Valérie Gruhn was an emergency room nurse with Doctors Without Borders/Médecins Sans Frontières (MSF) near Mosul, Iraq, from March to June 2017 during the battle for control of the city. She shares the following excerpts from her journal.
When I close my eyes, I can still see the reflection of the sun glistening on the Tigris river. The only bit of greenery hugs the river tightly, while stretching out into the horizon of the valleys that were once known as Mesopotamia.
To the right of the river lies West Mosul, now in ruins. Entire families have been torn apart and many of their loved ones still remain below the rubble.
I was in Iraq for three months, when the battle of Mosul entered its final phase. This journal captures my personal experience working in the war zone, and stories of what people lived through.
When I close my eyes, I see my friends in Mosul.
March 28, 2017: Erbil, Iraq
In Erbil, a man wearing an MSF jacket greets me with a welcoming smile and drives me to what turns out to be a long day of briefings.
I can't say that I know anything about Iraq. I spent most of my briefings learning about the different projects, but also about Iraq's long and complicated history, and what led to the current crisis.
I was scared before arriving here. I was not scared about going to Iraq, per se, or even going to Mosul, but mostly concerned that I would do or say something I should not. People are inviting and pleasant. I feel safe.
Briefings. Exhausted. Bed. Tomorrow to the field.
March 29, 2017: Hammam al-Alil, a town south of Mosul, Iraq
MSF's project in Hammam al-Alil serves as a trauma stabilization post with an operating theater to carry out life-saving surgeries. Several tents are pitched on an empty lot and hold an emergency room and post-operative area; a shipping container is set up for surgeries.
Civilians and Iraqi "soldiers" who are injured on the front line in Mosul are brought in by an ambulance from the Ministry of Health. We receive those patients at the front, triage them by scanning their injuries, and immediately bring them in for stabilization after a quick metal-detector sweep. There are several risks every time we go to triage a patient. One rumor spread yesterday of an ambulance circulating with a bomb inside of it. The staff was placed on lockdown and ambulances were forbidden to enter until the threat was lifted.
The trauma patients will either be transferred to our operating theater or to a higher-level facility. This gets complicated because of the Iraqi and Kurdish borders. Background checks at checkpoints can be time-consuming, and patients can die waiting in the ambulance. Since the start of the war, the political map of Iraq evolves almost daily. The Islamic State's territory grows smaller as Iraqi forces are recapturing neighborhoods, and the Kurdish territory has shifted as well.
I work beside an expat doctor and a great team of Iraqi nurses and surgeons. Teaching and training, which are major elements of working in a project, are hardly necessary.
The sound of an ambulance approaching the hospital gate at high speed. A little five-year-old girl hit by a mortar attack is lifted out of the ambulance. She has deep wounds on her left leg, and her left arm is starting to turn blue. She is still awake, but I can't stop noticing that her confusion is masked by cries and periods of sleep. She lost her mother and siblings in this attack. Her father, who survived the attack, was transferred to another hospital.
I comb her brown hair back from her face with my hands, take off her earrings and transfer her to our operation theater. I place her earrings in a little bag to save them for her. I think that perhaps her earrings are something by which she can remember her mother.
March 31, 2017: Hammam al-Alil
The drive from Qayyarah to Hammam al Alil takes around one hour, depending on the army personnel at the checkpoints and the other people who are waiting to pass. The guards know us and the logo on the car well by now. Most of them are young men in their twenties with machine guns on their shoulders and hand grenades across their chests. Alongside them are tanks with their barrels trained on the on-coming traffic. They check every car that goes through and sometimes this creates a jam. A few weeks ago, one Islamic State member detonated his improvised explosive device at another checkpoint nearby. Another bomb attack brought a small wave of dismembered children into the emergency room. I was standing at the entrance of the tent waiting for whoever was getting triaged up front. Then I saw it: A screaming father, holding his unconscious child, came running in. The outline of the father's ribs could be seen through his ripped shirt. Tears etched lines across the dust on his face, an expression of the paralysis of fear. Sometimes, I remember this as if it happened in slow-motion. It was surreal and looked like a TV news clip, but then I realized that he was actually running towards me. I quickly snapped out of it. I took the boy from him and applied oxygen to the child's face, which was missing a chunk of flesh from the left cheek. I looked up and saw four more children get carried in, one missing his nose.
These are the stories of the people of Iraq. Many have lost their lives, and few are spared from losing someone close to them. Yet on every drive, groups of kids gather on the street waiting for our car with smiles and laughter, while forming a small V with their little fingers for Victory.
