Paper trails

For an update and succinct review of attacks on hospitals and medical facilities in Syria – see also my ‘Your turn, doctor’ here – I recommend the latest fact-sheet from Physicians for Human Rights:

Attacks on health care, in gross violation of humanitarian norms and the Geneva Conventions, have been a distinctive feature of the conflict in Syria since its inception. PHR has documented and mapped 553 attacks on at least 348 separate facilities from March 2011 through December 2018. The reduction in the number of attacks over the past year is a clear reflection of the diminishing intensity of the conflict, which came as a direct result of the Syrian government’s takeover of most opposition-held areas. The systematic targeting of health facilities has been a crucial component of a wider strategy of war employed by the Syrian government and its allies – who are responsible for over 90 percent of attacks – to punish civilians residing in opposition- held territories, destroy their ability to survive, and draw them into government-held areas or drive them out of the country. This strategy of unbridled violence – which in addition to attacks on healthcare has included chemical strikes, sieges, and indiscriminate bombing of predominantly civilian areas – has devastated the civilian population, weakened opposition groups, and translated into direct military gains for the Syrian government.

Of the total number of documented attacks on health facilities, nearly 73 percent were carried out from the air. Nearly 98 percent of attacks on health facilities perpetrated from the air are attributable to the Syrian government and its ally Russian, which entered the conflict in 2015.

The share of attacks on health facilities from the air has grown from 38 percent of the total in 2012 to 90 percent in 2018. The Syrian government became steadily more reliant on airpower as the conflict evolved. Through their air forces, the Syrian government and Russia extended their strategy of collective punishment deep into opposition-held territory and far beyond hardened front lines. The Syrian government and its allies disabled or destroyed hundreds of facilities through aerial bombardment, leaving countless civilians without access to vital medical services.

The latest 20-page report from the Independent International Commission of Inquiry on the Syrian Arab Republic to the UN’s Human Rights Council is here.  I’ve drawn on many of these reports for my continuing work on siege warfare in Syria (see for example here, here and here), and this report – based on investigations carried out from 11 July 2018 to 10 January 2019 – makes for grim reading.  Here is the summary (but you really need to consult the full report):

Extensive military gains made by pro-government forces throughout the first half of 2018, coupled with an agreement between Turkey and the Russian Federation to establish a demilitarized zone in the north-west, led to a significant decrease in armed conflict in the Syrian Arab Republic in the period from mid July 2018 to mid January 2019. Hostilities elsewhere, however, remain ongoing. Attacks by pro-government forces in Idlib and western Aleppo Governorates, and those carried out by the Syrian Democratic Forces and the international coalition in Dayr al-Zawr Governorate, continue to cause scores of civilian casualties.

In the aftermath of bombardments, civilians countrywide suffered the effects of a general absence of the rule of law. Numerous civilians were detained arbitrarily or abducted by members of armed groups and criminal gangs and held hostage for ransom in their strongholds in Idlib and northern Aleppo. Similarly, with the conclusion of Operation Olive Branch by Turkey in March 2018, arbitrary arrests and detentions became pervasive throughout Afrin District (Aleppo).

In areas recently retaken by pro-government forces, including eastern Ghouta (Rif Dimashq) and Dar’a Governorate, cases of arbitrary detention and enforced disappearance were perpetrated with impunity. After years of living under siege, many civilians in areas recaptured by pro-government forces also faced numerous administrative and legal obstacles to access key services.

The foregoing violations and general absence of the rule of law paint a stark reality for civilians countrywide, including for 6.2 million internally displaced persons and 5.6 million refugees seeking to return. For these reasons, any plans for the return of those displaced both within and outside of the Syrian Arab Republic must incorporate a rights- based approach. In order to address effectively the complex issue of returns, the Commission makes a series of pragmatic recommendations for the sustainable return of all displaced Syrian women, men and children.

A report from Elizabeth Tsurkov in Ha’aretz confirms many of these findings.  Describing Assad’s Syria as a police state with rampant poverty’ and a ‘playground for superpowers’, she writes:

Eight years into the crisis, Syria’s economy is in tatters, half of its population displaced, hundreds of thousands of Syrians are dead, many of Syria’s cities and towns lie in ruins. Yet on top of this pile of ashes Assad sits comfortably, quite secure in his grip on power.
In areas reconquered by the regime — or as the regime euphemistically describes it, areas that “reconciled” and whose residents “returned to the bosom of the nation” — the Syrian police state is back, more aggressive than ever…

In 2011, Syrians took pride in “breaking the barrier of fear.” But fear now prevails, as the various branches of the regime’s secret police launch raids and arrest suspected disloyal elements. Many of those arrested are former activists, rebels, health and rescue workers, and civil society leaders. Syrians who wish to prove their loyalty to the regime, obtain power through it or simply settle personal scores inform on others to the regime. Suhail al-Ghazi, a Syrian analyst based in Istanbul, told Haaretz that Syrians are informing on each other “because they have been doing it for years or because they need money or favors from the regime.” In areas recently recaptured by the regime, “some locals were always pro-regime and stayed there to work as informants or just could not leave. Now they have the chance to take revenge on the majority of civilians who apparently held a more favorable view of the opposition,” Ghazi explained.

