Understanding the course of events and identifying the participants in the battle of Mosul is a difficult task. What is certain is that all parties neglected the fate of civilians and were unable to provide proper emergency medical relief. An examination of the battle is crucial to understanding the evolution of international humanitarian law in conflict zones.
Details about Iraq’s battle of Mosul, which raged from October 2016 to July 2017, have trickled out slowly and remain incomplete. The battle was fought by Iraqi and international forces to annihilate the self-styled Islamic State of Iraq and the Levant (Daesh in Arabic and also known by the acronym ISIS). After it ended, reporters, human rights organizations and relief agencies uncovered evidence of massive destruction, wanton cruelty and multiple violations of international humanitarian law. Drone videos of Mosul’s city center show physical damage frequently compared to 1945 Berlin, as well as to more recent devastation in Falluja, Gaza, Benghazi, Homs, Aleppo, Raqqa, Sanaa and dozens of other smaller urban population centers obliterated by civil conflict.
Civilian casualty figures are scarce and unreliable.  Widely disparate estimates exacerbate this battle’s particular fog of war. Does one use Patrick Cockburn’s maximum claim of 40,000 civilian deaths made right after the conclusion of hostilities,  the Associated Press estimate of 9,000 to 11,000 civilian deaths,  the Iraqi government estimate of 5,000,  or the 356 civilians confirmed, toward the end of the battle, as killed in attacks by the US and international coalition?  In 2018, reports described hundreds of corpses lying all over the ravaged cityscape, with minimal government interest in even properly disposing, let alone identifying, bodies or investigating causes of death. One report has described an estimated 1,000 bodies dumped in a mass grave outside the city, burying together non-combatants and militia fighters.
As with conflicts in Syria and Yemen, documenting what occurred is complicated by the multiplicity of participants engaged in fighting. On one side was ISIS and their supporters, which included former Ba‘athist locals, Chechen fighters, European volunteers and ideologically committed warriors from throughout the Middle East. The transnational, and in some cases transactional, nature of the ISIS alliance, along with a determination by the Iraqi and international coalition to wipe out the movement altogether, greatly complicates attempts to render justice to any transgressors in the wake of the battle. On the other side lay an even more complicated array of institutional actors, including Iraqi government forces of varying levels of competence, popular mobilization units from ideologically diverse militia organizations, Kurdish Peshmerga units and the international military personnel from the Combined Joint Task Force-Operation Inherent Resolve (CJTF-OIR), the military component of the Global Coalition against Daesh. Composed of 74 participating countries, the Global Coalition against Daesh is an exceedingly complex organization tasked in part with assisting the Iraqi government to reassert sovereignty over the districts occupied by ISIS. In the battle of Mosul, Australia, Belgium, Canada, Denmark, France, the Netherlands and Great Britain actively assisted the Combined Joint Task Force and its estimated 6,000 US service members who were committed to air and ground battlefield support in July 2017. 
In the course of the battle, Coalition military leaders chose not to prioritize the protection of civilians. Instead, US commanders blamed any civilian deaths on ISIS’ well-documented use of human shields during combat. Moreover, ISIS family members were apparently categorized as combatants.  It is unclear how a pilot flying a mission, or an investigator seeking information several months after the fact, can determine whether someone is related to an ISIS fighter. It is clear, however, that the laws of war do not allow the intentional killing of combatants’ family members.
Beyond neglecting to protect civilians, US Secretary of Defense James Mattis hinted at the level of sanctioned violence: “We have already shifted from attrition tactics, where we shove them from one position to another in Iraq and Syria, to annihilation tactics where we surround them.”  In the same interview, Mattis discounted the legal ramifications of killing civilians by adding that “civilian casualties are a fact of life in this sort of situation.”
Many parties to the conflict violated international humanitarian law, although in very different ways. ISIS disregarded humanitarian law altogether by considering the legal regime itself corrupt and biased towards the interests of Western governments, and also largely ignored by the very governments that originally negotiated it. Consistent with its behavior elsewhere, ISIS used Mosul residents as human shields, executed civilians who tried to escape, accepted no responsibility whatsoever for providing non-combatant medical assistance in the hospitals under its control and proved unreachable for humanitarian negotiations.  Ominously, the International Committee of the Red Cross (ICRC) claimed that, for the first time ever, it was completely unable to negotiate with both sides of a conflict because it found it impossible to establish lines of communication with ISIS. 
