Middle East Research and Information Project The Politics of Health in Counterterrorism Operations
In the early morning hours of October 3, 2015, a helicopter gunship operated by US special forces circled the Médecins Sans Frontières (MSF) trauma center in Kunduz, Afghanistan. It fired precise and repeated rounds on the main hospital building, quickly reducing it to rubble. Patients and staff who survived the airstrikes were shot while fleeing the burning building. By the end of the assault, 42 people had died, including 24 patients, 14 staff and four caretakers. The week prior to the attack on the hospital, the Taliban had taken control of the Afghan city of Kunduz. It was the first time the Taliban had gained control of a provincial capital since its fall from power in 2001 following the US-led invasion of Afghanistan. The MSF hospital in Kunduz was the only fully operational humanitarian project with international staff in a Taliban-controlled area.
The bombing of the hospital demonstrates how medical facilities are incorporated into contemporary armed conflicts. Although hospitals and clinics have always been targeted in times of war, there is something distinctive about the way the provision of health care interacts with military objectives and realities in contemporary counterterrorism wars. In these situations, groups deemed to be terrorists, as well as the civilians in their proximity, are deprived—often deliberately—of the protections typically accorded to hospitals, health care providers and the sick and injured.
In the conflict zones of Afghanistan, where multiple fronts shift concurrently, the lines between who is, or is not, a legitimate recipient of aid and protection are not just blurred but erased. As in other counterterrorism wars, these life or death issues are exacerbated by shifting power and territorial control between a growing insurgency, shrinking coalition ground forces and an escalating use of special forces and air operations. An additional element of confusion, deliberately created to allow room for maneuver, is the interchangeable roles and fluid rules of engagement for different international armed forces. More broadly, the parameters of humanitarian aid are shaped by the state and its international backers’ imperative that aid provision should only serve a state-building agenda, while limiting any benefits to the enemy.
In an environment such as Afghanistan, medical treatment in a government-controlled city—where the majority of wounded combatants are likely to be government soldiers—is accepted. But the moment an armed opposition begins operating in the area, any wounded patient who enters the hospital risks being labeled as a terrorist or criminal who can be subjected to domestic legislation, often enforced by Afghan special forces. The hospital is therefore forced to act as an extension of the state, and in the case of Afghanistan, an extension of US military interests, serving only those patients and ends that benefit the government. Hospitals are thus accepted or rejected based on their adherence to the state-building functions of health care provision. Special forces, which operate according to secret rules, perceive aid organizations primarily through the lens of limiting the immediate benefits to the enemy. Consequently, independent and impartial humanitarian aid is contested and those who try to implement it risk being attacked.
The Everywhere Enemy
The conflict in Afghanistan cannot be separated from the broader trends of the US-led “war on terror.” Derek Gregory argues that the US-led wars in Afghanistan and Iraq marked the beginning of the “everywhere war,” which is both a “conceptual and material project.” 
This project has three elements. First, “war has become the pervasive matrix within which social life is constituted.” Second, US military doctrine has shifted from war having a battlefield to war as an all-encompassing battlespace with “no front or back and where everything becomes the site of permanent war.” And third, war is played out in the “borderlands where the United States and its allies now conduct their military operations.” 
The concept of everywhere war posits that territorial control has become less important, if not irrelevant, to military strategizing. In this scenario, opponents are “extra-territorial,” elusive and constantly on the move. Gen. Joseph Votel, in a coauthored article published prior to his confirmation as commander of US Central Command (CENTCOM), suggested that, in the future, warfare will occur within a grey zone that is heavily reliant on highly mobile special forces that work alongside “intense political, economic, informational, and military competition more fervent in nature than normal steady-state diplomacy.” 
In contemporary military operations, this grey zone warfare is often defined by a reliance on local partners who make up the bulk of fighting forces. For the United States and other countries engaged in counterterrorism conflicts, there is a growing unwillingness to deploy their own military forces on the ground. Instead, they rely predominantly on aerial operations such as drone strikes or close air support to small special forces units and their ground force allies.