Most of Syria’s population now lives below the poverty line. Across all parts of Syria unemployment rates are high, as the normal economy has been disrupted by years of war and the mass flight of businesspeople and capital out of the country. Syria’s middle class has largely disappeared — many of them fled to neighboring countries or Europe, while others are now living in abject poverty, along with most Syrians.
A small group of war profiteers linked to the various armed groups have been able to enrich themselves by trading in oil, weapons, antiquities, stealing aid, and smuggling people and goods in and out of the country and into besieged areas, while most Syrians struggle to survive. Nearly two-thirds of Syrians are dependent on aid for their subsistence. Basic services like electricity, cooking gas, clean water and health services are lacking in many parts of the country.

Speaking on the condition of anonymity, a resident of Latakia — an area where many of the regime’s leadership and their relatives reside — told Haaretz: “You have corruption everywhere. Bribing was common before the war, but now it is endemic.”
He described the ostentatious displays of ill-gotten wealth: “High-ranking officials, they and their families, have more rights. They roam the city in fancy cars and do whatever they want. Half of the country is dying from hunger, while the sons of officials are arrogantly showing off their wealth. With money you can do everything. This is not new, but it has become more obvious because of the lawlessness prevailing in Syria.”

At the sub-regional scale Enab Baladi filed a revealing report last month on conditions in the Ghouta (which it describes as ‘military-ruled ruins’):

Today, Ghouta is living in a state of siege similar to that it witnessed between 2013 and 2018 at the service, relief and security levels, but the difference is that food is available.

With dozens of announcements about the restoration of electricity to areas east of the capital, as well as the restoration of water and communication services, the needs of civilians are still not covered by those services repeatedly announced by the regime.

Enab Baladi spoke to five people from the eastern Ghouta who returned to it, all of whom refused to be identified for fear of the regime prosecution. They described the service situation as “miserable”, especially with regard to the water and electricity services.

According to the five sources, the electricity is continuously cut for five hours, operates for only one hour, and then it is cut again, while water reaches homes one hour a day, and people rely on submersibles and artesian wells which they dug during siege in the previous years to get water.

Some areas of Ghouta also lacked many of the services that were the top priorities of organizations before the regime forces controlled the region, while food today enters without manipulated prices, unlike in the past….

The report describes Eastern Ghouta as riven by checkpoints; an emphasis on demolition rather than reconstruction; and continuing arrests and detentions.

In early August [2018], al-Assad forces launched a campaign of arrests, which has been considered as one of the largest security operations since the regime took over Ghouta, for it has targeted the regime dissidents and activists in the Syrian revolution. The campaign was carried out in the cities and towns of Saqba, Hamuriyah, Duma, Mesraba, and Ein Tarma.

The regime also subjected local activists, civil society workers, and former media professionals, as well as members of local councils and relief agencies, to investigations into the aids they received when the area was held by the opposition.

Security branches launched arrest campaigns targeting members of the former “local council” and other members of Rif-Dimashq Provincial Council in the city of Kafr Batna in central Ghouta, according to Enab Baladi referring to local sources.

Sources affiliated to the council told Enab Baladi that Syrian security forces raided the houses and workplaces of the detainees before taking them to an unknown destination. Other local council members, who preferred to stay in Ghouta rather than go to northern Syria, are detained for the same reasons.

In the face of all that, it’s not easy to find grounds for optimism, but there is a glimmer of hope in a report from Maryam Saleh at The Intercept:

Syrian activists and lawyers are testing the bounds of international law, making two new attempts to bring the government of Bashar al-Assad before the International Criminal Court.

Syrian refugees in Jordan, through London-based lawyers, sent communications to the office of the ICC prosecutor, asking her to exercise jurisdiction over Syria based on a precedent set last year in a case involving Myanmar’s persecution of Rohingya Muslims. The communications are the latest push by Syrian civilians to hold accountable the government whose brutality upended their lives. In recent years, Syrian lawyers and human rights activists have experimented with rarely utilized aspects of international law, succeeding in getting European and American courts to weigh in on atrocities committed in Syria.

“Because of how politicized the war in Syria became, lawyers and those fighting for accountability really had to be creative,” said Mai El-Sadany, the legal and judicial director at the Washington-based Tahrir Institute for Middle East Policy. “The most recent ICC Article 15 submissions” — a reference to communications with the ICC on information about alleged international crimes — “are evidence of this, that there is space for creativity in the accountability space.”

