The bitter taste of Mosul

In an article published in the Independent on 17 January, the journalist Robert Fisk questions the delivery of care by medical aid groups embedded with the international coalition during the offensive on Mosul. He quotes one MSF member, Jonathan Whittall, who argued in a blog post in June, that the presence of for-profit organizations and military medical units was a threat to independent and humanitarian action. Echoing Whittall’s concerns, Fisk points out that humanitarian actors would be endangered by being perceived as aligned with other healthcare providers working in conjunction with the Coalition’s goal. We think that this analysis is a smokescreen which is evading the main challenges faced by humanitarian actors in Mosul.

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It is a fact that during the offensive to regain Mosul from ISIS forces, MSF did not have a monopoly on medical assistance. The medical pathway for the wounded had been organized by the Iraqi government, international donors and the UN at the same time as they plotted military scenarios. A whole chain of medical referrals was set up, which included the wounded being evacuated from the front lines by Iraqi forces, being stabilized and subsequently being referred to secondary and tertiary medical facilities. Implementing partners were hired by the World Health Organization and included private health providers who were ready to work close to the frontlines and to be embedded with military personnel.

MSF was not one of those implementing partners. But we did not make this choice for fear of being perceived as too close to Iraqi forces. In fact, as in every war situation, we had no choice but to negotiate with the armed forces exercising actual control over the territory. With Mosul, because our attempts to engage in dialogue with ISIS had long since faltered, we were only able to work on one side of the conflict. It was with the Iraqi armed forces and their allied militias that we negotiated our access to the territories and the population, and that we negotiated the security of our teams. How could it have been otherwise, since they were the ones manning the checkpoints, and controlling the areas where we ran our activities?

On the battlefield

MSF staff assessed multiple locations along the front lines and concluded that it was simply too dangerous. Mines, drone attacks, explosions, airstrikes, snipers, possible chemical attacks – these were the tangible threats putting the lives of tens of thousands of civilians and humanitarian workers at risk. During a time when there were no functioning hospitals in Mosul, it became clear that it would be most pertinent to provide a wide range of health services (surgical and post-operative care, an inpatient feeding program, maternal healthcare and other lifesaving medical emergencies) to displaced people and local resident populations in safer locations away from the frontlines but still close enough to ensure a timely response.

A few weeks after the start of the offensive on the west of the city, MSF teams were struggling to help civilians who had managed to escape ISIS snipers, the Iraqi ground offensive and the coalition’s airstrikes. Many of our patients were in need of urgent, lifesaving surgery. Entire families were wounded by the same mortar shell, the same mine explosion, the same airstrike. Just one month after the launch of the offensive on West Mosul, we had already received as many wounded as during the entire battle for East Mosul, which lasted three months. Virtually all of the wounded we received had been referred to us by the network of trauma stabilization points coordinated by the Iraqi government and the UN. Many patients did not survive due to the severity of their wounds. Inpatient capacity was over-stretched and post-operative care insufficient. Many escapees were psychologically traumatized by their experiences, first in ISIS-held territories and then in besieged Mosul, as well as afraid for their future, in a context where many were considered to be ISIS accomplices.

In such circumstances, MSF’s ability to provide medical care on the basis of needs alone, and to give priority to the most urgent cases, was often put to the test. In Qayarah hospital for example, 60 km south of Mosul, we started to receive patient-detainees brought by various Iraqi authorities from detention centres, with many showing clear signs of ill-treatment and some in a very severe condition. Our medical teams did not know on what grounds the patients had been arrested, the conditions in which they were being held, or the criteria on which they were sent to us; nor did we know what happened to them once Iraqi authorities had returned them to the detention centers. The only assistance that MSF staff could provide to this group of detainees was medical care. And that is what we did. This situation highlights that our operations during this conflict did not take place without raising a great number of questions, but the questions were generally not related to the presence of private and military medical organizations at the frontlines.

During the final phase of the offensive on the Old City of Mosul, ISIS members were squeezed into a small, confined part of the city which was still inhabited by large numbers of civilians. Despite this, heavy bombing of the Old City was authorized. The patients treated in the aftermath had injuries ranging from shrapnel wounds, gunshots and blast injuries to burns and broken bones caused by collapsing buildings. With the city under siege, those civilians who did manage to flee reported a situation of extreme deprivation, with almost no food and water. This planned sacrifice of thousands of trapped civilians was the result of the encirclement of Old Mosul.

Certainly, the arrival of new aid groups on the frontlines, such as the ones described by Robert Fisk, did create multiple questions: who they were, how they operated, how they conducted the triage of their patients. But the primary issue at stake in Mosul was not the danger that these groups represented to a pure and principled humanitarianism. Although we were not aligned to the coalition’s objectives, although we were not an implementing partner of the UN, we were, however, a de facto component of the offensive’s damage control plan: by assisting those civilians who managed to escape, and by being powerless to do anything for those civilians condemned to die with ISIS militants inside the besieged town. That is the bitter taste of humanitarianism in Mosul’s war.

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Isabelle Defourny, MSF director of operations, Paris, and Christine Jamet, MSF director of operations, Geneva.