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Afghanistan20

20 years of war

2001—2021

Afghanistan20 is a project by EMERGENCY that tells the story of 20 years of war from the perspective of its victims. Afghanistan20 is the result of fieldwork carried out between June and early July 2021 at EMERGENCY's three main hospitals in Kabul, Anabah and Laskhar-Gah, supplemented with interviews, stories from our archives, and data collected over the years by EMERGENCY and UNAMA, the United Nations Assistance Mission in Afghanistan.
The contents were written before the military offensive that led the Taliban to seize power in mid-August 2021, so the stories refer to periods before that date. In any case, to protect the safety and privacy of the patients treated and of our Afghan colleagues, EMERGENCY has decided to replace their names with fictitious ones. The time frame chosen relates to the last 20 years of a conflict that has been ongoing in alternating phases since 1978/79. With one constant: civilian victims.
Afghanistan20 was realised with the contribution of researchers and journalists who have witnessed the consequences of the war and reported on it, year after year. All the opinions, views and judgements expressed in the articles written by authors external to EMERGENCY exclusively reflect their personal point of view, based on their own experience. EMERGENCY accepts no responsibility for the information contained in these sections.
EMERGENCY has been present in Afghanistan since 1999 and our work has always been based on a fundamental principle that we will continue to preserve: neutrality. Humanitarian intervention is not aimed at favouring any side in an armed conflict. EMERGENCY's activities in the country have never stopped and we have no intention of interrupting our work: we will continue to stand by the people of Afghanistan, a population that needed help before and needs help now.
2001

EMERGENCY opens its Surgical Centre for War Victims in Kabul in April.

Al-Qaeda commits suicide attacks on military and civilian targets on American soil. The United States reacts by invading Afghanistan, beginning a campaign of bombing, named Enduring Freedom, against the Taliban forces.

2002

At EMERGENCY’s Surgical Centre for War Victims in Anabah, opened in December 1999, war surgery gives place almost completely to general surgery, traumatology, internal medicine and paediatrics.

2003

EMERGENCY opens its Maternity Centre in Anabah in June.

NATO takes command of the International Security Assistance Force (ISAF) in Afghanistan.

2004

EMERGENCY opens its Surgical Centre for War Victims in Lashkar-Gah in September.

First elections since the war began. Karzai becomes the country’s first elected president

2005

The first of many First Aid Posts (FAPs) opens in Grishk, Helmand province. Today, the network has 44 FAPs and Primary Healthcare Centres across 31 Afghan districts.

2006

For the first time, EMERGENCY’s Kabul hospital admits over 1000 people for war wounds in a single year.

Southern Afghanistan sees the first great wave of invasion since the fall of the Taliban regime in 2001, by US-led NATO forces.

2007

EMERGENCY’s hospitals close temporarily after a member of staff is arrested for helping free the journalist Daniele Mastrogiacomo.

The death of Mullah Dadullah, one of the Taliban’s main commanders, is announced on 13 May.

2008

A First Aid Post opens in Ghazni, a place of continuous fighting. In just four years, over 1000 patients are seen here.

The number of American troops in Afghanistan, ever increasing, reaches 48,000.

2009

United Nations Assistance Mission in Afghanistan (UNAMA) begins collecting data on civilian victims. EMERGENCY’s three hospitals treat over 2,200 war victims, 32% of whom are children.

After Obama’s election, a timeframe for the US military’s presence in Afghanistan is set.

2010

The Kabul hospital becomes a centre for war surgery exclusively.

Three of EMERGENCY’s workers are arrested on false accusations at the Lashkar-Gah hospital. The general public mobilises to have them released. The ‘I’m with EMERGENCY’ appeal receives 400,000 signatures in four days.

2011

EMERGENCY’s hospitals are recognised as centres for training in surgery, gynaecology and paediatrics by the Afghan Ministry of Health.

Number of American soldiers reaches a peak, with over 100,000 present in the country.

2012

Six students receive specialist training at our hospitals, four in surgery and two in gynaecology.

2013

EMERGENCY begins to systematically collect data on the mass casualties coming to its Kabul hospital.

2014

The First Aid Post in Sangin, near Lashkar-Gah, sees a record number of patients (5,656).

The United States’ fighting mission officially ends after most troops are pulled out and the war becomes ‘Afghan-led’. However, 10,000 American troops remain in the country.

2015

UNAMA records a record number of child war victims.

This year has the highest percentage yet of civilian victims of explosions and the highest number of civilian victims per recorded incident (according to Action on Armed Violence, AOAV).

2016

The Lashkar-Gah hospital sees its highest ever number of war-wounded patients (2,997).

The Taliban surround the city of Lashkar-Gah.

2017

The staff at the Lashkar-Gah hospital handle 17 mass casualties.

The Secretary-General of the UN changes its assessment of the country from ‘post-conflict situation’ to ‘hit by an active conflict that shows no sign of diminishing’.

2018

EMERGENCY’s most dramatic year, with over 7,000 war victims admitted for surgery.

On 27 January, the Kabul Surgical Centre handles EMERGENCY’s biggest ever mass casualty, admitting 119 wounded people.

2019

EMERGENCY’s network of First Aid Posts celebrates its 20th anniversary and numbers over 40 clinics.

2020

All facilities are put under security measures to avoid the spread of Covid-19. None of EMERGENCY’s hospitals closes, even during the most intense months of the pandemic.

The United States and the Taliban sign an agreement in Doha to withdraw the former’s troops. In September, historic peace talks begin between the Taliban and the Afghan government.

2021

Between December 1999 and June 2021, approximately 70,000 war-wounded patients were admitted to EMERGENCY’s hospitals.

In response to the delay in the withdrawal of American forces announced by Biden, the Taliban launch a country-wide offensive.

We will continue to be pragmatic and, at the same time, cultivate a utopia.

We will continue to treat the victims and work to abolish war.

Thank you Gino.

Afghanistan20
emr logo
© Massimo Grimaldi
Know where you stand
Gino Strada, surgeon and founder of EMERGENCY

Afghanistan is in the headlines now that the withdrawal of international troops from one of the most strategically important corners of Asia has been announced.

For the benefit of those who do not remember, it may be worth casting our minds back to how this war started. In its resolution number 1368, approved the day after the attack on the Twin Towers in New York, the UN Security Council declared its ‘readiness to take all necessary steps to respond to the terrorist attacks of 11 September 2001, and to combat all forms of terrorism, in accordance with its responsibilities under the Charter of the UN.’ The UN called on all states ‘to bring to justice the perpetrators, organizers and sponsors’ of the attack. The resolution was ignored. The Council – the only international body with the right to resort to force – was not given the time to do anything.

The United States ignored the Council’s resolution and went ahead with a military plan of its own (and therefore in total violation of international law), as the decision to attack and occupy Afghanistan had already been taken back in autumn 2000, by the Clinton administration.

Dr Gino Strada in the operating theatre at the Surgical Centre for War Victims in Kabul
© Riccardo Venturi/Contrasto

On 7 October 2001 the US Air Force began aerial bombardment.

Officially, Afghanistan was attacked for giving support and succour to Osama Bin Laden’s war against the US. The War on Terror thus became in practice a war to destroy the regime of the Taliban, who had held sway since September 1996, and who had previously, for at least two years, been cosied up to by the Americans in the hope of a treaty.

The regime in Kabul was granted formal recognition and financial support in exchange for control of future oil and gas lines by American multinationals. The pipes would run from Central Asia to meet the sea in Pakistan; Pakistan, which had given life to, armed and funded Taliban groups since 1994.

Peace Costs vs War Costs

Maintenance costs of EMERGENCY hospitals
Italy war expenses
USA war expenses
5 billion10 billion15 billion20 billion25 billion30 billion35 billion40 billion45 billion50 billion55 billion60 billion65 billion70 billion75 billion80 billion85 billion90 billion95 billion100 billion105 billion110 billion115 billion120 billion125 billion130 billion135 billion140 billion145 billion150 billion155 billion160 billion165 billion170 billion175 billion180 billion185 billion190 billion195 billion200 billion205 billion210 billion215 billion220 billion225 billion230 billion235 billion240 billion245 billion250 billion255 billion260 billion265 billion270 billion275 billion280 billion285 billion290 billion295 billion300 billion305 billion310 billion315 billion320 billion325 billion330 billion335 billion340 billion345 billion350 billion355 billion360 billion365 billion370 billion375 billion380 billion385 billion390 billion395 billion400 billion405 billion410 billion415 billion420 billion425 billion430 billion435 billion440 billion445 billion450 billion455 billion460 billion465 billion470 billion475 billion480 billion485 billion490 billion495 billion500 billion505 billion510 billion515 billion520 billion525 billion530 billion535 billion540 billion545 billion550 billion555 billion560 billion565 billion570 billion575 billion580 billion585 billion590 billion595 billion600 billion605 billion610 billion615 billion620 billion625 billion630 billion635 billion640 billion645 billion650 billion655 billion660 billion665 billion670 billion675 billion680 billion685 billion690 billion695 billion700 billion705 billion710 billion715 billion720 billion725 billion730 billion735 billion740 billion745 billion750 billion755 billion760 billion765 billion770 billion775 billion780 billion785 billion790 billion795 billion800 billion805 billion810 billion815 billion
0 euros

US war expenditures include: the Department of Defense budget and related additions; the estimate of the interest on war loans; spending on veterans; the State Department budget.

Source: The Costs of War Project, The Watson Institute for International and Public Affairs at Brown University

Italy's war expenses include: the official cost of Italy's participation in military missions in Afghanistan that began in November 2001; the disbursement in support of the Afghan armed forces and police; additional expenses.

Source: MIL€X, Observatory on Italian military spending.

This stage was set for full-scale aggression against a whole country, in pursuit of a terrorist group.

Three months into 2002, the slaughter in Kabul and its environs alone had already claimed more civilians than were killed in New York. The places, the dates and the names of victims have been collected meticulously by Mark Harold, a professor at the University of New Hampshire. The information is less clear about the victims of the months and years that followed. Brown University’s ‘Costs of War’ documents approximately 241,000 people killed and hundreds of thousands more deaths from starvation, disease and lack of essential services. In the past decade alone, the UN Assistance Mission in Afghanistan (UNAMA) has recorded at least 28,866 child victims of war, a number which is certainly an underestimate.

I first met with war in Afghanistan in 1989, as a surgeon at the Red Cross hospital in Quetta. That was my first encounter with the Afghan people, who had been devastated by landmines and fighting between their pro-Soviet government and the mujahideen. There were farmers wounded while tending their crops, market sellers hit by bombs in the bazaar, women and children injured in their houses. I came back in 1999 with EMERGENCY. We had already opened a hospital in the Panjshir valley, an area then controlled by General Massoud. In spring 2001 we opened a second, in Kabul, then a third in Lashkar-Gah, Helmand province, in 2004. In each of these hospitals I operated on men, women and children of all ages. In Afghanistan, as in every war that I have seen with my own eyes, nine in ten victims are always civilians. I lived in Afghanistan for seven years all told. I saw the wounding and the violence rise year after year, as corruption and insecurity gradually devoured the country.

© Mario Dondero

20 years ago we were already saying this war would be a disaster for all. Now the results of the aggression are irrefutable; it has been a failure in every respect. With more than 241,000 victims and over 5 million refugees, including both migrants and IDPs, today Afghanistan is a country walking into civil war. The international troops have been defeated and their authority and very presence are even weaker than they were in 2001. It is a country destroyed. So many of its people choose to flee, even if it means going through hell to get to Europe.

© EMERGENCY NGO Archive

To fund all this, the United States has spent a total of 2 trillion dollars. An approximate but plausible estimate puts the average yearly cost of keeping an American soldier stationed in the country at 1 million dollars.

As always, the big arms dealers – of which Lockheed Martin, Northrop Grumman and Boeing are only the biggest three – are very thankful; they are the ones making a profit out of this war.

© EMERGENCY NGO Archive

EMERGENCY, meanwhile, has spent about 145 million euros in its 22 years in Afghanistan. This money has come from individuals, institutions and, in the last few years, the Afghan government. We have used it to treat more than 7.5 million people, train new doctors and other medical workers, and given jobs to about 2,500 Afghans. All at roughly the cost of keeping a small contingent of soldiers in the country for a year. As always in life, you have to know where you stand.

Where do the funds used by EMERGENCY come from?

EMERGENCY funds
Funds from institutional organizations
Funds from the Afghan government
2001
2001
2018
Source: EMERGENCY
© Vincenzo Metodo
Victims
The worst place to be a child
Elise Blanchard, journalist and photographer, Agence France-Presse (AFP)

The devastating impact of the Afghan war on children, especially in the remote countryside, can be hard to fully grasp. Even near frontlines, children continued playing and laughing. 

It’s not that they were not aware or affected. Their relatives and friends died in crossfire. Their village was attacked. Girls were taken out of school to get engaged because their families were too poor. But despite it all, the children kept smiling. 

Even boys who had just left Daesh - and who’d seen humanity at its worst - smiled. Even the pregnant teenage girl who’d been married to a Daesh fighter smiled. Even the 12-year-old boy whose parents, Daesh members, had been killed in an airstrike had a shy smile on his face.

© EMERGENCY NGO Archive

Children hide their trauma well, but it is there. In an ex-school where Daesh fighters’ wives were being kept, their children were running around and playing with toys. On the walls, they’d drawn Kalashnikovs, armed men on pickup trucks, explosions and drones. On all sides of the conflict, children are witnesses to the war. 

Teenage boy Moahibullah had seen Taliban arrive in his village located near the frontline in the violence-ridden Maiwand district of Kandahar. “In the 15 years of my life, there has been fighting. I have witnessed fighting - that is all. Every night, there is fighting,” the boy said. “My heart says peace will not come.”

© Vincenzo Metodo

The family fled for a few days and since they’d come back, his 13-year-old cousin, Rafiullah, would not leave the house at night, even to pray with his father. “I still cannot relax at night and I cannot go outside without fear. I worry there might be fighting again or an IED on the way,” he explained. 

What do they hope for the future besides peace? To go to school. That’s what all the children say in difficult areas, where, because of the violence, their school has been destroyed, or is too hard to access, or was never built.

In another village in Maiwand, a school for girls was finally supposed to be built in 2020. “But I am too old to start now,” said Malalai, 14. "I would have been happy if I had gone to school, everything would have been happier. But now I cannot, I am engaged.” Poverty, heightened by the war, pushes girls out of school in the countryside.

© EMERGENCY NGO Archive

When I went to several rural districts in Herat province in 2021, I met or heard of girls engaged and forced out of school - most often around 13 but sometimes younger - in every single family I met, in government-held areas, Taliban-controlled territory, and on the frontline.

It was a matter of culture but also of poverty according to some mothers - the parents of the bride receive money from the groom and for many it’s a way to survive.

One way or another, children end up directly affected by war. 

Many die just because they happen to be in the wrong place—their villages—at the wrong time.

In Ghoryan district, Herat, a child had recently died in crossfire. No one knew whose fault it was. It happened in a remote, grey area that didn’t really belong to anyone, where Taliban came every day to attack Afghan forces, and the child’s death wasn’t much heard of. Many places are too remote to get proper news coverage. 

In Kajaki district of Helmand, in the South, everybody had lost someone.

© Vincenzo Metodo

Agha Lala’s son had been killed in crossfire tending to his cattle. The classmate of Naveed, 13, had been killed by a Taliban rocket on his way to school - Naveed was wounded. His father had also died in crossfire. 

They lived in Tangi bazaar, stuck between endless stretches of Taliban territory and the government-held Kajaki dam.  The only way out was by helicopter and civilians struggled to access medicines.

“When a child is sick, he dies,” explained Kamal. That is how his grandson died.

Many children don’t get to start living at all, with Afghanistan’s alarming rate of infantile death. 

Women, especially in volatile, rural areas, struggle to access clinics and midwives. A situation I’ve witnessed in the South, and that is getting worse as international donors’ aid diminishes in view of the US withdrawal.

“My child died in Marjah because there was no access to a clinic”, explained Farzana, 20, who had fled the Taliban when they took over her village in Helmand. “A lot of children died in Marjah.”

© Vincenzo Metodo

All opinions expressed within the articles written by external contributors exclusively reflect their personal point of view, based on their own experience.

The impact of war on women in Afghanistan
Zuhal Ahad, Women’s Affairs Journalist, BBC

Even though women may not be directly involved in fighting this war, the impact of it on them is enormous, resulting from the destruction of their families, displacement, effects on psychological health, economic impoverishment, and sexual violence. Attacks on maternity wards, schools, universities, educational centres, TV stations, mosques, and wedding halls have killed so many civilian women. According to a recent UNAMA report, 14% of all Afghan civilian casualties in the first half-year of 2021 were women, a reminder of the huge number of Afghan women who are directly injured or killed in this conflict.

As the US withdraws all its troops from Afghanistan by 11 September, based on the US-Taliban deal inked in February 2020, a series of unprecedented targeted killings of civil society activists and journalists, mostly women, has taken place.

© Massimo Grimaldi

Many professional and well-known women were deliberately handpicked and killed in different parts of the country. Among them, journalists, lawyers and judges, activists, and many other prominent women. In one case, in March 2021, three female media workers were shot dead on the way to their homes in the eastern province of Nangarhar. They were three young fresh graduates who were working in the dubbing department of a local TV station in Jalalabad. Later, the TV network sent all their female employees home for the sake of their safety.

The most recent brutal attack was on 8 May. Twin explosions slaughtered nearly 100 female students in Sayed al-Shuhada School in Dasht-e-Barchi, a predominantly Shiite Hazara neighbourhood in the west of the Afghan capital. In my visit to a local hospital on the day of the attack, I saw tens of girls lying on the beds there; some were unconscious, some in severe pain, and some of them already dead. Firuza was in shock and tears at the loss of her 17-year-old daughter, who was meant to be graduating the following week. Meanwhile, she was worried about whether she should send her other children to school or not. “You have to be brave to send your children to school, if you send them it’s like this. If you don’t send them, they will remain without a future,” said Firuza.