She continues:

Even when the evidence of potential crimes exists, investigations into crimes committed in states that have not ratified the Rome Statute are near impossible because of jurisdictional issues, and U.N. Security Council members are quick to use their veto power to block investigations into crimes potentially committed by their allies.

That’s what makes the various avenues Syrians are pursuing so significant. As of last March, more than two dozen cases had been filed in European courts regarding atrocities committed by the Syrian regime, rebel fighters, and the Islamic State and other fundamentalist militant groups. The family of Marie Colvin, an American journalist killed in 2012 while reporting from the city of Homs, sued the Syrian government in a U.S. district court; in January, the court found Syria responsible for killing Colvin.

Many of the cases in Europe were brought under a legal doctrine known as universal jurisdiction; application of the doctrine varies from country to country, but it essentially allows for courts to prosecute cases regardless of where the crime was committed or whether the accused party has any links to the prosecuting state.

The biggest success so far has been in Germany, where authorities last month arrested a former high-ranking Syrian intelligence officer and two others who are accused of crimes against humanity for torturing detainees in Syrian prisons. Other cases remain pending in France, Sweden, and Spain….

These attempts are possible in part due to an unprecedented level of documentation of crimes in Syria. The victims in some of the cases were identified from a trove of 28,000 photos of people killed in Syrian detention centers, smuggled out of the country by a military defector codenamed Caesar. The U.N. General Assembly, in December 2016, took the step of creating the International, Impartial, and Independent Mechanism to investigate crimes in Syria since 2011. The IIIM, as the body is known, does not have independent prosecutorial authority, but it exists to collect information that could later be provided to courts or tribunals with jurisdiction over the crimes. Last year, 28 Syrian nongovernmental organizations committed to collaborating with the IIIM on its work.

This is heartening in its way, but whenever I’ve been asked about attempts to enforce accountability in relation to the systematic attacks on hospitals, I’ve had to say that the hideous intimacy between torturer and tortured allows for an identification and assignment of culpability that is much more difficult in the case of the extended ‘kill-chain’ involved in bombing.

But that doesn’t mean it’s impossible: we know, from the courageous work of activists cited in Maryam’s report, that Assad’s security apparatus fetishized record-keeping, and that many of those records have been smuggled out of Syria so that they can now serve as testimony and evidence  (For other testimonies, see the work of Forensic Architecture on Saydnaya Prison that I described here: scroll down).  To sharpen the point, hare some of the slides from a presentation I once gave around precisely these questions:

If my work on bombing in other theatres of war is anything to go by, there will also be extensive trails (paper or digital) that animated the air strikes: though how they can ever be exposed is another question.

War Doctor

I’m still converting my ‘Trauma Geographies‘ lecture into an essay – which has involved writing a prequel of sorts, ‘Woundscapes of the Western Front‘ – so, with my head buzzing with first-person accounts of trauma surgery on the front-lines, I was thrilled to see that David Nott has just published an account of his marvellous work in Syria (and many other conflict zones), War Doctor: Surgery on the Front Line (Pan Macmillan):

For more than twenty-five years, David Nott has taken unpaid leave from his job as a general and vascular surgeon with the NHS to volunteer in some of the world’s most dangerous war zones. From Sarajevo under siege in 1993, to clandestine hospitals in rebel-held eastern Aleppo, he has carried out life-saving operations and field surgery in the most challenging conditions, and with none of the resources of a major London teaching hospital.

The conflicts he has worked in form a chronology of twenty-first-century combat: Afghanistan, Sierra Leone, Liberia, Darfur, Congo, Iraq, Yemen, Libya, Gaza and Syria. But he has also volunteered in areas blighted by natural disasters, such as the earthquakes in Haiti and Nepal.

Driven both by compassion and passion, the desire to help others and the thrill of extreme personal danger, he is now widely acknowledged to be the most experienced trauma surgeon in the world. But as time went on, David Nott began to realize that flying into a catastrophe – whether war or natural disaster – was not enough. Doctors on the ground needed to learn how to treat the appalling injuries that war inflicts upon its victims. Since 2015, the foundation he set up with his wife, Elly, has disseminated the knowledge he has gained, training other doctors in the art of saving lives threatened by bombs and bullets.

War Doctor is his extraordinary story.

There’s a good review in The Guardian here,

If you’re unfamiliar with David’s extraordinary efforts in Syria, I touch on them – all too briefly – in ‘Death of the Clinic’ here.  And the David Nott Foundation Facebook page is here.