The author, center, in Iraq in 2017
April 5, 2017: Hammam al-Alil
Being a woman in Iraq is complicated. In Kurdistan, which is less conservative, women wear tighter clothes and do not cover their hair, but do cover their shoulders and hips. The areas where I work were under the Islamic State group's control for over two years, with stricter rules than the culture generally demands of women. Once their areas were retaken from the Islamic State, most women loosened the hijab and returned to their previous attire, and freedom to show their faces. One of our doctors wears a T-shirt and jeans and waves her long brown hair because she finally can. Nevertheless, the rules are different here. On one hand, women have a limited role in society, yet on the other, they are some of the fiercest women I have met.
A woman who had been shot ten days earlier came to us with an older woman and her husband. The husband had a white beard and wore a keffiyeh secured around the head by a black agal. I learned that men above the age of fifty wear this. His first wife was very supportive to his second wife, the patient. The patient looked young and did not speak much. We recommended transfer to another hospital for treatment of her necrotic and infected wound, but she refused to go, stating that she had to get home to care for her mother who had been burned from an airstrike. I again urged the family to rethink their decision so that she would not lose her leg. The husband eventually agreed.
Another injured woman arrived with her newborn and a toddler after escaping from a besieged area of Mosul. Her husband couldn't get out in time. Her injuries required her to be transferred to Erbil. Trying to enter Iraqi Kurdistan as an Iraqi coming from Mosul without papers is tricky, especially for a woman traveling without a man at her side.
The nursing staff is mostly male, and I am their supervisor. The staff is learning to get used to our funky ways of thinking and doing things. Sometimes, we (the women on staff) will smoke a cigarette without hiding ourselves, but for the most part we are respectful of the culture and dress appropriately. Dr. Mohammad came to me today as I was smoking (with my sleeves pushed up in the scorching heat) and said: "You are a very strong woman. Thank you for everything you do and for helping the people of Iraq."
April 19, 2017: Hammam al-Alil
The offensive started a few days ago. For Easter, instead of looking for eggs, we looked for a place to transfer military personnel and civilians. As we were flooded with waves of bodies, the Mosul dam, which may have had maintenance issues due to the conflict, decided to do the same to the bridges: Every bridge leading out of town was underwater. This meant that I was spending my fourth night at the hospital, but also that patients could not be transferred.
The cases were overwhelming. Legs and arms were blown off, requiring amputations. Abdominal gunshot wounds required laparotomies with chest tubes. Patients who stepped on landmines came in with only a head and a torso, and died.
A leg was found but we didn't know whose body it belonged to. When someone dies in Iraq, families want every part of the body in order to wash it and then bury it. This means that we return a leg after we amputate it, or anything else that comes off. However, with this leg we just didn't know.
April 23, 2017: Hammam al-Alil
The last few weeks were a busy time, between handing over of the project in Hammam al-Alil to another MSF team and the opening of a project in West Mosul. A young, pregnant woman was brought in after having been found under the rubble of a blast that happened the prior night. Trapped all night, she had held on, breathing through the cracks and crushed by bricks that were once her home, until people rescued her. She is 22 years old.
As I was working her up, she lay there and watched me, piercing me with her eyes. Her eyes reflected the darkness she had just lived through, but mostly they screamed with fear. She had big holes in her abdomen with the placenta peeking through, and both her legs were broken. We had no choice but to do an emergency C-section. As I stood in the operating theater on standby to give rescue breaths, a lifeless baby was handed over. Describing the neonate only adds to the horror of these stories, and either way I don't think I can ever forget it. (I visited her in Qayyarah one month after this incident. She is relearning how to walk, and has undergone several more surgeries since we transferred her to another MSF hospital. The road will be long for her. When I walked over to her and introduced myself, she replied: "I remember you well, thank you.")
We were also confronted with a few security threats. We immediately went into hibernation mode and stopped all movements. Somehow, we managed to make last-minute sleeping arrangements for our 25-person team, placing several mattresses in an empty house. This didn't affect us much, considering that we had been sleeping "camping style" for the last month in the same place we were using as an office. This place was only slightly worse, because it had no electricity or running water.
I finished my handover and started working on the recruitment of nurses for West Mosul.
April 29, 2017: Qayyarah
For the next few days, I lent a hand to the head nurse of MSF’s Qayyarah project. This project is very different from the one in Hammam al-Alil. It is a full hospital, and it includes an in-patient therapeutic feeding center (ITFC).
Food provisions are running low and the water supply has been cut to families that still live in besieged areas. People are hungry. Breastfeeding mothers are unable to produce breast milk due to the psychological trauma they had lived through and are obligated to give their newborns mashed bread with water.