The beginning phases of the war in Afghanistan were characterized by a highly mobile and fluid insurgency against a large number of NATO and US “boots on the ground.” The current phase of the war in Afghanistan, however, is characterized by highly mobile special forces fighting against an insurgency that, at the time of the Kunduz hospital bombing, was gaining more territory in a context of foreign ground troop withdrawals. In response to the growing Taliban threat, but in keeping with US domestic interests to withdraw troops from Afghanistan, the United States redefined the international and Afghan national forces’ operational role in 2015 to provide an ongoing combat role for special forces under the broad umbrella of the non-combat NATO mission.
Among the international forces in Afghanistan, the distinction between the different fighting units is purposefully blurred. The overall NATO mission is to train, support and advise their Afghan counterparts. As such, its role is largely limited to policy rather than direct fighting. US special forces, however, serve in Afghanistan under Operation Freedom’s Sentinel (OFS), which is primarily mandated to target al-Qaeda and its affiliates. The United States also makes use of the CIA and other US intelligence services to carry out attacks.  These clandestine forces carry out drone strikes, night raids and other targeted attacks against those on the US “kill list.” While these operational forces and missions are distinct in theory, they are closely linked and sometimes interchangeable. A pilot in an AC-130 gunship might be operating under Operation Freedom’s Sentinel one day and with the CIA the next. In practice, this means that various US and other international forces operate under different rules of engagement with different targeting protocols. The blurred command structures are no clearer on the Afghan side. The Afghan state’s military effort is carried out primarily by Afghan special forces. These troops are the best trained, best equipped and best able to move from one hot spot to another. They are by all accounts overworked, overstretched and battle fatigued. Supporting this official fighting force is a growing network of government-affiliated militia, defense units and local police.
Within these environments, proclaiming “self-defense” has become an ever expanding pretext to justify offensive military operations. Indeed, US special forces invoked self-defense extremely broadly during their attack on the MSF hospital in Kunduz. According to The New York Times:
The fact that the Special Forces were surrounded by Taliban also meant that the liberal use of American air power in Kunduz could be justified as self-defense. The military went further by applying what it called Persons with Designated Special Status to the Afghan commandos in Kunduz, a designation that allows American forces to consider temporarily defending certain partnered Afghan troops as part of their own self-defense—essentially, self-defense of someone else. 
Whereas the beginning of the war in Afghanistan marked the start of the US-led global “war on terror” and fits within Gregory’s definition of the everywhere war, there have been significant shifts over the last decade. Today, the war fought in Afghanistan relies more heavily on the counterterrorism operations of special forces. Moreover, the war on terror model has been adopted by many other states that are fighting their own self-declared counterterrorism wars. The “with us or against us” approach has resulted in entire communities being designated part of a criminalized and hostile enemy. This has been seen in Bahrain, Egypt, Syria and elsewhere where those in opposition to the state are castigated as terrorists, and by extension their health care providers are seen as providing unacceptable support to the enemy.
In the context of contemporary counterterrorism operations, the everywhere war has led to an “everywhere enemy.” Shifting focus away from analyzing the evolution of how wars are fought to how the enemy is constructed reveals how the expanded definition of the terrorist enemy is used to justify a certain conduct of war that brings both patients and health workers under fire. Health care delivered on the frontlines of these battles can no longer be considered external to this changing military environment, but rather becomes part of the battlespace when treatment is provided to the everywhere enemy.
Health Care and the Everywhere Enemy
The original Afghanistan/Pakistan strategy, developed in 2009 by President Barack Obama’s administration, had two core features. 
One was the attempt to divide Taliban actors into “good” and “bad” and to engage the good elements in brokering a deal to end the conflict. 
The other feature was the increasing importance of soft power as a core element of the US intervention. Characteristic of this approach was the 2009 “civilian surge” in Afghanistan, which saw a wave of US civilian experts mandated to increase government legitimacy through state-building activities. At the same time, large sums of money flowed into Pakistan in the form of development aid. 
These moves were in line with NATO’s “comprehensive approach,” which emphasized soft power and included the cooptation of non-governmental organizations (NGOs), 
setting the stage for full integration of the humanitarian system into the state-building and military stabilization project in Afghanistan. Initially, as the NATO troop presence expanded into more remote parts of the country, NGO activities were carried out alongside the provincial reconstruction teams and the coalition military. The military enacted the incorporation of health into military stabilization by directly carrying out medical activities themselves. Later, they focused on more indirect forms of building state legitimacy—such as through support to the Ministry of Health—as a way to undermine support for the opposition.
