Doctors Without Borders released an internal review of what happened before, during, and after its hospital in Kunduz, Afghanistan was bombed by U.S. military forces on October 3.

The review highlights how the U.S. violated the neutrality of the facility, which the U.S. had agreed to respect. It also demonstrates there were no “armed combatants” in the hospital and no fighting in the “direct vicinity” at the time of the airstrikes. It also significantly calls into question statements by anonymous officials or military operatives, which have been made to the press.

The aid group followed a “no weapons” policy, which had been implemented at the hospital, and staff remained in full control of the medical facility, according to the review. GPS coordinates were also provided to Kabul and New York, and the U.S. Defense Department and Afghan Ministry of Interior, as well as the U.S. Army in Kabul, were made aware of the location of the hospital.

Dr. Joanne Liu, the president of Doctors Without Borders International or MSF International, said even though the internal review [PDF] was an ongoing process, the organization had made the decision to share details to “counter speculation” and to be “transparent.”

“What we know is that we were running a hospital treating patients, including wounded combatants from both sides—this was not a ‘Taliban base,'” Liu declared. “The question remains as to whether our hospital lost its protected status in the eyes of the military forces engaged in this attack—and if so, why. The answer does not lie within the MSF hospital. Those responsible for requesting, ordering and approving the airstrikes hold these answers.”

How the carnage unfolded

U.S. airstrikes started around 2 am. At the time, staff were treating 105 patients and attempting to catch up on a “backlog of pending surgeries” because the night had been relatively quiet.

A “series of multiple, precise, and sustained airstrikes targeted the main hospital building, leaving the rest of the buildings in the MSF compound comparatively untouched,” which happens to correlate with the exact GPS coordinates that were provided to “parties to the conflict.”

Two of the three “operating theaters were in use,” and “three international and twenty-three national MSF staff were caring for patients or performing surgeries in this same main building. There were eight patients in the ICU and six patients in the area of the operating theaters.”

“MSF staff recall that the first room to be hit was the ICU [intensive care unit], where MSF staff were caring for a number of immobile patients, some of whom were on ventilators. Two children were in the ICU. MSF staff were attending to these critical patients in the ICU at the time of the attack and were directly killed in the first airstrikes or in the fire that subsequently engulfed the building. Immobile patients in the ICU burned in their beds.”

The review further recounts, “After hitting the ICU, the airstrikes then continued from the east to west end of the main hospital building. The ICU, archive, laboratory, ER, x-ray, outpatient department, mental health and physiotherapy departments as well as the operating theaters were all destroyed in this wave after wave of strikes.”

“After the first strike, MSF medical teams working in the operating theaters ran out of the OT [occupational therapy room] and sought shelter in the sterilization room. The two patients on the operating table in the OTs
were killed in the airstrikes.”

One MSF nurse showed up to the administrative building “covered from head to toe in debris and blood with his left arm hanging from a small piece of tissue after having suffered a traumatic amputation in the blast.” Staff immediately attempted to treat the nurse, who was bleeding from his left eye and oropharynx (the part of the throat behind the mouth).

Staff heard a propeller plane that sounded like an AC-130, the aircraft which was reported to have circled the MSF hospital.

“Many of those interviewed describe massive explosions, sufficient to shake the ground. These bigger explosions were most frequently described as coming in concentrated volleys. MSF staff also described shooting coming from the plane.”

The review recounts how staff were gunned down by the aircraft, as they tried to flee the main hospital building.

“Some accounts mention shooting that appears to follow the movement of people on the run,” according to the review. “MSF doctors and other medical staff were shot while running to reach safety in a different part of the compound. One MSF staff member described a patient in a wheelchair attempting to escape from the inpatient department when he was killed by shrapnel from a blast. An MSF doctor suffered a traumatic amputation to the leg in one of the blasts. He was later operated on by the MSF team on a make-shift operating table on an office desk where he died.”

“Other MSF staff describe seeing people running while on fire and then falling unconscious on the ground. One MSF staff was decapitated by shrapnel in the airstrikes.”

The aftermath of the airstrikes

The main hospital building was the “principal target of the attack,” however, other parts of the compound were hit, “including in the southern area of the hospital compound where two unarmed MSF guards were found dead as a result of shrapnel wounds.”

MSF determined three or four of the patients were “wounded government combatants” while around twenty patients were “wounded Taliban.” There were about 140 MSF national staff and nine MSF international staff in the hospital, and one International Committee of the Red Cross delegate was there as well.

Immediately after the airstrikes halted, wounded people arrived “in shock, vomiting, and screaming.” Numerous MSF staff remained at the compound from 3 am to 4 am while other staff searched for missing colleagues. The medical staff from the ICU, OTs, and ERs were apparently nowhere to be found.

Life-saving operations on the wounded began. MSF staff collected “what medical material they could and
converted one of the administrative rooms into a make-shift emergency room, performing surgery on an office desk and a kitchen table. The medical team quickly tried to organize the patients and to triage the critical from the non-critical patients.” Attempts were made to stop severe bleeding and treat shock, but at least two MSF staff died during operations.

Ambulances from the Ministry of Public Health arrived to pick up the wounded. At this time, some Afghan Special Forces entered the facility. There were two rounds of patients transferred to a Ministry of Public Health hospital.

