo has become a giant kill box.’

That night multiple strikes on M10 killed two people and injured ten others; the hospital had to be evacuated because one crater was so deep there were fears that the rest of the building would collapse.

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But the ordeal was not over: there were further, devastating strikes on 3 October:

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The underground hospitals have fared no better.  ‘The Cave’ – 15 metres inside a mountain, remember – was hit by two ‘bunker-buster’ bombs at 1500 on 2 October 2016. After 35 staff and patients had been evacuated a second strike occurred in the early evening involving missiles and cluster bombs. The E.R. was wrecked, ceilings collapsed, cement walls crumbled and generators, water tanks and medical equipment were destroyed (see image below).  Nobody was seriously injured but the hospital sustained critical damage and has been closed indefinitely. It used to treat 300 patients and perform 150 surgeries a month.

Cave Hospital hit by bunker-buster bombs

The exception to the exception

Once safe places under the protection of international humanitarian law – the exception to the space of exception that is the conflict zone – hospitals have become the targets of a new and extraordinarily vicious modality of modern war.  The systematic attacks on hospitals have not only threatened the lives of patients and healthcare workers; they have also made many patients reluctant to seek medical treatment at all.  In February 2015 a report from the Centre for Public Health and Human Rights at Johns Hopkins University was already warning of the consequences:

‘Unless they feel their life is in danger, many people won’t go to hospital because it is targeted for bombardment’ [Physician, Aleppo]. Two physicians reported that fear of travel and an understanding that the hospital is a target has led to a 50% decrease in clinic visits and surgery cases, even though the level of violence has not decreased.

Dr Farida, the OB/GYN in East Aleppo interviewed earlier, no longer has a hospital to work in – the last remaining hospital was reduced to rubble and closed on 18 November – and she now provides what medical care she can from a basement:

‘People know it’s a basement, but they are afraid to come here because they know any health facility is deliberately targeted by the regime. For women, they are afraid to come — but they don’t have any other option. When they don’t have a car or fuel to come here, they have to give birth at home. Women are bleeding at home and babies are born dehydrated without oxygen.’

Those that do make the precarious journey to a field hospital or other medical facility almost always now find that their care is compromised by the shortage or even the absence of doctors, nurses, medical supplies and even the most basic medical equipment.  So doctors use ordinary sewing cotton instead of surgical thread; local anaesthetic where they would normally use a general, or even home-made, improvised variants.  Dr Zaher Sahloul, who still tries to provide help to colleagues in Syria from his home in Chicago via WhatsApp, explains:

‘We operate on the mindset that they have basic things we take for granted… The reality is, they don’t have 90 percent of the things we think they have. They know better what they have and what they can do with it. These people are facing decisions we will never face in our lives. If you have 10 patients dying, who will you see first? Do you use spoiled gauze and dirty tubes at the risk of infection? It’s Hell for them.’

As I write, the Syrian Arab Army and its supporting militias are advancing into East Aleppo, where air strikes and artillery bombardments have left more than 250,000 people without access to any form of advanced medical care.  The World Health Organisation announced that ‘although some health services are still available through small clinics, residents no longer have access to trauma care, major surgeries, and other consultations for serious health conditions.’

The final irony – although in this catalogue of horrors it probably isn’t the last at all – is that the Kremlin has announced that it will send two mobile hospitals to treat patients from East Aleppo.  The Defence Ministry will operate ‘a special 100-bed clinic with trauma equipment for treating children’ and the Emergencies Ministry will provide a 50-bed clinic capable of treating 200 outpatients a day.

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While the Kremlin congratulates itself on its ‘humanity’, we need to remember that this minimalist contribution would not have been necessary at all had medical neutrality been respected and doctors and nurses, hospitals and clinics not been so ruthlessly, systematically and deliberately targeted in the first place.

UPDATE:  On 5 December the Defence Ministry’s mobile hospital (set up in West Aleppo to treat patients from East Aleppo) came under mortar fire from the crumbling opposition-held area to the east; one Russian doctor and two paramedics were killed.  It’s not clear whether the hospital was deliberately targeted – there have been accusations that the co-ordinates of the hospital must have been given to the militants for it to have been hit ‘right at the moment when it started working‘ – or whether it was caught in the indiscriminate shelling and mortar-fire that has hit other hospitals in West Aleppo.

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But I should make two things clear.  First, attacks on hospitals in West Aleppo – even though I don’t think they have exhibited anything like the scale or the systematicity of those directed against medical facilities and healthcare workers in opposition-held areas – are as reprehensible as those on hospitals in the East.  Second, the muted response from the US-led coalition to the shelling of the Russian field hospital is deeply disturbing.  The International Committee of the Red Cross announced after the attack that ‘all sides to the conflict in Syria are failing in their duties to respect and protect healthcare workers, patients, and hospitals, and to distinguish between them and military objectives.’  The Russian Ministry of Defence dismissed this as a ‘cynical’ display of indifference to the deaths of its doctors, but I don’t read it like that at all – what is cynical is the partisan appeal to medical neutrality when it suits, and its systematic violation when it doesn’t.

To be continued

Killing over Kunduz

This is the second in a new series of posts on military violence against hospitals and medical personnel in conflict zones.  It examines the US attack on the Trauma Centre run by Médecins Sans Frontières (MSF) in Kunduz on 3 October 2015.  I provided preliminary discussions here (on the conduct of US military investigations into civilian casualty incidents), here (on MSF’s own investigation into the attack), here (on the Executive Summary of the US military investigation), here (on two first-hand accounts from MSF personnel), here and here on the final report, and here (on the likelihood that the attack constituted a war crime).   This post draws on those discussions but also on a close reading of the redacted report of the US military investigation [all page references refer to that report], on work by investigative journalists, and on ancillary materials and commentaries. 

spooky-mainOne year ago today, in the early hours of the morning of 3 October 2015, a US AC-130U gunship (‘Spooky’) launched a concentrated attack on the Trauma Centre in Kunduz run by Médecins Sans Frontières.  In an otherwise probing report on what happened,  the Washington Post claimed that the gunship has sensors ‘that give it a “God’s eye” of the battlefield’.  Here  I explore some of the multiple ways in which such a view was – and remains – impossible.  For militarized vision, like any other optical modality, is never a purely technical affair.  A series of cascading technical errors bedevilled the US attempt to re-take Kunduz from the Taliban, who had swept into the city a few days earlier, but these were compounded by a series of profoundly human decisions and interactions and it was the intimate entanglement of the technical and the human that determined the hideous outcome.

At least 42 people were killed, including 24 patients, 14 medical staff and 4 caretakers.  Many others were wounded and traumatized.  Here is Dr Evangeline Cua, a Philippina surgeon who was on duty when the attack started:

msf164464-profileWe were like two headless chickens running in total darkness — me and the surgeon who assisted me in an operation. The nurses who were with us a moment ago had run outside the building, braving the volley of gunshots coming from above. I was coughing, half-choked by dust swirling around the area. Behind my surgical mask, my mouth was gritty, as if somebody forced me to eat sand. I could hear my breath rasping in and out. Layers of smoke coming from a nearby room made it hard to see where we were. Blinking around, I caught sight of a glow, from a man’s hand holding a phone. He seemed mortally wounded but was still trying to send a message…perhaps to a loved one?

