By LUKE MOGELSON
Several miles west of Kabul, the village Qala-e Naw sits deep in the barren foothills of barrener mountains that are perennially half-sunk in cloud. The ruins of old homes strafed by Soviet gunships crowd a gravel streambed that is dry most of the year but runs swiftly with snowmelt come spring. One morning early in December, a 12-year-old girl named Gulali followed the bed for almost an hour, along with her mother and little sister, in search of dry timber to fuel their stove. When they reached a steep rise with scattered saplings near its peak, Gulali scrambled up the slope and set to hacking at some of the skinnier trunks with a hatchet. In the small community of poor Pashtun farmers who inhabit Qala-e Naw, Gulali was well liked for her prideful and precocious work ethic, and true to form, when her mother said they had enough wood and it was time to go home, Gulali insisted on felling one last tree. Seconds later, she stepped on a land mine. The explosion hurled her through the air, nearly severing her right leg and pulverizing most of the left.
Gulali’s mother ran to her and began to stanch the hemorrhaging stump with a head scarf. Two of Gulali’s uncles, Pasha and Sartor, were working a field about a mile away when they heard the explosion and saw the brown plume drift and dissipate. It took Sartor, the younger one, more than 30 minutes to reach the scene, and when he arrived, he found Gulali cradled in her mother’s arms. Sartor put his niece over his shoulder and ran back to where Pasha and a group of nomadic herdsmen were waiting. An old shepherd offered his winter shawl, which Pasha and Sartor used as a makeshift litter to carry Gulali another 20 minutes to the nearest Afghan Police post. Gulali, who remained conscious the entire time, never made a sound. When she was 6, she fell down a 30-foot well that was dry at the bottom. Her father found her hours later, both of her legs broken. He had to climb down a ladder and lash her to his back with a rope to get her out. During that ordeal as well, her father told me, Gulali remained spookily calm.
Now her mother was screaming for help as they approached a metal shipping container with a machine-gunner’s nest on its roof. The police officer in charge of the post flagged down a car, put them in the back seat and instructed the driver to take them to the Emergency Surgical Center for War Victims in Kabul. “Don’t worry,” he tried to reassure Gulali’s mother. “The food and medicine are free there.”
• 'We Cannot be on One Side of the War'
• Triage After the Bomb
• What Do We Owe the Civilians Injured in a War We Started?
• 'If They Wanted to Treat Them, They Could'
• The Pacifists vs. the Military
• 'A Patient is a Patient. This is Our Rule'
• A Policeman's Last Delusions
• One Remedy Among the Tragedies
• 'They're Not Like Our Children'
When they arrived at Emergency — a former kindergarten built by the Soviets — Tijana Maricic, the head nurse, rushed Gulali from the car into the operating theater, her nearly severed right leg bundled in her mother’s scarf and a huge open wound on the left. Mine injuries, especially traumatic amputations, are uniquely vulnerable to infection — the blast often forces dirt, shrapnel and other contaminants deep into the stump — and a priority for the Afghan surgeons working on Gulali was to excise foreign bodies and damaged tissue. In the end, they also had to complete the amputation of the leg, removing it just below the knee.
“She was very brave,” Maricic said of Gulali’s stoic reaction to her pain. “Here, even most of the very young children with severe injuries never cry.” Maricic, a Serb, worked as a pediatric nurse in Belgrade before joining a cardiac center run by Emergency in Sudan. Now she is one of three foreign nurses at the hospital in Kabul. Maricic and the rest of the small international staff — the nurses, one doctor and a few administrators, most of whom are in their 30s — divide their time between the hospital and a quaint house directly across the street, in Kabul’s “new city,” a lively neighborhood of butcher shops, electronics stores, kebab stands, vagrants and panhandlers.
Despite Emergency’s central location, Maricic and her colleagues see little of the city outside the hospital grounds and almost nothing of the country. Inside the hospital, however, they see everything — the worst of what war can do.
“I prefer it here,” Maricic told me recently. “Sudan was closer to an ordinary life. You could go outside. You could go to the shop or for a walk. But here, we are more like a family, closer, and in this way it’s more like an ordinary life. After this, I don’t think any of us will be able to go back to a normal hospital.”
‘We Cannot be on One Side of the War’
Emergency is an Italian-based nonprofit that opened its first surgical center in Afghanistan in 1999, during the war between the Taliban and the Northern Alliance. One of its founders, Dr. Gino Strada, worked as a surgeon for the International Committee of the Red Cross in Kabul during the early ’90s, when the Soviet-backed government fell to rivalrous Mujahedeen factions. When Strada returned to Afghanistan in 1999, the Mujahedeen had been routed by the Taliban, and forces loyal to the Tajik commander Ahmad Shah Massoud had retreated north toward their mountain refuge in the Panjshir Valley. Sporadic fighting continued between Panjshir and Kabul. Massoud gave Strada a former police academy in Panjshir, which Strada and his team converted into a trauma hospital. “Immediately we thought, O.K., we cannot be on one side of the war,” Strada told me recently. “So I went to Kabul to talk to the Taliban and offered to balance our presence so that people could see we were neutral.”
