Dr Mathilde Berthelot is Médecins Sans Frontières’ (MSF) Operations Manager for Pakistan, Afghanistan, Iran and Palestine. She has more than 14 years of experience working in Afghanistan and is also in charge of MSF operations in Peshawar and FATA. We speak to her about the Trauma Centre, what it meant to the community in Kunduz, and whether it can be rebuilt

The human cost of the bombing can’t just be restricted to the dead and injured at the hospital; it should also include those who will be affected now that the hospital is no longer there. Can you sketch the extent of damage?

The trauma centre is unusable, particularly the emergency and trauma services wing, since it was at the receiving end of the bulk of bombardment.

The MSF had built this facility in 2011, and were running it independently since then. It was the only facility in the province of Kunduz that could absorb physical trauma patients; the capacity of admission was 92 beds. We used to receive all kinds of physical trauma cases: accidents, domestic violence, gunshot victims of tribal or familial conflict etc.

On October 3, 2015, the MSF Trauma Centre in Kunduz was pounded by American bombers for about 60 minutes. In the rubble were dead bodies and doused spirits — war-ravaged Kunduz had lost its only quality healthcare facility

For this hospital, the MSF had an annual budget of approximately $7 million; this was raised through MSF’s private donors. The equipment installed was high-tech. For example, we had an internal fixator to help with fractures. We had a thriving ICU, blood bank, lab. We had a modern orthopaedics department. We had respirators for our patients. We had x-ray machines; we had lots of material for physiotherapy, ambulances too.

This was all very expensive equipment, since the technical level of the hospital was very high. It was therefore the only place in Kunduz where trauma surgery could be carried out according to modern standards.

The other hospital in Kunduz, which is run by the Afghanistan Ministry of Health (MoH), is not comparable in terms of the facilities, equipment or sophistication. And so, for the one million strong population of Kunduz, this hospital represented hope.

Before the attack on our facility, as fighting broke out to take control of Kunduz, the Taliban had managed to capture the MoH hospital. That meant that the MSF facility was the only medically neutral and accessible facility available to the people of Kunduz.

The only hospital that is in any shape is the MoH hospital, but they are not capable of receiving any patients because of the situation of war. They don’t have electricity, they don’t have enough medicines supplies. A lot of the MoH staff also left the city because they were insecure. The MoH hospital is not functional at all.

After the attack, we moved our patients to our other facilities in Afghanistan, but for those still in Kunduz, the situation is bleak: there is no longer a highly-equipped, modern emergency trauma service in Kunduz.

In the wake of the first Taliban attack, did the MSF consider leaving Kunduz?

The Taliban tried to capture Kunduz city twice, and each time, we received a lot of wounded. On Sept 29, they managed to enter the city and capture the walled city of Kunduz in a few hours. Our teams were in the hospital and started receiving casualties due to the battle over Kunduz.

We decided that the situation was very unpredictable and dangerous; we didn’t know what the Taliban’s attitude will be towards the population or us, the MSF volunteers and workers. We were also mindful that the Afghanistan army could launch retaliatory attacks in an attempt to recapture the city.

The interior ministry spokesperson says that they have killed 15 Taliban, but on our side, when we look at the list of the dead, there are only patients and staff. There were no Taliban that we recovered from the rubble.

Given these considerations, we reduced staff. In total, there were 15 expatriates from nine nationalities working at the hospital — Africans, Australians, Asians, and Europeans. But after the 29th, we kept behind only nine expats to work in the hospital; they were to be assisted by the local Afghan staff employed by MSF.

In fact, the team of Afghan nationals working on this project in Kunduz is about 300. This includes doctors, nurses, drivers, cooks, laundry cleaners – everybody who is needed to run and manage a hospital. The expats are primarily there to mentor and train the large number of people who work with us, because in the final analysis, the Afghans will still be on the ground even if we were to pack up and leave. It was a way of transferring knowledge; our surgeons, for example, shared their expertise with local staff. In turn, they would learn from some highly qualified medical professionals.

On the 29th, we acknowledged that there will be fighting in town. We thought about it, about whether to stay or leave. We asked ourselves if we have an added value in Kunduz? The answer was an emphatic yes, because we were the only functioning hospital. Since the Taliban had captured the MoH hospital, our presence there was adding big, big value. We had to stay.

Did the MSF ever foresee the possibility that their facility could be attacked?