I stood transfixed, not knowing where to turn or what to do. All around us, bombing continued in regular intervals, shaking the ground, sending debris sweeping and flying. One. Two. Three. I tried to count but there seems to be no abatement to the explosions. I stopped counting at eight and silently prayed that we could get out of there alive.

Fire licked at the roof at one end of the building, dancing and sparkling in the dark, reaching towards the branches of the trees nearby. The ICU was burning.  Outside, only the constant humming from above pointed to the presence of something. An aircraft? Airstrike? Why the hospital? Why us? Then, without warning, another tremendous, ear splitting blast shook the building. The ceiling came crashing down on us and the last remaining lights were turned off, sending us to total darkness. I screamed in terror as wires pinned me to the ground. That was the last thing I could remember.

What follows is an attempt to answer those questions.  It is fraught with uncertainty: the most detailed investigation to date has been carried out by the US military, but the redacted version of the final report that has been released to the public is (by the standards of other US military investigations) profoundly unsatisfactory – redacted with a brutishly heavy hand.  Time and time again, ironically, references to the time of events have been removed; transcripts of radio communications and interviews by the investigating panel that have been released in other cases have been suppressed; and some redactions seem to have been made not for reasons of privacy or security but to avoid embarrassment (more here; you can download the report from US Central Command’s Freedom of Information Act (FOIA) library here).

All of this reinforces MSF’s original call for an independent investigation.  I understand May Jeong‘s pessimism:

A former Afghan special forces commander who was at the command and control center in Kunduz during the fight assured me I would never get to the bottom of the attack. The reason why I couldn’t figure out exactly what had happened, he said, was the fog of war. “Ground truth is impossible to know. Even those who were there wouldn’t be able to tell you what they saw.”

But when the ‘fog of war’ – so often a convenient cover for all manner of horrors – is deliberately thickened – when visibility is ruthlessly reduced by redaction – then perfectly proper public interest is trumped by political and military expediency.

***

When the NATO-led combat mission to Afghanistan conducted by the International Security Assistance Force (ISAF) finished at the end of 2014 it was replaced by a much smaller advisory mission, Resolute Support, which was ‘to provide further training, advice and assistance for the Afghan security forces and institutions’.  Resolute Support was authorized by a Status of Forces agreement between NATO and the Afghan government in Kabul.  Its central hub was Kabul/Bagram, with four ‘spokes’ formed by four other ‘Train Assist Advise’ Commands to support four Afghan National Army Corps outside the capital (more here and here):

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US troops were the major contributor to Resolute Support, but they were also assigned to the United States’s continuing (‘concurrent and complementary’) counter-terrorism mission now designated as ‘Operation Freedom’s Sentinel’.  Until March 2016 both missions were under the overall command of General John Campbell.

By September 2015 the focus of US concern in Afghanistan was Helmand in the south – where the Taliban were on the ascendant, forcing Afghan government forces to retreat as they seized control of key districts and gained control of the Kajaki dam – and US Special Forces were rushed to Camp Bastion after the fall of Musa Qala gave the insurgents a strategic advantage.

By contrast, Kunduz in the north was regarded as ‘secure’ [135] after a series of combat operations at the start of the fighting season earlier in the year.  As late as 13 August Brigadier-General Wilson Shoffner, Deputy Chief of Staff for Communications with Resolute Support, declared that although there had been ‘an attempt by the Taliban to try to stretch the Afghan security forces in the north’ the city of Kunduz ‘is not now and has not been in danger of being overrun by the Taliban’ (he also described the situation at Kajaki as merely a ‘local security challenge’).  But those previous operations in Kunduz had targeted Taliban operations areas and did not extend to support zones outside the city.

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Obeid Ali reports that during the summer the Taliban continued to make inroads until they controlled areas to the south west, north west and south east of the city.

On 28 September 2015, the Taliban stormed various ANSF locations in Kunduz city from the three different directions they had spent so long preparing… The simultaneous attacks on the city and the collapse of check posts at the city ‘gateways’ destroyed the confidence of the ANSF inside the city in their ability to stand against this unexpected offensive. In the face of the well-organised and coordinated insurgent operation, most held out for only a few hours. A chaotic environment quickly spread and government officials, ALP [Afghan Local Police] commanders and some of the ANA [Afghan National Army] officers, fled to the military base at the airport [Camp Pamir], leaving Kunduz effectively leaderless.

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Kunduz was a spectacular, strategic prize: the first city to fall to the mujaheddin in 1998 and the first time the Taliban had seized a major city since 2001, its capture signalled both a resilient Taliban and a faltering government footprint in the region.

•••

On 28 September there was a detachment of US Special Forces (‘Green Berets’) based at Kunduz airfield as part of the Train, Assist, Advise mission.  Like every Operational Detachment – Alpha (OD-A) it consisted of just 12 soldiers, all cross-trained and capable of operating for extended periods of time with little or no support.  On 29 September their superior command – the US Special Operations Task Force in Afghanistan – ordered two other OD-As to Kunduz.  While they were in the air the OD-A on the ground sketched out a contingency plan (‘Kunduz City Foothold Establishment’) to assist the Afghan forces to return to the city and secure the Kunduz City Hospital and the Prison.  There were repeated US airstrikes against Taliban positions in and around the city throughout the day, but by the time the OD-A reinforcements, together with other Afghan troops including Afghan Special Security Forces (below), arrived in the evening it was clear that the original plan was unworkable and their immediate priority had to be the defence of the airfield [032, 382].

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The US reinforcements included Major Michael Hutchinson, who assumed overall command of the combined OD-As (he was identified as the Ground Force Commander by the New York Times).  He had misgivings about the mission but accepted that ‘we can’t lose the provincial capital’ [377].   The next day a revised plan (‘Kunduz Clearing Patrol’) was submitted to the Special Operations Task Force for approval, which was granted that night, and the OD-As requested that Afghan Special Security Forces be accorded ‘designated special status’ that would permit the Green Berets to extend their own envelope of self-defence and assume a direct combat role (including calling in air strikes) to defend their partner forces if they came under attack [046-7].

By this time Médecins Sans Frontières had been in contact with both US and Afghan forces to ensure that they were aware of the location and status of its Trauma Centre in Kunduz.  It was in the eye of the storm.  Dr Kathleen Thomas, an Australian doctor in charge of the Emergency Room and the Intensive Care Unit, explained:

We all knew that at times, our hospital was in the middle of the rapidly changing front line – we could feel it. When the fighting was close – the shooting and explosions vibrated the walls. I was scared – we were all scared. When a loud “BOOM” would sound a bit closer to the hospital, we would all drop to the floor away from the large windows that lined the ICU walls. We also tried to move the patients and large (flammable) oxygen bottles away all from the windows, but the layout of the ICU prohibited doing this effectively. I worried constantly about the exposure from those windows – yet never thought to worry about the exposure from the roof.

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Most of the patients were civilians.  Of the combatants, MSF reported that most of them were from the Afghan army and police, as had been the case since the Trauma Centre opened, but once the city fell on 28 September ‘this shifted to primarily wounded Taliban combatants.’  The Afghan government speedily arranged the transfer of all its patients (apart from the most severely wounded cases) to another hospital.