Towards dissipating the fog of war

Following on from my previous post – and my work on the gas attacks on Douma in April 2018 (see here) – I’ve been reading a detailed analysis by James Harkin over at the Intercept, ‘What Happened in Douma? Searching for Facts in the Fog of Syria’s Propaganda War.’

James emphasises the multiple versions of the Douma attack that were produced (and remain in circulation) and the wider implications of this studied polyvocality:

At least one chemical attack did take place in Douma on April 7 [2018], and people died as a result. There could have been no other culprit but a Syrian army helicopter. But the way it happened bears little resemblance to what was broadcast to the world. From the start, the evidence presented by rebel media activists was fraught and confusing. That’s hardly surprising, because some of those behind it — including some who produced immediate and detailed reports — weren’t actually there. Into the gaps of that initial propaganda barrage seeped skepticism, which morphed into confusion and outright conspiracy-theorizing. State actors, Russian propagandists, and international observers joined the fray, cherry-picking details to illustrate the story they wanted told. Added to the fog of war, in other words, was a fractious new layer of electronic propaganda that turned every tweet or screengrab into a potential weapon in the hands of one of the belligerents.

Beyond the war in Syria, the cloud of misinformation that enveloped the attack in Douma stands as a cautionary tale. In the era of “fake news,” it is a case study in the choreography of our new propaganda wars. With the mainstream media in wholesale retreat — and, in the case of Syria, credibly threatened with death from many sides — new information actors have stepped into the breach. Reading the runes of their imagery is an exciting reporting tool. But their photos, video, and social media posts also offers a vanishingly narrow, excoriatingly subjective view of how conflicts unfold. As a result, such artifacts have become light weapons in an information war that easily becomes an end in itself.

He then provides an intricate choreography of his own visit to Douma on 9 July 2018, three days after the Organisation for the Prohibition of Chemical Weapons (OPCW) published its interim report on the attack (see also here).

James was accompanied by officials from the Syrian Information Ministry – and he’s clearly aware of the limitations this imposed on what he saw and what he heard from those who remained in Douma after the forced evacuations – and interlaces his observations and interviews with the digital evidence examined by Forensic Architecture and bellingcat that I discussed in my original essay.

It’s an unsettling analysis, though I think it makes remarkably little (much too little) of two issues.  First, the pre-existing pattern of chemical attacks in Syria in general and East Ghouta in particular (see, for example, here):

And second, the deliberate disinformation campaigns launched by Russia and Syria, revolving around multiple and demonstrably false narratives of ‘staging’ (again, the details are in my original essay here) and their circulation by witting or unwitting commentator-journalists.  This matters because (as is the case with other, ongoing investigations that have exposed systematic falsehoods on the grand, one might say presidential scale) the core question is surely: why lie if you have nothing to hide?

For all that, James’s investigation adds significant layers to our understanding of what happened on that awful April night.

First, like several analysts, James is puzzled by the location of the gas canisters shown on videos after the attack, and his interview with a former official with the Organisation for the Prohibition of Chemical Weapons (OPCW) is highly suggestive:

[S]uspicions that the canisters had been moved didn’t lead the former OPCW official to conclude that there hadn’t been a chemical attack by Syrian military aircraft. In fact, given the dozens dead, which didn’t fit with the usual toll of injuries from breathing difficulties and vomiting that result from a Syrian chlorine bomb, and that the victims had apparently dropped unconscious on the spot, he thought it possible that the Syrian air force had used another more murderous poison, one that hadn’t been captured in the OPCW report. But for camerapeople desperate to show they had the goods and get the world on their side, he guessed, those videos of gas canisters and outsized gas masks made “compelling images.” The temptation, he said, is to “bring your own munition in.”

He’d seen such staging himself, the former OPCW official confided. In an infamous attack on an aid convoy on the outskirts of Aleppo in September 2016, which killed 14 civilians, he concluded that pieces of alleged photographic evidence had very likely been introduced or faked. In addition, he maintained, “some opposition witnesses had clearly been coached.” Ultimately, it didn’t matter, the official said; six months later the United Nations had rightly declared the Syrian government responsible. It was just “media ops,” he said; the activists had simply been concerned to get their narrative out as quickly and forcefully as they could.