“At the moment of transferring patients, the atmosphere was chaotic as there were a large number of patients to be transferred and Afghan Special Forces had just arrived at the hospital amidst ongoing clashes in the area outside of the hospital compound,” according to the review. “Some Afghan Special Forces started to search for Taliban patients in the MoPH and MSF ambulance on leaving the hospital. At approximately 6 am, an ambulance was caught in the crossfire while exiting the main gate of the Trauma Center. Bullet impacts are visible on the car.”

There was no fighting around the hospital when U.S. forces attacked

The day before, Friday, October 2, MSF put two flags on the roof of the hospital. All MSF staff indicated the area in and around the hospital was “very calm.”

“No fighting was taking place around the hospital, no planes were heard overhead, no gunshots were reported, nor explosions in the vicinity of the hospital,” the review indicates. And, “From approximately 12.20am to 1.10am, the MSF coordinator conducted the nightly security round of the hospital compound. The coordinator reported that the [hospital] was calm, with no armed combatants present, nor any fighting on the hospital grounds or within the audible vicinity. All MSF guards were on duty and MSF was in complete control of the compound. All of the MSF staff reported that the no weapons policy was respected in the Trauma Center.”

Fighting intensified on September 28. The review mentions MSF proposed patients “remove any military identification or clothing from the hospital, as is our standard practice to reduce possible tensions in the hospital with both parties to the conflict being treated within the facility.” Some wounded Afghan government forces were treated at the hospital, but for the most part, the Afghan government forces preferred to have their wounded transferred to another hospital.

The same day, at about 6 pm, “two Taliban combatants arrived at the hospital gates to inform MSF that they were in control of the area.” And by 10 pm, the medical teams at the hospital had treated 137 wounded, including 26 children.

As the fighting remained intense, on September 29, MSF once again emailed GPS coordinates to the U.S. Defense Department, Afghan Ministry of Interior and Defense, and U.S. Army in Kabul. The Defense Department and U.S. Army representatives confirmed they had received the coordinates. The Afghan Ministry of Interior confirmed the coordinates had been received as well.

Then, on October 1, a U.S. government official in Washington, D.C., who is not named in the report, asked if the hospital or any other MSF locations had Taliban “holed up” in them. The official asked about the safety of staff. MSF informed the official that staff was “working at full capacity in Kunduz and that the hospital was full of patients, including wounded Taliban combatants.” MSF made it clear that both sides had an obligation to respect the neutrality of the hospital.

U.S. military & other forces had agreements to respect the hospital

MSF had agreements with the health authorities of the Afghan government and the health authorities affiliated with “relevant armed opposition groups,” like the Taliban. The agreements referenced international humanitarian law and were established to guarantee the right to treat all wounded and sick individuals without discrimination. The intent was also to ensure patients and staff were not harassed while providing medical care, medical and patient confidentiality was respected, and medical staff were immune from prosecution for treating combatants.

“These commitments were discussed and endorsed by the militaries involved in the conflict, including all international military forces such as the United States, both the regular and special forces branches, ISAF and later Resolute Support command structures, Afghan National Army, National Police and National Security agencies as well as the military command structures of armed opposition groups,” according to MSF. “The local military hierarchy of all warring parties endorsed compliance by agreeing to a no-weapons policy within the MSF facility.”

Yet, Representative Duncan Hunter has apparently been informed by a few special forces operatives that the Combined Joint Special Operations Task Force-Afghanistan, which is in charge of overseeing airstrikes, did not know the compound contained a hospital. The U.S. Army’s $5 billion intelligence network was down and affected the ability of forces to avoid bombing civilians.

The trouble with this new “fog of war” explanation for bombing the Doctors Without Borders hospital is it marks another shift in the U.S. account of what happened.

The story of what happened shifted four times in four days after the airstrikes. First, the U.S. military was unsure if the hospital had been bombed but claimed U.S. forces had been under fire. Then, the U.S. military claimed strikes were in the “vicinity” of the hospital and the bombing was an accident. Then, the commander of U.S. forces in Afghanistan claimed Afghans had called for the strike and U.S. forces had never been under any threat. Then, while addressing a Senate committee, he stated U.S. forces had called for the airstrike after receiving a request from the Afghans.

The Associated Press has also reported a senior Green Beret officer advised a special forces unit on October 2 that MSF had personnel in the hospital, and the hospital was under control of “insurgents.” An objective for the next day was to “clear the trauma center” of any enemy forces, which was in clear violation of agreements MSF established with U.S. and Afghan forces. On top of that, there is no evidence that MSF was informed airstrikes were coming and so they needed to evacuate so U.S. forces could raze a hospital they suspected was under control of the Taliban.

There also is no legitimate explanation for why the U.S. military and the chain of command, which authorized strikes, did not believe MSF when it asserted the facility was not under Taliban control.

In the end, the Kunduz Trauma Center was one of the only facilities of its kind in northeastern Afghanistan. It offered free surgical care to victims of traffic accidents and civilians hit by bomb blasts or gunfire from ongoing warfare. Now, there is no facility for Afghans to receive treatment when they are caught in the crossfire and in need of medical attention.