By that night the Taliban announced that it was in control of the district.  Kathleen Thomas described the scene:

The first day was chaos – more than 130 patients poured through our doors in only a few hours. Despite the heroic efforts of all the staff, we were completely overwhelmed. Most patients were civilians, but some were wounded combatants from both sides of the conflict. When I reflect on that day now, what I remember is the smell of blood that permeated through the emergency room, the touch of desperate people pulling at my clothes to get my attention begging me to help their injured loved ones, the wailing, despair and anguish of parents of yet another child lethally injured by a stray bullet whom we could not save, my own sense of panic as another and another and another patient was carried in and laid on the floor of the already packed emergency department, and all the while in the background the tut-tut-tut-tut of machine guns and the occasional large boom from explosions that sounded way too close for comfort.

Although the Trauma Centre had been on US Central Command’s ‘No-Strike List’ since October 2014 MSF now re-supplied its GPS coordinates and reminded the Ministry of Defence in Kabul that ‘MSF and its personnel observes strict neutrality and impartiality in the name of universal medical ethics and rights of populations affected by conflicts to humanitarian assistance’ and claimed ‘full respect of these principles and rules in order to be able to continue responding to the humanitarian and medical needs of all Afghans’ [144].  On 29 September MSF issued what would prove to be a remarkably optimistic statement:

We are in contact with all parties to the conflict and have received assurances that our medical personnel, patients, hospital and ambulances will be respected.  With the government provincial hospital not currently functioning, MSF’s hospital is now the only place in Kunduz where people in need of urgent trauma care can receive it.

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MSF had withdrawn from Afghanistan in August 2004 – after the targeted killing of five of its aid workers in June, the government’s failure to arrest those responsible, and Taliban threats to target organizations like MSF that they falsely claimed ‘work for US interests’ – and returned five years later with agreements from the US-led coalition, the Afghan government and the Taliban to respect the de-militarization of its hospitals (including a strict ‘no-weapons’ policy inside them). Initially MSF assumed responsibility for two public hospitals in Kabul and Helmand; two years later it opened its Trauma Centre in Kunduz inside the old Spinzer cotton factory.  It soon became immensely important:

operative-volume-at-msf-trauma-centre-kunduz-2011-2015-trelles

[Source: Miguel Trelles, Barclay T Stewart and others, ‘Averted health burden over 4 years at Médecins Sans Frontières (MSF) Trauma Centre in Kunduz, Afghanistan, prior to its closure in 2015’, Surgery (2016) in press]

Between August 2011 and August 2015 the Trauma Centre cared for 6,685 patients; roughly one-third were suffering from ‘violence-related trauma’, which included land mines and bomb blasts, gunshots, stabbings, assaults, rape and torture; one quarter of those were children.  Procedures for complex wounds were the most common – debridement (excision), removed of shrapnel, care of burns – followed by orthopaedic procedures (including amputation).  Those injuries increased dramatically in the months before the city fell to the Taliban.  Miguel Trelles and his collaborators estimate that during this period the Trauma Centre averted 154, 254 ‘Disability Adjusted Life Years’; more prosaically:

The MSF Kunduz Trauma Centre provided surgical care for a large number of wounded and injured patients in the region. The surgical epidemiology is consistent with reports from other areas of prolonged insecurity in that unintentional, traumatic, non–war-related injuries generally outnumber those from violence. Nevertheless … the Trauma Centre provided surgical care for many adults and children injured directly by conflict (eg, injuries due to gunshots, land mines, bomb blasts). The health burden averted by surgical care at the Trauma Centre was large…

And yet, despite the importance of the Trauma Centre and its inclusion on a centralized No-Strike List that database was not consulted during the operational vetting and legal approval of the two plans drawn up by the OD-As [032, 045] (which, to be fair, had never been in the city and had no direct knowledge of the terrain; their Joint Terminal Attack Controllers had tried to print hard copy of ISR imagery before they set out from Camp Pamir but the base’s only printer was so old all it could produce were ‘giant magenta blobs’  that were completely useless [383] – so initially they relied on a single 1:50,00 map to plan and execute their operations [048]).

In fact – the irony is extraordinary – one member of the Special Operations Task Force testified that even they had no access to the No-Strike List and only discovered the existence of the Trauma Centre by accident, when ‘somebody was looking for additional medical facilities for use as emergency means to treat our own casualties’ if they could not make it back to Camp Pamir and the Forward Surgical Team based there [217, 219].  It was only then, late in the night of 29 September, that the Trauma Centre was added to the database maintained by the ISR [Intelligence, Surveillance and Reconnaissance] Tactical Controllers at the Special Operations Task Force at Bagram; early the next morning e-mails with this information were sent to ‘all ISR assets supporting operations in Kunduz’ [213].

***

us-army-personnel-leave-a-truck-inside-afghan-military-base-kunduz-1-oct-2015

On 30 September there was a secure videoconference between General Campbell, his Afghan counterpart and Major Hutchinson.  It was clear that Campbell was exasperated at the conduct of the Afghan forces and attached great importance to re-taking the city.  Fired up, Hutchinson briefed his men on the planned Kunduz Clearing Patrol, relaying the spirit of Campbell’s comments and telling them this was ‘a no fail mission’, that ‘all of the civilians have fled and only the Taliban are in the city’, and that ‘everything is a threat’ [256].  That night, once the mission had been approved, the Green Berets fought their way into the city alongside the Afghan Special Security Forces, with Close Air Support from US aircraft including an AC-130 gunship that ‘continuously called out and engaged [Taliban] ambush sites’ [325].  This seems to have been the same aircraft and crew that returned on 2/3 October; the sensor operator described that fateful mission as their third flight over Kunduz, following two others on 2 September and 30 September, the last when they provided armed overwatch for a US convoy into the city centre and engaged the Taliban at multiple locations.  Indeed, he claimed that those previous missions had provided them with ‘good situational awareness’ of Kunduz and the ‘patterns of life’ of both civilians and insurgents [362].

Before dawn on 1 October the US and Afghan troops had cleared several key buildings and established a defensive strongpoint in the Provincial Chief of Police Compound [PCOP].  They hunkered down and came under repeated mortar, rocket-propelled grenade and automatic weapons fire, and throughout that day and the next their Joint Terminal Attack Controller called in multiple strikes from F-16 aircraft, many of them ‘danger close’, in immediate proximity to the PCOP [332].

nyt-map-kunduz-ops

By the end of the afternoon on 2 October several Afghan troops had been wounded.  Their commander was all for taking the casualties back to Camp Pamir immediately, but Hutchinson persuaded them that this was madness: they were stable so the medical evacuation should wait for the cover of darkness.  The Afghan Special Security Forces agreed; while they were at Pamir they would re-supply and then return to attack a command and control centre they said had been established by the Taliban in the National Directorate of Security compound (NDS) to the south west of the PCOP which the Afghan SSF also referred to as ‘the NDS prison’ [386-8].  The investigation report includes this map showing the relationship of the PCOP to the NDS Compound and the MSF Trauma Centre:

map-pcop-msf-and-nds-in-kunduz

[A similar map included in a detailed analysis by The Intercept mis-locates the PCOP – almost certainly confusing it with the NDS Prison that the Operations Center in Bagram wrongly assumed was the intended target of the air/ground operation: see below]

The Afghan Special Security Forces were assured that Close Air Support would be extended to the convoy once they had returned to the ‘self-defence perimeter’ beyond the PCOP – a ‘bubble’, Hutchinson called it, roughly defined by the range of the heavy machine guns and anti-aircraft guns used by the Taliban [387].