Eventually, Mullah Omar, the leader of the Taliban, agreed to let Emergency open its hospital in the former kindergarten. Because of the ever-shifting front, Strada said, “we had Taliban fighters who were taken to Panjshir, and Northern Alliance fighters who were taken to Kabul. As soon as we discharged a patient on either side, he would be in trouble. So we started to negotiate with both sides.” Strada managed to persuade both Massoud and the Taliban to guarantee the safe transportation of discharged patients to their respective places of origin. Today Emergency’s commitment to neutrality endures: the Tajik policemen who guard the entrance to the Panjshir Valley still permit Taliban casualties to be taken to the hospital there, and insurgents are treated alongside wounded Afghan security forces at the surgical center in Kabul.
A vast majority of Emergency’s patients, however, are civilians. In 2011, the war in Afghanistan killed more than 3,000 civilians, more than any year since 2001. According to the United Nations, 77 percent of these deaths were caused by insurgents, who escalated their use of improvised explosive devices and suicide attacks. At the same time, the number of civilians killed by coalition airstrikes also rose in 2011. Because of the unconventional nature of the fighting — because the violence comes from all sides, in small doses, everywhere — it can sometimes feel not quite like a war at all but more like an interminable cycle of murder. In this war that is not exactly a war, Emergency represents one of the few places that offers something like an accounting.
Triage After the Bomb
Until she came to Emergency, Gulali grew up somewhat insulated from the conflict. For years, her father fought the Soviets in Qala-e Naw; the rusted carcass of a Russian tank, which one of his compatriots set alight with a rocket-propelled grenade, still sits on the bank of the stream near their house. But since 2001, Qala-e Naw has been relatively peaceful, and Gulali’s childhood was uncorrupted by violence. The Shiite holy day of Ashura, commemorating the martyrdom of the Prophet Muhammad’s grandson Imam Hussein, arrived during Gulali’s first week at Emergency, however, and that afternoon visited on the hospital some of the grisliest brutality that 11 years of fighting has managed to produce.
Shiites represent a small minority in Afghanistan, and they are mostly ethnic Hazaras. While Gulali was lying in bed, recovering from her operation, hundreds of Hazaras were congregating about a mile away, at the Abul Fazal Abbas shrine in Kabul’s old city. It was a clear day, and on the street outside the shrine, worshipers circled a group of young shirtless men lashing themselves with steel blades affixed to lengths of chain. Self-flagellation is a customary form of mourning Imam Hussein; as the men swung the blades against their backs, they shouted: “Ya Hussein! Ya Hussein!” There was an element of defiance in how fervently the Shiites exhibited their devotion. Soon many of the half-naked flagellants were covered in their own blood.
Sometime shortly after noon, a suicide bomber infiltrated the ceremony and detonated himself. The explosion ripped through the heart of the crowd. It cleared a wide swath and at the periphery of its force created a semicircle of wrecked bodies piled along a strangely geometric arc. More than 200 people were injured or dead: crumpled improbably, heaped among odd scraps of clothes and limbs as if they had plummeted from a great height. In the carnage and confusion, the dying were hard to distinguish from the dead. Bodies in all manner of distress were taken to Emergency in taxis and cars and in the backs of pickup trucks. When Luca Radaelli, the hospital’s 35-year-old medical coordinator, opened the first ambulance’s doors, he found several dead infants stacked atop a mass of bloodied but breathing women and men. “I also found the head of what was probably the suicide bomber,” Radaelli later told me. “As I took out the first patient, the head fell down at my feet.”
A mob of distraught relatives and survivors began to form outside. Radaelli shut the hospital’s gate, allowing only patients to enter. Some of the bereaved tried to break down the gate, others to scale the walls. More victims continued to arrive. Soon gore and body parts littered the sidewalk. When I arrived at the main entrance, about an hour after the bombing, a brain lay on the street. It was perfectly intact and surprisingly white. An Afghan employee of the hospital, wearing heavy rubber gloves and equipped with a wheelbarrow and a hose, was hurrying to clean up the mess.
A mass-casualty triage tent was hastily erected on the lawn where the local staff members sometimes play volleyball. In Gulali’s ward, injured children came and went. She sat in her wheelchair, watching. It’s difficult to imagine what it all must have looked like through her eyes or how she understood it. At the time, no one understood it. Never before during the decade-old war had there been an attack targeting Shiites on such a scale. Within the maelstrom of ethnic, tribal, economic and political enmities churning the violence in Afghanistan, sectarianism simply didn’t rate. Even the Taliban condemned the bombing.
Late in the afternoon, the orderlies began collecting the bloody mattresses and backboards and stretchers that littered the lawn, scrubbing them clean with antiseptic. The nurses hurried from ward to ward, attending the dozens of moaning wounded in line for surgery. I went out to talk with some of the relatives crowded around the gate, where a list of names was posted on the wall. The sun was starting to go down, but dozens of Hazaras still anxiously awaited news.
When I asked whom they blamed, everyone said Pakistan. This was to be expected — many Afghans see Pakistanis as the ultimate source of all their woes — but what came as a surprise was their unanimous refusal to impugn Sunnis or ascribe a religious motive to the attack. “We don’t blame the Sunnis,” insisted a young man named Ali Bahram, whose nephew was inside. “Islam belongs to Sunnis and Shia both. It’s the I.S.I. who are the enemies of Islam,” he added, referring to Pakistan’s spy service. Several men had gathered around us, nodding in agreement. “The I.S.I. wants us to retaliate,” one of them yelled. “They want to create strife between the Shia and Sunnis in Afghanistan.” (The organization that eventually claimed responsibility for the bombing, Lashkar-e-Jhangvi, is in fact from Pakistan and once enjoyed the support of the government, though it has since been outlawed.)
