Healthcare Devastated by the Use of Explosive Weapons in Mosul

The battle for Mosul, Iraq – one of the most destructive urban battles since the Second World War due in large part to the use of explosive weapons by all parties to the conflict – devastated the city’s healthcare system. This article explores the long-term impacts of the use of explosive weapons on the provision of healthcare in Mosul from the end of the battle through present, highlighting the evolving healthcare needs of civilians at different points in the last seven years. 

Introduction

The battle for Mosul, Iraq – waged from October 2016 to July 2017 – has widely been referenced as one of the deadliest and most destructive urban battles since the Second World War.1 For nine months, Iraqi security forces, backed by a US-led Coalition, fought to dislodge the Islamic State, also known as ISIS, ISIL and Daesh, from Mosul. The group had seized control of the city in June 2014, amidst rising instability in Iraq and Syria.2 In August 2014, the US-led Coalition began conducting airstrikes against ISIS. These were conducted by the Coalition’s military contingent of 14 states, including Belgium, France, the Netherlands, Saudi Arabia, Türkiye and the United Kingdom.3

The battle for Mosul was characterised by widespread use of explosive weapons by all actors. The US-led Coalition’s air and artillery units fired more than 29,000 munitions at the city. Local Iraqi forces also frequently deployed explosive weapons. Iraqi armed forces, for example, engaged fighter jets and attack helicopters, artillery, mortars and rockets, while the Iraqi Federal Police reportedly used improvised rockets known as IRAMs in western Mosul. ISIS also deployed artillery, mortars and improvised explosive devices (IEDS) widely in Mosul, including more than 700 vehicle-borne IEDs, according to Coalition officials.4

The use of explosive weapons in Mosul has had lasting impacts on the provision of and access to healthcare. Drawing on available data, this article will highlight healthcare needs and services at different points in time since the end of the battle, almost seven years ago. This can serve as an example of some of the foreseeable reverberating effects of explosive weapons use in cities on healthcare.

Death and injury from the use of explosive weapons in Mosul

The extensive use of explosive weapons in Mosul caused significant civilian death and injury. There is no definitive number of civilians killed as parties to the conflict did not engage in comprehensive civilian harm documentation. An analysis by the Associated Press (AP) in 2017 estimated that between 9,000 and 11,000 civilians were killed during the nine month-long battle. At least a third of the civilians killed were attributed to ISIS by the AP. Similarly, the media outlet found that at least one third were killed by the use of airstrikes, artillery fire and mortar rounds by US-led Coalition forces or Iraqi forces. The AP analysis referenced reports by the Health Ministry, which described the majority of these civilian bodies as “crushed” - likely caused by the weight of collapsed buildings hit by explosive weapons.5

The number of people permanently injured from the use of explosive weapons in populated areas far exceeded the number of civilians killed, the Chief Executive of Humanity & Inclusion UK remarked following a visit to Mosul in 2021. Many people permanently injured in Mosul would require long-term medical care, including almost five thousand amputees registered with the Mosul Rehabilitation Centre as of 2018.6

The United Nations Office for the Coordination of Humanitarian Affairs (OCHA), reported that 20,000 severely wounded people were referred to hospitals during the battle.7 Beyond physical injury, the World Health Organization (WHO) estimated at the end of 2018 that nearly two percent of people affected by the conflict suffered from “serious mental health problems,” in particular extremely vulnerable women, children and the elderly.8  Although not all of these injuries were caused by explosive weapons, their prevalence suggests they caused a high proportion of harm.

Increased burden on the healthcare sector: impacts of the use of explosive weapons in conflict on the provision and need of healthcare in Mosul

The use and impact of explosive weapons in conflict puts extra pressure on the healthcare sector at a time when the need for it is the greatest. Whilst weapons-related injuries increase the need for healthcare, damage and destruction of infrastructure also reduces the sector’s capacity to provide it. This can cause avoidable deaths, disabilities and diseases for months or years into the future. 

In Mosul, widespread use of explosive weapons in populated areas contributed directly to these stresses. Damage and destruction to and around healthcare facilities impacted the provision of healthcare, civilians’ access to facilities and the supply of drugs and medical equipment. Capacity and provision was also impacted by the injury, death or displacement of healthcare personnel. 