Second, James contacts Theodore Postol – who, as I noted in my own essay, had cast doubt on reports of earlier chemical attacks on East Ghouta – who provides a plausible counter-narrative to claims that the attack was somehow staged:

When I showed videos of the canisters to Theodore Postol in Boston, he was immediately certain that both had been launched from the sky by the Syrian military and that any “brouhaha” from the Russians to the contrary could be safely ignored…

[He] concurred with the analysis of internet investigators like Eliot Higgins [at bellingcat], with whom he often ferociously disagrees. The canister, he reckoned, would have weighed around 250 pounds and carried about 120 kilos of chorine. But it landed in an entirely unexpected way. Since the concrete-and-steel-mesh roof wasn’t very strong, the bomb punched a hole in the ceiling. The effect was as if the nose of the canister had been deliberately rammed into the external wall, so as to point gas directly into the room below, creating a gas chamber. That room would have filled with chlorine in one or two minutes. Drawing on Forensic Architecture’s modeling of the building onto which it fell, Postol estimated that the chlorine gas would have poured out into the upper floor at a magnitude several hundred times higher than a lethal dose, its density much greater because the release occurred in an enclosed space. As it made its way down into the two floors below, its density would have decreased, but still would have been much more than enough for a lethal dose.

When it filled the building, the chlorine would have spilled out via open windows and doors and then drifted along the street, like a thick fog, at much lower concentrations. As it sank through the building, the residents hunkered down in the basement would have smelled it too. Many likely ran headfirst onto the street, only to be confronted by a chlorine gas cloud forming all around them. Instinct and training likely kicked in; since chlorine is thicker than air, the instructions they’d been given would have been to head for the roof. Under most circumstances, this would have been excellent advice, like the injunction to workers at the World Trade Center on 9/11 to stay put at their desks, but in this case, it failed the residents of Douma. As they ran back upward through the building, they’d have been rendered unconscious very quickly and dead within minutes. Delivered at that kind of dosage — thousands of milligrams per cubic meter — chlorine could easily have caused the frothing at the mouth, skin burns, and damaged corneas observed by medical workers, as well as the horrible smell and breathing difficulties of which residents complained. It also makes sense of what the motorbike rider had told me: that the whole street had been affected by the foul odor. To panic and terrorize the population was, after all, what this was for.

The murderous result, concluded Postol, was “a very peculiar set of circumstances” and a terrible twist of fate. If the building had had been larger with a firmer roof, the balcony canister would probably not have fallen through; even if it had broken open and begun dispersing its payload, the chlorine would have wafted off into the open air and likely not injured anyone. If the roof had been even weaker and the canister had fallen right through onto the third floor, its valve might not have opened at all, like the one on the bed. But because of the way the canister punctured the concrete, its valve snapped so as to spew the contents directly into the enclosed space below. A lot of stars would have had to align for something like this to happen, just as the former OPCW inspector had said. But in this case, they did.

And James ends with a sobering counter-factual.  Throughout my analysis of siege warfare in Syria, I have criticised the selectivity of public concern (where there has been any at all), and in particular the outrage over chemical weapons compared with the insouciant disregard for other, no less murderous forms of military and paramilitary violence.  (I admit this has become an obsession: hence my dismay at the political and critical energy directed against drone strikes in the world’s borderlands to the exclusion of other forms of aerial violence that have killed and maimed many, many more people).

If a 500-pound bomb had collided with the roof of that apartment block near al-Shuhada Square instead of a chlorine canister, it would have punched clean through and landed slap on one of the higher floors. There would have been a tiny delay, only a fraction of a second, while the fuse sensed that it had reached its destination, after which the building would have blown apart and its entire weight fallen downward onto the basement. Everyone hiding there would likely have been buried alive.

Whose voices would have been raised against that?

War, truth and peace

A fascinating essay in the weekend’s New York Times from William Davies at Goldsmith’s, ‘Everything is war and nothing is true‘.  It’s a remarkably wide-ranging essay, travelling from Brexit through ‘post-truth’ regimes to martial politics, and it’s derived from his new book, published in the UK at the end of last year as Nervous states: how feeling took over the world (Jonathan Cape/Penguin) and about to be published in North America as Nervous states: democracy and the decline of reason (W.W. Norton).

Here’s an extract from the NYT essay:

The principle that military and civilian operations should remain separate has been a cornerstone of liberal politics since religious and civil wars tore through Europe in the mid-17th century. The modern division between the army and civil policing originates in late-17th-century England, when early forms of public administration came to treat (and finance) the two independently of each other. Since then, the rule of law has been distinguished from rule by force.

However, there is an opposing vision of the modern state that also has a long history. According to this alternative ideal, the division between civil government and the military is a pacifist’s conceit that needs overcoming. And it’s not a coincidence that these days nationalists are especially keen to employ the rhetoric of warfare: The wars that fuel the nationalist imagination are not simply military affairs, going on far away between professional soldiers, but also mass mobilizations of politicians, civilians and infrastructure. Ever since the Napoleonic Wars witnessed conscription and the strategic mobilization of the economy, nationalists have looked to war to generate national solidarity and a sense of purpose.