Back inside, two teams of surgeons — five Afghans and one Italian — performed operations until 4 in the morning. For many of the Afghan employees, the day had been all too familiar. One senior surgeon, Dr. Hamed Nazir, was reminded of being a young physician in the northern city Mazar-e Sharif during the war between the Taliban and the Northern Alliance. When the Taliban finally took the city in 1998, they massacred thousands of people, mostly Hazaras. Every afternoon, wounded civilians would be dropped off by taxis and vans at the hospital where Nazir was working. “It was exactly the same this time,” Nazir told me. “Mostly dead children. It’s always like that.”
What Do We Owe the Afghans Injured by a War We Started?
The gulf between how this war impacts the people living in its midst and how it is represented back in America might be inevitable. But the relatively small amount of coverage and interest that Afghanistan garners, compared with previous conflicts, makes that gulf all the more conspicuous. A pattern seems to have developed of periodic embarrassments provoking momentary outrage: Marines urinating on dead insurgents, NATO helicopters killing children collecting firewood, the burning of Korans at a U.S. base, the murder of 17 civilians in their homes. The reality, on the other hand, is that between these intermittent headlines, Afghans die less sensational deaths, suffer less dramatic travails and survive less repugnant but equally traumatic violence on a regular basis.
Last year, Emergency’s three hospitals and 34 clinics across Afghanistan treated nearly 360,000 patients. During the course of reporting this article, after visiting these facilities and meeting a number of these patients, I began to wonder how such a responsibility had fallen to a small, modestly financed Italian NGO. This, of course, was connected to a larger question: What is our responsibility to the Afghans who are maimed, burned, disabled and disfigured by a war we started and can’t seem to end?
According to NATO, even civilians who are injured during operations by U.S. or other coalition forces are only “entitled to receive emergency care if there is threat to their life, limb or eyesight.” In such cases, “discharge or transfer to an appropriate Afghan civilian facility is recommended as soon as the patient is stabilized.” On paper, this might appear to make sense; after all, the United States and other foreign donors have invested vast sums of money in Afghanistan’s public health system. But given the poor quality of care, scarcity of equipment and pervasive graft that still defines most government hospitals, “discharge or transfer” can look a lot like abandonment.
In April, I traveled to Sayad, a town in Kapisa Province, to meet a 14-year-old boy named Zobair, who had recently been discharged from a hospital at Bagram Air Base, one of the largest American military installations in Afghanistan. Zobair’s uncle Nasir had taken him to Sayad in a borrowed Toyota hatchback, its rear seats folded forward to accommodate the green U.S. Army litter on which Zobair reclined. We were parked on the bank of a wide river with small wooden platforms extending over the water’s edge, where you could order lunch from local fishmongers. My interpreter and I arrived early and bought food for Zobair and Nasir — a gesture that felt ridiculous now, in light of Zobair’s condition.
Both of his legs were gone, and wounds covered his hands, arms and back. He was nauseated and fevered; every movement elicited a grimace. “Most of the pain is in my stomach,” Zobair told me as soon as we met. His eyes were half-shut, heavy with fatigue, and he spoke so softly that I had to lean close to catch his words. Without a wheelchair, Zobair had no way to reach the landing where we had set up the meal. When Nasir climbed into the back of the Toyota and raised Zobair’s shalwar kameez, he revealed a pouching system attached to a stoma and four pink tubes sticking out of Zobair’s sides. Fifty-two metal staples held together an incision running the length of his abdomen.
Zobair and Nasir were from Tagab District, where French troops have struggled for years to dislodge a deeply entrenched insurgency, without much success. In February, a French airstrike, mistaking them for insurgents, killed seven boys while they were herding sheep not far from Tagab. A few weeks later, according to Zobair and his family, Zobair was sitting outside his house with four cousins, watching the sun go down, when two low-flying helicopters approached from the distance. Helicopters have long been a daily occurrence in Tagab, but something about the way this pair hovered near the house made Zobair nervous. He said as much to his cousins, who mocked him for being overanxious.
Zobair stood up and began to walk away. He does not know what kind of ordnance or ammunition the helicopter fired. Given the damage, it was likely a Hellfire missile. Two cousins — ages 14 and 18 — were killed immediately. Zobair, who had taken about four steps before the explosion, was thrown into an irrigation ditch. Villagers rushed the survivors to the French military base in Tagab, where another of Zobair’s cousins soon died. In response to my questions about the helicopter strike, a representative for the French military told me that they had conducted an investigation, the conclusions of which were “full positive”: “On that day, after having checked there were no civilians in the area, one helicopter fired at a group of five insurgents with hostile intentions.”