But by then the F-16s providing close air support were running low on munitions and in the early evening, with the situation in Kunduz remaining precarious, the Special Operations Task Force scrambled the AC-130 gunship from Bagram to take over.

***

The AC-130 (call-sign ‘Hammer’) was a mission in a hurry and the aircraft took off without a proper briefing or any geospatial intelligence products.  All the aircrew had was the grid location of the PCOP and the call sign and contact frequency for the OD-As [052].  By then, superior commands had received the e-mail detailing the location of the Trauma Centre, and at 1847 the Fires Officer from Combined Joint Special Operations e-mailed a package of ‘mission products’ to the Electronic Warfare Officer onboard the AC-130 which included that information.  But en route to Kunduz one of the aircraft’s communications systems failed and the message never arrived; when the aircrew did not acknowledge receipt, the Fires Officer at Bagram made no attempt to pass the information over the radio (which was working) [052].

At 0130 on 3 October the Afghan convoy left on its evacuation and re-supply mission, and Hutchinson contacted the AC-130 through his Joint Terminal Attack Controller (JTAC) to ask them to carry out a ‘defensive [infrared] scan’ of the area of operations.  Specifically, he wanted to prepare the ground ahead of the convoy’s return: if they were ambushed and ‘got fixed in place what I wanted to do was to reduce heavy weapons and strongpoints so that they would be able to effectively maneuver on to the objective’ [390].  To that end he supplied the aircraft with a grid location for the NDS compound.

It is unclear – from the redacted report, at least – how the co-ordinates of the target were obtained. Hutchinson said that when the Afghan Special Security Forces showed him their plan for securing the NDS compound it included ‘a grid [which] said, I think, NDS prison’, but when he plotted the location he realised it was not the Prison to the south that was one of the objectives included in the original plan to establish a foothold in the city. Hutchinson riffed on the multiple NDS facilities throughout Kunduz, but this begs a crucial question: how did he plot the grid to confirm the location?  He claimed to have been working from the 1:50,00 map spread out on the hood of his armoured vehicle, which could hardly have provided the co-ordinates required for a precision strike.  The Joint Terminal Attack Controllers would have had access to digital imagery stored on their laptops, but by this stage they were running low on batteries and cannibalising the radios of other Green Berets to keep communications with the AC-130 open [334, 383].  ‘The worst part of it,’ Hutchinson said, was that the day after the strike they found a detailed 1:10,000 map produced by a Provincial Reconstruction Team in 2013 ‘with nice crisp imagery, and it had everything labelled with 10-digit grids’ [397].  The commanders of the other two OD-As remembered it differently, both testifying that the map was found in the provincial governor’s office on 1 October.

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All this matters because when the TV sensor operator on the AC-130 (above) inputted the grids that were passed by Hutchinson via his JTAC he found ‘it put me in a field with residential buildings’.  The AC-130 has a sophisticated sensor suite, including high resolution sensors (an All Light Level Television system, infrared detection set and strike radar to permit all weather/night target acquisition).  But reading between the redactions in the investigation report there is some suggestion that there are also known technical issues with the system (perhaps distortion introduced by the aircraft’s height and/or orbit, because the AC-130 had been forced out of its overhead orbit at 2220 by taking evasive action against a surface-to-air threat): ‘Nothing in the immediate location matched the target but from training I was aware that at significant [redacted]…’ [363].

So the sensor operator widened the search and found a large compound 300 metres to the south that appeared to match the description of the target.  It was not difficult to find: the Trauma Centre had its own generator and was the only building in the city that was still brightly illuminated.  At first sight the sensor operator said ‘there was nothing else near the original location that could match the description of a prison.’

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‘As we got closer,’ s/he continued,

I observed multiple [redacted: this is surely MAMs or ‘military-aged males’, a term the US military was supposed to have discontinued, which would explain the otherwise puzzling deletion] walking in between buildings [redacted] entrances with [redacted: guards?] posted. After passing back the information to the JTAC he said the compound was under enemy control and that those [redacted: MAMs?] were declared hostile [363].

The navigator had informed the JTAC that the grids had originally plotted to the middle of a field but they now had a large compound in their sights, a T-shaped structure with an arch gate and nine people ‘roaming outside’.  The Green Berets conferred with the Afghan Special Security Forces in the PCOP who confirmed that this was the NDS compound, and the Fire Control Officer on the AC-130 adjusted the target location in the fire control system accordingly [054, 242].

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But the sensor operator, more mindful of the Tactical Guidance issued by General Campbell (below), testified that he wanted ‘to make sure we were not inadvertently declaring civilians hostile’.

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So he re-entered the original co-ordinates (‘to determine any system [redacted: error?]’) – by then the AC-130 had moved to a more accurate, overhead orbit [057] – and this time the sensor homed in on a second compound:

a much smaller compound with two large buildings, what appeared to be a third smaller shack, two overhangs, a wall surrounding, what appeared to be guard towers at the four corners with a single entrance on the south side of the compound and was unable to observe any movement in that compound [363].

This underscored his concerns.  ‘Now that we are closer,’ he told the rest of the crew,

even though that compound [is] the only one that’s limited and has activity, if you look in the TV’s screen you can see this hardened structure [the second compound] that looks very large and could also be more like a prison with cells. So I just want to verify that before we start declaring people hostile, that we are 100 per cent sure that this is the correct compound [057].

He asked the navigator to request a more detailed target description from the Joint Terminal Attack Controller (though the JTAC was not told that the aircraft’s sensors had now identified two different compounds from the same grids).

The JTAC came back with a target description of multiple buildings with a wall surrounding, and a main gate with an arch shape. I asked for further clarification on which side of the compound that gate was on, to which he replied the North side of the compound. The gate I was able to make out at the first compound was on the north side and matched the target description [363].

The first compound was the MSF Trauma Centre; the second was the NDS compound.

***

The redacted version of the investigation report includes a satellite image of the MSF Trauma Centre but conspicuously failed to include a corresponding image of the NDS compound.  Yet from TerraServer’s satellite imagery (below) it is clear that the two are radically different, and in fact the gate on the NDS compound faced south not north.

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Neither Hutchinson nor his JTAC had access to real-time imagery from the AC-130 because the same antenna that prevented the aircraft receiving the e-mail with the No-Strike List also prevented it from transmitting a video feed to the JTAC’s laptop, and so both the aircrew and the US forces on the ground had to rely on verbal descriptions.  The investigation report calls the characterisation of the target building ‘a vague description’ [034] but, as Mathieu Aikins pointed out in a superb analysis of the strike, ‘it’s actually a rather specific description that corresponds to MSF’s distinctive layout.’  Indeed, when the aircrew compared the two compounds they were persuaded by the description of a ‘T-shaped structure’ that they had identified the correct target.