Today, the vast majority of the aid system in Afghanistan has been incorporated into the state-building effort. The health system is subcontracted to NGOs by the state. The World Bank, USAID and the European Union provide resources to a trust fund that the Ministry of Health administers. NGOs therefore receive direct funding from one of the parties to the conflict for the delivery of health services. The limits on what are considered acceptable forms of humanitarian assistance are defined by this relationship to the state. Compliance is enforced through the criminalization of those who step beyond those limits.
The US and Afghan governments’ selective framing of parts of the conflict as a war to combat terrorism has allowed for more leniency when defining standards for acceptable targets and is far more restrictive when delineating legitimate humanitarian action. Domestic laws and minimalist interpretations of the Geneva Conventions are prioritized under a national security framework where international military forces are operating at the invitation of the state in what is classified as a non-international armed conflict. This status allows military operations to be conducted within hospitals for the purposes of law enforcement, thereby undermining the neutrality of medical facilities in the midst of an armed battle. If one side of the conflict can expect their fighters to be arrested by the other side within the grounds of a hospital, the very principle of neutral and impartial medical assistance—enshrined within international humanitarian law—is made meaningless. By respecting the state’s sovereign right to conduct law enforcement operations that target criminals, health providers are forced to take sides by accepting the legitimacy of a contested state and the criminality of its opposition. In the case of Syria, for example, the United States would never adopt this approach because it would require accepting the legitimacy of the Syrian state. Agreeing to this approach means that medical providers on a frontline—such as MSF—would only be able to operate within the territorially-controlled parts of those states seen as legitimate by the dominant international politics of the day.
The “war on terror” has created a legal and moral framework for justifying attacks on hospitals. This justification is bolstered by a rhetoric of warfare that claims greater precision in the use of advanced military technology. The loss of civilian life is explained away not as a problem of the conduct of warfare but rather a problem of where terrorists choose to hide themselves or a problem of human and technical errors during the fog of war.
While the United States may use the rhetoric of the “war on terror” less these days, its “with us or against us” logic has created a legal grey zone which is gaining ground in the Middle East and elsewhere. Many states, such as Syria, violate humanitarian law with little regard for the consequences, largely because they do not seek political validation from their allies or opponents. Other states, such as the United States or Israel, go to painstaking lengths to justify their actions within the bounds of an acceptable legal framework, constantly seeking the moral high-ground in the court of public opinion. The act of justifying creates greater space for those who would operate with disregard for the law. When the most powerful get away with something, it reduces the political costs of the same action carried out by weaker states.
The Kunduz hospital bombing and its aftermath demonstrate that a lack of accountability is becoming a norm. In this case, US unaccountability was justified by deploying a “mistake” narrative rooted in a “with us or against us” approach to warfare that turns entire communities into acceptable targets before a strike, and into mistaken targets when it is determined, afterwards, that they were in fact not part of hostilities. This shift away from accountability is facilitated by the emerging military doctrine, explored by Neve Gordon and Nicola Perugini, which exempts the military from restrictions of precaution and proportionality when a terrorist enemy takes “human shields” in locations such as schools and hospitals. 
This emerging norm was pioneered by the Israeli military in their wars in Gaza. As Lisa Hajjar points out, “This rhetoric of ‘innocent civilians’ amidst ‘legitimate targets’ foreshadowed Israel’s reframing of ‘enemy civilians’ as de facto human shields used by groups against whom Israel was waging war, in an effort to shift blame for the civilian casualties caused by Israeli strikes onto the organizations being targeted.” 
The dangers of this approach for medical facilities become even more stark when one considers the evolution from fighting wars with ground forces to a greater reliance on special forces or remote-controlled drones. For humanitarian workers, there is little room in such an environment to create a space that is not considered part of the enemy terrain if medical facilities are established or functional in areas controlled by an enemy designated as terrorist or criminal.
Attacks such as the one on the Kunduz hospital can happen in any place where the state determines the acceptable limits of humanitarian assistance and where everyone in the grey zone is a potential enemy. In Syria, the provision of health care by non-state actors—including state-opposing armed groups and political structures (or “shadow governments”) and NGOs that are funded primarily by states supporting the opposition—represents for the Syrian government a challenge to the central prerogative of the state: the delivery of social services. This prerogative is deeply rooted in the ideology and practice of the post-colonial Syrian state. 