In the case of one Mosul hospital, the exhaustive damage caused by the battle stopped its provision of services altogether:

“The destruction of Mosul Ibn Sina Teaching Hospital symbolises the collapse of the healthcare system caused by the war. The impacts are widespread and long-lasting with the increased pressure on remaining health facilities meaning people suffer for longer before receiving treatment or surgery, while chronic diseases worsen with time.” 9 
- International Committee of the Red Cross (ICRC)

The destruction of Ibn Sina, as well as widespread damage to other hospitals and primary healthcare centres, dramatically reduced the capacity of Mosul’s healthcare providers to treat people. 

Thousands of people were seriously wounded during the conflict in Mosul, including from the use of explosive weapons, with a significant proportion facing life-changing injuries and permanent disability.14 Many required specialised care, including urgent and emergency care, long-term follow-up, rehabilitation, mental health and psycho-social support. Yet, in Mosul, limited capacity and high costs, caused in part by the damage and destruction of healthcare facilities from explosive weapons, posed serious barriers to adequate and timely treatment.15

In July 2019, Humanity & Inclusion’s Middle East Director said that “thousands of victims still await treatment,” including patients that had been waiting for prosthesis for more than a year.16 A survey to identify people with disabilities conducted the following year identified 1,300 ‘new’ people with disabilities, 61 percent of which were in need of assistive devices and required wheelchairs.17

Moreover, civilians continued to experience weapons-related injuries after fighting had stopped. As the end of the battle approached its one-year mark, MSF reported that dangerous living conditions, caused by the widespread destruction of housing and other infrastructure, posed a growing risk to civilians’ health and heightened the need for healthcare facilities.18 As more people returned to Mosul, a growing number were seeking emergency healthcare due to injuries obtained from living in post-conflict environments. Indeed, this was the cause of 95 percent of trauma cases received at a MSF hospital in western Mosul in May 2018. These trauma cases - including injuries from collapsing buildings, falling from unsafe structures and falling debris - show some of the indirect impacts explosive weapons use in populated areas has on civilian life over time.19

Assessing the impact of explosive weapons on the healthcare infrastructure and provision in Mosul 

The use of explosive weapons in Mosul had a severe impact on access to, and the availability and quality of, healthcare. The nine month-long battle saw the damage or destruction of nine out of the city’s thirteen hospitals. The ICRC reported that the number of hospital beds dwindled from nearly 2,800 before the battle, to just one hundred directly following its conclusion. Six years later, only 1,200 beds were available, some 40 percent of pre-battle numbers.20 

The United Nations Mine Action Service (UNMAS) Chief of the Mine Action Programme in Iraq told the author that “most of the city’s healthcare infrastructure had been destroyed or was not accessible,” and that in western Mosul it was “more or less non-existing.”21 Ibn Sina Teaching Hospital, Mosul’s main healthcare provider for over three decades and Iraq’s second largest hospital complex, was damaged so severely that healthcare services stopped entirely.22 The complex, which had been used as a base by ISIS fighters, was heavily bombed by Coalition forces. The levels of contamination from IEDs and other unexploded ordnance was very high, especially in west Mosul, with UNMAS clearing some 1,500 explosive items from the hospital complex alone.23

“When we first came here, it was a pile of debris, a barren place, there was nothing we could use,” said Shatha Mahmood, a Senior Pharmacy Assistant, of her first visit to the hospital after the battle. The hospital complex which had once provided quality healthcare for a million people was unusable, and with it, a range of free or affordable services it had provided, from urgent and emergency care and operations, to cardiology, neurosurgery and maternal, neonatal and paediatric care. To this day, the site remains one of construction, with parts of the hospital’s services being offered in temporary facilities elsewhere in the city.24

The explosive hazard contamination and immense amounts of rubble - estimated at some 7.5 tonnes - were major obstacles to assessing and rehabilitating healthcare infrastructure and restoring the provision of healthcare in Mosul, according to the UNMAS Chief of the Mine Action Programme in Iraq. A particular challenge was the unprecedented level of “three-dimensional” contamination - explosive hazards could be found anywhere in the urban environment, not just buried in the ground, but also under rubble, attached to household appliances, or concealed inside walls or children’s toys. 