Once the AC-130 aircrew’s description of the Trauma Centre had been confirmed by the Afghan Special Security Forces as the NDS compound, the circle was closed.  As Hutchinson testified, he had a report from the AC-130 ‘that describes a target, the disposition of the target and the pattern of life on it that’s completely consistent with what I’ve heard from the Afghans…’  Whether the Afghans deliberately substituted a description of the Trauma Centre for the NDS compound remains an open question.  From their own (separate) interviews in Kunduz, both May Jeong and Mathieu Aikins repeatedly raise this as a distinct possibility.  Some informants insisted that the Trauma Centre had been overrun by the Taliban, confirmed (so they said) by raw intelligence and communications intercepts, even that it was being used as a firing position – a claim that was repeated by the government in Kabul in the immediate aftermath of the strike – while others complained that MSF treated Taliban casualties who then returned to the fray: ‘patching up fighters and sending them back out.’  Much of this is ex post facto rationalisation; clearly many Afghans regarded the attack on the Trauma Centre as perfectly justified.  But Aikins asks a more pointed question: Did Afghan forces, out of longstanding mistrust of MSF, draw the United States into a terrible tragedy?’

If they did, then it had to have been a spur-of-the-moment decision to take advantage of a developing situation, since the Afghan Special Security Forces had originally provided the correct grids for the NDS compound.

More telling, I suspect, is that from 0100 until well into the attack on the Trauma Centre the only people who had the co-ordinates for the target now in the sights of the AC-130 were the aircrew, who did not pass the grid location for what they had incorrectly identified as the target back to Hutchinson.  And yet the ground force commander had already told the navigator he had ‘great confidence in the grids passed [057]’, and it is astonishing that this did not prompt a more extensive discussion among the aircrew since the original grids had plotted first to an open field and second to the NDS compound but never to the Trauma Centre that had now been designated as the target.

Neither did the aircrew pass the revised grids back to the Special Operations Task Force who were monitoring events from Bagram.  Repeating Hutchinson’s earlier mistaken assumption, the staff in the Operations Center at Bagram believed the target (‘the NDS prison’) was the Prison in the south of the city which had been included in the original Kunduz City Foothold Establishment plan, and they tasked an MQ-1 Predator to provide surveillance over that location [059].

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Hutchinson could not view the video feed from the Predator, since the laptops in the PCOP were desperately short of batteries, but the Special Operations Task Force did have access to the drone’s real-time imagery.  Nothing was happening around the Prison, and confident that this was the strike location nobody at Bagram attempted to confirm the coordinates until the attack on the Trauma Center was well under way.  At 0207 they heard a sudden, direct transmission from the AC-130 – ‘unreadable numbers followed by going hot/rounds away’ – and ‘the quickness of the going hot call’ suggested to one experienced JTAC at Bagram that ‘there was possibly a dire situation on the ground.’  But ‘the passing of engagement grids was broken, unreadable’, and s/he immediately ‘made multiple attempts to get a resend of [the] grid of engagement’.  Those requests ‘were either not acknowledged or met with “still engaging/hot”‘, but this was ‘not uncommon due to the task saturation during coordination and employment by ground JTACs and aircraft’.   Meanwhile another JTAC in the Operations Centre, realising that ‘no activity was noted at the facility’ – presumably by the Predator on station over the Prison; the Taliban had reportedly freed all the prisoners when they took the city – tasked the Predator crew to ‘find the engagement area’ [261-4].  At 0220 they were successful, and once the new grids had been checked the Operations Center realised that the AC-130 was attacking the Trauma Center.

***

Hutchinson provided two contradictory rationales for the attack.  One was offensive: his JTAC relayed to the AC-130 that Hutchinson’s intent was to ‘soften the target’ (meaning the NDS compound) for the Afghan convoy returning from Camp Pamir.  When the aircrew asked for clarification they were told they were to ‘destroy targets of opportunity that may impede partner forces’ success’ [059].  When he was questioned by the investigating officers, Hutchinson represented this as pre-emptive and precautionary: ‘If they were going to take contact I did not want to play twenty questions while they were taking fire’ [391].  The other was unambiguously defensive: the immediate trigger for Hutchinson to clear the AC-130 to open fire was the sound of automatic gunfire from the east-west road near the NDS compound.

What did it for me in the end was when I believed the [redacted] convoy to be at that parallel cross street … or the perpendicular cross street … to the facility, I heard sustained automatic weapons fire … and it was coming from that general direction. And so I asked the [redacted] are they in contact yet. He can’t get through [to] them at first, and so I think okay, so that’s a sign they’re probably in contact… Fire continues and I ask him again and he says strike now, assume they are decisively engaged’ [393-4].

It’s not clear from the redactions who Hutchinson was talking to, but it was almost certainly someone from the Afghan Special Security Forces in the PCOP.  What is certain – and known to the aircrew on the AC-130, who were also tracking the convoy, but not to Hutchinson – was that the convoy was nowhere near the NDS compound or even the Trauma Centre at that time but 9 km away, still within the northern perimeter of the airfield.

Hutchinson’s attention was on the sound of gunfire.  He explained that most of the fire directed against his forces in the PCOP compound had been from the west, and it was ‘unthinkable’ that ‘there would have been anything functional over there in terms of essential services’ [394] – like a hospital.

And so, at 0202 Hutchinson had his JTAC instruct the AC-130 to strike the ‘objective building first’ and then to provide ‘suppressing fire’ (which the JTAC later described as a ‘PAX cocktail’ and the aircrew translated as ‘MAMs’ [military-aged males]).   Again the aircrew sought clarification; they wanted to be sure that their target was the ‘large T-shaped building in the centre of the compound’ and that ‘we are [also] cleared on people in this compound.’  It was and they were; at 0208 the first round was fired as the Electronic Warfare Officer announced the grids over the radio: the garbled transmission received at Bagram [064-6].

***

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The AC-130 made five passes over the Trauma Centre at 15-minute intervals, firing a total of 211 rounds.  But ’rounds’ fails to convey the scale of the ordnance involved.  As May Jeong notes, the AC-130 is ‘built around a gun’; it is, after all, a gunship.  It has a 105 mm M102 Howitzer that fires high explosive shells at 10 rounds a minute (reputedly the largest gun ever operated from a US aircraft); a 40 mm Bofors cannon that fires 120 rounds a minute; and a 25mm 5-barrelled Gatling cannon that fires incendiary rounds at 1,800 rounds a minute.  YouTube has a video of a live-firing exercise carried out by the 4th Special Operations Squadron in 2016 that is truly chilling:

All these weapons are side-firing; the AC-130 performs a slow left-banking pylon turn in a five-mile orbit to keep its weapons on target for much longer than a conventional strike aircraft:

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The results on the ground were catastrophic.

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All the patients in the ICU died except one, alongside the caretakers who were with them; one doctor, three nurses and a cleaner who were in the ICU were also killed.  Here is Kathleen Thomas again:

I hope with all my heart that the three sedated patients in ICU, including our ER nurse Lal Mohammad, were deep enough to be unaware of their deaths — but this is unlikely. They were trapped in their beds, engulfed in flames.