The last thing Zobair remembers before losing consciousness was a foreigner sticking him with a needle. He woke up “in a white room with white walls,” he told me. “They wouldn’t tell us where we were.” Back in Tagab, no one from the base would inform Nasir where Zobair had been taken; it was generally known, however, that casualties from Kapisa were often airlifted to Bagram. “We came to Bagram several times to write our names and give them to the interpreter at the gate,” Nasir said. “Sometimes the interpreter told us, ‘Yes, he is here.’ Sometimes he told us, ‘No, he is not here.’ Zobair called us one time. He told us: ‘I am in a hospital, but I don’t know where. I’m not allowed to tell.’ ” When I asked NATO why Zobair was not allowed to speak with his family, a representative replied, “We know there is a policy on this and are seeking more information at this time.” I was later told that he should have been allowed to call home.
After 23 days, Nasir received a call from an interpreter at Bagram, who told him to come pick up his nephew. At the airfield, Zobair was carried out from the hospital and put into the ambulance, accompanied by an Afghan interpreter. The interpreter told Nasir that they should go to the Red Cross in Kabul so that Zobair’s amputated legs could be fitted for prostheses. She then handed Nasir some papers detailing, in English, the treatment that Zobair received.
‘If They Wanted to Treat Them, They Could’
If Nasir had been able to read the papers, he would have learned that American surgeons at Craig Joint Theater Hospital saved Zobair’s life with a battery of sophisticated procedures. The incision on Zobair’s abdomen was from a laparotomy that enabled the doctors to repair his lacerated spleen, colon and kidney; the pouching system was to collect feces from an ileostomy, where a section of damaged intestine had been removed; and the four tubes sticking out of his sides were internal compression sutures helping to hold his abdomen together. Curiously, the only future treatment recommended for Zobair was to “follow up with a surgeon in six months to have the ileostomy takedown” — that is, to have the intestine reattached and the temporary pouching system removed. According to Nasir, he was not given any guidance about what to do for the internal sutures and 52 metal staples, though both were meant to remain in place no longer than a week or two, after which they posed a risk of becoming infected.
The ambulance took them to a Red Cross orthopedic center in Kabul. There, doctors saw immediately that Zobair was in no condition to have been discharged. He could not even sit up. (A spokeswoman for Craig Joint Theater Hospital said that “in accordance with accepted international clinical practice, the patient had recuperated well enough to be considered by his physicians for discharge.”) The Red Cross told the Afghan escort accompanying the ambulance that Zobair required further medical attention before the orthopedic phase of his recovery could begin.
When the ambulance left with Nasir and Zobair, the staff at the Red Cross assumed they were returning to Bagram. Instead they were taken to Kapisa’s provincial hospital, Mahmud-i-Raqi, where doctors informed Nasir that few if any public hospitals in Afghanistan possessed the special tool required to remove the metal staples that were used on Zobair. “They said they were not able to fix this problem,” Nasir told me, “and they sent us away.” Craig Joint Theater Hospital says that it previously arranged to transfer Zobair to Mahmud-i-Raqi and secured its consent to accept Zobair before his discharge. But the director of Mahmud-i-Raqi, Dr. Mustafa Faiz, says this is untrue. According to Faiz, no one from Bagram ever contacted the hospital about Zobair.
I visited Mahmud-i-Raqi twice. Part of the hospital is made of free-standing plywood and sheet-metal rooms with corrugated tin roofs, while the main building suffers from severe disrepair. Paint peels from walls; water creeps from ceilings; and the floors are covered in dirt. The first time I went there, I arrived at around 3 in the afternoon, but I was told that all the nurses and doctors had gone home early. The second time I visited Mahmud-i-Raqi, it was overrun with people jostling to be seen. Faiz, the director, gestured at the melee and asked, “Why would a hospital like the one at Bagram want to send a patient here?” He explained that Mahmud-i-Raqi could never accept a patient like Zobair for the simple reason that it had no surgeons. He then asked me if I could procure his staff some medical textbooks the next time I went to Bagram.
Nasir says that when Mahmud-i-Raqi refused to admit Zobair, the Afghan escort from the ambulance called Bagram and asked what to do. When he got off the phone, the escort told Nasir: “Zobair didn’t have much problems. He only needed his dressings changed. He said we could take him home.” The ambulance returned to Bagram, and Nasir hired a taxi to drive him and Zobair back to Tagab. The following afternoon, an elder from the village visited Zobair to help with his dressings. When he saw the incision, the elder told Nasir that he needed to get Zobair to a hospital immediately. They went to Emergency’s medical center in Panjshir Valley the next morning.
The only patients Emergency does not accept, however, are those who have already been operated on at NATO facilities. They adhere to this policy very strictly — some might say brutally. In the past, Emergency used to treat patients like Zobair, “but we stopped,” Emanuele Nannini, the program director for Afghanistan, told me. “They kept dying in our hospital.” Nannini describes NATO’s practice of discharging injured Afghan civilians requiring further care as an unethical one, which Emergency has opted not to participate in. “They don’t take responsibility for the patients,” he said. “They start a job, and they give all the complications to somebody else.” He added: “If they wanted to treat them, they could. That is the point. They have the capability.”
One nurse at Emergency who helped make the decision to turn Zobair away later told me: “It was a disaster. The incision was not clean. It was infected.” When I asked Radaelli, the medical coordinator, whether Zobair was in danger of dying from the infection, he said, “If someone doesn’t take him, for sure.” He added, “We see this all the time.” Nannini, the program director, is strident on the subject of NATO’s discharge policies, going so far as to characterize them as criminal. “They did nothing for this patient,” he said of Zobair. “It’s better to let him die than to suffer while going from one hospital to another.”