For this reason, the only humanitarian organizations that have been able to work there without risk of deliberate attack by state forces and their allies are those that operate under the full control of the Syrian government or through its auxiliary, the Syrian Arab Red Crescent Society. The tactic of besieging opposition areas and attacking their populations demonstrates how the battle for the provision or denial of health services is at the center of the Syrian government’s struggle to maintain and extend its control.
What is evident in both Afghanistan and Syria is that attacks on health care facilities are defined by the relationship between the provision of care and the interests of the state, and the extent to which the destruction of the infrastructure of life and health can be justified as necessary and legitimate in the battle against terrorists. The assertion of a sovereign prerogative to battle one’s own terrorists is being actively supported by members of the UN Security Council, four out of five of which have been involved in attacks on MSF-run or supported health facilities over the past few years. This self-serving position can be seen in Security Council resolutions—such as the one calling for a ceasefire in Syria’s Eastern Ghouta—that contain the clause that the ceasefire does not apply to attacks on terrorist groups. These resolutions therefore contain loopholes so big that you can flatten an entire city through them.
The mutual complicity of the foreign backers of the warring parties must be seen for what it is: the most powerful have an interest in preserving the space to battle whomever they consider terrorists. From Eastern Aleppo to Mosul, Raqqa and now Eastern Ghouta, the various armies and their backers want to keep the trump card of fighting terrorism as the ultimate justification for any atrocities committed against trapped populations. The question for health care providers is whether the notion of an impartial hospital can fit within an environment where the “conventional ties between war and geography have come undone.” 
Instead of conflicts being delineated by territorial control, there is now a grey zone within which hospitals can come under attack for treating patients from a designated enemy that can incorporate entire communities. The “war on terror” narrative is used to justify the elimination of a population’s means of survival, with the ultimate goal of reasserting the monopoly of the state over the provision of social services as a source of legitimacy. The role of NGOs is entrenched in the state building logic. Therefore, when they operate impartially, they are considered a hostile part of the battlespace.
The full incorporation of the hospital into the battlespace occurs not only through the direct targeting and destruction of medical facilities but also through raids on hospitals to arrest patients or through the criminalization of health care provision itself. 
The “war on terror” has sought to create a new framework of justification for the inclusion of the hospital as a legitimate battlefield target. This is facilitated by the vague status given to combatants, the applicability of domestic law enforcement within the hospital, the evolution of the military doctrine of legitimate targeting of human shields and the kill/capture approach of special forces going after high value targets, often under the guise of self-defense. These trends have set new limits on what are considered to be acceptable forms of humanitarian assistance. In the context of the everywhere war, the hospital is now part of the battlespace, and, in the context of the everywhere enemy, everyone is a potential target.
1. Derek Gregory, “The Everywhere War,” The Geography Journal 177/ 3 (September 2011), p. 239.
3. Joseph L. Votel, Charles T. Cleveland, Charles T. Connett and Will Irwin, “Unconventional Warfare in the Gray Zone,” Joint Force Quarterly 80 (January 2016).
5. Matthieu Aikins, “Doctors with Enemies: Did Afghan Forces Target the MSF Hospital?” The New York Times Magazine, May 17, 2016.
6. Bob Woodward, Obama’s Wars (New York: Simon & Schuster, 2010).
10. Neve Gordon and Nicola Perugini, “Military Attacks on ‘Hospital Shields’: The Law Itself Is Partly to Blame,” Just Security, October 20, 2016.
11. Lisa Hajjar, “Normalizing Extreme Violence: The Israeli Case,” Jadaliyya, May 29, 2016.
12. Unpublished draft of the Lancet Commission on Syria, Thematic Group, paper authored by Omar Dewachi and Fouad Gehad Marei with contributions from Ghassan Abu Sita and Jonathan Whittall.
13. Gregory, “The Everywhere War,” p. 239.
14. For example, see the MSF statement
of July 3, 2015 which condemned a “violent intrusion” and arrest of three patients from the Kunduz hospital.
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