© EMERGENCY NGO Archive

According to the World Bank, women make up only 16% of the labour force in Afghanistan, the lowest proportion in the world. Hence, when a man gets killed or injured, the heavy responsibility of supporting the family lies on women who are mostly uneducated and jobless. Masoumah, 42 years old, lost her husband in a Taliban attack on the Malistan district of Ghazni. She fled to Kabul with her son, daughter and unborn baby in her womb. “I am wondering who would take care of us and how, and what we would do in Kabul,” she says. She is an example of thousands of war widows in Afghanistan.

War has contributed to women’s lack of access to education and health services in the country, especially in the small cities and provinces. The conflict between warring parties has escalated in recent months, as the US and its allies withdraw their troops. Aqela, who is seven months pregnant, has travelled with her husband to Kabul from Ghazni in order to visit a doctor. “Because of the ongoing fighting, all the doctors have left the clinic in our area,” she said. “Many women that I knew have lost their lives while giving birth to their babies, they would be alive if there was a good female doctor and clinic near us.”

© EMERGENCY NGO Archive

In Kandahar, Nasrin, 17 years old, had been deprived of going to school for four years due to the ongoing war. “My family did not allow me to go to school, saying that there is a war and you have to stay at home and get prepared for getting married,” said Nasrin, who like many Afghans goes by one name. She is now studying in eighth grade and she wants to be a lawyer in the future, but she says she might not be able to achieve that dream. “Seeing my family and the war in my province, I don’t think I will be able to finish school, let alone become a lawyer.”

All opinions expressed within the articles written by external contributors exclusively reflect their personal point of view, based on their own experience.

Our story
Giuliano Battiston, journalist
First day at work

“There are people who hurt others, who cause pain and suffering. Then there’s us. We treat others.” Zahra really stakes her claim to be a nurse; it has taken her courage to keep constantly at her job for so many years in a country at war. “After everything we’ve been through, after having to rebuild my house three times, I’m not afraid of anything anymore, just Allah.” She proudly shows us her plastic EMERGENCY card, bearing a special date: “My first day at work, 7 April 2001.”

EMERGENCY has chosen not to publish photos of Afghan colleagues and patients to protect their privacy and safety.

After 20 years, in spite of everything, she is still here at the Surgical Centre for War Victims in Kabul. “By now I feel a bit like a mother to everyone here, but I was young when I first arrived,” she says as the traffic piles up outside on the streets of Shahr-e-Now, a central district of the 6 million-strong city. “I was the first to pass the exam with Gino Strada and Kate Rowlands. I remember it like it was yesterday. I couldn’t speak English, just French, but they reassured me. They said what mattered was competence and commitment.” Since then, she goes on, “so many things have changed, in Kabul and at the hospital. Intensive care, the pharmacy, physiotherapy, higher walls, the garden.” What has not changed is that “ordinary people are still dying every day. Every day they come in wounded. And every day we treat them.”

Leila Borsa and Silvia Triantafillidis, Surgical Centre for War Victims in Lashkar-Gah
EMERGENCY has chosen not to publish photos of Afghan colleagues and patients to protect their privacy and safety.

“I was heading back from the mosque to my shop when I was hit in the neck. I thought that was me done for. But now they’ve operated on me and taken the bullet out.” Noor is 35 years old, with long hair and stubble. He lives near Maidan Shahr, capital of Wardak province, not far from Kabul. He shows us his neck and chest with their bandages. He laments that Maidan Shahr is becoming ever more unsafe: “In the last few days another four people have been wounded in clashes between the Taliban and soldiers.” At first they fought further afield, “away from the city, but now they’re coming nearer and nearer. It means trouble for everyone.” He says he is worried for his five children, who are waiting for him to come home. Within the hospital’s walls he feels protected. “Outside, the situation is getting worse day by day.”

Marco Puntin, EMERGENCY’s Country Director in Afghanistan.

Marco Puntin has been in Afghanistan since January 2018, first as a logistician, then as a grant manager. In January 2020 he became EMERGENCY’s Programme Coordinator in the country. In all that time he has been looking beyond the hospital’s walls, taking stock of what the last 20 years have wrought. “Luckily, compared to when we started, there are more medical facilities available now and a larger healthcare network. There are other hospitals looking after wounded people here in Kabul now, like the Wazir Akbar Khan.” That facility is about a mile and a half from here. “But our centres are still the most important in Afghanistan when it comes to war surgery,” Puntin explains. Patients “come to our Surgical Centre in Kabul even from provinces far off to the north, like Takhar, Faryab and Badakhshan, and the west, like Herat. Sometimes it takes them a week’s journey to get here.” The local healthcare network may have grown over time but it cannot yet satisfy people’s needs, for either ordinary injuries or war wounds. There has been conflict here for over 40 years, after all.

EMERGENCY has chosen not to publish photos of Afghan colleagues and patients to protect their privacy and safety.

Arguably the event that began it all was the so-called Saur Revolution. In a coup on 27 April 1978, the People’s Democratic Party of Afghanistan (PDPA) overthrew the republic of president Mohammed Daoud Khan. Yet another coup in December of the following year led to the invasion of Soviet troops, who withdrew 10 years later, in 1989. This was the first act of the conflict. The next lasted from 1992 to 1996, when the victorious anti-Soviet resistance splintered into warring groups of mujahideen. Eventually the Taliban seized power and held it until their Islamic Emirate of Afghanistan was toppled by military force in late 2001. The fourth act of the tragedy was the war between the Taliban and the government in Kabul, the latter backed by the United States and NATO.

Dead and wounded

The United Nations Assistance Mission in Afghanistan (UNAMA) began collecting data on civilian victims in 2009. According to the UN’s researchers, between then and the first six months of 2021, when their last report was published, there have been 116,076 civilian victims overall: 40,218 killed, 75,858 wounded. The yearly average is shocking, at 8,929 victims per year: 3,094 killed, 5,835 wounded.

Civilian casualties of the Afghan war

Dead
Wounded
2009
2009
2021
UNAMA data collection began in 2009.

For 2021, the data refer to the first six months of the year.

Source: United Nations Assistance Mission in Afghanistan – UNAMA

It is instructive to read EMERGENCY’s own data alongside UNAMA’s. Whereas UNAMA takes its definition of ‘civilian’ from international humanitarian law, as a person not participating or no longer participating in hostilities, EMERGENCY includes all patients who have come to its hospitals as victims of war since 2001, out of respect for the principles of neutrality, impartiality and humanity. Nonetheless the two sets of data have significant trends in common. While, as we have seen, the UN recorded 75,858 wounded civilians between 2009 and 2021, in the same period 60,958 patients were admitted to and treated at EMERGENCY’s three main surgical centres, in Anabah, Kabul and Lashkar-Gah.

If we look back to the years before 2009, though, the picture is blurrier. EMERGENCY opened its first Surgical Centre in Afghanistan back in 1999 in Anabah, in the Panjshir Valley, to give free treatment to victims of the fighting between the Taliban and the Northern Alliance, as well as the landmines placed by the Russians during their offensive. But over the years (as we shall see in chapter three) “it has really become a general hospital. War surgery has given way almost entirely to general surgery, traumatology, internal medicine and paediatrics.” Since 2003 it has also hosted a Maternity Centre, “the only free, specialist facility in the area providing obstetric, gynaecological and neonatal care.” Our Surgical Centres in Kabul and Lashkar-Gah, meanwhile, opened their doors to war victims in 2001 and 2004 respectively, the second in response to the conflict taking a new turn.

War victims treated by EMERGENCY in its three surgical hospitals

Patients
2001
2001
2020

Surgical Centre in Anabah: opened December 1999.

Surgical Centre in Kabul: opened April 2001.

Surgical Centre Lashkar-Gah: opened September 2004.

Data is not available for 2002

Source: EMERGENCY

Turning to the data again, if we look at the last 20 years as a whole, one thing glares out at us. “If you look at our overall data from 2001 to 2021, there’s an unmistakeable trend – a relentless rise in civilian victims,” confirms Matteo Rossi. First as a nurse, then as a field officer and now finally as a Medical Coordinator, Rossi has spent five years working in Lashkar-Gah. When we met him, he had just got back from a mission to Yemen.

EMERGENCY has chosen not to publish photos of Afghan colleagues and patients to protect their privacy and safety.

“I was in Lashkar-Gah when the Taliban laid siege to the city in 2016,” he remembers. “They were fighting near the hospital. That’s when I realised how difficult the conflict really was for civilians, what its effects on the population really were, the losses.” By UNAMA’s reckoning, the worst year was 2016, which claimed 11,452 civilian victims, 7,925 of them wounded and 3,527 killed. The highest number of deaths in one year was 3,803, in 2018. EMERGENCY’s data confirm the trends UNAMA has found. “The peak in patient admissions was between 2016 and 2019, thanks to changes in fighting tactics, to the government and anti-government forces using new strategies,” Rossi continues, referring to the rise in suicide attacks and aerial bombing, which we will look at more closely in chapter two.

In 2016, EMERGENCY admitted the second highest number of war-wounded patients to its centres in any of its working years: 6,660, almost half of them (2,997) in Lashkar-Gah, Helmand province. The only worse year on this front was 2018, with 7,106 war-wounded patients, 4,002 of them in Kabul alone. “2018 was particularly difficult,” Puntin confirms. “We saw a series of high-level attacks here in Kabul. There was one mass casualty every two weeks on average. 30 in just one year.” Rossi adds: “Something like 20 patients were turning up at a time. There were lots of other civilians left dead on the ground. Huge numbers.” It confronted us with the cost of the war for women and children, which is why we went to Lashkar-Gah, in the country’s deep south.

© Mathieu Willcocks
Children
EMERGENCY has chosen not to publish photos of Afghan colleagues and patients to protect their privacy and safety.

Outside the main entrance to the Surgical Centre for War Victims stands the imposing figure of Sayed. He has been with EMERGENCY for a long time and remembers when the hospital was opened, in late summer 2004. He remembers, too, the old days “when the international troops could go down to the river or over to the bazaar.” Formerly a driver, he is now head of security here. “I’m sort of a filter between inside and outside,” as he puts it. Inside are the patients, outside are their relatives and other visitors. Beyond the gates are a few kiosks selling sweets and drinks. “But a lot of our patients don’t have enough money even for some juice. Sometimes we have to give them our own clothes when they’re discharged.” There are also a couple of buckets with Covid masks outside the entrance. The pandemic is a concern, but the violence of war is a bigger one, and Amina is one of its victims.

She is in bed number four in intensive care. There is a doll with blonde hair and a yellow dress lying on the bed with her. The doll is facing her owner. Three-year-old Amina is one of the youngest patients at our Surgical Centre, which is dedicated to Tiziano Terzani, a journalist and man of peace. She comes from Kariz on the river Helmand, not far from the airport. Thanks to the grown-ups’ war, she has had to go through two operations and is expecting a third in the next few days. Nurses Leila Borsa and Silvia Triantafillidis are optimistic about it: “She’s responding well. She’s recovering.” With her big eyes, sweet expression and shaggy hair, Amina stares in silence at the doctors scurrying around her. Her wound is to the stomach and they have had to tie her hands to stop her pulling off the little tubes that feed her. She never complains, though. “What are you doing?” she asks, when a doctor starts putting a tube in her nose. In the next bed to her is five-year-old Saqina, who is saying over and over that she wants to go home.

EMERGENCY has chosen not to publish photos of Afghan colleagues and patients to protect their privacy and safety.

Between 2009 and the first three months of 2021, UNAMA’s data states that 28,866 children have been killed or wounded by the conflict. The worst year was 2016, when 3,512 children fell victim. It was also the worst year here for us in Lashkar-Gah, where the total was 795. In Kabul, 2018 was the worst; 1,174 children admitted. Overall, 2018 saw the highest number of child patients at EMERGENCY’s three centres; totalling 1,887, they represented 27% of all patients. In the last 20 years, we have operated on 19,510 injured children.

EMERGENCY has chosen not to publish photos of Afghan colleagues and patients to protect their privacy and safety.

EMERGENCY’s historic archive contains their stories. Asadullah came to us on 18 February 2010 from the Helmand province with his father, Ruhollah “A bullet went right through his head. He’s still alive and they’re operating on him. He went to the window to see what was happening in the street, because he was curious about the noise the tanks were making. A soldier saw his silhouette appear in the window and shot him. A single shot to the head.” Two days later, on 20 February, Esmatullah turned up here in Lashkar-Gah, “an 11-year-old with a lively expression. He was going to get water when suddenly he felt an intense burning in his leg. As soon as he arrived, he asked after Asadullah. They’re friends and neighbours. They play together all the time.”

War victims treated by EMERGENCY in its three surgical hospitals

Women
Children
Men
2001
2001
2020

Surgical Centre in Anabah: opened December 1999.

Surgical Centre in Kabul: opened April 2001.

Surgical Centre Lashkar-Gah: opened September 2004.

Data is not available for 2002

Source: EMERGENCY

When we first told Esmatullah and Asadullah’s story back in 2010, we ended it with a hope “that the day will come when they can tell each other their tragic stories over a cup of tea, with the roar of war finally vanished from outside.” That day still has not come. The fighting goes on, most of it at night. EMERGENCY’s international staff have their accommodation in a traditional Afghan bungalow, with white walls and charming gardens, shrouded in silence. At night, the noise of the fighting is no more than a dull, muffled rumble from over the river. Our staff keep a walkie-talkie on at all times, which every now and then crackles into life with updates from the hospital guards.

Women

It is just coming up to nine o’clock and medical staff are doing the daily morning rounds. Dozens and dozens of visitors are sitting on the benches that run along the outside wall. Inside, doctors and nurses are finishing up, seeing to the latest patients admitted, one after another. Radiographic images flash up on bright screens. Surgeons in chairs listen carefully. Someone is taking notes, someone else is asking the opinion of the colleague next to her, who is shaking his head. Higher up, on one of the boards that they update every day, the numbers make it quite clear: the hospital is full. There are no more beds free. They are really fighting it out in this province.

© Vincenzo Metodo

Aziz is a surgeon, around 42 years of age, who has been working here “for eight years. In all that time I haven’t had a moment’s rest. Helmand is one of those provinces that is always at war. I can’t remember a single day when we haven’t had patients. New ones are arriving all the time, day after day.” The admissions criteria are strict. “We’re forced to admit none but the most serious cases. They’re fighting in the districts, they’re fighting around Lashkar-Gah. There’s never a moment of peace. In the last few days we’ve had lots of patients from Grishk,” explains the doctor when he gets a break.

EMERGENCY has chosen not to publish photos of Afghan colleagues and patients to protect their privacy and safety.

Lying 40 miles to the north of Lashkar-Gah, Grishk is a strategically important town on the country’s most important road. Going west you come to Farah, then Herat, then the long Iranian border. To the east you have Kandahar, then Ghazni, then the border with Pakistan. 19-year-old Ismail arrived in Lashkar-Gah from Grishk a few days ago. He is unemployed, in his penultimate year of school, and speaks a little English. “The Taliban got to the bazaar in Grishk. The government helicopters shot them from above. They dropped bombs.” He describes buildings and market stalls going up in flames, civilians dead and wounded. People “couldn’t get away.” Though he and his mother did manage to escape in what seemed to be a brief moment of calm, he was hit by shrapnel and left with a wound to the chest. He sighs. “My mother was injured too. I don’t know where she is now.”

The rounds are still in progress when the clinic opens its doors. Three new patients arrive, all women, rushed in on stretchers. The calm of the morning’s work is shattered by hustle and bustle. Doctors and nurses hurry about, stabilising patients then evaluating them and deciding who to admit. Over the years we have seen more and more women admitted for war wounds. “The ratio of men to women stays pretty constant, but the percentage of women admitted to our hospitals goes up by about 10 per cent every year,” says Rossi. This means that “indiscriminate attacks, against civilians, are rising.” The distinction between civilians and combatants – a fundamental humanitarian principle – is getting increasingly blurred.

© Vincenzo Metodo

Generally “about 40 per cent of our patients are either under 14 years old or female. A third of all our patients are under 14 years old.” The reason? “More violent attacks, including on civilian buildings, like medical facilities” – as we shall see in the next chapters. “Even if you take just our hospital in Kabul, you can see that from 2003 to 2020 there was a 196 per cent rise in the number of women admitted, from 92 to 271, about three times as many.”

Among their number in Kabul was 30-year-old Mirza, from Tangi Wardak, in Wardak province. “I’ve been here about two weeks,” she tells us. “We were at home, on the second floor. There was fighting going on between the Taliban and the government. A grenade landed nearby, so we hid in the courtyard. Then another one landed there.” She was left wounded in the chest. “I’ve got two children waiting for me at home. It’s not the first time there’s been fighting near my house. But things have got worse now.”

Women and children treated by EMERGENCY - percentage

17.4%
2001
2002
14%
2003
15.9%
2004
14.8%
2005
12.5%
2006
14.8%
2007
11.7%
2008
16.7%
2009
11.6%
2010
11.4%
2011
11.8%
2012
12%
2013
12.4%
2014
11.2%
2015
11.8%
2016
9%
2017
8.6%
2018
9.9%
2019
10.6%
2020

The patients considered for the graph only include war victims.