I met Nasir and Zobair in Sayad the day after they were refused by the Panjshir facility. I had to sit facing backward in the front seat of the Toyota to talk to Zobair, who could barely lift his head. He was febrile, and Nasir told me he had been suffering from nightmares. When I asked Zobair about the nightmares, he explained, “I see it happening again.” A couple of the staples had worked themselves loose, and the incision did not look good: red, swollen, encrusted with pus and tender to the touch.
Zobair complained that it was hot in the Toyota and that he felt ill and wanted to go home. Nasir wrapped all the fish I had bought in an old newspaper to bring back to Tagab. He seemed embarrassed to be doing so, and he explained that their family was very poor. The men were all laborers who often had to travel to Iran for work. “I don’t know what to do now,” Nasir told me as he got into the car. “I don’t know where to take him.” I told him I’d ask around in Kabul about hospitals that might be able to help.
The Pacifists vs. the Military
It’s easy enough to dismiss pacifism as quixotic or naïve. But nowhere does it appeal more strongly to reason than among the wounded and the maimed. At Emergency’s hospital in Kabul, it’s not unusual to find Afghan national security forces recovering in the same ward as Taliban insurgents, and after a while, the ideas that make enemies of the two men lose their relevance; the daily spectacle of their impact on human bodies invalidates them. Nearly everyone who works at Emergency opposes not just the war in Afghanistan but war in general. If they didn’t feel this way before they arrived at the hospital, they inevitably come to before they leave.
Emergency has always promoted a pacifist agenda. In 1994, the year it was founded, Emergency initiated a campaign against the manufacture of antipersonnel mines, leading to their prohibition in Italy. In 2003, it organized demonstrations against Italy’s participation in the invasion of Iraq. And two years ago, Emergency published a kind of manifesto repudiating the use of violence for any purpose.
That same year, President Obama deployed an additional 30,000 American troops to Afghanistan. One primary objective of the surge was to clear out insurgent strongholds in the South. In Helmand Province, the U.S. Marines announced plans for a major operation focusing on the Taliban-held town of Marja. Emergency’s surgical center in the provincial capital Lashkar Gah, just northeast of Marja, was the only international hospital in Helmand, and its Italian staff vehemently denounced the offensive. Matteo Dell’Aira, the hospital’s medical coordinator, posted online a series of profiles of civilian victims that were nakedly indignant. In June 2009, Dell’Aira wrote about a box of propaganda leaflets dropped from a NATO plane that failed to open and landed instead on a sleeping 5-year-old girl, fracturing her pelvis and destroying her rectum, vagina and urethra. She later died from her injuries. When the invasion of Marja began in February, Dell’Aira embraced the role of witness with renewed passion.
“During the first period of the operation, we didn’t receive many patients,” Dell’Aira told me. “Or sometimes we saw patients who had been injured seven days earlier. The coalition, together with the national military and police, blocked the roads around Marja and prevented the injured civilians from reaching the hospital. This for us was absolutely a crime against humanity.”
During several interviews with Western journalists, Dell’Aira and Gino Strada condemned the military cordon. Theirs was a counternarrative that contrasted starkly with the assessments of military commanders who lauded the operation as a triumph. The reality seen at Emergency continues to contradict the military’s message. “In Helmand, over 40 percent of our war-victim patients are children,” Strada told me. “This obviously disturbs people who are trying to convince the public that they are doing surgical operations.” In fact, last year the Helmand surgical center admitted 1,864 patients, of which more than half were younger than 14.
On April 10, 2010, an Afghan employee of Emergency in Lashkar Gah told the international staff that he had been warned of a possible attack against the hospital. Following protocol, the Italians vacated the premises for their living quarters elsewhere in the city. An hour later, an Afghan doctor called to say that armed men had entered the hospital. Weapons are banned, without exception, from all Emergency facilities, and Dell’Aira, along with Marco Garatti, a surgeon, and Matteo Pagani, an administrator, decided to go back and find out what was happening. They were stopped by several Afghan Army soldiers outside the entrance to Emergency. The three Italians eventually were handcuffed, blindfolded and taken to a prison run by the National Directorate of Security, Afghanistan’s intelligence agency. There they were locked in separate cells, and after several days they were told that suicide vests, hand grenades, ammunition and pistols were discovered in the hospital’s medical-supply room. “There was a paper,” Dell’Aira said, “written in Dari and Pashto they kept trying to get us to sign.”
Later that afternoon, the governor of Helmand called a press conference, during which he claimed that the weapons and munitions were taken to Emergency by one of its Italian staff members, who had been paid half a million dollars to assassinate him. He also later charged that the hospital was purposefully amputating the hands of Afghan soldiers.
Dell’Aira and his colleagues spent four days in the custody of Helmand’s National Directorate of Security before being transferred to its central prison in Kabul. “Every morning, afternoon and night they interrogated us,” Dell’Aira recalled. After five days in Kabul, they were released. Six Afghan staff members had also been arrested, and all of them were freed except one: the employee who originally warned Dell’Aira of an imminent attack on the hospital. According to Emergency, he is still in prison.