There is another distinctive characteristic of military situations that civilian life often lacks: the promise of an instant response, without the delays that go with democratic argument or expert analysis. Warfare requires knowledge, of course, just not of the same variety that we are familiar with in times of peace. In civil society, the facts provided by economists, statisticians, reporters and academic scientists have a peace-building quality to the extent that they provide a common reality that can be agreed upon. The ideal of independent expertise, which cannot be swayed by money or power, has been crucial in allowing political opponents to nevertheless agree on certain basic features of reality. Facts remove questions of truth from the domain of politics.

War demands a different, more paranoid system of expertise and knowledge, which looks at the world as an uncertain and hostile place, where nothing is fixed. In situations of conflict, the most valuable attribute of knowledge is not that it generates public consensus but that it is up to the minute and aids rapid decision making. Meanwhile, the information shared with the public must be tailored to incite mass enthusiasm and animosity rather than objectivity.

The conditions that most lend themselves to military responses are those in which time is running out. Of course, many of the emergencies that we face today are fictions: the “emergency” at the Mexican border or, perhaps, the British government’s intentional exaggerations of the threat of a “no deal” Brexit to put pressure on Parliament. Framing an issue as an emergency where time is of the essence is a means of bypassing the much slower civilian world of deliberation and facts.

There’s much to think about here, though my immediate reaction is to suggest that much of what has come to be described as a ‘post-truth’ regime is in fact about establishing a post-trust regime: setting a thousand hares running across a hyper-accelerated public sphere so that it becomes exceptionally difficult to reach a common consensus – hence evidence yields to emotion.  I’ve been thinking about this in relation to the disinformation campaigns that have bedevilled the war in Syria (see, for example, here), and working on a more general formulation of the argument, and I’ll try to return to this in detail in a later post.

‘Is this thy body’s end?’

There are all sorts of ways in which the war on Syria has been a throwback to the First World War – and all sorts of differences too – but today brought news of yet another (and, unusually, a welcome one).  Peter Walker reports for the Guardian:

The UK government is taking part in a pioneering international aid project which could see consignments of maggots sent to crisis zones such as Syria as a simple and effective way to clean wounds, it has been announced.

So-called maggot therapy has been used since the first world war, when their efficacy in helping wounds heal was discovered by accident, and it is sometimes used in the NHS, for example to clean ulcers.

The initiative, co-sponsored by the Department for International Development (DfID), will develop techniques to help people in conflict zones or areas affected by humanitarian crises to use maggots where other medical facilities might not be available, such as Syria and South Sudan.

Over at the Telegraph Sarah Newey adds:

Modern larvae treatment was developed following WWI after an American scientist, William Baer, noticed the benefits of maggots on soldiers wounds. Today the therapy is used in hospitals in developed countries, including the NHS, but they are yet to be used in war zones.

While photos of the maggots at work are unsavory, the treatment is highly effective.

Flies are reared in a lab, where their eggs are sterilised. The hatched maggots are then grown for a day or two, before they are applied to skin and soft tissue wounds either directly or in a biobag, which is wrapped around the injury.

Not only do the maggots remove dead tissue and flesh, but they control infection as their spit and saliva act as a natural disinfectant and promote healing. The maggots can be used to treat anything from burns to bedsores to gunshot wounds, and are left on an injury for two to four days.

The martial history of maggots is an interesting one.

In ‘Trauma Geographies‘ I described the experience of one young soldier, John Stafford, who was wounded on the Somme in the early hours of 8 August 1916, and I’ll draw on that account here.  He managed to crawl (and fall) into a shell-hole, where he examined his wound:

‘A bullet had passed through the flesh of the upper left thigh and entered the extreme inner high point of the right leg.  The thigh bone was considerably shattered, the bullet having travelled downwards towards the knee.  My field dressing was used and I lay flat again…’

There was no sign of rescue.  His thirst increased as the sun climbed higher, but he knew nobody would venture out to rescue him until it was dark.

When night fell his hopes rose, though he was weak from loss of blood, but still nobody came.  The next day the bleeding had stopped so Stafford removed the field dressing and to his horror ‘discovered that it was one mass of white grubs … I saw that my wounds were infested with maggots.’ Sickened, he hurled the heavy dressing away, but worse was to come:

‘Eventually the maggots spread over my leg from hip to knee and then settled on the other leg which was not so badly wounded.  Occasionally I looked at their swelling rhythm, then finally turned away in disgust.’

He was eventually – and accidentally – rescued, but the maggots had probably already saved his life.  In eating the damaged flesh they had performed a ‘natural’ debridement of the wound,

Stafford’s experience was by no means unique.  It was not uncommon for wounded men to lie out in the open for days before they were recovered by stretcher-bearers, and often their wounds became infected – but the problem was bacterial infection not maggot infestation.