The same horror that rocked the ICU rocked the rest of the main building as the plane hit with alarming precision. Our ER nurse Mohibulla died. Our ER cleaner Najibulla died. Dr. Amin suffered major injuries but managed to escape the main building, only to then die an hour later in the arms of his colleagues as we desperately tried to save his life in the makeshift operating theater set up in the kitchen next to the morning meeting room.  The OT nurse, Abdul Salam, died. The strikes continued further down the building, tearing through the outpatients department, which had become a temporary sleeping area for staff. Dr. Satar died. The medical records officer Abdul Maqsood died. Our pharmacist Tahseel was lethally injured. He also made it to safety in the morning meeting room, only to die soon after, having bled to death. Two of the hospital watchmen Zabib and Shafiq also died.

Our colleagues didn’t die peacefully like in the movies. They died painfully, slowly, some of them screaming out for help that never came, alone and terrified, knowing the extent of their own injuries and aware of their impending death. Countless other staff and patients were injured; limbs blown off, shrapnel rocketed through their bodies, burns, pressure wave injuries of the lungs, eyes, and ears. Many of these injures have left permanent disability. It was a scene of nightmarish horror that will be forever etched in my mind.

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***

The loss of life and the destruction of the hospital was appalling.  But the effects of the air strike have reverberated far beyond the Trauma Centre and the events of 3 October.  In February this year Sophia Jones told the troubling story of a father of four who lost his right arm and the sight of one eye when he was caught in cross-fire between the Taliban and the Afghan army.  With the destruction of the Trauma Centre in Kunduz there were no local hospitals capable of treating his life-threatening injuries, and it took him two agonising days to travel 200 miles to the Surgical Center for War Victims run by another NGO, Emergency, in Kabul – now ‘the only free, specialized trauma hospital of its kind treating war victims in Afghanistan.’  Like MSF, Emergency is absolutely clear that ‘we cannot be on one side of the war’: ‘a patient is a patient’.  Like MSF, most of Emergency’s patients are civilians.  But, as Luke Mogelson found in the spring of 2012,

At Emergency’s hospital in Kabul, it’s not unusual to find Afghan national security forces recovering in the same ward as Taliban insurgents, and after a while, the ideas that make enemies of the two men lose their relevance; the daily spectacle of their impact on human bodies invalidates them.

That was then.  ‘After Kunduz’, Emergency’s program co-ordinator now concedes, ‘anything is possible.’  It would be truly, desperately awful if one of the casualties of the air strike on the Trauma Centre turned out to be the core principle of medical neutrality.

One year after Kunduz, Christopher Stokes, MSF’s General Director, warned that ‘A war without limits leads to a battlefield without doctors.’  MSF pledged not to allow that to happen.  They must not stand alone.

To be continued

Rights and REDACTED

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At Just Security the debate over the US air strike on the MSF Trauma Centre in Kunduz (see here and here) rumbles on, specifically around whether acknowledged violations of international humanitarian law (‘the laws of war’) constitute war crimes (see my previous post here).  The latest contribution is from Adil Ahmad Haque and it is extremely helpful.

But I’m struck by its title: ‘What the Kunduz report gets right (and wrong).‘  I’ve now read the report several times, and am working on my own commentary: but it turns out to be extremely difficult to know what the report gets right or wrong.

I say this having read multiple Investigation Reports, known collectively as Army Regulation 15-6 Reports, into civilian casualties caused by US military action.  They vary enormously in quality – the scope of the questions and the depth of the analysis – and in what has been released for public inspection.   Of all those that I have read, the report into the Uruzgan air strike in February 2010 that I discuss in ‘Angry Eyes‘ (here and here; more to come) now seems a model to me (see also here).

It’s redacted, but it includes real-time transcripts of radio communications between the aircrews and the ground force commander through his Joint Terminal Attack Controller, and after action transcripts of (sometimes highly combative) interviews with the principals involved.  In Kill-chain, Andrew Cockburn reports that the first act of the Investigating Officer, Major-General Timothy McHale, was to fly to the hospital where the wounded were being treated, and six weeks later he and his team had created ‘a hand-drawn time-line of the events that ultimately stretched for sixty-six feet around the four walls of the hangar he had commandeered for his office.’

This is very different from the unclassified version of the report into the Kunduz incident.  The investigation was headed by Major-General William Hickman, with two Assistant Investigating Officers – Brigadier-General Sean Jenkins and Brigadier-General Robert Armfield – supported by an unidentified Legal Advisor and five unidentified subject matter specialists in Special Operations; Intelligence, Surveillance and Reconnaissance;  AC-130 Aircrew Operations (this was the gunship that carried out the attack); Joint Targeting; and JTAC Operations.

The final report with its annexes reportedly runs to 3,000 pages, but the released version is much slimmer.   It has been redacted with a remarkably heavy hand.  I understand why names have been redacted – they were in the Uruzgan case too – but to remove all direct indications of rank or role from the various statements makes interpretation needlessly burdensome.

Some redactions seem to have been made not for reasons of security or privacy but to save embarrassment.  For example: from contextual evidence I suspect that several references to ‘MAMs’ or ‘military-aged males’ – a term that was supposedly removed from US military vocabulary – have been excised, but some have escaped the blunt red pencil.  On page after page even the time of an event has been removed: this is truly bizarre, since elsewhere the report is fastidious in fixing times and, notably, insists that the aircraft fired on the Trauma Center for precisely ‘30 minutes and 8 seconds’. The timeline matters and is central to any proper accounting for what happened: why suppress it?

Again in stark contrast to the Uruzgan report, the public version of the Kunduz report includes remarkably few transcriptions of the ‘extensive interviews’ its authors conducted with US and Afghan personnel or with MSF officials – too often just terse memoranda summarising them.

The AC-130 video has been withheld from public scrutiny – this was done in the Uruzgan case too – but, apart from a few selected extracts, the audio transcripts that were central to the Uruzgan case have been omitted from this one as well: and they are no less vital here.

Even if we bracket understandable concerns about the US military investigating itself, how can the public have any confidence in a report where so much vital information has been excluded?  If the military is to be accountable to the public that it serves and the people amongst whom (and for whom) it fights, then its accounts of incidents like this need to be as full and open as security and privacy allow.  Otherwise we pass into an Alice-in-Wonderland world where the Freedom of Information Act becomes a Freedom of Redaction Act.

As you’ll see, I’ll have more questions about the substance of the report when I complete my commentary.

War crimes

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In my preliminary commentary on the US military investigation into the air strike on MSF’s trauma centre in Kunduz in October 2015 – and I’ll have much more to say about that shortly – I circled around the Pentagon’s conclusion that even though those involved in the incident had clearly violated international humanitarian law (‘the laws of war’) and the Rules of Engagement no war crimes had been committed.

That conclusion has sparked a fire-storm of protest and commentary, and to track the narrative I’ve transferred some of my closing comments from that post to this and continued to follow the debate.  (It’s worth noting that when the Pentagon published its updated Law of War Manual last year it produced an equally heated reaction – much of it from commentators who complained that its provisions hamstrung commanders and troops in the field: see here and scroll down).