Data is not available for year 2002

Source: EMERGENCY

According to UNAMA, 9,939 women fell victim to the conflict between 2009 and 2021. The equivalent number of children in 2020 alone was 2,619 (30 per cent of the total), of women 1,146 (13 per cent). In 2020, the war in Afghanistan took the lives of 390 women and 760 children. The data that UNAMA made public in mid-July 2021 show that in the first six months of this year, 1,659 people were killed and 3,524 wounded, representing an overall rise of 47 per cent compared with the same period in 2020. Among women the increase was 50 per cent, among children 55 per cent. The UN Secretary-General’s Special Representative in Afghanistan, Deborah Lyons, has implored all parties in the conflict to “urgently find a way to stop this violence,” but her pleas have fallen on deaf ears. Women and children make up 43 per cent of Afghan civilian victims.

Multiple wounds
EMERGENCY has chosen not to publish photos of Afghan colleagues and patients to protect their privacy and safety.

“We perform war surgery here in Lashkar-Gah. We do a lot of bilateral and trilateral amputations. We do the kind of operations we never want to see again, which are the result of ever more violent conflict,” says Dimitra Giannakopoulou, who has spent a good many years of her life as a Medical Coordinator here. “The admissions criteria for patients establish which of them have priority and respond to developments in the conflict. The worse the fighting gets, the stricter the criteria for admission to our centres become. It’s difficult but often necessary.”

“Our hospitals might feel like closed-off islands, but the work in them is strongly influenced by what’s going on outside,” Michela Paschetto tells us over the phone. “They change based on people’s particular needs in a given period.” Paschetto has just got back from Yemen. She spent seven years in Afghanistan and knows the healthcare network here well, including the prison health services, First Aid Posts (FAPs) and Healthcare Centres that we will look at in chapter three.

“Admissions criteria change over the years. Patients change, wounds change, medical needs change. In my first few years, from 2009 to 2011, things were different, including safety. In both Kabul and Lashkar-Gah, there were patients with injuries that had nothing to do with the conflict. Then for a little while at Lashkar-Gah we alternated between admitting patients with ordinary injuries and admitting only patients with war wounds. As of 2010 our hospital in Kabul has been purely for war surgery.”

War wounds treated by EMERGENCY

Mine
Shell
Bullet
2001
2001
2020

Data is not available for year 2002

Source: EMERGENCY

EMERGENCY has chosen not to publish photos of Afghan colleagues and patients to protect their privacy and safety.

One of the patients in Kabul is Saifullah, a 52-year-old farmer. “I grow potatoes, green vegetables, tomatoes. We’ve got a few cows as well. I was coming home from the mosque when I was hit. I’d wandered into a clash between the Taliban and the government soldiers. I come from [the province of] Logar, from Pul-e-Alam. There’s real fighting there.” There are eight of them in Saifullah’s family. “I have five children, but I got married late and they’re still young and going to school. I have to get back there as soon as I can, so I can get back to work.” He arrived here “more than a month ago. My leg was in a shocking state. Now I’m much better.”

Saifullah’s clinical process and the amount of time he has spent at the hospital are representative of a wider trend. Even after being enlarged, the operating theatres at EMERGENCY’s Surgical Centres have seen their workload increase all the time. The number of patients has gone up, their injuries have got more serious. In the last 20 years we have performed 70,865 operations here at our hospital in Kabul. Patients go into theatre twice on average (1.72 times to be precise) and take more than eight days (8.74) to recover. Violence is spreading outside. We are seeing multiple wounds that require patients to stay longer in hospital, which is partly why we have had to tighten the admissions criteria. The Surgical Centre in Lashkar-Gah had similar figures: a total of 56,402 operations and an average time in hospital of just over seven days (7.13).

Days in hospital
caret

per war-wounded patient (annual average)

Kabul
Anabah
Lashkar-Gah
012345678910111213012345678910111213
2001
2001
2020

Data relating to 2002 and 2004 are not available.

The patients considered for the graph only include war victims.

Source: EMERGENCY

EMERGENCY has chosen not to publish photos of Afghan colleagues and patients to protect their privacy and safety.

“What has really changed in the last few years is the kind of wounds we find ourselves operating on. They’re a lot deeper and more complicated,” says Ghulam, a surgeon. The number of surgeries per patient (about two at both surgical centres) has stayed fairly constant, in keeping with guidelines for treating war victims. The number of procedures per surgery, however, is going up, which is one indicator of how serious a condition patients are in. They are turning up more and more often with multiple wounds. In 2012, the average patient in Kabul had two wounds; now the average there is four, and just under three in Lashkar-Gah. Violence has increased. “It’s bearing down more and more on civilians. It’s like some kind of asphyxia,” Dr Ghulam goes on, placing his hands round his throat. He was born in the province of Kapisa in 1977, but was forced to move to Kabul at just six years of age due to the war. Today, he is one of the most respected surgeons in the city, indeed the whole country, and has worked with EMERGENCY since September 2004. “I remember there being so many ordinary injuries that year, from road accidents. The admission criteria were more flexible. Then the number of war victims began to rise again and the criteria were tightened. The hospital’s often overflowing nowadays.”

35-year-old taxi driver Sardar’s voice and hands tremble. His car was burnt. “There was an explosion. I think it was a magnetic bomb. Our streets are never safe.” He shows us his leg. “They took the skin off my left leg and put it on my right one, which was in an awful way.” He has no money. “They treat me for free here. I don’t know how I would have done it otherwise.” He arrived a week ago and has had one operation. It will take time for his wounds to heal. “I come from the district of Tala Wa Barfak, in Baghlan province.” After he was wounded, they took him to a clinic in Tala Wa Barfak, then on to Pul-e-Kumri. “But they weren’t able to treat me.” Before Kabul, he stopped at the Medical and Surgical Centre in Anabah, Panjshir Valley – EMERGENCY’s first ever Surgical Centre here which opened in December 1999.

EMERGENCY has chosen not to publish photos of Afghan colleagues and patients to protect their privacy and safety.
No ordinary hospital

“In the last few months the number of patients needing war surgery has gone up,” says Mirjana Grubanov, Medical Coordinator at the hospital in Anabah. We found her in her office on the top floor of the hospital, not far from the canteen, where dozens and dozens of nurses descend in their lunch break, to talk about the latest patients who have come in or chat about their own things. It is all thanks to a quiet revolution, which EMERGENCY wrote a report about and which we will look at more closely here in chapter three. “We chose to prioritise elective surgery here, because it’s always been one of the most peaceful provinces, but things are changing quickly. Now we have got patients arriving from different provinces with war wounds,” Grubanov goes on. There are some “even from our most isolated First Aid Post, in the Anjuman pass,” where the province of Panjshir meets that of Badakhshan.

This is no ordinary hospital. “We save lives here at the same time as helping women bring new lives into the world.” On the one hand, we treat patients, some of them in a very serious condition. On the other, we deal with maternity. “When we first opened, we only took in people with war wounds,” remembers Shirin, a man of about 50 from Obdarak, “a village a little way up the valley from here.” He is an old face at EMERGENCY. “I was here back in 1999, when they built the hospital by renovating an old barracks,” he says, looking around him. “It was all sand and rocks.” Taken on as a nurse, he went on to do various jobs before becoming the staff manager. “We have more than 500 employees, medical and non-medical. It’s a big operation. 24 hours a day.”

Surgical operations performed by EMERGENCY

Operations
2001
2001
2020

Data is not available for 2002.

The patients considered for the graph only include war victims.

Source: EMERGENCY

EMERGENCY has chosen not to publish photos of Afghan colleagues and patients to protect their privacy and safety.

“At the time, about 90 per cent of the country was held by the Taliban,” adds Nazar, another pillar of the organisation. “The conflict was intense. So many patients would arrive. It was hard. Anabah was the first hospital we opened. I remember the month of training, the way Gino Strada trained us, the day work started on 15 December 1999. Then in 2001 we opened in Kabul. Then in 2004 in Lashkar-Gah.” As our national Programme Coordinator and administrator of the hospital in Panjshir, Nazar is well placed to reflect on how things have changed. “We started in the Panjshir Valley with a Surgical Centre for War Victims. That was what was needed then. Fighting was going on very near the hospital. In 2001, we changed our admissions criteria a little. The situation was different. In 2002 we started thinking about building a Maternity Centre, which we went on to open on 4 April 2003.” Before all that, “when the area was more peaceful, we started working on elective surgery in Anabah, not just surgery for war wounds.” The data tallies with the changes Nazar describes. The centre in Anabah performed a lot of operations for war wounds in the first few years of its existence, but these decreased as births and maternity took on more and more importance. In the last 22 years there have been 9,677 operations for war wounds in Anabah.

“At that time the front stood more or less at Charikar,” recalls Gino Strada. “It was exhausting work. The operating theatre was constantly full. There were injured people everywhere. The number of civilians who have paid and are still paying the price of war is terrifying. Dead and wounded civilians. Women and little children. Teenagers, boys in men’s shoes. In those first few years, I remember there were many patients who didn’t even know what had happened on 11 September 2001.”

Photography by Giuliano Battiston
© Giulio Piscitelli
Attacks on civilians
Explosive violence
Emily Griffith, researcher, Action on Armed Violence (AOAV)

Action on Armed Violence (AOAV) has been tracking the casualty numbers and details of incidents of explosive violence worldwide since 2011 – ten years into the US-led invasion of Afghanistan. In the Explosive Violence Monitor, AOAV records the number of civilian and/or armed-actor casualties from each incident of explosive violence reported in English-language media, as well as information about the location, perpetrator, age and sex of the victims, type of weapon used and the mode of detonation.

In the last decade, 2011 – 2020, Afghanistan has consistently fallen within the top five countries worst-affected by explosive weapons. This decade of data shows that civilians in Afghanistan have suffered disproportionate harm from explosive weapons, accounting for 58% of the total casualties of explosive violence in the country. In total, AOAV has recorded 49,107 casualties from explosive weapons in the last ten years, across 4,223 incidents. Of these, 28,424 have been civilians. Women and children have been gravely harmed by explosive violence, with at least 2,758 children and 1,212 women among these casualties, though these numbers are an underestimation as the sex and age of casualties is often unspecified in media reporting.

© Giulio Piscitelli

When looking at the most harmful explosive weapons used, the data tells a story of two very different wars lived in the country: one where 12,296 armed-actors were killed and injured by various state-led airstrikes, compared to 2,323 civilians; and one where 22,350 civilians became casualties of IEDs, at least 76% of which were reportedly detonated by non-State actors, compared to 6,951 armed-actor casualties.

IEDs have caused, by far, the highest number of deaths and injuries among civilians from 2011-2020, accounting for 79% (22,350) of all civilian casualties from explosive weapons in the country. Car bombs and roadside bombs have caused the next highest levels of injury and death among civilians, resulting in 6,707 and 3,837 casualties respectively. The blasts from these two types of explosive attack cause a particularly high level of harm per incident. The degree of harm to civilians from these IED attacks has been especially high when the mode of detonation is by suicide bombing. Of the 2,362 IED attacks recorded over the decade, 517 have been suicide attacks. These bombings have resulted in 17,124 deaths and injuries, of which 13,654 were civilians, 61% of the total civilian casualties from IED attacks.

© EMERGENCY NGO Archive

Though the number of recorded suicide attacks has seen a general decline in the last decade, the number of civilian casualties from suicide attacks has increased substantially. The average number of civilian casualties from suicide bombings in 2011 was 18, whereas in 2016, the average number of casualties per attack hit a decade-high of 43. In 2019, the average remained more than double that of 2011, with 41 civilian casualties per suicide attack recorded. The locations in which the highest number of civilian casualties from suicide attacks were recorded between 2011 and 2020 have been public buildings (3,030), places of worship (1,882), public gatherings (1,491), and roads (1,398).

Kabul has been the worst-affected province for civilian casualties every year since 2011, and has frequently been the stage of violent and large-scale attacks by non-state groups. In the last decade AOAV has recorded 8,296 civilian casualties in the province, 7,855 of whom were killed or injured by IEDs. In 2020, for the first time since AOAV began recording, Afghanistan was seen to be the worst impacted country in the world with regard to civilian casualties harmed by explosive weapons.

EMERGENCY has chosen not to publish photos of Afghan colleagues and patients to protect their privacy and safety.

This year, 2021, explosive violence in the country surged after the US announcement of the withdrawal of troops on the 1st of May 2021. 55% of all recorded casualties from explosive weapons in Afghanistan in 2021 occurred in May. In one incident alone, a car bomb detonated outside a school in a Hazara neighbourhood of western Kabul killed at least 90 civilians and injured 230 others, most of whom were school girls. Attacks such as these are woefully common and on the rise in Afghanistan. Data from the Explosive Violence Monitor continues to show that it is the country’s civilians who suffer the greatest harm from explosive weapons.

EMERGENCY has chosen not to publish photos of Afghan colleagues and patients to protect their privacy and safety.

All opinions expressed within the articles written by external contributors exclusively reflect their personal point of view, based on their own experience.

No country for journalists
Fabrizio Foschini, Analyst, Afghanistan Analysts Network

All the various phases of the conflict that has been ravaging Afghanistan for more than four decades have led to a high number of civilian casualties. Some of the main risks for those living in Afghanistan in 2001 may have nowadays subsided, although old landmines or unexploded ordnance still kill. However, new types of weapons and violence have appeared since, posing new threats to civilians. During the years when NATO troops had a massive presence, the main insurgent group, the Taliban, waged largely asymmetrical warfare against its opponents. This included the widespread use of suicide bombers and suicide commando attacks against high-profile targets in the midst of residential areas. For many years, it was these types of attacks which caused the bulk of civilian casualties.

Notwithstanding the promulgation by the Taliban of a code of behaviour for their fighters already in 2011, officially commanding them to ‘take care of the lives of common people’, suicide attacks on targets inside populated areas which were posed to cause massive civilian casualties were not discontinued until recently – while they continue to be employed, and deliberately so on civilians on the grounds of sectarian hatred, by ISKP/Daesh.

© Massimo Grimaldi

The years of NATO presence also saw a high incidence of airstrikes, both as air support during ground fighting and in the form of targeted killings of insurgents.

The role of NATO airpower has largely ceased since the Doha Agreement between the US and the Taliban in February 2020, and most of the airstrikes are now being carried out by Afghan air forces. This has resulted in limited capacity, in terms of frequency but also of accuracy. It occurs at a time when the enhanced ability of the Taliban to contest the government’s control of territory by occupying and holding onto populated centres has brought the battle into areas with civilian homes, increasing the risk of residents becoming ‘collateral damage’ to government airstrikes or artillery shelling by the two opposing sides.

A concerning trend observed since the end of 2020 and continuing in 2021 is constituted by the sharp increase in targeted killings of civilians: family members of military personnel, civil servants, healthcare and NGO workers and, in particular, journalists and other media workers.

Journalists killed

1 journalist
Source: CPJ Commitee to Protect Journalists

Among the latter category, there were so many assassinations that in June 2021, global media watchdogs formally requested the International Criminal Court (ICC) to investigate the issue. Starting in November 2020 with the killing of prominent media figures Yama Siahwash of Tolo News in Kabul and Mohammad Aliyas Dayee of RFE/RL in Lashkar-Gah, the list has grown ever longer, including many female reporters and presenters. In Jalalabad, Malalai Maiwand, a TV presenter and representative of the Centre for the Protection of Afghan Women Journalists (CPAWJ) was assassinated on 10 December 2020, and three female media workers of a local TV station were shot dead by gunmen on their way to work on 2 March 2021. In Kabul, the news anchor for Ariana News, Mina Khairi, was killed along with her mother and sister when her car was blown-up by a magnetic explosive device on 3 June.

© EMERGENCY NGO Archive

Although in some instances the intimidation or even targeting of journalists may be attributed, due to personal enmities or abuse of power, to both sides of the conflict, the elimination of civilians considered ‘on the opposite side’ has long been practiced by the Taliban.

While the Taliban have recently ramped up their military campaigns focusing on taking control of rural districts rather than carrying our attacks inside cities, it is unlikely that they have altogether given up the objective of putting pressure on the urban areas controlled by the government.

While seldom claiming attacks targeting civilians publicly, and sometimes rejecting accusations of being responsible for them, the Taliban are likely to exploit many of these killings in order to pressure the government by demonstrating its inability to guarantee security. Other objectives are to subdue the population into uncertainty and fear, and to facilitate their future inroads by pushing ‘disturbing elements’, who hardly fit in the type of society the Taliban imagine, to leave their jobs or flee the country.

© Victor J. Blue

Moreover, the dangers for those journalists, both local and international, who cover the war by reporting from the frontlines are extreme, as the recent killing of Reuters photojournalist Danish Siddiqui on 17 July 2021 showed. This poses a serious challenge to any fair reporting of the conflict.

The threat posed to journalists in this new phase of the conflict is particularly severe not only for the survival of a professional category whose independence and professionalism represented one of the few true achievements of the past decades of reconstruction, but for the future perspectives of fairly monitoring the situation in Afghanistan and preventing further violence and abuse against all its citizens.

All opinions expressed within the articles written by external contributors exclusively reflect their personal point of view, based on their own experience.

Our story
Giuliano Battiston, journalist
Princess India

“I remember that day very well. It was a Thursday, the day before an Afghan holy day. I had gone to a few hospitals, as I do every morning, to see how a few adult and child patients I knew were doing. In the evening I risked ending up one of the patients at EMERGENCY’s hospital. If that bomb had been more powerful, I wouldn’t be here talking about it now.”

The exterior of the Surgical Centre for War Victims in Kabul

Princess India of Afghanistan lives in a flat in the Prati district of Rome, a few hundred yards from the “big house at Via Orazio 14 that looks like a palace,” where she lived with her father, mother and many other relatives as a little girl. Her mother was Queen Soraya, “a mother and teacher” with a firm belief in education. “As Minister of Education in the 1920s she founded the first girls’ school in the country and sent her daughters, my elder sisters, to it. She had the first women’s hospital built and trained its first nurses. She encouraged women to read textbooks.” Her legacy still lives on, as we shall see in chapter four.