That same month (and in more or less the same place) Captain Lawrence Gameson was stationed with the RAMC’s 45th Field Ambulance in a shattered cellar at Contalmaison (above).  It was a bruising experience;, and he said there ‘was hardly a part of the body I did not see cut or exposed’:

Maggot invasion was common. I can recall an unconscious man who arrived with part of a frontal lobe protruding through a hole in his skull. The protruding portion of brain was moving with maggots. When men had had to be left out wounded for some time, often their shoulders, buttocks or whole back were invaded by the creatures in the areas of skin compressed by the weight of their immobilised bodies. One man I saw had been lying out because both his legs were wounded. Prolonged pressure had caused necrosis of the skin over his buttocks and of the superficial portions of muscle beneath it. Maggots had invaded the deeper tissues. I had to pick them out with long forceps. The man was unaware of his condition. Maggot invasion was always accompanied by a foul smell, since it flourished only in tissues undergoing some degree of decomposition. As a rule, the victim did not notice the stink, or did not know that it came from his own body if sensitive enough to notice it.

The association of maggots with death, decay and decomposition was pervasive.  Gameson described how he was called to extricate the body of a dead German soldier from a captured dugout:

He had fallen head foremost and was stuck there. On my preliminary examination in the dim light I could see only his field boots. I had come without my torch. Subsequently, on looking closer, I found that his flesh was moving with maggots. More precisely, I noticed that portions of his uniform were heaving up and down at points where they touched the seething mass below.

The smell was pretty awful. None of the men would touch him, although troops as a rule are not noticeably fastidious. The job was unanimously voted to me, because it’s supposed, quite wrongly, that doctors don’t mind. I went down the stairway with a length of telephone wire and lashed it round the poor chap’s feet. We hauled him up and dragged him away for some distance. The corpse left behind it a trail of wriggling, sightless maggots…

And yet, writing in the British Medical Journal on 3 March 1917 about the treatment of compound fractures, Captain Basil Hughes observed that ‘the presence of maggots in … wounds seems to exert an inhibitory action on the growth of the most virulent bacteria, and so acts beneficially.  Maggots only thrive in dead tissue and seem to hasten its removal.’

This should have been – could have been – a crucial finding, for Hughes also emphasised that ‘all shell wounds are bound to become infected, whatever care be taken’, and listed ‘the bacteria most to be feared’.  But it was those other associations – the smell of decay and the seething sight of the maggot-riddled bodies – that inhibited an appreciation of the therapeutic agency of maggots.

As Sarah notes, William Baer (left) had made a similar observation while treating two soldiers also with compound fractures of the femur.  These were among the most serious wounds of the war because the penetration of the skin by the bone made them peculiarly vulnerable to sepsis.  In 1917, he wrote,

‘two soldiers with compound fractures of the femur and large flesh wounds of the abdomen and scrotum [shades of Trey Parker] were brought into the hospital. These men had been wounded during an engagement and in such a part of the country, hidden by brush, that when the wounded of that battle were picked up they were overlooked. For seven days they lay on the battlefield without water, without food, and exposed to the weather and all the insects which were about that region. On their arrival at the hospital I found that they had no fever and that there was no evidence of septicaemia or blood poisoning. Indeed, their condition was remarkably good, and if it had not been for their starvation and thirst, we would have said they were in excellent condition. When I noticed the extent of the wounds, of the thigh particularly, I could not but marvel at the good constitutional condition of the patients. At that time the mortality of compound fractures of the femur was about seventy-five to eighty per cent…’

He continued:

‘I could not understand how a man who had lain on the ground for seven days with a compound fracture of the femur, without food and water, should be free of fever and of evidences of sepsis. On removing the clothing from the wounded part, much was my surprise to see the wound filled with thousands and thousands of maggots, apparently those of the blow fly. These maggots simply swarmed and filled the entire wounded area. The sight was very disgusting and measures were taken hurriedly to wash out these abominable looking creatures. Then the wounds were irrigated with normal salt Solution and the most remarkable picture was presented in the character of the wound which was exposed. Instead of having a wound filled with pus, as one would have expected, due to the degeneration of devitalized tissue and to the presence of the numerous types of bacteria, these wounds were filled with the most beautiful pink granulation tissue that one could imagine. There was practically no bare bone to be seen and the internal structure of the wounded bone, as well as the surrounding parts, was entirely covered with the pink, rosy granulation tissue which filled the wound. Bacterial cultures were made and, while one found a few Staphylococci and Streptococci still remaining, they were very few in number and not sufficient at that time to cause a pus formation. These patients went on to healing, notwithstanding the fact that we removed their friends which had been doing such noble work.’

Bauer drew on these findings to pioneer the use of ‘maggot therapy’ (myiasis) –  but he did so at the Children’s Hospital in Baltimore ten years after the war ended.  His first step was to grow maggots on raw meat ‘so he could observe their effect on destroying tissues,’ a colleague recalled, setting up the experiment in the hospital’s dining hall—’an unfortunate location for unwitting visitors’.