The ITFC opened no longer than one month ago, after babies were coming out of Mosul malnourished. Iraq is not a place where malnourished children are common, hence when the staff first saw this, they were puzzled, saying, "I've only seen this on TV with children suffering from famine.”
Doctors prepare a patient for abdominal surgery at MSF's Field Trauma Clinic, South of Mosul, Iraq (photo by Alice Martins)
May 12, 2017: West Mosul
We leave Hammam at 8am to head towards West Mosul. It is impossible to miss the destruction of homes. Every few kilometers we see the rusty shells of burned-out cars that had been used as car bombs. What were once businesses, homes or mosques are now empty streets and piles of rubble.
You also see truckloads of people who had fled, but are now returning from the camps to homes that may not be standing anymore. This is very different from the road up to Qayyarah or Hammam al-Alil. The intensity of the devastation of this once-lively city is multiplied considerably.
We found an abandoned structure a few weeks ago. It is one of the few buildings left that is not completely damaged, and has a basement which is a safe location to perform surgery. This will be our hospital. In the near distance, loud explosions followed by black smoke paint the blue sky. I hear the sound of whistling bullets during the exchanges of fire, and just down the street, the military is firing shells into the old city.
We are trying to open before Ramadan — the same deadline set by the Iraqi army to recapture Mosul. Let's see who will finish first. Though the last few weeks' frustrations are still dragging into this week, things are slowly coming together. We interviewed over thirty nurses today. Everyone is desperate for work, desperate to make money again, desperate to feed their families and get out of the camps. However, important paperwork, such as medical licenses, are lost or stolen.
Back in Hammam al-Alil, a sand storm picked up whatever it found along its path and left us all covered in dust and sand. The jets flying above us keep us from sleeping well into the night. Now that I think about it, the military spoke of a change in strategy. Does this mean more aggressive tactics? Maybe they will take West Mosul before Ramadan after all. In any case, people will die.
May 17, 2017: West Mosul
People continue to flee the areas of Mosul that are getting retaken. Temperatures are reaching almost 50 degrees Celsius (122 degrees Fahrenheit). The women are completely covered, often carrying a baby with four or five other kids walking beside them. The husband is missing; he was most likely killed or unable to escape.
Hundreds of thousands of families are now living in filthy camps with no access to primary health care, no money, nothing left except the scars they carry.
May 26, 2017: West Mosul
Today is the first day of Ramadan. I was woken up by a bell and a man yelling something in Arabic, which I assume is the announcement of Ramadan. This was followed by the early morning prayer at the mosque, which was done twice this time around.
Back in Hammam al-Alil, I would often see the staff buying food for patients with their own money, or handing out money to help their community, even though MSF had a fund set aside just for this. "It is our duty as Muslims to take care of each other," they would say.
We are supposed to open a hospital tomorrow in a building that was previously used as a kindergarten. The hospital was cleaned yesterday; the unpacking continued late into the day; the surgical team arrived; the training of the staff is happening, as well; and we are ready to collapse. And half of us are sick with giardia, one really evil parasite. It's our final push to open, and funny enough, the military's operation is called: "The Final Push."
May 29, 2017: West Mosul
Today we officially opened the MSF West Mosul “Kindergarten Hospital.” I think of what we have done so far. The hospital is running, all our supplies are in place and I am training the staff. I have a little under one month left to my mission, and though I helped build a hospital in a war zone, my work is far from done. The hospital is really impressive, now that I think about what persistence and hard work can achieve. We fought to get it open and running, and I am happy to be surrounded by such amazing people. Most of all, the hospital serves its ultimate purpose: to give people in west Mosul a second chance.
The nighttime staff invited me for iftar dinner, which was really nice because I hadn't eaten much over the last few days. A blanket covered the hospital floor and everyone placed the dish they’d prepared, which we all shared. They spoke in Arabic and I spoke in English, and we understood each other enough to share many moments of laughter and sadness. They are all victims as well; everyone has lost someone, or has been imprisoned, or worse (tortured and/or traumatized). With every patient that enters our hospital, the staff relive the atrocities they experienced themselves, and at times, that patient is a member of their own family.
June 10, 2017: West Mosul
We received an ambulance full of women and children after the city of Zanjili was retaken, a battle in which hundreds of people were injured. Amongst those we received were a young girl and boy with his mother. He came in with a gunshot entry wound in the abdomen and an exit wound through the anus. The bullet tore through the bowels. He made it out of surgery alive, but went into septic shock within a day. I had been on call that night and stayed at the hospital. I walked away for a few hours in order to give the nurses some autonomy, but also to get some sleep. I was exhausted, yet I couldn't sleep. I knew something was wrong.