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At Just Security Sarah Knuckey and two of her students complained that the report provided no justification for such a claim. After listing the gross violations of IHL (failure to take precautions in an attack, failure to distinguish between civilians and combatants, failure to respect the requirement of proportionality), they concluded:

While it is legally correct to state that the war crime of murder requires an “intent” to kill a protected person (e.g., a civilian), nowhere in the 120-page report is there an analysis of the legal meaning of “intention.” The report actually makes no specific or direct findings about war crimes. (“War crime” appears only once, in reference to a report by the United Nations Assistance Mission in Afghanistan) [Here I should note that UNAMA’s view of what constitutes a war crime has on occasion changed with the perpetrator.  As this commentary shows, the Taliban have sometimes been held to a higher standard than the US military: in one case UNAMA suggested that the very use of high explosives in an urban area ‘in circumstances almost certain to cause immense suffering to civilians’ rendered the Taliban guilty of war crimes, whereas after the Kunduz air strike UNAMA declared that ‘should an attack against a hospital be found to have been deliberate, it may amount to a war crime’ (emphasis added)] .

Under international law, “premeditation” is not necessary for the war crime of murder, but the precise scope of intention is less clear. Numerous cases have stated that genuine mistakes and negligence are insufficient for murder. But a number of international cases and UN-mandated inquiries have found that “recklessness” or “indirect intent” could satisfy the intent requirement. Article 85 of Additional Protocol I also provides that intent encompasses recklessness. (See The 1949 Geneva Conventions: A Commentary, from page 449, for a full discussion.)

The investigation released today makes clear that US forces committed numerous violations of fundamental rules of the laws of war, violations which should and could have been avoided. Yet the report provides zero direct analysis of whether these violations amounted to war crimes. Given the seriousness of the violations committed, the US should specifically explain why the facts do not amount to recklessness, and explain the legal tests applied for the commission of war crimes.

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Over at Lawfare, Ryan Vogel argues that the report will ‘will surely attract the attention of the International Criminal Court’s (ICC) Office of the Prosecutor (OTP)’. In fact, while the OTP has acknowledged

that the strike was being investigated by the United States [it has also] declared that “the [a]lleged crimes committed in Kunduz [would] be further examined by the Office” as part of the ongoing preliminary examination [see extract below]. By characterizing the incident as a violation of international law (and choosing not to prosecute), the United States may unwittingly be strengthening the OTP’s case. It is true that CENTCOM’s release statement makes clear that the investigation found that the actions of U.S. personnel did not constitute war crimes, noting the absence of intentionality. But the OTP might disagree with CENTCOM’s legal rationale, as it seems to have done previously with regard to detention operations, and decide to investigate these acts anyway as potential war crimes.

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As both commentaries make clear, much hangs on the interpretation of ‘intentionality’.  At Opinio Juris the ever-sharp Jens David Ohlin weighs in on the question.  Drawing from his essay on ‘Targeting and the concept of intent‘, he notes:

The word “intentionally” does not have a stable meaning across all legal cultures. … [It] is generally understood in common law countries as equivalent to purpose or knowledge, depending on the circumstances. But some criminal lawyers trained in civil law jurisdictions are more likely than their common law counterparts to give the phrase “intentionally” a much wider definition, one that includes not just purpose and knowledge but also recklessness or what civilian lawyers sometimes call dolus eventualis.

He concludes that the consequences of the latter, wider interpretation would be far reaching:

If intent = recklessness, then all cases of legitimate collateral damage would count as violations of the principle of distinction, because in collateral damage cases the attacker kills the civilians with knowledge that the civilians will die. And the rule against disproportionate attacks sanctions this behavior as long as the collateral damage is not disproportionate and the attack is aimed at a legitimate military target. But if intent = recklessness, then I see no reason why the attacking force in that situation couldn’t be prosecuted for the war crime of intentionally directing attacks against civilians, without the court ever addressing or analyzing the question of collateral damage. Because clearly a soldier in that hypothetical situation would “know” that the attack will kill civilians, and knowledge is certainly a higher mental state than recklessness. That result would effectively transform all cases of disproportionate collateral damage into violations of the principle of distinction and relieve the prosecutor of the burden of establishing that the damage was indeed disproportionate, which seems absurd to me.

His solution is to call for the codification of  ‘a new war crime of recklessly attacking civilians, and the codification of such a crime should use the word “recklessly” rather than use the word “intentionally.”’  This would then  ‘create a duty on the part of attacking forces and then penalize them for failing to live up to it.’  And this, he concludes, would allow a prima facie case to be made that those involved in the attack on the Kunduz trauma centre were guilty – but in his view, clearly, they also escape under existing law.

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Note those five, deceptively simple words: ‘those involved in the attack’.  I’ve had occasion to comment on this dilemma before – the dispersal of responsibility that is a characteristic of later modern war (see also here: scroll down) – and Eugene Fiddell, writing in the New York Times, clearly dismayed at the way in which the military inquiry was conducted, sharpens the same point:

Among the challenges a case like Kunduz presents is how to achieve accountability in an era in which an attack on a protected site is not the act of an isolated unit or individual. In today’s high-tech warfare, an attack really involves a weapons system, with only some of the actors in the aircraft, and others — with real power to affect operations — on the ground, in other aircraft, or perhaps even at sea.

And what if some of those ‘actors’ are algorithms and/or machines?

UPDATE:  Kevin Jon Heller offers this counter-reading to Jens’s:

As I read it, the war crime of “intentionally directing attacks against a civilian population” consists of two material elements: a conduct element and a circumstance element. (There is no consequence element, because the civilians do not need to be harmed.) The conduct element is directing an attack against a specific group of people. The circumstance element is the particular group of people qualifying as a civilian population. So that means, if we apply the default mental element provisions in Art. 30, that the war crime is complete when (1) a defendant “means to engage” in an attack against a specific group of people; (2) that specific group of people objectively qualifies as a civilian population; and (3) the defendant “is aware” that the specific group of people qualifies as a civilian population. Thus understood, the war crime requires not one but two mental elements: (1) intent for the prohibited conduct (understood as purpose, direct intent, or dolus directus); (2) knowledge for the necessary circumstance (understood as oblique intent or dolus indirectus).

Does this mean that an attacker who knows his attack on a military objective will incidentally but proportionately harm a group of civilians commits the war crime of “intentionally directing attacks against a civilian population” if he launches the attack? I don’t think so. The problematic element, it seems to me, is not the circumstance element but the conduct element: although the attacker who launches a proportionate attack on a legitimate military objective knows that his attack will harm a civilian population, he is not intentionally attacking that civilian population. The attacker means to attack only the military objective; he does not mean to attack the group of civilians. They are simply incidentally — accidentally — harmed. So although the attacker has the mental element necessary for the circumstance element of the war crime (knowledge that a specific group of people qualifies as a civilian population) he does not have the mental element necessary for its conduct element (intent to attack that specific group of people). He is thus not criminally responsible for either launching a disproportionate attack or intentionally directing attacks against a civilian population.