India’s father was Ghazi Amanullah Khan, the man who in 1919 won his country’s independence from Britain. Coming to the throne on 28 February 1919 “at the age of just 27, when we do everything in too much of a hurry,” this radical reformer was forced to abdicate on 14 January 1929, retiring to Kandahar, then India, and finally Rome. Princess India has had the opposite path in life – from Italy to Afghanistan – and is affectionately known by friends and acquaintances as Bibi Jan.

EMERGENCY has chosen not to publish photos of Afghan colleagues and patients to protect their privacy and safety.

On Thursday, 11 December 2014, I invited Jan to the French cultural centre at the Lycée Esteqlal, a secondary school in Kabul over the road from Zarnegar Park and Abdur Rahman Khan’s mausoleum. (Khan, known as the Iron Emir, ruled in the late nineteenth century; Princess India, his granddaughter through the paternal line, keeps a photo of him on a chest of drawers in her living room.)

That December evening in 2014 was an unusual one. There were hundreds of pupils, the boys with their hair neatly combed, the girls with tight trousers and knee-length dresses over the top, crowding the hall at the cultural centre. Headteacher and choreographer Laurence Levasseur, accompanied by Inge Missmahl, a German psychologist and head of a charity, walked through the audience explaining the play they were about to see: Heartbeat: The Silence After the Explosion.

© Mathieu Willcocks

“We’ve put the moments after an attack on stage, when time seems to stand still and you look around in disbelief, feeling lost,” said Missmahl before the play started. It was a collaborative effort by Afghan, German and French writers. Also in the hall that day was ustad (maestro) Ahmad Naser Sarmast, founder and director of the Afghanistan National Institute of Music (ANIM).

EMERGENCY has chosen not to publish photos of Afghan colleagues and patients to protect their privacy and safety.

It was the first time anywhere in the country that the performing arts had been used to address suicide attacks. By 2014, attacks of that kind had claimed a great many civilian victims, especially in the years when NATO troops had a large presence on the ground, as Fabrizio Foschini, a researcher from the Afghanistan Analysts Network, recalls. He says suicide attacks were part of the asymmetrical war between the Taliban and their enemies. “Their main characteristic is the widespread use of suicide bombers against high-profile targets in the middle of residential areas.”

Music and dance shared the stage at the French cultural centre that evening. The music would rise in intensity, then diminish, then rise again and finally come to a climax. Lying down on the stage floor, the actors mimed the moments after an attack. Then out of nowhere came a deafening explosion. “It happened about 20, 30 minutes after the play began,” Jan remembers. “There was little light and so much soot. Debris was falling from above us. There was a burning smell. For the next few moments everything was unclear. I was sure it was just part of the play, but then I heard the screams. I saw a man lying on the ground, perhaps on the stairs. I don’t remember well. His stomach was ripped open. He died from his wounds in the next few days. We walked out covered in blood. Outside they insisted that I go and get myself to EMERGENCY’s hospital.”

© Pieter Ten Hoopen

The hospital is less than three kilometres from the Lycée Esteqlal. “A police car took us there. Both my ears were ringing. I couldn’t hear well, but I chose not to say anything about it and just got a general assessment. I had serious injuries.” A lot of wounded people turned up at the Surgical Centre for War Victims in Kabul that evening, brought by the emergency services. This is known technically as a ‘mass casualty’, and EMERGENCY has been keeping detailed records of them since January 2013; when suicide attacks became more frequent. The attack on 11 December was the fifth in 2014. It was not even the worst that year, nor was it to be the last.

The statistics are revealing. They show a gradual, progressive rise in mass casualties and patients from them over the years. Between January 2013 and December 2020, the hospital in Kabul handled 136 mass casualties. 13 more were recorded in the first five months of 2021, from which EMERGENCY treated 145 patients (36 of them assessed and treated in the clinic for superficial wounds, 109 admitted to hospital). A recent mass casualty was on 8 May, when a triple explosion struck the Sayed al-Shuhada girls’ school, in the district of Dasht-e-Barchi, a part of Kabul mostly home to Shiite Hazara people. 20 girls, seven women and two men came to the hospital that day. The pupils still have to face the psychological trauma of the attack, which is discussed in chapter four.

Mass casualties managed in the Kabul Surgical Center for War Victims

1 mass casualty

Mass casualty describes a massive influx of patients who arrive at the hospital in a short amount of time. In the event of mass casualty, the medical staff and equipment are overwhelmed by the number and severity of the victims.

Data available from 2013 to 3 August 2021.

Source: EMERGENCY

All 10 of the wounded patients arriving at EMERGENCY’s hospital on the evening of 11 December 2014 were men. Among them was ustad Sarmast, who had a lot of metal shards stuck in his head. Seven years on from that day, we meet him in his new office - the organisation has started expanding its activities in just the last few weeks. Despite being accused by anti-government militants of corrupting young people with his music courses, which are popular with both boys and girls, Sarmast has no intention of leaving the country – not any more, at any rate. “Before the attack I was working on a sort of exit plan to get back to my family in Australia,” he explains. “But the attack convinced me to stay. It showed that we were really bringing change, which was annoying the extremists. Music is a right for all, men and women. We need it now more than ever.”

“If that bomb had been more powerful,” says Princess India, “if that boy had set it off in a different place, I wouldn’t be here talking about it now.” Her description of the Lycée Esteqlal’s attacker is right: he was not even 18 years old, “sent to die and to be himself a victim of the culture of war.” The daughter of the reformer king Amanullah Khan lives in Rome, but she will come back to Kabul as soon as it is safe for her to do so. In the last few years she has watched the attacks made on civilian targets with ever greater concern. “Innocent victims,” she says.

© Pieter Ten Hoopen
Inside EMERGENCY’s hospitals

The rise in attacks is borne out by the data EMERGENCY has gathered. In 2013, the hospital in Kabul handled six mass casualties, treating 91 patients (of whom 28 were outpatients and 63 were admitted). In 2014, there were five mass casualties, with 86 patients (15 outpatients, 71 admitted). There were seven mass casualties in 2015 and number of patients rose to 168 (59 outpatients, 109 admitted).

The rise in the number of patients treated in 2015 (48 per cent more than in the previous year) did not bode well, and indeed it opened the door to the worst years. Mass casualties almost doubled in 2016, numbering 12, with 239 patients (64 outpatients, 175 admitted). The total rose yet again in 2017, with 18 mass casualties and 390 patients (91 outpatients, 299 admitted)

Marco Puntin, EMERGENCY’s Country Director in Afghanistan.

But 2018 was the worst of them all. After years of delays, parliamentary elections were finally held, meaning several attacks were made on the country’s polling stations, claiming dozens of victims. “2018 was a particularly difficult year,” says Marco Puntin, EMERGENCY’s Programme Coordinator in the country. “We saw a series of high-level attacks here in Kabul. There was one mass casualty every two weeks on average. About 30 in just one year.” There were 31 mass casualties in 2018, with 534 patients (162 outpatients, 372 admitted), no less than 38 of whom were children and 31 of whom were women. Among the 372 patients we admitted from mass casualties in 2018, 19 died soon after arriving due to the seriousness of their wounds. Those 372 patients are just a fraction of the war victims EMERGENCY treated in 2018, when the organisation’s hospitals received more war-wounded patients than in any previous year: 7,106 to be precise, of whom 4,002 were in Kabul. UNAMA also has 2018 down as the year with the highest number of civilian deaths from the conflict: 3,803, an 11 per cent rise on the previous year and a five per cent rise in all victims, both killed and wounded. This was due in part to expanded military operations and raids on the ground. Action on Armed Violence (AOAV) say this year had the highest total of people wounded and killed by suicide attacks (2,563).

“When it comes to mass casualties, 2018 was our hardest year, but they have remained a presence in the years since here in Kabul,” Puntin continues. Indeed, 2019 saw 28 mass casualties with 369 patients (123 outpatients, 246 admitted), 10 of whom died after arriving. 54 of those patients were children and 37 were women. In 2020, mass casualties fell to 21, total patients to 201 (52 outpatients, 149 admitted).

© Vincenzo Metodo

Mass casualty victims treated by EMERGENCY’s Surgical Centre for War Victims in Kabul

Hospitalised patients
Patients treated in the outpatient department
2013
2013
2021

Data available from 2013 to 3 August 2021.

Source: EMERGENCY

Mass casualties

Yet the numbers only tell part of the story. “Tackling a mass casualty is very complicated. It takes preparation, coordination and nerves of steel,” Puntin says. It starts all of a sudden with a walkie-talkie going off: “Mass casualty. Mass casualty starting now. All staff into positions.” If you have not been there yourself, it is hard to grasp what those moments are like, but we will try to describe them, in the words of Roberto Maccaroni, a nurse who witnessed a mass casualty in Lashkar-Gah:

“A row of white bags at the gate. Accident & Emergency is like a slaughterhouse. Dozens of people are running this way and that way, slipping on the blood and dodging the stretchers. The operating theatre calls in on the walkie-talkie for more blood bags. Staff are rushing around the wards with bandages in their hands, trying to dress everyone who’s waiting to be operated on.” And it goes on. “You’ve only just got the time to go over the numbers in your head, the patients and what you need to do. The local staff have only just got the time to get their breath back after doing their extra shifts, spending extra hours handling the flow of patients in the wards, restocking materials, assigning every patient a decent bed. And then they’re back into it. Plunging their heads back underwater. No coming up for air.”

© Mathieu Willcocks

Not only do they have to keep their heads underwater a long time, they have to follow strict rules while they are doing it. Nadia De Petris talked about an attack on 16 March 2009 in EMERGENCY’s quarterly journal in June that year. Once again, it was an experience from the Surgical Centre for War Victims in Lashkar-Gah, Helmand province. “A suicide bomber set off a beltful of explosives in the middle of a group of policemen waiting to pick up their wages outside the central police station. In the space of a few minutes the hospital will be full of wounded people. We run into position in silence. There’s a mass casualty plan for every EMERGENCY hospital, for when huge numbers of injured people flood in due to a particularly serious terrorist attack or clash between forces.”

The plan, De Petris goes on, “contains a precise role for every member of staff and it’s essential they follow it if we’re to respond effectively to the emergency. The organisation of the hospital changes radically. Some nurses are taken out of their wards and transferred to the most important points of the hospital, or to the garden, where tents are put up. The patients turn up in ambulances, cars, vehicles they’ve been lucky enough to flag down, some even in other people’s arms.”

That day the hospital in Lashkar-Gah took in 50 wounded people. “All of them had multiple injuries from shrapnel, mainly in their arms, legs and faces. Some of them had wounds to the chest and stomach. There was nothing more we could do for some of them, like the first two men who arrived already dead, with head injuries and shrapnel in their stomachs.” The operating theatres were at full capacity. “That evening we did the counting for the day. 50 had arrived wounded. 21 were operated on and now asleep in the wards. The others had been given medicine and sent home. 12 were dead on arrival.”

Operating theatre, Surgical Centre for War Victims in Lashkar-Gah
Explosive weapons

The data from AOAV’s Explosive Violence Monitor show that civilians are bearing the brunt of explosive weapons in the Afghan conflict. 58 per cent of all victims of violence are victims of explosions.

According to UNAMA’s data, explosive devices, including those used in suicide attacks, were responsible for 23 per cent of recorded injuries and deaths among women in 2020; the equivalent figure for children rises to 25 per cent. Again in 2020, explosive ordnance left over from different phases of the longer Afghan conflict, including mines, account for 15 per cent of injuries and deaths among women and 12 per cent among children. In the worst year for civilian victims and particularly for child victims, which was 2016, 86 per cent of those who fell prey to ordnance were children.

According to UNAMA, aerial bombing was responsible for 11 per cent of injuries and deaths among women and children, a figure which has oscillated wildly over time. In 2010, it claimed 39 per cent of all civilian victims and 53 per cent in 2011, but the percentage fell appreciably in the following years, to just three per cent in 2015. Then it climbed back up to nine and 10 per cent in 2018 and 2019 respectively.

© Mathieu Willcocks

In 2010, one of the deadliest military actions for civilians was the so-called "Operation Moshtarak", launched by the international and Afghan military forces during the night between 12 and 13 February in the district of Marjah, in the southern area of Helmand, and conducted for several weeks. This is how EMERGENCY nurse Matteo Dell'Aira gives an account of it, a month after it began. “Even if we hadn't read the news, from our EMERGENCY hospital in Lashkar-Gah we would have had no difficulty in realising that another phase in the war was looming: planes were flying over our heads every day, helicopter gunships were constantly coming and going, the windows of the wards were shaking. And then there was the sound of the explosions that alerted all the staff. The first wounded people arrived on 13 February 2010. From the village of Marjah alone, we received 45 war-wounded patients in 15 days, mostly from bullets. Single shot. As has been the case in all 'modern' wars for at least 60 years, many of the wounded were civilians: children first and foremost. Our local colleagues were very worried: almost all of them have relatives or friends living in that area. The injured who managed to reach EMERGENCY's hospital in Lashkar-Gah, about 30 kilometres from Marjah, were the luckiest. The others were left to die in the town’s rubble. Military checkpoints prevented cars carrying wounded people from leaving Marjah, forcing them to drive along mined roads to seek help. A crime within a crime.”

EMERGENCY has chosen not to publish photos of Afghan colleagues and patients to protect their privacy and safety.

It is not only large-scale military operations or aerial bombardments that cause civilian casualties. Fighting on the ground between government and non-government forces claimed 48 per cent of women victims and 46 per cent of child victims in 2020. Here too, UNAMA’s figures oscillate over the years. In 2014 and 2015, when the International Security Assistance Force’s mission came to an end and training by Resolute Support began, there was an increase in casualties due to fighting on the ground. The percentage of victims claimed by this fighting went from 14 per cent in 2012 to 37 per cent in 2015 and finally up to 38 per cent in 2016.

Over the course of 2020, UNAMA’s report states, improvised explosive devices (IEDs) claimed more than a third (34.5 per cent) of all victims in the conflict. The data set out by Emily Griffith in her chapter on the topic gives an overview of the decade from 2011 to 2020, a period in which 79 per cent (22,350) of all civilian victims in Afghanistan were attacked with explosive weapons. Car and roadside bombs took the second and third highest tolls of injured and dead civilians, at 6,707 and 3,837 respectively.

Between 2017 and 2020, the percentage of injuries from handmade IEDs was high and constant; in 2017 it was 40 per cent, in 2018 and 2019 it was 42 per cent. The percentage went down to 34.5 per cent in 2020, the year that the United States and the Taliban signed a bilateral agreement in Doha. That was an unusual year.

Types of attack (Source: United Nations Assistance Mission in Afghanistan - UNAMA)

IEDs (Improvised Explosive Devices)
Air raids
Ground attacks
Other
Unspecified attacks
2008
2008
2020

Data available since 2008.

Source: United Nations Assistance Mission in Afghanistan – UNAMA

EMERGENCY has chosen not to publish photos of Afghan colleagues and patients to protect their privacy and safety.

UNAMA’s records report that in 2020 the conflict left 3,050 people dead and 5,785 injured, as stated in chapter one. The most significant development came in the last three months of the year, when the so-called ‘intra-Afghan dialogue’ began between the Taliban and the ‘republican front’ in Kabul. Rather than a drop in violence, “there has been an escalation”, as UNAMA’s researchers write. From October to late December, what is usually a period of annual respite turned out to be one of the bloodiest phases of the conflict since the UN’s records began in 2009. Those three months alone saw 891 people killed and 1,901 wounded.

Surgeon Roberto Bottura can look back on the range of weapons used over the years, the wounds from which he saw in the operating theatre. He has spent a lot of time in Afghanistan. He helped launch EMERGENCY’s work here and was there at the opening of its first Surgical Centre in 2002. The facility in Anabah, in the Panjshir Valley, is given over entirely to general surgery and traumatology. “I first came here in 1999,” he tells us. “In those days you had to fly to Dushanbe in Tajikistan, then take a jeep through the countryside to the Panjshir Valley. Clinical work began soon after and it’s never stopped since. In this country, injuries from firearms have remained high as a percentage over the years. What has gone up massively is injuries from explosions.”

© Mathieu Willcocks

“We’ve gone more and more from conventional mines to IEDs,” Michela Paschetto, from EMERGENCY’s medical division coordination, says. “They’re easy to design and the parts for making them are easy to get hold of and not expensive. They hit everyone without distinction, women and children included. It’s in part because of IEDs that fighting has moved into the cities. The people have paid the price.”

According to Saeed, a surgeon at the hospital in Lashkar-Gah, “overall, day after day, the number of war-wounded patients has gone up. At the beginning, in 2004 and the years after, when I started here, it was mainly injuries from bullets and shrapnel, but further down the line we’ve seen more and more wounds from explosions, mines and ordnance. At first, they were made abroad and imported. Now they’re designed and put together in people’s houses, handmade. They’re making more of them and more easily.” And civilians are feeling the effects. “We have very serious cases turning up, patients dead on arrival.” What is true in Kabul goes for Lashkar-Gah too.

EMERGENCY has chosen not to publish photos of Afghan colleagues and patients to protect their privacy and safety.

“The violence is suffocating for civilians,” as Ghulam, a surgeon at EMERGENCY’s hospital in Kabul, said in chapter one. She goes on: “We have patients arriving burnt, seriously injured, who are going to need complicated recovery processes.” The cause? “These wounds are from explosions. We treat so many of them. Three weeks ago my cousin arrived here after he was injured by a mine. He was kept in hospital for two weeks. Every day there’s another case like his.”

EMERGENCY has chosen not to publish photos of Afghan colleagues and patients to protect their privacy and safety.