The bombing started around 2am, and it was directed at the front side of the building. When the first bomb fell, there was a team inside the operating room along with the patient they were supposed to operate on.

Hospitals are safe places, even in times of war. We had taken all necessary precautions; we needed to be sure that all parties who were fighting on the ground were duly informed that this is a hospital and as such, should be spared of any damage.

If you were to go to any MSF facility in Pakistan, you’d notice big signboards saying that no weapons are allowed in the premises. It’s the way we operate everywhere, because our principle is to treat people without any bias. We admit patients on their medical need, irrespective of their political affiliation. All along the week, we kept this principle intact. Everyone was aware of the rules to enter the hospital: no weapons, and that triage will be according to patients’ needs.

We contacted the various parties on the 29th — the Afghan army, the Americans and the Taliban. We basically said the same thing to everyone: we are here to work, please let us work, that this facility is a hospital, this is its exact location, please don’t shoot at the hospital, and please respect this as a safe place.

In retrospect, the experience reminded us that we cannot be sure of such things in times of war. But in the moment, we believed that the hospital will be safe. And that is why we continued to work.

Talk us through the attack, how it happened, and its aftermath.

As fighting broke out to take control of Kunduz, the Taliban had managed to capture the MoH hospital. That meant that the MSF facility was the only medically neutral and accessible facility available to the people of Kunduz.

We admitted more than 400 patients between Monday [Sept 29] and Friday — we had three operation theatres and they were all in use all the time. Even though the hospital’s admission capacity was 92 beds, we were obliged to increased capacity to 150 patients. We had to put beds in the corridors, in operation theatres, in any available space.

On the night of the attack, there were 80 staff members in the hospital; some were not even supposed to be there, but they were there to work and to help in various ways. The majority of Afghan staff wasn’t able to go home, because it was too dangerous to go out into the street. They stayed in the hospital; some caught up on sleep, others continued working because there was too much to do around the hospital.

On the night of the attack, there was a team that was about to operate on a patient in one of the rooms, and there were three patients in the recovery room who had been operated on in the evening. Then there was a team of doctors, nurses and attendants who were around in the operation theatres and recovery rooms, tending to their patients. On the other side of the building, there was an in-patient unit where we had 105 patients plus the rest of the staff as well as the expatriates who were present in the hospital.

The bombing started around 2am, and it was directed at the front side of the building. When the first bomb fell, there was a team inside the operating room along with the patient they were supposed to operate on. This building also had an intensive care unit and a recovery room for post-operative care.

The other part of the building, where the wards were, remained untouched. Some patients along with their caretakers managed to go hide in the bunker in the basement of the hospital. The expatriates too sought cover in the building that was untouched.

The project coordinator immediately informed the head of mission, who was in Kabul, and requested him to call the military and tell them that the hospital was under attack, and to give them GPS data of the hospital to stop the bombing on the hospital.

The head of mission contacted the US government in Washington, to inform them and to request them to stop. Unfortunately, the bombing continued and went on for about an hour — between 2am and 3am. They were bombed five times, every 10 minutes for 60 minutes.

There are multiple versions about what really happened and lots of different explanation being provided. That’s why we are very, very upset that nobody is telling us who is really responsible, and we are requesting that there is an inquiry to explain what had happened. Because in one hour, the bombing did not stop. And in the end, all patients who were in the first building died.

Ten patients died in total: the patient who was on the operating table, the patients who were in the recovery room, and six patients who were in the ICU, including three children. All these patients were in such serious condition that they were all in bed and couldn’t escape. They couldn’t have left, they couldn’t have stood up, and they couldn’t have found any refuge.

All these patients were bombed in bed. Instead of being cured in a hospital, they died inside a hospital.

In addition, there were 12 MSF staff who died. There were three doctors, there was one cleaner, there was four nurses, two watchmen, one pharmacist, and one patient information agent [officer who provides orientation to the patient’s family, handles paperwork etc]. These people had been associated with the MSF for long. Some of them died immediately; some of them died soon after the bombing. All of them who died were in the same building.

It’s the first time ever that an MSF hospital has been bombed like this and resulted in such a high death toll. It is the first time that we have lost very dedicated colleagues this way. It is devastating.

How was the experience of working with Afghan staff?