Iraqi government and Coalition authorities also chose to ignore international humanitarian law in several instances, while never openly disavowing the strictures of the Geneva Conventions. As with ISIS, they did not accept responsibility for providing non-combatant medical assistance. The Iraqi government claimed to have insufficient resources, while the Combined Joint Task Force quietly declined to extend its substantial medical assets to assist anyone except injured Iraqi soldiers or Coalition advisors. Instead, these governments chose to fund medical assistance provided by the World Health Organization (WHO). 
Further complicating matters, serious frictions emerged between WHO and the two most prominent medical humanitarian organizations, ICRC and Médecins sans Frontières (MSF/Doctors Without Borders), while planning for the battle of Mosul in the fall of 2016. The dispute eventually left WHO as the provider of last resort after ICRC and MSF declined to serve as WHO’s implementing partners on the front lines of the planned battle.  ICRC and MSF objected to the terms of engagement presented by WHO officials prior to the conflict, stating that they compromised their humanitarian principles of neutrality, impartiality and independence. All humanitarian agencies conceded that neutrality was unattainable, since in practice it was impossible to negotiate with ISIS. But MSF and ICRC also balked at being instrumentalized as the fully integrated medical relief arm of the Coalition when Iraqi forces were aggressively screening everyone trying to cross the front lines to reach safety and medical relief. United Nations and WHO officials, on the other hand, advocated a “Humanity First” doctrine, which prioritized saving as many lives as possible over the other three main humanitarian principles.
Eventually, this disagreement forced WHO to rely on non-traditional partners such as militia-affiliated volunteers, NYC Medics Global Disaster Relief, Aspen Medical and Samaritan’s Purse as first-line medical providers. These groups fully integrated their operations with Iraqi government forces and Combined Joint Task Force advisors, a process that WHO officials referred to as “co-locating,” while external observers preferred the more well-known term “embedded.” There were problems with each of these providers. The militia-affiliated medical volunteers had an inconsistent level of medical skills. NYC Medics were primarily ex-military who wore military-style uniforms, collected intelligence and acted like members of the US military. Aspen Medical, a for-profit company, initially provided no more medical services than the minimal trauma treatment stipulated in their WHO contract. Finally, Samaritan’s Purse, which successfully built a field hospital in a matter of days, was overly “bunkerized,” with a full military contingent protecting it. In addition, this American evangelical Christian relief organization so fully embedded itself that it practically served as an arm of the US military. When Mosul residents were asked after the battle who had provided medical assistance during the conflict, over 50 percent replied that “the military” had provided the medical relief, even though that was nowhere the case. 
Meanwhile, during the battle, MSF opened three independent field hospitals beyond the purview of the Combined Joint Task Force’s authority. While this move sufficiently preserved MSF’s humanitarian principles of neutrality, impartiality and independence, it also meant that their facilities served relatively fewer patients than the other WHO contractors, who received patients directly from the front lines with the assistance of Coalition transport.
Coalition officials categorized the battle of Mosul as a non-international armed conflict (NIAC), a classification which renders certain international humanitarian law clauses moot. Human rights agencies refuted this categorization, accusing Coalition partners of breaching humanitarian law in their use of shelling and aerial bombings. Confirming what drone videos now show of Mosul’s destruction, Amnesty International documented numerous cases where Coalition military forces were insufficiently precise in their targeting of ISIS fighters and insufficiently restrained in their choice of munitions. In one frequently repeated scenario, ISIS fighters locked civilians inside homes in order to use them as human shields. Spotted shooting from the roofs of these houses, the fighters were then targeted by Coalition forces, often with large, less expensive, non-discriminating munitions. 
The battle of Mosul attracted relatively scarce media coverage. Its particular significance for the ongoing evolution of international humanitarian law and the provision of medical relief in conflict zones has yet to receive the attention it merits. Due to a confluence of state interests, unknown thousands of civilians died in a “battle of annihilation” and have been tragically ignored.
6. Hosanna Fox, Abby Stoddard, Adele Harmer and J. Davidoff, “Emergency Trauma Response to the Mosul Offensive, 2016–2017: A Review of Issues and Challenges,” Humanitarian Outcomes (March 2018) p. 10.
7. Statement to Vice News by Lt. General Najim al-Jabouri concerning the causes of civilian casualties.
9. “At Any Cost: The Civilian Catastrophe in West Mosul, Iraq,” Amnesty International, 2017.
10. Paul B. Spiegel, Kent Garber, Adam Kushner and Paul Wise, “The Mosul Trauma Response: A Case Study,” Johns Hopkins Center for International Humanitarian Health, February 2018, p. 43.