There are magnetic bombs, car bombs, landmines. Zahra knows the consequences all too well. “Six years ago I was at work here in the hospital when they told me they were looking for me in the clinic. I ran over there and found my husband. He was in an awful state. I fainted. He was a judge at the supreme court. He was walking to work that day, towards Maidan Wardak, when they attacked the gates of Kabul. We looked after him here for a month and a half. He was one of the few survivors [of the attack] but he was left paraplegic.”

The civilians of Kabul province have been the worst hit of any every year since 2011 and the area “has frequently been the stage of violent and large-scale attacks by non-state groups,” as Griffith notes in her contribution. Between 2011 and 2020 “AOAV recorded 8,296 civilian victims in the province, 7,855 of whom were killed or wounded by IEDs.” The most common locations for civilians to be killed in suicide attacks between 2011 and 2020 were public buildings (3,030), places of worship (1,882), public gatherings (1,491) and streets (1,398). Gyms were also targeted.

Matiullah’s story

Late in the afternoon on 5 September 2018, dozens of athletes had gone to the Maiwand club, a very popular gym in Dasht-e-Barchi, the Shiite district of Kabul already mentioned. “It was a terrible day. I was at the gym exercising. Our fights were set for two days later. We were wrestling and fighting. Around six in the evening, when we’d finished preparing, we heard a shot. It was aimed at the guard outside the entrance. We immediately ran for the emergency door. But there was a massive explosion.” A suicide bomber with a bomb hidden in his gym bag had made his way to the door.

EMERGENCY has chosen not to publish photos of Afghan colleagues and patients to protect their privacy and safety.

The man telling us all this, with the hesitant look and the squashed baseball cap on his head, is 28-year-old Matiullah. He counts himself lucky: “I’m alive. I lost 10 friends that day. One of them was in front of me in the car that took us to the hospital. He was dead before we got there. I was lucky,” he repeats. We are talking with him on the terrace of a café in the district of Shahr-e-Now, in the centre of the capital.

30 people were killed and 91 wounded in the attack, for which the local branch of Islamic State claimed responsibility. And this was a double attack. A car bomb exploded once the rescuers and the journalists arrived. Among the victims were Samim Faramarz and Ramiz Ahmady, a journalist and cameraman from the Tolo channel; they were killed live on television as they reported on the first attack. This is an increasingly common method among attackers: wait for the emergency services and the journalists to arrive on the scene of the attack and set off a second bomb. In the months and years that followed, as Fabrizio Foschini summarises above, many others in the world of journalism would find themselves caught in the sights of government and anti-government fighters.

EMERGENCY has chosen not to publish photos of Afghan colleagues and patients to protect their privacy and safety.

A seriously wounded Matiullah lost consciousness. “I came to again in EMERGENCY’s hospital. My arm was in a terrible condition. Half of it was covered in blood.” He takes his phone out of his pocket and scrolls down the screen to show us a few photos. One is of his left arm before the operation. “I was in a bad way.” He drinks some more of his mango juice. The scar from a second operation, thanks to which he got back the use of his hand, still shows on his wrist. That evening he risked losing his arm. “An Italian surgeon operated on me. They told me later that I said to him, ‘I have a family, doctor. Please don’t amputate my arm.’”

EMERGENCY has chosen not to publish photos of Afghan colleagues and patients to protect their privacy and safety.

The doctor in question was Enrico Paganelli, an orthopaedic surgeon from Livorno. We meet him in Kabul shortly before he sets off for a mission in Lashkar-Gah. “It was a hard day with a complicated mass casualty. If I’m not wrong, we operated on 23 patients in a serious condition,” Paganelli remembers. EMERGENCY’s records state that 36 patients arrived that evening, 29 of whom were admitted. The operations were complicated, requiring years of experience in war surgery.

“The guidelines for war surgery and reconstructive surgery were set out in the 70s by the Red Cross,” Paganelli explains. “In our years in the field, we have learnt to adapt them, to shape them to practical demands. Now our approach to patients with trauma is to give them less destructive surgery. We do less amputations. Where possible we prefer reconstructive plastic surgery.”

And that is what Matiullah got. He has a five-year-son, Musah, and another baby on the way in just a few months. “I was a sportsman. That’s why I recovered in just over a year. But I can’t forget that day,” he tells us, before heading back to work.

Photography by Giuliano Battiston
© Giulio Piscitelli
Access to healthcare
The continued struggle to access medical care
Nico Piro, journalist, RAI

“They’ve shot Mohammad. We’re bringing him to the EMERGENCY hospital. Can you help us? Can you call your friends?” The Afghan man’s voice was desperate. I tried to give him a reassuring answer, realising the phone had rung a few times before I noticed it.

A friend had been injured in Kabul and his first thought was to bring him straight to EMERGENCY’s hospital in the heart of the capital. Statistics show the Afghan health system has grown over the last twenty years. According to the World Health Organization (WHO), it now has 3,135 facilities of various levels, from clinics to hospitals, and 87% of the country’s population live within two hours’ reach of at least one of them.

© Vincenzo Metodo

But these statistics do not tell the whole story. Accessing medical services is still difficult in Afghanistan, and not just because of the lack of transport links and the high mountains everywhere. The Covid-19 crisis has shown as much, although its effects are massively understated by the official figures. There is now a trade in oxygen cylinders, which patients’ relatives are often forced to buy and bring into the ward themselves. Corruption is still endemic, as is private insurance. Drug-taking has led to phenomena like antibiotic resistance that would once have been unthinkable. Afghans are pushed to make optimistic, and almost invariably futile, journeys to Pakistan or India. Private hospitals are forceful in carving out their market, and healthcare in general does not come cheap. And quite simply, you cannot get the staff. These all add up to a health system rebuilt on weak foundations. Which is why I ended up getting a call from halfway across the world asking – as if approval were needed – for admission to EMERGENCY’s hospital in the heart of Kabul, despite the many other hospitals in the city, on a day when there were no emergencies and the A&E were not remotely crowded.

© Mathieu Willcocks

There are other reasons why healthcare in Afghanistan is still in such disarray, 20 years after the Western military intervention first set foot in the country. According to UNICEF, it is still one of the worst places in the world to be a mother or a baby; the maternal mortality rate is still extremely high, at 638 women per 100,000 births, as is infant mortality, with four in 10 Afghan babies dying before their first birthday. Tradition alone – young mothers and poor family planning – is not to blame, as prevention and primary medicine are sorely lacking in such a young country (40% of the population are between 10 and 19 years old).

© Mathieu Willcocks

All these problems are being aggravated further by new challenges thrown at the country’s health system, from HIV to heroin and synthetic drugs addiction. But they pale into insignificance if you cast your eye over a timeline of the country’s recent history. In 2021, Afghanistan is sliding once more into civil war. By their very nature, the past 20 years of war could not have avoided harming healthcare, primarily by making it difficult to get around on the roads and indeed to cross whole areas on the way to medical facilities. Of course, the war also greatly and tragically increased demand on hospitals and clinics, heaping stress upon them and forcing them to deal with emergencies at the sacrifice of ordinary treatment.

War also turns medical facilities into targets. In the last decade, the places that treat war victims have no longer been inviolable. War has been waged for 20 years under the banner of rebuilding and bringing democracy to the country. It has left us with a place where sick people have to struggle along mule tracks and through fighters’ checkpoints to a hospital bed, yet even lying there they cannot be safe.

© Vincenzo Metodo

All opinions expressed within the articles written by external contributors exclusively reflect their personal point of view, based on their own experience.

Covid-19 in the midst of war
Andrew Quilty, freelance journalist and photographer based in Kabul

The first positive cases of Covid-19 in Afghanistan were recorded in the western city of Herat in February 2020. At that time, there were just over 50 cases detected across the country, but the Government proved to be comparatively aggressive in instituting containment measures: schools, universities, government offices and all non-essential businesses in Kabul and provincial capitals were ordered shut, domestic airlines grounded and road travel restricted. As in countries around the world, health facilities in Afghanistan were converted into coronavirus treatment centres, with the Afghan Japan Hospital in Kabul as the capital’s primary coronavirus treatment facility.

© EMERGENCY NGO Archive

Afghanistan seemed initially to avoid the high rates of infections and deaths experienced in Europe, the U.S. and neighbouring Iran. Yet, the explosion of infections in the latter saw more than 200,000 Afghan migrant workers streaming back across the border in March 2020.

The workers piled into crowded buses and vans in Herat and dispersed across the country, rejoining the large, multigenerational households they had left to support in the first place. Infections were soon detected in all 34 provinces, and Afghanistan encountered its first wave. The spread of Covid-19 was inevitable, first and foremost due to the country’s limited testing and tracking capacity. As of 7 July 2021, 647,029 samples had been taken, with 131,586 confirmed cases and 5,561 deaths. The ministry had the capacity to test, on average, only 3,888 of the 11,000-21,000 samples collected countrywide on a daily basis, meaning at least 80 - 90 percent of potential cases remain undiagnosed.

Since humanitarian aid for Covid support has been directly linked to the number of proven cases, having such a low number of confirmed positive results has meant the resources supplied and the demand for them are unmatched.

© Mathieu Willcocks

Within a socio- political- economic context plagued by an ongoing war, the national health system was critically weak even before the pandemic hit, and this has caused a lack of basic preventive measures, resources and supplies from the start. At the beginning of the pandemic, only 300 ventilators were available countrywide, some of which were unused because staff had not been trained to operate them. The WHO gave Afghanistan testing kits, but only two laboratories in the country were equipped with machines that could process the test samples. The Afghan Japan hospital’s shortages in oxygen saw patients’ families fighting for tanks when delivery trucks arrived, while medical workers were equipped with hand sanitizer found by international NGOs assisting the Ministry of Public Health to be inauthentic.

Afghanistan faced Covid-19 with almost a quarter of its population deemed to be in need of humanitarian assistance according to the UN Office for the Coordination of Humanitarian Affairs. The WFP’s Deputy Country Director assessed the “situation in Afghanistan as quickly turning from a health emergency to a food and livelihood crisis.”

© Mathieu Willcocks

In this respect, Kabul’s karachais – the wheelbarrow who provide day labour or carry groceries for shoppers, and who are among the breadwinners for just over half of all Afghan households whose survival relies on informal employment – symbolise the great inequities that the coronavirus is exacerbating. They have come to represent the great majority of Afghans who, after lockdowns to prevent the spread of the coronavirus, are now struggling to feed themselves. Many already were. 

The risk of succumbing to poverty, as experts predicted, has thus appeared greater than that posed by the coronavirus. Indeed, few Afghans can afford to stop working, even as infection rates increase, whereas the vast majority of Afghans cannot afford to follow the kind of behavioural change that has been effective in containing outbreaks elsewhere around the world.

© Mathieu Willcocks

With widespread poverty, no welfare system to support them, doctors interviewed throughout the pandemic have described that many Afghans with symptoms prefer to wait out the illness rather than risk a visit to the hospital and a long wait for results. Most who succumbed to the virus likely never sought treatment at all, and will never figure in official statistics. “Afghans have experienced so much hardship in the past that they aren’t so worried about a disease, no matter how much experts sound warnings,” the former director of the Afghan Japan Hospital told me in 2020. More people died in 2019 in Afghanistan’s war than in any other conflict around the world, a fact that goes part-way to explaining why Afghans have confronted the coronavirus with the same fatalism they have adopted through the ebb and flow of more than 40 years of war. Although the virus itself does not discriminate, its effects are far more devastating and widespread among poor and vulnerable populations like Afghanistan’s.

All opinions expressed within the articles written by external contributors exclusively reflect their personal point of view, based on their own experience.

Our story
Giuliano Battiston, journalist
Health network

“We’re in Lashkar-Gah. Even when calm seems to reign here, you’re always expecting something to happen. And in the last few weeks things have taken a turn for the worse. They’re fighting right outside the town. The people are trapped here. They aren’t free to get in or out. The roads are no longer safe. Flights have stopped. We’re in the hands of Allah now.”

Sayed, head of security at EMERGENCY’s Surgical Centre for War Victims, breaks off from our conversation to answer the phone. The hospital gates open and an ambulance rolls in with its wheels covered in dust. Straight away they tear open the back doors, bring out a patient on a stretcher and wheel him inside. “It’s pretty serious,” the driver, Naseer, tells us. You can see the heat and tiredness in his face as he wipes his forehead and lets out a sigh of relief. He has just driven here all the way from the district of Musa Qala, a long way off to the north. “It took four hours. All in all it went well. Nothing serious happened on the way.” He gets back in the ambulance to drive it over to the garage just outside the hospital walls. Then he heads to the canteen, his patient now in the doctors’ hands.

An ambulance arrives at the Lashkar-Gah hospital.

Naseer’s ambulance belongs to the network of First Aid Posts (FAPs) and Primary Healthcare Centres (PHCs) that EMERGENCY has built over the years. These stable medical outposts are linked to the organisation’s hospitals by 24-hour ambulance services. At PHCs, doctors and nurses provide basic treatment and, when necessary, transfer patients to second- and third-level facilities. At the FAPs they stabilise wounded people so they can be taken safely to hospital.

“Ever since we started here in 1999, we’ve sought to plan the locations for our work in the country around the needs of its people,” says surgeon Roberto Bottura. “It’s always been important to know where we should operate. That’s why we opened first our Surgical Centre for War Victims in Anabah, in the Panjshir Valley,” – running since 2002, it has since given over almost entirely to general surgery and traumatology – “then our hospitals for war victims in Kabul in 2001 and Lashkar-Gah in 2004, so people living on the frontlines of the conflict could get treatment. That’s why we started and went on to expand our network of First Aid Posts.” Today, there are 44 of them around the country.

EMERGENCY First Aid Posts (FAPs) in Lashkar-Gah zone

1 active First Aid Post

Data available from 2004.

Source: EMERGENCY

“The idea is that around traumatology hospitals you have an extended traumatology network covering the whole country, and that this network follows as closely as possible the map of the conflict, which is constantly shifting in Afghanistan,” says Gino Strada. Free, high-quality treatment should be available to all, be they civilians or fighters in the conflict, if access to treatment is to be truly realised as a human right. It was with this basic aim in mind that EMERGENCY set up its FAP network. Strada thinks it has had good effects “both in terms of its capacity to answer the needs of an ever-wider area, and in terms of the quality of its treatment for war patients, for whom stabilisation is crucial.”

© Vincenzo Metodo

Saeed, who we met in chapter two, says the same. He has been working in the hospital in Lashkar-Gah since it opened in 2004. “First aid treatment is essential. Whether a patient lives or dies often depends on how he or she is stabilised. That’s true especially in a country like ours, which has geographical barriers, bumpy roads and fighting in rural areas. And it’s true above all for people with war wounds. Sometimes they have to wait hours before reaching a hospital. If they weren’t stabilised, they would die.”

EMERGENCY has chosen not to publish photos of Afghan colleagues and patients to protect their privacy and safety.

“If you haven’t seen it with your own eyes, it’s hard to imagine what goes on in the furthest-off districts, where the conflict is most fierce and which we can only reach thanks to our network of First Aid Posts,” Basir tells us. “A lot of the wounds are very serious and they get treated straight away.” We met Basir in his office, in a white building opposite the main one which hosts the operating theatres, clinics and wards. Between the two is a well-tended garden with tall sunflowers and pomegranate trees. Behind Basir’s desk is a low metal table with a tidy array of blue folders, one for each FAP. “We run eight here in Helmand province. One of the most important is in Grishk, where we have got six male nurses, two female nurses, three guards and two drivers working in shifts. It’s on the road between Herat and Kandahar, so it gets a lot of patients. It’s a well-equipped clinic. It’s got five beds and a separate women’s part with two beds.”

EMERGENCY’s statistics show that 3,669 war patients were treated at the clinic in Grishk in 2020 and that 472 of them were transferred to our hospital in Lashkar-Gah. In the first four months of 2021, we treated 1,171 patients in the clinic and transferred 166 of them. “But the First Aid Posts in Sangin are always very busy too,” Basir goes on, “and in Musa Qala and Marjah.” In Sangin, EMERGENCY treated 4,238 people for war wounds in 2020.

Daily work at the Surgical Centre for War Victims in Lashkar-Gah

34 years old, with two sons aged eight and five and a daughter aged three, Basir has been working for the organisation since 2006. He has held a variety of posts but is now a field officer. Among his duties is managing the FAP network from Helmand. “It’s tiring work but it has to be done,” he says after the umpteenth phone call from Grishk. “I try to visit every First Aid Post twice a month. Last Thursday I was in Marjah. There was an attack the day after.” Most patients, he explains, “come here at night, when the fighting gets worse.” That is when the FAP network becomes even more important: “The network is essential because the districts where they’re fighting are far from Lashkar-Gah and difficult to reach. The people living there are poor and don’t have cars. If it wasn’t for our ambulances, patients would die on the street.” Many other medical facilities in the province often provide services to dubious standards, if they are operating at all, and at any rate at too high a price for local people. But in EMERGENCY’s FAP network, as Basir says, all patients, no matter how poor they may be, can get free, high-quality treatment.

When a patient arrives “the nurses on shift stabilise them, then they call me and we decide whether to transfer the patient to us here in Lashkar-Gah. Sometimes we have to consult our Medical Coordinator. The aim is to transfer the patient as quickly as possible, but sometimes we are forced to look after them for several hours or a whole night. It depends how safe things are on the roads.”

EMERGENCY has chosen not to publish photos of Afghan colleagues and patients to protect their privacy and safety.

The time it takes to treat and transfer is crucial. “If patients are going to have advanced surgery and treatment,” explains Matteo Rossi, a former Medical Coordinator in Lashkar-Gah, “it needs to be done within three or four hours of injury. That’s a sort of golden period. Getting treated quickly guarantees an initial stabilisation but it also affects the processes of hospitalisation, healing and recovery, and thereby strengthens the FAP network and helps it gradually widen.