The Afghan staff was incredible; they worked tirelessly to receive people. They have been working with us since several years. The salary that they make with the MSF is quite low as compared to what they could earn in the private sector. They could have opened private clinics but they don’t.

They decided to work with an NGO because they wanted to return immense services to their people. The care provided by the MSF Trauma Centre was expensive by private standards; poor people who needed intensive care would otherwise not have access to quality medical help.

The Afghans who worked with us were aware they were giving invaluable service to their compatriots. But unfortunately, some of them lost their lives because of their commitment to their people and their profession.

Allegations made by the Afghan government and the American army claimed that the Taliban were misusing the facility to attack them. How would you respond to that?

When we first learnt that the strikes were from US bombers, we were totally in shock, because their planes are not some old aircrafts from the First World War. They are GPS-equipped, they know how to identify a place. What we really don’t understand is why they continued to bomb when they knew this was a hospital.

And now, we have declarations from the spokespersons of the Afghanistan interior ministry and the US army that they had to target the hospital because they were sure there were Taliban inside. The interior ministry spokesperson says that they have killed 15 Taliban, but on our side, when we look at the list of the dead, there are only patients and staff. There were no Taliban that we recovered from the rubble.

It is completely disproportionate to destroy a hospital to kill enemy combatants, and then to justify the attack. When they started to say that they knew this was a hospital, we were very, very shocked — if they knew, it means that they are admitting that they committed a war crime by bombing a hospital.

For us, that was extremely shocking and that’s why, now, we demand an enquiry to clarify what happened. The military say they have started their own investigations, but we will probably not have access to all the details of the enquiry. They will provide conclusions, but we don’t want to accept the conclusions of the aggressor. We want to have another enquiry, from an independent source.

As it stands, there are multiple statements being issued about what happened, and we have the impression that nobody really wants to tell the truth. But we don’t really know what the truth is either; the only element that is clear is who died in the attack.

Does the MSF think that this was a planned, targeted attack aimed at destroying the hospital’s emergency and trauma services wing? Why not bomb the other wings? Why only this one in an hour of relentless bombing?

We want to know what happened, we want to understand the details to honour the memory of our colleagues. Since this attack has happened in one place, how do we know that it will not be repeated elsewhere in Afghanistan? There are only questions for us: was it really a mistake? Was it something in the chain of command?

According to the Geneva Convention, functioning hospitals are not to be touched or harmed in any way. If someone does attack, this is considered as a war crime.

Did the MoH hospital not have emergency and trauma services?

The capacity of the public hospital was 200 beds; the number of beds dedicated to surgery was not 100 like ours. We were the only one doing orthopaedic surgery; the public hospital did not have that. In war, you need orthopaedic support, but they don’t have anything comparable to what the MSF had.

Where will those people go now?

We evacuated our team from Kunduz on Saturday, Oct 3. We also rushed the wounded to other MSF facilities in Afghanistan. But we have left the hospital in Kunduz, since it is not functional at all. All the surgical capacity has been destroyed; the building has been razed by the bombs.

The trauma centre and the ICU are destroyed, there is no way to work there. Nobody can use anything from the hospital because there is nothing usable there, it is impossible to work in the hospital.

The only hospital that is in any shape is the MoH hospital, but they are not capable of receiving any patients because of the situation of war. They don’t have electricity, they don’t have enough medicines supplies. A lot of the MoH staff also left the city because they were insecure. The MoH hospital is not functional at all.

Today, in Kunduz, there is no longer any capacity to do what we were doing. If the fighting continues, there is no trauma facility for the wounded. Imagine there being no place for the wounded in a city of 300,000 and a province of one million. There is fighting across the province, but no trauma facility means that there will be catastrophic consequences for the local population.

I don’t know if we’ll go back, because we don’t have any guarantees to assure us of safety and security. We can probably rebuild the hospital, but we can’t bring back our colleagues.

Do you think that the Afghan government is willing to be complicit in murdering its citizens by depriving them of warzone emergency services?

We are thinking about all possibilities, but I cannot begin to imagine that people will consciously do that. Maybe people are in fact able to do something as inhumane as this to punish their opponents. But it is true that in France there were places where hospitals were bombed. It is happening in Yemen, in Syria too. Sometimes people think that doctors are involved in war too. It is something that I cannot fathom as a doctor, because medicine is about neutrality.

The writer tweets @ASYusuf

Published in Dawn, Sunday Magazine, October 11th, 2015

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