It’s a sharp reminder that international humanitarian law offers some protections to civilians but still renders their killing acceptable.  The exchange between Kevin and Jens continues below the line to this conclusion:

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But if you read Charles Dunlap at Lawfire (sic), you will find him insisting that the mistakes made by the US military in firing on the MSF hospital ‘do not necessarily equate to criminal conduct’ – even though the investigation report concedes that they amounted to violations of international law – and that the charge of recklessness needs to be laid at the smashed-in door of MSF.  Really.  Here is what he says:

Had, for example, the hospital been marked with large Red Crosses/Red Crescents or one of the other internationally-recognized symbols (as the U.S. does) or something that would make its protected use clear from the air, isn’t it entirely plausible that the aircrew (or someone) might have recognized the error and stopped the attack before it began?

There were in fact two large MSF flags on the roof of the Trauma Centre, which was also one of the few buildings in the city on that fateful night to have been fully illuminated (from its own generator).

But in case you are still wondering about the responsibility borne by MSF – as ‘one of the few international humanitarian organisations that carries professional liability insurance’ (in contrast to amateur insurance, I presume), Dunlap says that is an admission that ‘even honest, altruistic, and well-intended professionals do make mistakes, even tragic ones, especially when trying to operate in the turmoil of a war zones’,  here is a paragraph from that investigation report:

MSF reach-out JPEG

How reckless was that?  The crew of the gunship that carried out the attack – in case you are still wondering – ‘specifically did not have any charts showing no strike targets or the location of the MSF Trauma Center.’

And if you picked up on Dunlap’s suggestion that if not the aircrew then ‘someone’ might have recognised the error, try this for size from the same source (and note especially the last sentence):

Multiple command failures JPEG

More to come.

‘Acceptable CIVCAS is 0’

Kunduz 0 Extract JPEG

Finally US Central Command has released a redacted version of its investigation into the US airstrike on MSF’s Trauma Center in Kunduz (see my posts here, here and especially here).  You can download it from CENTCOM’s Freedom of Information Act library here.  (All the extracts pasted below capture communications exchanges before the attack, but the report includes redacted interviews with the participants involved in clearing, executing and continuing the air strike; the image above – and the title for this post – is taken from a briefing slide included in the report).

Kunduz A extract JPEG

I’ll be spending the weekend reading it, but meanwhile the Intercept has published its own long-form account of the attack by May Jeong – ‘Death from the sky: searching for ground truth in the Kunduz hospital bombing‘.  It was written before CENTCOM’s investigation was released but includes details from a series of interviews and is truly compelling reading.

Kunduz B extract JPEG

I obviously won’t be alone in working my way through the report.  Yesterday MSF was briefed by the head of CENTCOM, General Joseph Votel, and today released this preliminary statement:

MSF will take the time necessary to examine the U.S. report, and to determine whether or not the U.S. account answers the many questions that remain outstanding seven months after the attack.

MSF acknowledges the U.S. military’s efforts to conduct an investigation into the incident. Today, MSF and other medical care providers on the front lines of armed conflicts continually experience attacks on health facilities that go un-investigated by parties to the conflict. However, MSF has said consistently that it cannot be satisfied solely with a military investigation into the Kunduz attack. MSF’s request for an independent and impartial investigation by the International Humanitarian Fact Finding Commission has so far gone unanswered….

The hospital was fully functioning at the time of the airstrikes. The U.S. investigation acknowledges that there were no armed combatants within – and no fire from – the hospital compound.

The nature of the deadly bombing of the MSF Kunduz Trauma Centre, and the recurring attacks on medical facilities in Afghanistan, demand from all parties to the conflict a clear reaffirmation of the protected status of medical care in the country. MSF must obtain these necessary assurances in Afghanistan before making any decision on if it is safe to re-start medical activities in Kunduz.

Kunduz C extract JPEG

The Pentagon has insisted that no war crimes were committed but confirmed that 16 people had been punished.  Mark Thompson explains:

None of those involved will face court martial, but the administrative punishments levied against them—ranging from removal from command, letters of reprimand, to counseling—likely mark the end of their careers in uniform. None was identified by name. Those involved—the highest-ranking was a two-star general—included those aboard the AC-130 gunship that repeatedly fired on the Doctors Without Borders hospital in Kunduz, as well as members of the Army Special Force team on the ground that called in the strikes.

MSF has, understandably, condemned this response, arguing that the punishments

are out of proportion to the destruction of a protected medical facility, the deaths of 42 people, the wounding of dozens of others, and the total loss of vital medical services to hundreds of thousands of people. The lack of meaningful accountability sends a worrying signal to warring parties, and is unlikely to act as a deterrent against future violations of the rules of war.

That last sentence is particularly important, because there has been a steady increase in the targeting of medical personnel and medical facilities in Afghanistan, occupied Palestine, Syria and elsewhere: all gross violations of medical neutrality.

Kunduz D extract JPEG

So this commentary from Joanne Liu (International President of MSF) and Peter Maurer (President of the International Committee of the Red Cross) – also published today – is much more than a response to the bombing of yet another MSF facility, this time in Aleppo:

What we are witnessing is a sustained assault on, and massive disregard for, the provision of healthcare during times of conflict. Under international humanitarian law and principles, health workers must be able to provide medical care to all sick and wounded regardless of political or other affiliation, whether they are a combatant or not. And under no circumstances should they be punished for providing medical care which is in line with medical ethics. The doctor of your enemy is not your enemy.

But we are confronted with violations of these fundamental rules, with serious humanitarian consequences, for entire communities and healthcare systems that are already stretched to the limit. And this is not just the opinion of MSF and the Red Cross Red Crescent Movement.

That is why we, as the presidents of MSF and the ICRC, welcome the proposal for a landmark UN resolution to protect healthcare. But we urge the UN security council to make the resolution effective. First, it should send a powerful political message that healthcare needs to be protected. All parties to an armed conflict must fully comply with their obligations under international law, including humanitarian law. And they must clearly state their respect for the delivery of impartial medical care during times of conflict.

Second, it must urge states and all parties to armed conflict to develop effective measures to prevent violence against medical personnel, facilities and means of transport. States need to bolster, where appropriate, their legislation including by lifting restrictions and sanctions impeding impartial wartime medical care.

Armed forces and all parties to a conflict should integrate practical measures for the protection of the wounded and sick and for those engaged in medical work. These should be incorporated into orders, rules of engagement, standard operating procedures and training.

Third, it must acknowledge that when attacks on medical facilities and personnel do take place, there needs to be full, prompt, impartial and independent investigations to establish the facts. It cannot only be the victims or perpetrators who attempt to establish the facts. And there should be regular and formal reporting of such attacks at the highest level and an annual debate in the security council.

Underpinning everything has to be the acceptance that the medical needs of people – no matter who they are, where they are from or what side they support or fight for – must take precedence. Medical staff are present in areas of conflict in order to care for the sick and wounded, on the basis of need. And only need. This is the fundamental principle of impartiality and is the basis of medical ethics. It is the very fact that doctors treat on the basis of need – and are not involved in hostilities – that they can claim protection under international humanitarian law.

But there is more.  John Sifton from Human Rights Watch insists that General Viotel was simply wrong to claim that war crimes must be deliberate or intentional, so that those involved in the attacks on the MSF hospital could be absolved of criminal responsibility because the acts they committed were genuine mistakes.  According to the New York Times, Sifton argued:

There are legal precedents for war crimes prosecutions based on acts that were committed with recklessness, and that recklessness or negligence do not necessarily absolve someone of criminal responsibility under the United States military code.