Decent time frames “are kept to for more than a third of patients, whether they’re transferred to Kabul or Lashkar-Gah, our two war surgery centres that pick patients up from the FAP networks,” Rossi says, as we go over EMERGENCY’s statistics together. “If you take both hospitals together, more than 60 per cent of patients arrive within the window of time needed to ensure effective, quality treatment.”

EMERGENCY First Aid Posts (FAPs) in Kabul zone

1 active First Aid Post

Data available from 2004.

Source: EMERGENCY

Figures

EMERGENCY began systematically collecting data on its FAP network in 2004, when the ‘healthcare belt’ encircling the hospital in Kabul was made up of just eight FAPs. Those nearest the capital were closed in 2006, then reopened in more remote districts to serve people to whom less treatment was then available. In 2013, EMERGENCY had five FAPs in Helmand province, now it has eight.

The first in the province opened in 2005, in Grishk. Ten years later, the conflict had worsened considerably, there were six FAPs in the province, and figures from the data on the network were rising by a factor of ten.

In 2015, the FAP network treated 10,458 patients and transferred 1,478 of them to Lashkar-Gah, where they made up 50.9 per cent of its total of 2,903 patients. Of those transferred, 63.1 per cent (1,831) arrived within four hours of being injured. Of the 10,458 patients treated, 5,707 were admitted at the FAP in Sangin alone. In the bigger picture, “since 2015, when the number of FAPs in Helmand settled, EMERGENCY has provided about 10,000 medical services.”

In 2016 there were fewer transfers, 766 to be precise, about half as many as in the previous year. “The city was under siege and it was hard to get to our hospital,” says Rossi. Transfers from the FAP network accounted for just 22.4 per cent of all patients admitted that year.

Patients received in the First Aid Posts

Transferred to EMERGENCY hospitals
Treated in the clinic
2004
2004
2020

Data available from 2004.

Source: EMERGENCY

EMERGENCY was also forced to close its FAP in Sangin in 2016. “The district had become a backdrop to some particularly bloody fighting,” Rossi recalls. “Conditions were not safe enough to work in. We had to close it. The bazaar in Sangin was razed to the ground. Our clinic was used as a post by soldiers. The town was partly rebuilt later, around the so-called New Bazaar, and that’s where we opened our new facility [early in 2018]. But two months on we were hit by a shell.” Rossi touches on something we will address below: attacks on medical facilities, which go to show how humanitarian workers are losing what protection they had.

In 2020, EMERGENCY treated 15,974 people in the First Aid Posts in Helmand province and transferred 2,582 of them from FAPs there to other medical facilities, including 1,130 to the hospital in Lashkar-Gah, where they accounted for 29.7 per cent of the total of 3,805 patients admitted over the year. Of those transferred, 73.3 per cent got to hospital within four hours of being injured. The numbers from Sangin in 2020 are equally remarkable: 4,238 of the almost 16,000 patients treated at all the First Aid Posts that year were treated there.

Patients arriving at hospitals within four hours of trauma

73.7%
2003
68.8%
2004
66.1%
2005
71.1%
2006
66.6%
2007
68.5%
2008
62.9%
2009
60.1%
2010
57.9%
2011
58.4%
2012
56.7%
2013
53.8%
2014
50%
2015
52.6%
2016
53.8%
2017
54.2%
2018
58.4%
2019
61.5%
2020

Data available from 2003

Source: EMERGENCY

“It may not be easy to see a linear association,” says Rossi, “but it’s clear that in the course of the years, as our number of facilities has increased, so has the number of transfers.” Also, as the FAP network has expanded, “the time patients have to wait for operations, as well as the death rate during transfer, have been cut, two crucial factors.”

In the last four years, from 2017 to 2020, the death rate during transfer to the hospital in Lashkar-Gah has remained under one per cent; it was 0.35 per cent in 2017 (eight patient deaths), 0.44 per cent in 2018 (10), 0.5 per cent in 2019 (10) and 0.66 per cent in 2020 (17).

These data may belong to the past, but they can help shape choices in the future. “Monitoring, recording changes and gathering data and statistics are indispensable for understanding what more we need to do, what to strengthen,” adds Nasim, with some conviction. We met him at EMERGENCY’s hospital in Kabul, along with a few nurses, who have come from other provinces for two weeks of refresher training. They all work in the FAP network.

© Laura Salvinelli

Nasim, who is a field officer for EMERGENCY, confirms that there is a clear link between the expansion of the FAP network and the reduction of the death rate during transfer: “Just take the example of the FAP in Pul-e-Alam, in Logar province. Before it opened in 2013 a lot of patients were dying on the roads. That doesn’t happen anymore.” And the same is true not only at that clinic – which treated 692 patients in 2020 and transferred 144 – but every single one in the network. “Before we strengthened them,” Nasim goes on, “patients would die before they reached our First Aid Posts or during transfer. Now they’re alive when they get here 99 per cent of the time, provided they haven’t died straight away. Lives are being saved.”

The numbers bear all this out. As with transfers from the FAP network to Lashkar-Gah, the death rate during transfers to the hospital in Kabul is consistently below one per cent. It was 0.56 per cent in 2015 (12 patient deaths), 0.42 per cent in 2016 (11) and 0.56 per cent in 2017 (16). In 2018, with the network expanded to 12 clinics, the death rate during transfer was 0.78 per cent (34); in 2019, 0.73 per cent (23) and in 2020, 0.98 per cent (29).

Patients received in the First Aid Posts

0.56%
2015
0.42%
2016
0.56%
2017
0.78%
2018
0.73%
2019
0.98%
2020

Source: EMERGENCY

As we saw in chapters one and two, 2018 was a particularly tragic year for civilians. The 12 FAPs by then answering to our hospital in Kabul saw 6,667 patients, our highest total in any year so far. Of them, 4,363 were transferred, and 2,222 went to Kabul, which that year admitted 4,076 patients overall, meaning that 54.5 per cent of this last group came from FAPs. 54.2 per cent of patients arrived in Kabul within four hours of being injured. A full 886 patients, a record high, were transferred from the FAP in Ghazni, where we treated 649 people for war wounds.

In 2019, 6,757 people were treated for war wounds at the clinics answering to Kabul, of whom 3,163 were transferred, 1,704 of them to the hospital in Kabul. Of those transferred, a good 509 came from the FAP in Ghazni alone. Overall, patients transferred from the FAP network accounted for 44.5 per cent of the 3,831 patients admitted to Kabul in 2019, and 58.4 per cent of them got there within four hours of injury.

Numbers fell in 2020, thanks above all to Covid and the tightening of admissions criteria in response; only the most serious cases were allowed into the Surgical Centre in Kabul. Over the year, 6,089 patients were treated at the FAPs, 500 of them in Ghazni alone, and 2,971 were transferred, 1,040 of them to EMERGENCY’s hospital in Kabul, which admitted a total of 2,050 patients (230 of whom came from Ghazni). The FAP network contributed 50.7 per cent of these patients and 61.5 per cent of them arrived within four hours of injury.

Focus: First Aid Posts in Ghazni (Kabul) and Sangin (Lashkar-Gah)

Transferred to EMERGENCY hospitals
Treated in the clinic
2008
2008
2020

Data available from 2008.

Hard roads to travel

“But in some cases you need more time,” Nasim tells us. “Some FAPs, like the ones in Ghazni and Metherlam, in Laghman province, are used as local hubs. They take patients from the districts and other provinces. That makes transfer times longer.” He is thinking of how dangerous the roads are in Afghanistan; they are the scene of prolonged, vicious fighting.

EMERGENCY has chosen not to publish photos of Afghan colleagues and patients to protect their privacy and safety.

Nasser is a 27-year-old with a serious countenance who works at the FAP in Ghazni. “We’re in the centre of town,” he explains when we meet him in Kabul during a break in his refresher training. “We’re busy every day. Patients turn up with wounds from explosions, guns and shrapnel. They come from all 18 of the province’s districts, some of them even from the provinces of Paktika and Zabul.” The provincial hospital in Ghazni, Nasser tell us, “does not have the equipment for treating certain things, like stomach wounds. If it wasn’t for us, the patients would die. We treat them and stabilise them. Then we organise things with the supervisor.”

Whether to transfer “depends on the capacity of the hospital in Kabul, the nurse’s assessment of the seriousness of the case, and how safe things are on the roads,” Nasim adds. Due to the last concern, “getting to the area has become harder in the last few months.” Going through “areas controlled by the opposition used to be easier. There seem to have been some changes in the chain of command. The roles are less clear. Also, the conflict has got more violent. The risks are greater. Recently they shot an ambulance of ours in the district of Baraki Barak.”

© Mathieu Willcocks

“It takes under four hours to get from our FAP in Ghazni to Kabul,” Nasser goes on, “assuming there are no unexpected hurdles. It’s not rare to come up against them. There are shootings. Mines exploding. Sometimes, instead of four hours, it takes eight or even twelve. It depends on each case and on the time of the year. The fighting here is seasonal,” Nasser goes on. “Sometimes they attack the ambulances. It happened recently in the district of Andar [in Ghazni province].”

Wakil is a nurse at the FAP in Metherlam, capital of Laghman province. His workplace is the newest FAP in the Lashkar-Gah network, having been opened in 2019. Wakil says he is proud of his work: “We give free, quality treatment. People can’t afford treatment. They don’t have the money. They don’t even have the money for transport if they get ill. Our ambulances are available for anyone who needs them. We provide instant, primary treatment and we offer transport to our hospitals, where the treatment is of very high quality. The important thing is to be fast.” But that is not always possible. As Nasser adds, “Not everything is down to us. The roads are hard. There can be fighting or checks by soldiers or militants. In most cases everything goes smoothly. Sometimes not, though.”

EMERGENCY has chosen not to publish photos of Afghan colleagues and patients to protect their privacy and safety.

Tahir, one of the patients at EMERGENCY’s hospital in Kabul, had such an experience. “I was seriously wounded, bleeding a lot, but the special forces kept us for over an hour. They were convinced we were Taliban.” He is 35 years old and comes from Maidan Wardak province, south of Kabul. “A dangerous place,” he says. He arrived here 16 days ago in one of EMERGENCY’s ambulances. “A suicide bomber had blown himself up with everyone else in the shared taxi he was in, including my cousin. Perhaps it was a mistake, perhaps someone set the bomb off. I don’t know. All I know is that I’ve already gone through three operations and I have to face another one.”

EMERGENCY has chosen not to publish photos of Afghan colleagues and patients to protect their privacy and safety.

18-year-old Salim has light eyes and a deep voice. He comes from the district of Aryob Zazai, in the eastern province of Paktia. “I was left wounded after a fight with my cousins.” He unbuttons his pyjama top and shows us the narrow scar across his stomach. Then he points to all the other wounds on his body, one by one. “A bullet hit me in my left buttock and came out of my intestine.” A month has passed since then. “A public ambulance took me from Aryob Zazai to Gardez. An EMERGENCY ambulance brought me here from Gardez.” Nurse Wakil adds: “He was dying. We only just managed to save him in time.”

Nationwide network

The village that Salim calls home, lies near the Pakistani border, in one of the most cut off parts of the country, about five hours’ journey from the hospital in Kabul. The fact that Salim was transferred there is testament to how far-reaching and effective the FAP network is.

EMERGENCY has chosen not to publish photos of Afghan colleagues and patients to protect their privacy and safety.

“The FAPs are our antennae in the country’s rural heartland, near the frontlines,” says Emanuele Nannini, who spent five years as a Programme Coordinator in Afghanistan before becoming the Area Director for Emergency and Development within EMERGENCY’s Field Operations department. “Expanding the network,” he goes on, “which was made possible by more funding,” took place at an unusual point in time, “around 2014, when NATO’s military mission, ISAF, ended and the gradual withdrawal of foreign troops was announced by US president Barack Obama.” This signalled a move away from the military surge in 2009 and 2010. EMERGENCY did the opposite to NATO: “We expanded the FAP network, increased the capacity of our operating theatres in Kabul, increased the number of beds in Lashkar-Gah from 60 to 100, and renovated our Maternity Centre in Anabah – a sign of our presence and desire to continue here. Expanding the FAP network meant we could update our work, bringing it more in line with the evolving nature of the conflict, which was spreading over a greater area.”

Rossella Miccio, formerly head of the project in Afghanistan, later coordinator of the Humanitarian Office and since 2017 president of EMERGENCY, believes that the geographical expansion of the First Aid Post and Primary Healthcare Centre network is a reflection of something else, something fundamental. “It’s a sign of the trust that’s placed in us. The FAPs are opened in step with the progress of the conflict, of course, but at least half of those new openings are at the request of local communities. In the last few years I’ve seen so many letters with requests, signed or marked with lots of fingerprints in place of signatures.”

© Vincenzo Metodo
EMERGENCY has chosen not to publish photos of Afghan colleagues and patients to protect their privacy and safety.

Nasim, field officer in Kabul, outlines: “Basically, there are two criteria we use to decide whether or not to open a new FAP. On the one hand we analyse the statistics, to see how local needs are changing. On the other we listen to local people’s requests.” Down in Lashkar-Gah, Basir, coordinator of the FAP network in Helmand province, explains the procedure: “The village elders come to us as representatives of the community. They ask us to open a new clinic. We assess the request with our Medical Coordinator and then with the head office.” It is a long process; we have to establish what existing services there are in the area, how safe the facility is, how far it is from military structures, we have to analyse its distance and accessibility from the referral hospital. And that is not all. There are a lot of requests. “In the past few weeks we’ve had so many requests from the district of Maiwand, in Kandahar province. They’re really fighting hard there.”

EMERGENCY has chosen not to publish photos of Afghan colleagues and patients to protect their privacy and safety.

“We get a lot of requests from the district of Delaram [in Nimruz province],” adds Sayed when we go back to see him again. “And from the district of Maiwand [in Kandahar province].” He believes EMERGENCY’s work in the districts would be “impossible without the community’s support.” We have earned that support over the years by respecting an imperative principle: neutrality. “In Helmand province everyone knows us. They know all about the work we do. Since the FAPs have been there, they’ve known more about us in the districts too. We get so many patients coming from afar, getting treated here, then going back home. They talk about us. They’re poor, very poor. But it doesn’t matter here who’s poor and who’s rich. Everyone is treated the same way.”

Having the community’s trust, Miccio notes, leads to greater responsibility: “A great responsibility to the population and local institutions. At times their expectations are greater than what we can do in reality, which is why transparency is absolutely essential. We have to say clearly what we can and can’t do. Trust comes from transparency and equality of treatment, without distinctions.”

EMERGENCY has chosen not to publish photos of Afghan colleagues and patients to protect their privacy and safety.

For Gino Strada, surgeon and founder of EMERGENCY, “the responsibility can be taken on by working seriously and with integrity, sharing our projects with local authorities, and with absolute neutrality. It can be difficult, like the time we found a Taliban commander in our hospital in Kabul and had the mujahideen baying for him outside the gates. But we’ve always managed to keep ourselves neutral.” And we always will. “We’re not judges. We don’t take sides. We’re doctors. We deal with injured people, for whom we must respect the ethical imperative of treatment.”

Over time, that ethical imperative, as followed by every one of EMERGENCY’s workers, has given them a sort of safety net, as Fawad testifies. He has worked with EMERGENCY for 15 years and his childhood home is nine miles from Lashkar-Gah. “I’d like to bring my parents to live here in town, where I live with my own family. But my father’s against it. He wants to be by his fields in the countryside.” The village he comes from “belongs to the government by day and falls into Taliban hands by night.” But Fawad is not afraid, because he enjoys a special status. “Everyone knows I’m a doctor, a doctor with EMERGENCY. Even the Taliban respect our work.” He tells us a story by way of proof. “I was walking to Kabul for a check-up once. We came up against a Taliban road block. “Good morning, doctor,” I heard one of them say. It was an old patient of ours. He’d spent two months with us.” Fawad says that here at the hospital in Lashkar-Gah, “no one asks who the patient is. It doesn’t matter who’s who. What matters is patients, wounds to be treated. Respect for human beings, whoever they are, is central to healthcare.”

EMERGENCY has chosen not to publish photos of Afghan colleagues and patients to protect their privacy and safety.
Medical facilities under attack

Sometimes, however, neutrality of treatment and the trust earned in Afghanistan are not enough to protect EMERGENCY’s medical workers, or indeed those from other medical facilities in the country. According to UNAMA, in the first six months of 2021 there were 28 attacks on medical facilities and health workers which caused 12 deaths and more than a dozen wounded. There were 90 attacks on medical facilities in 2020, 75 in 2019, 62 in 2018, 75 in 2017 and 120 in 2016, which had the highest number of attacks of any year except 2012. “These are indiscriminate attacks against medical facilities and workers,” says Luca Radaelli. Today Radaelli is a medical staff planning manager, having worked in Afghanistan for seven years, first as a nurse in Lashkar-Gah, then as a Medical Coordinator in Kabul and, over the last two years, as Programme Coordinator for EMERGENCY’s hospitals and FAPs in the country. He has seen “a gradual worsening of safety, including for medical workers.”

Radaelli remembers, among other incidents, when international and government forces bombed the Médecins Sans Frontières hospital in Kunduz in October 2015, killing 45 people, and the attack on Sardar Daud Khan military hospital, also known as the ‘400-bed hospital’ in March 2017, which killed at least 30 civilians.

Attacks on healthcare facilities

1 attack

Data available from 2012.

Source: United Nations Assistance Mission in Afghanistan – UNAMA

EMERGENCY has also suffered attacks from various parties to the conflict, right from the start. On 17 May 2001, for instance, under the Taliban’s Islamic Emirate, the religious police from the Ministry for the Propagation of Virtue and the Prevention of Vice broke into the hospital in Kabul fully armed, railing against its staff canteen for not strictly segregating men and women. EMERGENCY’s local and foreign staff were forced to kneel and held at gunpoint for two hours. Some were hit or beaten up and three local workers were arrested for resisting. EMERGENCY decided afterward to suspend its work there, which only resumed when the United States’ intention to invade Afghanistan became clear, soon after 11 September 2001.