For Gino Strada, the meaning behind the whole ordeal was obvious: “It was an operation aimed at pushing us out of Helmand, clearly.” The possible reasons for this are plenty. Aside from Strada’s and Dell’Aira’s public denunciations of the cordon around Marja, the hospital’s neutrality made it a source of suspicion to both militaries. “Sometimes, we have known Taliban commanders trying to reach the hospital,” Strada said. “They are free inside our hospital. We were under a lot of pressure to provide information, and we kept saying we can’t. It’s not our role to be a sort of medical intelligence.”
‘A Patient Is a Patient. This is Our Rule.’
One afternoon in March, after visiting Gulali, I met a 22-year-old paraplegic named Safiullah who had recently been shot in the back by an Afghan Police officer. The shooting took place in the Ghorband Valley of Parwan Province, during a protest of the burning of Korans at an American-run detention center on Bagram Air Base, which is also located in Parwan. A few days earlier, Afghan employees at Bagram witnessed American soldiers discarding Korans into a garbage incinerator, and since then violent demonstrations had spread throughout the country.
Safi, as he is called, told me that on the day he was shot, several thousand villagers from throughout Ghorband Valley had gathered to march toward the Shinwari District center. A student and young father of two girls, ages 1 and 4, Safi claimed that he was not especially anti-American or antigovernment. He also repeatedly insisted that there were no Taliban in the Shinwari District or the Ghorband Valley, which is untrue. Last summer, Taliban insurgents in Ghorband kidnapped and beheaded a provincial council chief, attacked the Shinwari District center and tried to assassinate the provincial governor.
Nevertheless, Safi said that when the demonstrators reached the district center at around 11:30 in the morning, there were no Taliban among them and none of the protesters had weapons. All the same, they found the district center guarded by several ranks of heavily armed security forces. The first rank was made up of the Afghan Local Police, a controversial and relatively young program overseen by American Special Operations forces that recruits, trains, arms and pays Afghan men in rural communities to defend their home villages against insurgents. The procession came to a halt about 500 meters before the district center. Safi and his cousin Noor, who was also there, claimed that the Local Police then fired on the protesters, without warning or provocation. Using AK-47s and PK machine guns, they indiscriminately sprayed the crowd. Some of the villagers scrambled to the roadsides, trying to hide in shallow irrigation ditches; others dropped and made themselves as flat as possible. Noor remembers seeing three of his friends lying dead in the road. As soon as he heard the first barrage of gunfire, Safi dove to the ground. Before he landed he felt a slamming pain in his back and lost consciousness.
Noor put Safi in the back of a car with several other wounded men. They were taken to a public hospital in the provincial capital Charikar. The doctors there, recognizing that the bullet had shattered Safi’s spine, told Noor they couldn’t help him and offered to transport Safi in an ambulance to Emergency.
A few days after speaking with Safi, I went to Charikar to meet with the deputy chief of police, who showed me a video of the demonstration where Safi was shot. In the video, at least a dozen men in the crowd outside the district center are seen waving white Taliban flags. The deputy also said that some of the protesters were throwing Molotov cocktails, and he claimed vaguely to have evidence of there having been a weapon in the crowd, though he declined to elaborate.
Back at Emergency, Safi and Noor rejected everything the deputy said. Neither of them seemed very happy with my questions, and our parting was much cooler than usual. When I left the ward, the Afghan nurse attending Safi followed me out and stopped me under the breezeway. He was an older, bearded man, and he wanted me to know that Safi and Noor were likely not being entirely truthful. “They’re probably Taliban,” he said. “It’s all Taliban where they’re from.”
It was more a statement of fact than an accusation. The nurse didn’t care. Maybe they were Taliban, maybe they weren’t. Maybe the Local Police were thugs who fired on them for no reason, and maybe it was much more complicated than that. My interest in these things arose from a mentality that was alien to the hospital. Who Safi was, why he had been shot — the answers to these questions didn’t matter there. Several weeks later, when I had a chance to speak with Safi’s nurse at greater length, he told me he was a Tajik from Panjshir and had served as a medic in the Northern Alliance during its war with the Taliban. When I asked how he felt about caring for wounded Taliban now, he shrugged and said: “A patient is a patient. This is our rule.”
A Policeman’s Last Delusions
A couple days after Safi arrived at Emergency, while Noor was still looking after him, a wounded Local Police officer, exactly his age, was assigned a bed in the same ward. The officer, Abdul Nafeh, was taken to Emergency from a public hospital in Kandahar, and he arrived in extremely bad condition. One of his legs was gone and the other severely wounded. Whoever treated him in Kandahar did a poor job. The stump was already infected, and much of the tissue on the injured leg had become necrotic.
Nafeh was originally from Zhari District, the scene of intense fighting every summer and close to where Staff Sgt. Robert Bales is accused of murdering 17 villagers this March. (I once met a Talib from Zhari who lost his leg to an I.E.D. placed by one of his compatriots; not even the local insurgents can keep track of all the bombs.) Nafeh was 12 when his father died of a stroke, prompting him, his mother and his two younger brothers to move to the provincial capital, where he went to work painting houses. Even during the best of times, the wages Nafeh earned were barely enough to support the family, and about four months ago, when his cousin became the deputy commander of a Local Police unit back in Zhari, Nafeh asked to join.
Nafeh told me that he loved being in the Local Police; he felt for the first time that he possessed a sense of purpose about which he could be proud. During our last conversation, a couple days before he died of sepsis, Nafeh said: “I lost one leg. But if I lose the other and both of my hands, I will still be a policeman.”