In fact, the use of maggot to treat wounds has an even longer history.  They have been a common resource in many forms of indigenous medicine for thousands of years, and within a recognisably Western tradition Baron Dominique Larrey, Napoleon’s field surgeon (above), had observed their beneficial effects a hundred years before Bauer:

‘While the process of the suppuration of their wounds was going on, the wounded were much annoyed by the worms or larvae of the blue fly… These larvae are indeed greed only after putrefying substances, and never touch the parts which are endowed with life.’

Ironically, this was during the Syrian campaign (1798-1801).

(If you want more after all that, try here and here).

1418 strikes and you’re still in…

The Syrian Archive has announced the release of a database of Russian-led airstrikes on civilian targets in Syria between September 2015 and September 2018.

Several years of monitoring alleged Russian airstrikes in Syria reveals a pattern of indiscriminate targeting of civilians and civilian infrastructure. In an analysis of 3303 videos documenting alleged Russian airstrikes from 116 sources between 30 September 2015 and 9 September 2018, Syrian Archive has identified 1418 incidents in which Russian forces allegedly targeted civilians or civilian infrastructure of little to no military value. Content included in this database can be viewed, analysed and downloaded.

While data presented in this collection does not include all incidents of alleged Russian airstrikes on civilians between 2015 and 2018 [my emphasis], it presents all incidents for which visual content was available and verifiable as of the date of publication. Syrian Archive hopes this will support reporting, advocacy, research, and accountability efforts…

This open source database is fully searchable and queryable by date, location, keyword, relevance, and confidence score..

The database includes more than 3,000 videos of 1,400 incidents (some taken by citizens and activists, some by human rights organisations, and some by the Russian Ministry of Defence); its compilation involved a series of negotiations with YouTube over the removal of some of the video evidence (see here and my extended discussion of visual evidence here).

Airwars continues to do stellar work documenting civilian casualties from the US-led coalition’s military operations in Syria and elsewhere, but the Syrian Archive’s contribution is particularly valuable since, as Airwars notes:

Airwars maintains an extensive database of all known allegations in which civilians have been reported killed by Russian forces in Syrian casualty events since September 30th 2015. Our published month by month records include a case report on each known alleged event; photographs, videos, names of the dead where known; archived links to all known sources; and our provisional assessment as to whether Russian forces were likely responsible.

Due to the scale of the Russian campaign and the number of reported civilian casualty allegations, our team rolls out monthly assessments as we are able to complete them. Much of our deep assessment work had to be suspended in early 2017 given the high number of alleggations against the US-led Coalition.

Chemical weapons in Syria

A new, detailed report from the BBC investigates the Assad regime’s strategic deployment of chemical weapons.  The joint investigation by the Panorama team and BBC Arabic determined ‘there is enough evidence to be confident that at least 106 chemical attacks have taken place in Syria since September 2013, when [President Assad] signed the international Chemical Weapons Convention (CWC) and agreed to destroy the country’s chemical weapons stockpile‘ (my emphasis).

The BBC team considered 164 reports of chemical attacks from September 2013 onwards. The reports were from a variety of sources considered broadly impartial and not involved in the fighting. They included international bodies, human rights groups, medical organisations and think tanks.

In line with investigations carried out by the UN and the OPCW, BBC researchers, with the help of several independent analysts, reviewed the open source data available for each of the reported attacks, including victim and witness testimonies, photographs and videos.
The BBC team had their methodology checked by specialist researchers and experts.
The BBC researchers discounted all incidents where there was only one source, or where they concluded there was not sufficient evidence. In all, they determined there was enough credible evidence to be confident a chemical weapon was used in 106 incidents.

Almost half the documented attacks were in Idlib and Hama; most casualties were recorded in Kafr Zita (in Hama) and Douma (in East Ghouta).  Aircraft were used in almost half the attacks, and the experts consulted by the BBC concluded that in the majority of cases it was overwhelmingly likely that the Syrian Arab Air Force was responsible.  In this connection, it is telling that:

Many of the reported attacks occurred in clusters in and around the same areas and at around the same times. These clusters coincided with government offensives – in Hama and Idlib in 2014, in Idlib in 2015, in Aleppo city at the end of 2016, and in the Eastern Ghouta in early 2018.

The report pays particular attention to the use of chemical weapons during the offensive against East Ghouta earlier this year – see my detailed analysis here; see also here – and provides a detailed map:

Panorama: Syria’s Chemical War will be broadcast in the UK on Monday 15 October on BBC One at 20:30. It will be available afterwards on the BBC iPlayer. It will also be broadcast on BBC Arabic on Tuesday 23 October at 19:05 GMT.