The Accident & Emergency entrance at the Surgical Centre for War Victims, Lashkar-Gah

In April 2010, wrote Gino Strada in an article at the time, the hospital in Lashkar-Gah was “violently shut down by men from the Afghan police and security services, alongside British soldiers, who took away nine of EMERGENCY’s workers.” After being accused of planning to assassinate the provincial governor, they were subjected to nine days of intense interrogation, declared ‘completely innocent’ and freed. The hospital is reopened when, as Gino Strada emphasises, “it can once again become a 'hospitable' place for all, a place without enemies, where those in need are treated - well and free of charge - where they are treated without discrimination, simply because those who need treatment must be treated.”

EMERGENCY has chosen not to publish photos of Afghan colleagues and patients to protect their privacy and safety.

In May 2016, EMERGENCY was forced to temporarily close its FAP in Sangin. In 2018 and 2019 there were a range of incidents at the FAP in Andar, in Ghazni province, including a raid on 14 May 2019 by about 100 members of the Afghan and international forces ‘in search of a Taliban commander’. A few months later, on the night of Saturday 30 November to Sunday 1 December 2019, a new raid took place in the Zokuri Khail area where the FAP in Andar is located. This time, there are about 40 Afghan and international military personnel, accompanied by dog units. On duty are two nurses, a cleaner and the ambulance driver. No patients are present. The operation lasts two hours. The military personnel insistently ask about the admission criteria for patients. The staff reply by reminding them that EMERGENCY operates in compliance with humanitarian law: anyone in need is treated, without discrimination, without being questioned. The four staff members were stripped naked. Their telephones and the patient register for the month of November were confiscated. A serious episode, condemned by the organisation. The most dramatic episode dates back to August 2014, when the driver of an EMERGENCY ambulance was accidentally killed while transporting a wounded man from Tagab to Kabul. In July 2019, Gul Ahmad, the supervisor of the First Aid Post in Andar, and Musa Khan, the cleaner, were killed by an airstrike while riding their motorbikes on the road to Ghazni. Their "mangled bodies were only recognised thanks to the EMERGENCY badge they were carrying," explains a press release from the organisation. “Hospitals and aid workers are also paying for the consequences of the conflict,” says Rossella Miccio. And so are the patients at the EMERGENCY hospital in Kabul.

EMERGENCY has chosen not to publish photos of Afghan colleagues and patients to protect their privacy and safety.

22-year-old Nadir lies with his arm bent under his pillow, his body covered by a white cloth. He came here 12 days ago, still in shock, from Baghlan province. He is a mine clearer for the HALO Trust, a charity that has been active in Afghanistan since the 1990s. He tells us: “It was about 10pm when a group of people burst into our lodgings. They took our money and our phones. Then they put us up against the wall. They asked my colleague next to me who was in charge and if any of us were Hazaras. He didn’t reply, so they shot him. They did the same with the others.” 10 people were murdered and 16 wounded in the attack on 8 June 2021. “They didn’t explain anything to us,” he continues. “They just shot us, in cold blood. I was hit by two bullets. One went in my back and came out of my stomach. Another hit me in the leg.” The bullet, explains nurse Haji, also hit him in the spine. “Now the patient is paraplegic. But there’s hope he might recover. We’ll do our best.” Nadir still cannot believe what has happened. “We saved so many lives by clearing mines. In return they shot us. I can’t understand why.”

Photography by Giuliano Battiston
© Vincenzo Metodo
Future
Opium won the war
Amalia De Simone, freelance journalist Marta Serafini, journalist, Corriere della Sera

“I’m 60 years old and I’ve been taking drugs since I was 30.” Abdullah bears the scars of time and living. He has lost his sight in one eye. What teeth he has left are completely rotten. He became a drug addict in Iran, after fleeing there from Afghanistan during the war. “I found a job tarmacking roads. But then I started taking drugs, first opium, then heroin. Then I lost everything.”

Now Abdullah lives under Pul-e-Sukhta, the bridge that shelters the wretched of Kabul, having returned to the city. He is alone and has heard no news of his wife and children. “I’ve been stabbed and beaten up many times. No one will help me,” he says, wiping his cheek with his filthy shirt.

© Victor J. Blue

15 afghanis, about 19 US cents, will buy you a ball of opium. One dose of heroin is dearer, at two or three US dollars. There are 2.5 million people taking opioids in Afghanistan, 800,000 of them women and 100,000 of them children. 40% of them are addicted. The ranks of this veritable army are swelled by refugees returning from Iran and Pakistan.

Opium came to Afghanistan in the 13th century, with Genghis Khan, and for a long time it was cultivated locally for medical use. Only in the 19th century did the opium trade venture beyond the country’s borders, when the emir Abdur Rahman Khan forced the Pashtun tribes to move to the Iranian border. His motives were two: to silence the protests of the Pashtuns, who were desperate for work and better places to live, and to foment ethnic divisions, according to the old principle of divide and rule.

© EMERGENCY NGO Archive

Two centuries later, opium is still centre stage. “As happened in Laos, Vietnam and Colombia, the drug trade helped finance the conflict after the Soviet invasion,” writes Fariba Nawa in her book Opium Nation. Then, in 1979, the Reagan administration gave the go-ahead for Operation Cyclone and started providing weapons to the mujahideen, then at war with the Soviet Union. Washington’s only goal was to defeat Moscow. Among the bearded men hiding in the mountains, however, was one Osama Bin Laden, the man who would one day become America’s Public Enemy Number One but whose name rang no bells as yet. The CIA stood and watched as the rebels trafficked opium to buy their weapons, and allegedly even helped them set up heroin laboratories. In an interview years later, Charles Cogan, director of the CIA’s Afghan operations, said: “Our main mission was to do as much damage to the Soviets. We didn’t really have the time to devote to an investigation of the drug trade. I don’t think that we need to apologize for this. The Soviets left Afghanistan.”

© Vincenzo Metodo

From 2001 on, the story is easily summarised. When the United States began operation Enduring Freedom in the wake of 11 September, opium production was at a historic low; the Taliban had banned its cultivation. After their defeat, however, the power vacuum and the need to fund fresh guerrilla warfare saw the country wrapped in a pink cloak of poppies. Every attempt, civilian and military, to destroy and reseed the fields was in vain. “We have failed,” declared John Sopko, the American government’s Special Inspector General for Afghanistan; despite 13 years and over seven billion dollars spent waging war on the poppies, the fields had spread over more than 750,000 acres (which is more than 400,000 football fields).

“In Afghanistan today, opium is grown on over 200,000 hectares [500,000 acres]. In the lead are the southern provinces of Helmand, Kandahar, Oruzgan and Farah. But since 2015 the western regions, too, now they are out of the Taliban’s control, have become producers,” explains Jelena Bjelica, from the Afghan Analysts Network. Given that opium is the most lucrative crop for any farmer (the total business is estimated to be worth about three billion dollars a year), it is hardly surprising that the poppies keep flowering, and that 90% of heroin in the world is made with opium from Afghanistan.

In the midst of the turmoil as United States and international troops get ready to withdraw from Afghanistan, one certainty remains: the pink fields of poppies will go on growing, and with them the army of drug addicts in Afghanistan and the rest of the world.

EMERGENCY has chosen not to publish photos of Afghan colleagues and patients to protect their privacy and safety.

All opinions expressed within the articles written by external contributors exclusively reflect their personal point of view, based on their own experience.

The final chapter
Ezzatullah Mehrdad, journalist based in Kabul

For six years now, Fazel sells bolani, an Afghan dish, in front of EMERGENCY’s hospital in the Shahr-e-Now neighborhood of Kabul, the Afghan capital. His customers are all companions of patients at the hospital - his bolani is fine, but the customers are in a grim mood as they wait to hear about the fate of their family members inside the gates.

“My heart aches,” says Fazel, who is in his 20s but looks like a 50-year old man with a wrinkled face. “I have seen everything of death. I have seen people with heads chopped off or cut off from the middle.” He has seen a constant average of 20 patients arriving at the hospital every day.

With the United States and its allies’ troops set to leave Afghanistan, it is now a deathlike country. It is being thrown into further layers of conflict as the months pass. As the war rages on, peace negotiations between the Afghan government and the Taliban move in slow-motion, laying the groundwork for fresh outbreaks of violence.

© Mathieu Willcocks

The patients at the hospital and Fazel’s customers are not all victims of Taliban violence and crossfire between the Afghan forces and the Taliban fighters, but also smaller groups that flourish in the shadow of the long war. It is Eid al-Adha, an important Islamic festival, and 23-year-old Mohammad Mohammadi is sitting outside the hospital’s gates, waiting to hear about this father’s condition.

“It’s been Eid, but very painful,” said Mohammad, whose father was stabbed all over his body and was thrown into a creek on the family’s field. “Death is much better than this life. This situation cannot get worse.”

But it is getting worse. In the northern corner of Afghanistan, Mirza Mohammad, 33-year-old father of five children, was leading a peaceful life until the war reached his home in Takhar province. After the Taliban took over Mirza’s district in the province, Afghan governmental forces conducted airstrikes against the Taliban’s positions.

The Taliban sought refuge in his house, pushing Mirza and his family out. As the family was fleeing, crossfire between the Afghan forces and the Taliban caught Marwa, his 12-year-old daughter. Marwa’s foot was hit and her father brought her all the way from Takhar province to EMERGENCY’s hospital in Kabul.

“Life is becoming harder and more brutal every day,” said Mirza, waiting outside the hospital. “I don’t think there will be any peace.”

© Francesco Cocco

In February 2020, the United States signed an agreement with the Taliban - raising both concerns of more war and hopes for a deal between the Afghan government and the Taliban to end the conflict. During the months after the US-Taliban deal, war overcame chances for peace and pushed Afghanistan down a path where violence remained a vital tool for survival.

Even with the US troop withdrawal, diplomatic efforts on a global level, and multiple grand discussions between the Afghan government and the Taliban in foreign countries, the war dragged on. In a swift campaign, the Taliban took over scores of districts across Afghanistan, pushing Afghan government forces to focus on protection of urban areas across the country.

As the Taliban continues waging war for more districts and surrounds half a dozen provincial capitals, the chances for peace slip further and further away. For the Taliban, victory over the Afghan government seems in sight, but at the cost of plunging the country into a long and brutal civil war. Taliban victories are leading to local anti-Taliban groups across the country to arm themselves.

© Mathieu Willcocks

When the Taliban took over districts, anti-Taliban militias lined up behind Afghan government forces and waged resistance across the country. In a scenario where the Afghan government collapses and the Taliban takes over the country by force, it is predicted that local militias will continue waging war against the Taliban.

Much of the local resistance against the Taliban stems both from ethnic conflict and atrocities committed by the Taliban. Ethnic communities such as Uzbeks and Hazaras are more likely to engage in a long fight against the Taliban, given that these groups have been deliberately targeted. However, to shift Afghanistan from the path of violence to the path of peace, victory is no longer an option.

© Mathieu Willcocks

However, a military stalemate could put Afghanistan on a path of less violence and more peace. Dr. Jonathan Schroden, a senior analyst at the USA-based CAN Corporation says that a military stalemate between the Afghan government and the Taliban can teach the parties that a political solution to the war is the only way that both they and Afghanistan can survive.

“There is a possibility of a complete Taliban takeover or a possibility of any number of other scenarios - breakdowns, warlordism, all kinds of other scenarios are out there,” General Mark Milley, the chairman of the US Joint Chiefs of Staff, said in a press conference. “I don’t think the end game is yet written.”

“My heart is really broken into pieces,” said Ibrahim, a grocery and cigarette seller in front of the cafes. “I just wish for fewer customers at the EMERGENCY Hospital but more customers for the cafes.”

All opinions expressed within the articles written by external contributors exclusively reflect their personal point of view, based on their own experience.

Our story
Giuliano Battiston, journalist
Salima, pupil at Sayed al-Shuhada school

“I’m weak and I still can’t rest my heel well, but I feel much better and I’m alive.” Salima is 17 years old. She goes to school, loves maths and would like to become an engineer. We meet her at her parents’ home in Dasht-e-Barchi, a suburban district of south-west Kabul, home mostly to Hazara people. This Shiite ethnic minority have suffered discrimination since the Islamic Emirate of Afghanistan came to power and are now being targeted by the local branch of the Islamic State.

The district is poor, Salima’s home simple. Her whole extended family live in four low buildings spread around a small garden with a handful of fruit trees. “We come from Bamiyan province,” her uncle Quadratullah tells us, worry showing in the 30-year-old’s features, “but we left 20 years ago when the Taliban Emirate was in power. We felt safer here. We don’t now.”

EMERGENCY has chosen not to publish photos of Afghan colleagues and patients to protect their privacy and safety.

Salima lies on a little mattress in the corner of the living room. She is being taken care of by two of her little brothers, teenage Mahmoud and nine-year-old Bashir, who massage her feet and arrange the veil on her forehead. Salima is recovering. She is one of the survivors of the three-part attack on schoolgirls leaving Sayed al-Shuhada school – about a mile away from the room we are meeting in now – on 8 May 2021.

Aqila Tavaqoli, a former teacher at the school and its headteacher since 2012, meets us in her office. “It was four thirty in the afternoon,” she tells us. “About 4,500 boys and girls and 150 teachers, a lot of them volunteers, were leaving. The first car packed with explosives shot up into the air 100 yards from the school gates. Then there were another two explosions even closer.” These were improvised explosive devices, or IEDs, lethal weapons that took three times as many lives in the first half of 2021 than in the same period in 2020, according to UNAMA’s latest report. As we saw in chapter two, IEDs also claimed 79 per cent of all civilian victims of explosive weapons in the decade between 2011 and 2020 in Afghanistan, to go by the data from Action on Armed Violence.

EMERGENCY has chosen not to publish photos of Afghan colleagues and patients to protect their privacy and safety.

Aqila Tavaqoli remembers trying to call the police and an ambulance after the first explosion, with no luck. She remembers the screaming, the people rushing about, the chaos. “I fainted. When I came to again, the school was empty.” The ambulances were late in coming. Mothers, fathers, brothers, sisters, neighbours and teachers all lent a hand. They carried the wounded, picked the dead bodies up from the ground, and tried to identify their own daughters, nieces and other girls from rucksacks, books, pencil cases and blood-stained single shoes.

“Someone took Salima to Mohammed Ali Jinnah [a hospital on Shaheed Mazari Road],” her father Mubarak tells us. “It took us three hours to find her. She was unrecognisable. It was her who recognised us.” He believes Allah saved her life. “A doctor told us, ‘There’s nothing more we can do. Her body’s there. You can take it with you.’ She was lying there with schoolmates of hers, all of them dead. But she recognised us, she asked for oxygen and she came back to life. Then we took her to EMERGENCY.”

One of the Sayed al-Shuhada school buildings.

“She was in recovery for 20 days,” adds uncle Quadratullah. “Her face was burnt, she had so many wounds on her arms, her back and her legs, her stomach was destroyed, her heel was terrible. She was in the worst possible condition.” At the Surgical Centre “she had an operation on her stomach. They took out so much shrapnel from her back and her legs. They did so much for her, really, without asking us for any money.” Salima’s father says he could never have afforded to pay for her treatment. He carts material around in a wheelbarrow for a living, putting himself at people’s service in the city’s markets. What he earns is just enough to feed his family. He says EMERGENCY “doesn’t work like other hospitals, where you can’t get treated unless you have money or you know someone.”

Salima was treated and eventually discharged. “I feel much better,” she tells us, “although I still can’t walk very well. Every day I have to do an injection to ease the pain in my heel. The other wounds are all right”. She was treated alongside other girls from Sayed al-Shuhada school. “There were three of my classmates in the hospital and a lot of other girls from my school.” EMERGENCY’s mass casualty records show that the one on 8 May brought 20 girls, seven women and two men to our hospital.

EMERGENCY has chosen not to publish photos of Afghan colleagues and patients to protect their privacy and safety.

Luca Radaelli was also at the hospital in Kabul that day. He spent seven years in Afghanistan, from 2010 to 2017, as a project coordinator in the hospitals and FAPs. On 8 May he was visiting Kabul in his current capacity as a medical staff planning manager. “Sadly, over the years I’ve spent in Afghanistan, I’ve had to deal with a lot of mass casualties. I’ve seen an increase in suicide attacks, attacks on medical facilities and workers, but it still wasn’t easy to face that day. Dozens of girls arrived here, all of them from the Hazara community, all of them schoolgirls, all of them in a serious condition. We asked ourselves what they’d done to deserve this. Wanting to learn, perhaps?”

According to UNAMA, in the first six months of 2021 there have been 16 attacks on schools and school staff. There were 62 attacks in 2020 on schools, universities and other places of education in Afghanistan, down from 70 in 2019. In 2018, however, there were 191; as we saw in chapter one, the same year holds the record for deaths according to UNAMA (3,803) and for patients admitted for war wounds by EMERGENCY (7,106). According to UNAMA’s data for the first half of 2021, there were 16 attacks on school buildings. The most serious figures pertain to the attack on the Sayed al-Shuhada school in Kabul, in which 300 people were left wounded or dead, most of them schoolgirls under 18 years of age.

Attacks on education facilities

1 attacks

Data available from 2007.

