Frantic Doctors Without Borders officials sent out at least 17 phone calls and text messages pleading for the airstrikes against the Kunduz hospital in northern Afghanistan to stop.
They repeatedly called the U.S. military in Kabul as the strikes continued for more than an hour in the early morning of Oct. 3. They called the Afghan military. They called the Pentagon. They called the Red Cross.
When told of the devastating attacks by an Air Force Special Operations Command AC-130U gunship, a U.S. official at the headquarters of NATO's Operation Resolute Support in Kabul said, "I'm sorry to hear that. I still do not know what happened."
When told that the attacks were continuing, another Resolute Support official said, "I'll do my best, praying for you all."
Doctors Without Borders, better known by its French name Medicins Sans Frontieres (MSF), released a log of the phone calls and text messages as part of its initial review of what happened in the attacks believed to have killed at least 30 people.
The review suggested that some of the victims were shot by the AC-130's mini-guns as they attempted to flee the hospital while the aircraft lingered over the compound.
"Many staff describe seeing people being shot, most likely from the plane, as people tried to flee the main hospital building that was being hit with each airstrike," the report said. "Some accounts mention shooting that appears to follow the movement of people on the run."
First reports said that 23 were killed but MSF said the death toll now was at least 30, "including 10 known patients, 13 known staff, and 7 more bodies that were burnt beyond recognition and are still in the process of being identified."
"Patients burned in their beds, medical staff were decapitated and lost limbs, and others were shot by the circling AC- 130 gunship while fleeing the burning buildings," the review said.
The organization has maintained that the location of the Kunduz Trauma Center (KTC) had already been made well known to the U.S. and Afghan militaries, NATO, the United Nations and the Taliban as well.
As the Taliban moved to take control of Kunduz, MSF on Sept. 28 -- five days before the airstrikes -- "re-affirmed the well-known location of the KTC by once again e-mailing its GPS coordinates" to the U.S. Defense Department, the Afghan Ministries of Interior and Defense, and the U.S. Army in Kabul, the review said.
"Confirmation of receipt was received from both the U.S. Department of Defense and the U.S. Army representatives, both of whom assured us that the coordinates had been passed on to the appropriate parties," the review said.
"Oral confirmation was received from the Afghan Ministry of Interior. MSF also shared the GPS coordinates with a United Nations intermediary who confirmed transmission directly to Operation Resolute Support," the review said.
MSF on Wednesday shared the review with the Pentagon and with Army Gen. John Campbell, the U.S. commander in Afghanistan, said Navy Capt. Jeff Davis, a Pentagon spokesman.
In testimony to the Senate Armed Services Committee last month, Campbell said the U.S. must take responsibility for the strike.
Initial reports were that U.S. Special Operations troops on the ground in Kunduz had called in the airstrike at the urgent request of the Afghan military, but Campbell said it was "a U.S. decision made within the U.S. chain of command."
Davis said the military was continuing to work with MSF to identity victims and determine the extent of damage "so that we can conclude our investigations and proceed with follow-on actions, to include condolence payments."
A U.S. Casualty Assessment Team currently is attempting to determine the exact number of victims and their identities, and also to gauge the extent of damage to the hospital compound.
Last week, Campbell announced the appointment of Army Maj. General William Hickman to lead an Article 15-6 investigation under the Uniformed Code of Military Justice of the Kunduz airstrikes.
MSF has called for an independent, international investigation, but Davis said that the advantage of a military Article 15-6 investigation was that "it can be used as a legal basis for any follow on actions," including "courts martial, non-judicial punishments and other legal proceedings."
Retired Marine Lt. Col. Gary Solis, a Vietnam veteran and former Judge Advocate General, said a case against either the Special Ops on the ground or the aircrew will be difficult to make.
"Obviously, somebody screwed up -- the question is who? The investigative link is not in the chain of command but in the chain of communication," Solis said.
"Can the guys on the ground be identified? Did they pass on accurate information? Were the guys in the aircraft aware of the ‘no target' list? Or did they misinterpret what was said?"
"Was it a violation of the law of armed conflict? It's always a violation to purposely fire on civilians. It's always a violation to purposely fire on a protected structure, like a hospital. So in that sense it was a war crime. The question is, is it a war crime without a perpetrator?"
"To be prosecutable, you're going to have to have a colorable case and that case must include intent," Solis said, and intent will be next to impossible to prove.
"How are they going to prove that somebody consciously and purposely targeted a hospital? I don't think that happened," said Solis, who teaches the Law of War at Georgetown University.
The U.S. has thus far rejected calls by the MSF for the investigation to be conducted by the International Humanitarian Fact-Finding Commission, which was set up in 1991 under the additional protocols of the Geneva Convention to look into alleged violations of international humanitarian law.
However, Air Force Gen. Philip Breedlove, the NATO and U.S European Command commander, in recent weeks appeared to suggest that he would be open to an international investigation.
"I think this is their (MSF's) absolute right to ask for this investigation," Breedlove told the German news outlet Deuutsche Welle last month. When asked if he would support an international investigation, Breedlove said. "We will support it; we're going to support it."
Breedlove then backtracked at a Pentagon news briefing last Friday. "I am in favor of whatever it takes to get to a full, open, transparent investigation," he said, adding, "I think that our U.S. investigation is ongoing."
For MSF, "The view from inside the hospital is that this attack was conducted with a purpose to kill and destroy," said Christopher Stokes, the general director of MSF.
"But we don't know why," he said. "We neither have the view from the cockpit, nor the knowledge of what happened within the U.S. and Afghan military chains of command."
Stokes also acknowledged that Taliban wounded were being treated at the hospital, which did not distinguish between combatants in providing care.
"Some public reports are circulating that the attack on our hospital could be justified because we were treating Taliban," said Stokes. "Wounded combatants are patients under international law, and must be free from attack and treated without discrimination."
"Medical staff should never be punished or attacked for providing treatment to wounded combatants," Stokes said.
--Richard Sisk can be reached at Richard.Sisk@military.com.