By this time he was already half-lost to the delirium of his final hours. It was a taxing effort for him to speak at all. A nurse had wheeled his stretcher and IV stand into the breezeway, where he shut his eyes against a warm sun and told fantastical stories. My questions about his life seemed to afford him an opportunity to imagine one that was much grander than reality — or maybe, alternately, Nafeh was lucid to the end and, knowing that his words were limited, used those remaining to embellish what was finally a short and unexceptional past. He told me he had served for years as the trusted assistant to Kandahar’s powerful chief of police, who, along with the governor of Nangarhar, arranged for his medical care after he was injured while leading an operation against would-be Taliban assassins.
A couple of weeks after Nafeh died, I went down to Kandahar and met with his family. I rode out to Zhari and talked to members of his unit. And I found one of the surgeons who treated him before he came to Kabul. The truth was that after stepping on an I.E.D. during a routine patrol, Nafeh was evacuated by an American helicopter to a sprawling NATO installation with one of the most advanced trauma centers in Afghanistan, called Role 3. A remarkable 98 percent of patients admitted there survive, according to the hospital. Because he was an Afghan, though, Nafeh was sent next door to Kandahar Regional Military Hospital, where doctors treated his mangled stump and discharged him two days later to Mirwais, an underresourced and overcrowded public hospital in Downtown Kandahar, supported by the Red Cross.
Nafeh’s cousin Dad Gul told me that doctors at Mirwais recommended he take Nafeh to Kabul if he wanted to save his remaining leg. So the day after Nafeh was admitted to Mirwais, Dad Gul bought three tickets on a civilian flight to Kabul and showed up at the airport with his still-bleeding cousin. On the plane, Dad Gul sat by the window and rested Nafeh’s head on his lap, his bandaged stump and leg laid across the other two seats. (When I met with the surgeon who treated Nafeh at Mirwais, he said that Nafeh left the hospital against medical advice and that his wounds were in good shape.)
“He arrived in very bad condition,” Radaelli, the medical coordinator at Emergency, told me. He said the doctors in Kandahar didn’t do a proper debridement or amputation. “The other leg was hopeless,” he said. “It was completely open. You could see both bones.” Maricic, the head nurse, told me, “He already had sepsis when he arrived.”
A few days later, Nafeh came down with a fever. Maricic removed the dressings on Nafeh’s leg and discovered that it was completely black. The hospital called Dad Gul and persuaded him to allow them to amputate. Nafeh was rushed into the operating theater. After the surgery, he never fully emerged from the anesthesia. The infection had become systemic, and a couple of hours later, Nafeh went into cardiac arrest.
In retrospect, the saddest of Nafeh’s delusions was his belief that important people cared about what happened to him. As we talked outside in the sun the week before he died, Nafeh repeatedly boasted of the powerful men who exercised their influence on his behalf. He seemed unaware that both his stump and remaining leg were infected because of the sloppy treatment he received in Kandahar and that the resulting sepsis was already claiming him. Nor did he appear to realize how close he had been, immediately after his injury, to one of the best trauma centers in Afghanistan.
Of course, then again, Nafeh might have understood everything perfectly. One of the last things he said to me was: “I don’t want my brothers to join the police. It’s no good. I would like to see them become doctors or engineers.”
One Remedy Among the Tragedies
About a week after I met Zobair, the 14-year-old boy from Tagab injured in the helicopter attack, a colleague of mine found a hospital willing to accept him. The French Medical Institute for Children, based in Kabul, is widely acknowledged as one of the best pediatric hospitals in Afghanistan. It also offers a welfare service for indigent patients and their families. In Zobair’s case, the institute agreed in advance to treat him free.
I was unsure which would be the better course: to take Zobair to the institute or to try to get him back into Craig Joint Theater Hospital at Bagram. Early one morning in April, my interpreter and I met Zobair and his uncle Nasir in a hectic bazaar just outside one of Bagram’s heavily guarded entry checkpoints. Zobair lay on the same U.S. Army litter in the same Toyota hatchback. After agreeing to try accessing the hospital there before going to Kabul, we explained our situation to the Afghan soldier guarding the checkpoint, who directed us to a different gate around the base.
Following a rutted road along stacked Hesco barriers topped with razor wire, we arrived at a dirt lot crowded with groups of ailing Afghans, maybe a hundred or more in all. A rifleman in a tall guard tower looked down on them. One elderly, feeble-looking man lay on the ground, next to a plastic bin that held a bag of urine connected to his catheter. He had been taken there by his nephew, who told us that in another hour, at 9 o’clock, someone from Bagram would come out, review everyone’s paperwork and determine who could be admitted into the hospital. The old man proudly showed us a handwritten note from an Afghan clinic.
Nasir and I were debating whether to wait or to continue on to the French Medical Institute for Children, where its chief of pediatric surgery awaited, when Zobair asked us to please not send him back into Bagram. He was worried, he said, that he would again be forbidden from speaking to his family. That decided the matter, and Nasir agreed to follow us to the institute.
When we reached Kabul an hour later, as we began to navigate the congested streets toward the part of the city where the hospital is, I noticed the Toyota pull onto the shoulder behind us. My interpreter and I stopped and walked over to see what was wrong. Nasir got out of the car.