At 3 am, I was called in by the nurses when they could not get a blood pressure reading from him. His glucose level was 40. We did everything we could, and even put him on a dopamine drip, in a place that is not suited for intensive care. We didn't walk away until lunchtime the next day, when he died. He was four years old. The mother, after fighting a battle to survive and escape, dropped to the floor, grieving the loss of both her husband and her child. She refused to take a sip of water, not to break her fasting during Ramadan.
Another patient, a little four-year-old girl who had a terrible head injury with her skull partly exposed, was also brought in seemingly lifeless. However, she recovered well. She had the most beautiful eyes. She was scared because she was alone, but once she grew to trust us she helped us find her family. Her name is Rama. The staff posted her picture on Facebook and within a day her uncles came to identify her and the family was reunited. The father had died and the mother and siblings were alive but injured. I told the uncle to bring them in to receive medical treatment. When Rama saw her siblings and her mother she was so relieved; she cried and threw herself at her mother. We referred the family to keep them all together and avoid another separation.
All the stories here are weighing on me now. I don't know if it's because I am tired, or because this is not easy to deal with. At night, the rockets and airstrikes are lighting up the sky, while choppers are attacking the old town. I lie awake on the floor of our pharmacy, watching the nighttime sky light up and the walls and windows shake, waiting for patients to maybe make it out alive. I fear every rocket that flies over me, because they sound like they are coming towards me. There is a sense of relief when that's not the case, and yet it is destroying someone else who I may or may not treat. It is conflicting to be here. I know the risks that I take every second I am here, but I refuse to leave. There are other little Ramas out there.
June 12, 2017: In transit to Erbil
We had a security incident, and now we're being evacuated. The people here have faced and dealt with these threats, disappointments and losses for three years, and now, after we all thought this hospital would serve as a fresh start for everyone, the opposite is happening.
June 20, 2017: Paris
So, I left. I am back in Paris at the MSF office to discuss my experience in West Mosul, including our successes and, mostly, our failures.
Once the project was placed on hold, we were evacuated to Erbil to discuss the future of our activities with the coordination team. We walked in and found the head of mission and every person from the coordination team sitting in a circle, waiting for us to start our meeting.
The night in West Mosul was one of the worst in a long time. The Islamic State attacked the Iraqi forces on the edge of the old city and retook some territory. At the same time, a mortar landed in the center, next to a Federal Police checkpoint along the main road. We were lucky we had evacuated, especially since it was my night to stay in West Mosul.
In such a complex war, it is impossible to remain completely safe. So, while we succeeded in setting all this up with the bare minimum of things, we still failed because we did not remain open to do what we were meant to do. In total, we received fifty patients, including those from one mass casualty incident.
The offensive for the old town started yesterday. Civilians are unable to escape at this point. The streets of West Mosul are covered in corpses, and those that are in hiding are starving or wounded.
Iraq's future is bleak. People who survived lost everything they had - their homes, their limbs, and their loved ones. I'd never seen so many wounded children. I never understood what it was like to live in a place where just being alive means you are privileged. I've seen plenty of suffering in the world, but never anything like this. People's faces and eyes painted the horrors they had lived through, and if they still had their limbs, their feet were raw from walking barefoot for kilometers to reach the nearest hospital. Everyone has post-traumatic stress disorder, and I am not sure how the children will ever grow up to be okay. Most are parentless and living in camps now, and it is impossible to find a remaining family member in this shuffle of people that happens with the referral process.
At the same time, as this war rages on, another one is about to begin. No one will have time to rebuild their lives. Meanwhile, they will remain hopeful that one day God will finally give them the very basics of human dignity. I will never forget the stories, the people and the hardships of the Iraqis I met. It is impossible to walk away from this unaffected. Insha’allah (God-willing) I will see them again one day, and hopefully then, they will be thriving.
After the battle for Mosul was declared officially over at the end of June 2017, people started to return to the city. However, much of the west side of the Mosul was destroyed, and there was a dire lack of health care services available. An MSF hospital in West Mosul has been working around the clock for the past six months due to the high demand for medical care, and MSF expanded its sexual and reproductive health program to offer antenatal, postnatal and family planning services. In December 2017, the MSF hospital assisted 261 deliveries and admitted 2,370 patients in the emergency room.
Valérie Gruhn is a Haitian and Canadian emergency and trauma nurse, aid worker, and activist. She grew up in Germany and in France, and is currently based in New York. Her public health work has taken her to Gaziantep, Turkey, where she worked on the Syrian refugee crisis, as well as the Philippines. Gruhn has worked with Doctors Without Borders/Médecins Sans Frontières (MSF) in Kenya and Iraq.