The same hospital room of before and after the battle for Mosul. Ibn Sina Hospital Complex, Mosul, Iraq. © Photo UNMAS

The cost of clearing cities of mines and unexploded ordnance comes at an estimated cost of six times that of rural settings, according to Humanity & Inclusion.25 In 2017, Mosul’s governor assessed that it would cost US$ 50 billion to remove explosives and rebuild Mosul over the five years following the battle.26

The slow process of rebuilding and rehabilitating a city’s healthcare system 

Rebuilding Mosul’s healthcare infrastructure, increasing its capacity and providing affordable, quality services has been slow. According to healthcare experts with knowledge of Mosul, the city is still years from reaching the capacity it had before the battle.27 This, despite Iraq being the recipient of the most successful and well-funded international appeal for humanitarian assistance globally from 2017 to 2020, with 95 percent of funding requirements met.28 

From the beginning of the battle for Mosul, local healthcare personnel and international partners rallied to provide emergency and trauma healthcare for civilians. After the battle, work rapidly began to rehabilitate primary healthcare and provide provisional locations for emergency hospital services.29 However, the scale of the damage to Mosul’s healthcare infrastructure was significant. A 2017 assessment by the United Nations Development Programme (UNDP) established that sixteen primary healthcare centres and three hospitals in east Mosul had differing degrees of damage, whilst in western Mosul, sixteen primary healthcare centres and five hospitals were all still in various states of disrepair.30

One year after the end of the military campaign, MSF reported that the healthcare system was in ruins, with a large gap between needs and available services. The number of hospital beds was unimproved, standing at only 30 percent of the pre-offensive capacity. For a population of 1.8 million people, Mosul had less than 1,000 hospital beds, half of the internationally recognised capacity required to ensure the minimum standard of healthcare provision in a humanitarian situation.31

MSF’s Head of Mission in Iraq said that “emergency room services and surgical, oncology and burns facilities are urgently needed, as well as medical equipment and a steady and affordable supply of medication.” They added that every day, thousands of Mosul’s inhabitants were struggling to access healthcare.32 Needs for mental health services, follow-up surgery, pain management and physiotherapy for wounded civilians were also in high demand.33

In the years that followed, accessing healthcare continued to be a struggle for many. In 2021, limited availability and cost were cited by Humanity & Inclusion as notable obstacles.34 That same year, a local official in Mosul told PAX, a Dutch peace organisation, that 80 percent of the city’s healthcare facilities continued to operate out of temporary locations.35

In 2022, five years after the end of military operations, MSF identified limited improvement, but emphasised that the need for medical care remained high. Many of the damaged facilities had yet to be fully renovated and made fit for use, and medical supplies were in shortage. Whilst hospitals had reopened in temporary structures and caravans, thousands of families found it difficult to receive quality, affordable care.36

Across Mosul’s healthcare providers, a pattern of decreased capacity and increased demand continued six years after the end of the war. For example, before the battle in 2016, the Ibn Sina Teaching Hospital received up to 21,000 patients per month for operations and treatments. During this time, its 600 beds were often occupied, and 800 to 900 patients were referred to the hospital daily. Six years later, in 2023, the number of daily referrals had increased to 3,000, whilst the hospital’s capacity was reduced by 90 percent. The hospital’s original site remained in ruins, the ICRC said in December of 2023, with temporary locations operating at 10 percent of its pre-battle capacity.37

Yet, during the past seven years, significant efforts have been made to better Mosul’s healthcare provision, and it is slowly improving. Today hospitals and primary healthcare centres are functioning and providing basic services, including immunisation, curative care and treatment for non-communicative diseases, a healthcare professional told the author. However, secondary healthcare services, they estimated, are only able to provide around half of the services needed for the population they serve. Whilst lifesaving services such as emergency reception rooms are up and running, operating theatre capacity and other tertiary treatment remains limited.38

Efforts are underway to rebuild Mosul’s hospitals. The site which housed the Ibn Sina Teaching Hospital is currently being cleared in preparation for reconstruction. The IQD 300 billion project (approximately US$ 230 million) is expected to be complete in 2027. The timely completion of the hospital was described by the ICRC in late 2023 as “a matter of life and death,” as Mosul continues to operate at a significantly reduced capacity.39

Conclusion

Mosul may reach its pre-battle healthcare provision capacity within the next three to five years, a healthcare professional with insight into its rehabilitation said. This, however, will require significant commitment from the Iraqi government and additional financial and implementation support from external actors.40