“Where are you taking us?” he demanded.
“To the hospital,” we said.
“No, you’re not. You’re lying. There is no hospital. You’re taking us to Pul-e-Charkhi.”
Pul-e-Charkhi is Afghanistan’s infamous national prison. Nasir was convinced that I had deceived him. In order to lure them into a trap, I had invented the hospital, the welfare program, the surgeon waiting for Zobair.
We argued for a while, and eventually, reluctantly, Nasir agreed to keep going. A few minutes later, however, their car stopped again, and again I had to get out and assure Nasir that the hospital was real. This happened three times. Finally we found ourselves standing in a busy rotary with traffic rushing past us, my interpreter yelling that we were trying to help them and Nasir repeating that he was taking Zobair back to Tagab. An Afghan soldier appeared and told us to move out of the street. Nasir asked him whether the hospital existed. The soldier said it did.
In the end we made it to the institute, and surgeons there removed the internal sutures and the metal staples in Zobair’s abdomen. They sutured and dressed his open wounds and gave him antibiotics. After a few days, he was able to sit up comfortably.
“There is no doubt that they did a very good and big operation,” Dr. Abdul Jalil Wardak, the chief of pediatric surgery, said of the doctors at Bagram. “The result is that the child survived. But of course the way they discharged him is not fair.” I asked what might explain it. “It’s difficult to understand,” Wardak said. “You have to ask them.”
In a written response to my queries, a representative for Craig Joint Theater Hospital said, “Should his clinical condition have necessitated it, this gentleman would have been kept in C.J.T.H. for longer.” The representative added that after they learned that Zobair had been rejected from Mahmud-i-Raqi, “repeated attempts were made by C.J.T.H. staff to contact his guardian’s cellphone number. Alas, his guardian had provided a nonworking cellphone number, and so these attempts were unsuccessful.”
Nasir gave me the same number that he said he gave Bagram. It worked every time I called.
‘They’re Not Like Our Children’
A few months after the Ashura bombing, a new girl was admitted to the hospital and given the bed next to Gulali’s. She was roughly the same age, and they quickly became friends, staying up to talk at night after the nurses turned off the lights. Abeda was from Wardak Province, where her family lived in a small mud house about 50 meters from Highway 1, the critical connecting route between Kabul and Kandahar.
About a year ago, a convoy of Afghan government vehicles was passing by Abeda’s house when it came under attack. Afghan security contractors were escorting the convoy, Abeda told me, and when she stepped outside to see what was happening, one of the contractors shot her three times in the gut with a Kalashnikov. “When he shot me, everything came out of my stomach,” Abeda said. She remembers lying in her doorway, her brother yelling for their father. Then she was at Emergency.
Abeda remained in the hospital for a couple months before going home; in April she returned to Emergency to have her stoma closed and her intestine reconnected. While recovering, Abeda and Gulali spent their days wandering the hospital grounds: Gulali in a wheelchair, and Abeda pushing an aluminum stand with an IV bag. One day when I came to visit, Abeda was gone, and Gulali seemed depressed. Though they live maybe 30 minutes apart, it’s very unlikely the two girls will ever meet again. Gulali’s village straddles the border of Wardak Province, on the very edge of the small and increasingly isolated security bubble surrounding Kabul. The place where Abeda lives, just a few miles away, constitutes another world entirely.
Eventually Gulali went home as well. When her parents and uncles came to Emergency, they brought some of her old clothes with them. For the first time in months, she changed out of her hospital gown. It was the happiest I’d seen her.
I followed Gulali and her family back to their village. We stopped at the police post where Gulali was taken after her injury. The shallow stream ran nearby; Gulali’s mother pointed beyond it to the hill where Gulali had stepped on the mine. It seemed a very long way to be carried with a half-severed leg, and I was reminded of something Tijana Maricic, the head nurse at Emergency, said to me shortly after Gulali’s surgery: “They are different. They are really strong. They’re not like our children.”
A few weeks later, across the street from Emergency, a group of insurgents barricaded themselves in the upper floors of a half-constructed building and began firing into nearby foreign embassies. Afghan Special Forces quickly took up positions surrounding the building, including on a rooftop situated directly between Emergency and the gunmen. During the ensuing 18-hour battle numerous rounds impacted inside the hospital grounds. A physiotherapist was taking a shower when the shooting started, and before he could get out, a bullet pierced the bathroom door and slammed into the wall beside him. Luca Radaelli immediately began setting up a mass-casualty triage tent, just as he had done for the Ashura bombing, but abandoned the plan when bullets began loudly whizzing by his head. Another round hit the wall of the children’s ward, a few inches from a high glass window. Later, when the rocket-blasts and automatic salvos were in a frantic crescendo, a young boy stood on his bed and peered out of the window. He stood there craning his neck until someone yelled at him to get down. He wanted to see what was happening outside.
Four dead civilians and several wounded Afghan Special Forces soldiers were rushed into the hospital late in the afternoon. With nightfall, the fighting died down, only to start again with even greater intensity around 1 a.m. By dawn, when the last of the insurgents was killed, 27 wounded Afghans, mostly soldiers, were being treated at Emergency. Every one of them survived.
No one from the hospital slept that night, but the next day, new gunshot, shell and mine victims arrived from northern Afghanistan, and the staff went back to work.
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