Source: United Nations Assistance Mission in Afghanistan – UNAMA

Many of those girls are still burdened with the psychological effects of the attack. Salima does not attempt to hide her anxiety but she is intent on going back to school: “I hope to go back as soon as possible. I hope I can go back to my lessons. I love maths so much. But we need safety, we need to be protected.” When we visit the school on a sunny day in June, lessons still have not started again. But there are lots of girls hanging about outside the building, which has just been painted with messages of encouragement. Among them is 12-year-old Zarifa, who was also wounded in the attack. She takes a crumpled piece of paper out of her pocket. In a confident voice, she reads out her ‘Sad Poem on the Attack’ to the little audience around her: “The first explosion killed the daughters. The second, the mothers. The last explosion killed the fathers. The enemy of our country is a devil who feeds on the blood of his own people… We are crushed flowers lying in the road outside our school; caged birds, murdered in ignorance… This poem does not offer a cure; the only cure is learning.”

EMERGENCY has chosen not to publish photos of Afghan colleagues and patients to protect their privacy and safety.

That cure is still thin on the ground in Afghanistan, especially among women, but it has been spreading. According to UNESCO, while in 2011 the literacy rate among women was 17 per cent and among men 45 per cent, by 2018 it had gone up to 30 per cent among women and 55 per cent among men. The overall literacy rate was 18.2 per cent in 1979, 31.4 per cent in 2011 and 43 per cent in 2018. The secondary school enrolment rate rose from 1.2 per cent in 2003, to 3.7 per cent in 2010, to 8.2 per cent in 2014, to 9.7 per cent in 2018.

EMERGENCY has chosen not to publish photos of Afghan colleagues and patients to protect their privacy and safety.

Between 2011 and 2017, government spending on education was consistently under 4.5 per cent of GDP; it oscillated between 2.6 per cent in 2012 (when it was 10.4 per cent of all public spending) and 4.23 per cent in 2016 (16.2 per cent of all public spending). As Afghanistan’s literacy rate improves, so will awareness grow of how important learning and training are.

School enrollment rate in Afghanistan

1.2%
2003
3.7%
2010
3.6%
2011
8.2%
2014
9.7%
2018
Source: United Nations Educational, Scientific and Cultural Organization – UNESCO
Training at EMERGENCY’s facilities

“One of this country’s biggest problems,” says Safar decidedly, “is a lack of education.” We meet the 30-year-old at EMERGENCY’s hospital in Kabul, on a break from refresher training for him and his colleagues from the FAP network. Safar has been working with EMERGENCY since 2014, at the FAP in Tagab, in Kapisa province. “We’re here for training,” he tells us. “They take us in detail through the medical techniques to use in an emergency, we talk about the type of treatment to give, for example when there’s a patient with injuries from gunshots or mines.” His job “is made up of practice and study,” he says, in effective summary.

EMERGENCY has chosen not to publish photos of Afghan colleagues and patients to protect their privacy and safety.

We meet other people at the Surgical Centre in Kabul, like Rahmat and Omar. Rahmat is 30 years old and works at the Surgical Centre for War Victims in Lashkar-Gah, in the southern province of Helmand. Omar was born in Charikar and works at the hospital in Anabah, in Panjshir province. Both of them have come to Kabul to sit an exam.

Rahmat’s lively countenance sits atop a well-kept, dark beard. He tells us he is “in my last year of specialisation in surgery. I’ve completed the first four years. I practice in EMERGENCY’s hospitals, thanks to an agreement with the Ministry of Health, and the exams are held by a commission from the ministry.” General surgery, orthopaedics, traumatology; there are so many disciplines to study and work on, Rahmat explains. “Trauma surgery and orthopaedics are practised at the hospitals in Kabul and Lashkar-Gah, which are for war victims, and in Panjshir they do elective surgery too. We go there on rotation, once a month.”

EMERGENCY has chosen not to publish photos of Afghan colleagues and patients to protect their privacy and safety.

31-year-old Omar has just passed an exam in paediatrics. “I remember when I was still a little boy, finding myself at the hospital in Charikar, the town I was born in. There were so many women with children. That’s when I decided I would become a paediatrician.” Omar has worked at EMERGENCY’s hospital in Anabah for two years. “After graduating, I spent a bit of time at a private clinic in Kabul, but I left feeling disenchanted. I wasn’t growing professionally. In Panjshir, with EMERGENCY, I’ve learnt a lot in the last two years.” For both men, the exams are an important, indeed necessary step, but what is equally important is daily practice. “The hospital in Lashkar-Gah is for war victims,” Rahmat says. “There’s never a moment of peace. Often, we don’t have time to eat or pray. It’s as if we’re doing practical exams every day, working under the supervision of senior surgeons or colleagues from abroad.”

EMERGENCY has chosen not to publish photos of Afghan colleagues and patients to protect their privacy and safety.

These two young doctors are able to take their exams in Kabul today thanks to a broader legacy, which Gino Strada, surgeon and founder of EMERGENCY, summarises as follows: “From the very start of each of our projects, we’ve made training fundamental. We’ve always found ourselves working with local staff who have had no opportunity for proper training, either because of a lack of local structures for training or because they haven’t had the chance to talk to anyone about their work.” Strada says that training is important “not only to provide an immediate response to people’s needs, but because it gives medical workers the autonomy they need if we’re to hand our projects on in the future.” EMERGENCY’s model of operating “is to give immediate responses and form new skills at the same time.”

The outer gate of the Anabah hospital

“In the first ten to fifteen years, EMERGENCY emphasised on-the-job training. Then we decided to give training for medical workers a formal structure.” EMERGENCY’s first agreement with the Afghan Ministry of Health was back in 2004. “On the basis of that agreement,” Strada continues, “anyone who has worked as a nurse at one of our centres for at least two years is eligible for the state exam. That’s how the first nurses here were trained.” After this, nursing schools began to pop up around the country.

Pietro Parrino says that “medical training is woven into every country’s history. The number of surgeons and doctors who can work independently in Afghanistan is low. A lot of doctors here were trained in the bloodiest phase of the conflict. That’s why it’s important to train new recruits, to see every hospital as a place of continuous training. That way, we can help train a new generation of doctors, who will help reinforce the country’s entire health system in the medium to long term, improving the possibilities for treatment open to its people.” Even more important “was our official agreement with the health authorities, who recognised our hospitals as schools of on-site specialisation for their practical work.”

The ‘Health Book’, a record that helps communication between medical staff and the patient

Emanuele Nannini was a Programme Coordinator in Afghanistan for five years. “I came to Afghanistan at a very odd time,” he says, “after our colleagues and coordinator were arrested in Lashkar-Gah in 2010. Our relationship with the authorities was strained. With our national Programme Coordinator, Nazar, I got to work establishing what had gone wrong and improving relations. Recognition of our training work by the authorities has been crucial.”

EMERGENCY has chosen not to publish photos of Afghan colleagues and patients to protect their privacy and safety.

Here he refers to EMERGENCY’s agreements with the Ministry of Health. First, “there was an agreement on surgery, then one on gynaecology and finally on paediatrics. Now we’re working to set up a school of anaesthesiology and resuscitation, and to get it recognised.”

EMERGENCY’s hospitals have been recognised by the Ministry of Health as training centres for surgery, gynaecology and paediatrics. Between 2012 and 2020 the number of students specialising in surgery rose substantially; in 2012 it was four, in 2013 it was eight, by 2018 it had risen to 20, in 2019 it was 22 and in 2020 it was 29. The organisation had two students specialising in gynaecology in 2012, four in 2016, 10 in 2019 and 10 in 2020. In 2015, the Anabah facility hosted four students. It had five in 2016, doubling to 10 the next year, 13 in 2018, 11 in 2019 and 12 in 2020.

Trainees at EMERGENCY hospitals

1 surgeon
1 gynaecologist
1 paediatrician

Data available from 2012.

Source: EMERGENCY

All in all, EMERGENCY had six students specialising in surgery, paediatrics and gynaecology in 2012, 10 in 2013, 14 in 2014, 18 in 2015, 24 in 2016, 30 in 2017, 40 in 2018, 43 in 2019 and 51 in 2020.

© Laura Salvinelli

EMERGENCY also provides training for the Ministry of Health’s own medical workers. Between 2014 and 2019, 1,680 people have been involved in training, including both medical and non-medical staff. This comprises of short courses for medical staff working in the ministry’s district or provincial facilities. Also important is our on-the-job training, which we gave to 1,023 medical and non-medical workers between 2011 and 2018; 506 of these were trained in 2011 and 121 of them in 2018.

“Training is an integral part of our work, every single day,” explains Dejan Panic, formerly a Programme Coordinator for EMERGENCY in Afghanistan and now working in the same capacity in Sierra Leone. Panic says you learn “so much in the field, in your daily practice, both medical and non-medical.” This is thanks in part to the organisation making a fundamental choice: “At EMERGENCY we’ve always been keen to share experience and skills. Our doors are open to anyone who wants to learn.” Training “is not only for younger colleagues and new arrivals, it’s for all members of staff, local and foreign.”

EMERGENCY has chosen not to publish photos of Afghan colleagues and patients to protect their privacy and safety.

Besides everyday training, Dejan Panic remembers taking courses in pre-hospital trauma management, run since 2014: “They helped improve the services in the FAP network,” which we discussed in chapter three. “The young supervisors from the furthest-away provinces came back afterwards and told me those courses really worked. Thanks to them, they had saved human lives.” In Afghanistan, Panic goes on, it is not a matter of “handing out medicine. We do war surgery. A missionary approach isn’t enough. You have to try and do your best, including when it comes to teaching.” For him, “teaching is a full-time job, but so is learning.”

EMERGENCY has chosen not to publish photos of Afghan colleagues and patients to protect their privacy and safety.

“We have colleagues who’ve been working with us for 15, 16 years,” Rossella Miccio says. “They’re well aware what their responsibilities to the community are. They were trained at our hospitals and now they train their more junior colleagues.”

Generations of doctors

Among these old hands is Saeed, a surgeon we met in the preceding chapters. He has been working at our hospital in Lashkar-Gah ever since it opened. We sit down to talk with him in the large doctors’ room at the Surgical Centre here in the capital of Helmand province, as he swaps professional tips with a couple of colleagues. “It was in September 2004 that we started,” Saeed recalls, looking back over the years. “It was just us three Afghan doctors then. Now there are 15 of us. Things have changed a great deal.

The foreign surgeons would tell us they weren’t here to build, they were here to build capacity, and that’s just what they did.” He thinks back with fondness on all his foreign colleagues, but lets his thoughts linger on ‘Dr Anton’.

Plaque for Dr. Anton Lugo

Dr Anton is Jorge Anton Lugo, a surgeon born in Mexico City in 1968, who died in June 2020. He became a point of reference for EMERGENCY’s doctors and nurses in Afghanistan. Today, a white marble plaque graces the garden of our hospital in Lashkar-Gah, in memory of his ‘having dedicated his life to helping and treating the Afghan people.’

EMERGENCY has chosen not to publish photos of Afghan colleagues and patients to protect their privacy and safety.

So many people remember him in Lashkar-Gah, surgeon Nooruddin for one: “Dr Anton taught us everything, starting with the ABCs of surgery. He was always on the frontline, ready to advise and support us. He was an extraordinary doctor and teacher. Sadly, he’s no longer with us.” Nooruddin has been with EMERGENCY since 2013. “I studied in Kabul and once I passed my exam at the Ministry of Health, I started and completed my specialisation in surgery here at EMERGENCY’s hospital. Now I’m trying to pass on what I’ve learnt to my younger colleagues.”

Dimitra Giannakopoulou works as a medical coordinator in Kabul and Lashkar-Gah. She remembers: “Dr Anton used to say he was here in Afghanistan to teach a specialism that no longer existed in Europe – general surgery.” For the Raissa, as she is known in Lashkar-Gah, “there’s no going back now. The work on training has done the job. That goes for technical and medical skills but also the fundamentals of the system – absolute impartiality when treating patients, whoever they may be. That principle is clear to every member of staff now.”

EMERGENCY has chosen not to publish photos of Afghan colleagues and patients to protect their privacy and safety.

It is perfectly clear to Hayat. A native of the district of Nadali, with dark eyes and a serious stare, the 31-year-old now lives in Lashkar-Gah and has worked with EMERGENCY since August 2008. “I was about to finish secondary school and I was looking for a job. I was taken on as a medical assistant. I’ve grown so much thanks to EMERGENCY. I’ve had the chance to go to a state nursing school, after which I took the exam at the ministry.” Hayat has been going to university for four years. “I’ve just got one last exam before I become a doctor.” He hopes he can go on to specialise in traumatology: “It’s a long road but I’d like to become a surgeon.”

EMERGENCY has chosen not to publish photos of Afghan colleagues and patients to protect their privacy and safety.

Hayat’s family is poor. “Here in Afghanistan it’s not to be taken for granted that you’ll be able to study, like elsewhere. But with the wages EMERGENCY pays me, I can support my siblings too.” Some of them sound rather less fortunate than him. “My brother had to emigrate. There’s no work here. Now he’s in Shiraz, in Iran.” Hayat has a message for the international community: “Believe in us, give us opportunities, let us study. Everything’s hard here. I’ve got a lot of friends who have fled abroad even though they have master’s degrees.”

From training to handover

“Over the years, doctors’ and nurses’ skills have multiplied,” says Roberto Bottura, with EMERGENCY since 1999. “There has been a sort of domino effect. The number of surgeons trained as time has gone on demonstrates that. Our end goal has always been to give our Afghan colleagues more autonomy.”

“One of our organisation’s primary objectives,” president Rossella Miccio confirms, “is to provide decent training to local staff, so they can run facilities with the aid of just a few foreign workers and take control of everything in the long term.” Marco Puntin adds: “Our Afghan colleagues know that we’re here for two reasons – to treat war victims and train medical workers.” Covid and the consequent shrinking in transport between countries “accelerated a process that was already part of EMERGENCY’s strategic plan – to gradually hand over responsibility to local colleagues.”

EMERGENCY has chosen not to publish photos of Afghan colleagues and patients to protect their privacy and safety.

Handing over is EMERGENCY’s ultimate aim in Afghanistan. It will be some time before this can be fully achieved, but the plan is in motion. “Kabul is our pilot project,” Puntin goes on, “where we’ve already identified the key figures to one day hand responsibility to.” He explains that foreign staff there are gradually being replaced by locals. Panic adds that “you always have to ask yourself what you’re leaving behind. It’s crucial that the project can be carried on by people living in Afghanistan, that more and more responsibilities are given to our local colleagues, until they have full ownership of it.”

This transition is also a medical and surgical one, as Enrico Paganelli, the doctor from Livorno who we met in chapter two, will tell you. “Things have changed by choice, by natural evolution and to some extent also out of necessity, due to the death of Dr Anton, who was a point of reference for everyone, as well as a link between Afghanistan and the head office in Milan.” Although, as Paganelli explains, even when Dr Anton was still around, “we decided to involve a higher number of senior Afghan surgeons, so as to make them as independent as possible when it came to assessment and clinical practice. Our role today is increasingly behind the scenes.”

Health personnel trained by EMERGENCY (government hospitals)

1 person

Michela Paschetto, who has spent seven years in Afghanistan and is now part of EMERGENCY’s Medical Division Coordination, thinks that the training courses have set in spin a real virtuous circle, benefiting not only the organisation but society as a whole. “We invested a lot of energy in training, because we believe it’s important to strengthen local skills, not only for our staff but for the entire country.” Paschetto tells us that “some of the people taking our courses end up working elsewhere, which helps improve the health system.” Sadly, that system still is not capable of satisfying the population’s needs, but things have improved over time. “In 2009, it was hard to find trained staff,” says Paschetto. “Now things are different. And when you go to our hospital in Panjshir, it’s impressive to see how many female staff it has.”

A silent revolution in the Panjshir Valley
EMERGENCY has chosen not to publish photos of Afghan colleagues and patients to protect their privacy and safety.

EMERGENCY’s first hospital in Afghanistan was in Anabah. Opened in 1999 to treat war victims, since 2002 it has been given over predominantly to general surgery and traumatology. In 2003, EMERGENCY added a Maternity Centre, and it is here, in intensive care, that we meet Hawa who has worked for EMERGENCY for 14 years. “Nine years in the surgery department, the last five years here at the Maternity Centre.” She tells us how she went to a nursing school, studied obstetrics in Kapisa, in Parwan province, took lots of courses, but learnt most of all on the job here in Anabah. “I live in Kapisa,” Hawa says. “I come here every day on the EMERGENCY minibus. It takes about an hour.”

The Maternity Centre in Anabah

Her colleague, 24-year-old Oshila, comes from Parwan province. She began working here “a little over a year ago.” She does not deny the social constraints on women here, but maintains “that today we can do a lot more things than we used to.” Hawa says EMERGENCY’s hospital in Panjshir has brought “a great change. Women weren’t allowed to go out of their houses before. Now they come here to give birth. The message has spread that it’s here for the benefit of mothers’ and babies’ health.”

EMERGENCY has chosen not to publish photos of Afghan colleagues and patients to protect their privacy and safety.

25-year-old Sheila gave birth just hours ago. Her son Murad was “born at two o’clock last night.” She comes from Kapisa province. “There’s another hospital near our house but I preferred to give birth here, one hour’s journey away on the road, because the service is better.” She has two daughters waiting for her back home. “I gave birth to them elsewhere. But for my next child, I’ll be coming back here,” she says firmly. Nasira is 24 years old and has had her first child, Mukhtar. She comes from Panjshir province, but “my village is three hours from here by car.” She says the doctors and nurses here have been very accommodating.

In their lunch break, we find a lot of those medical workers in the canteen, a big, colourful metal gazebo with vines growing over it and tables and picnic benches underneath it. The young nurses talk amongst themselves. Like Hawa and Oshila, a lot of them have come here from other provinces. For women here in Afghanistan, having a job is not to be taken for granted, let alone one far from home. But in Anabah, Nazar explains, “the staff include 210 women. They’re all well-trained and know how to do their jobs with professionalism.” She is the administrator of the hospital in Panjshir as well as our national Programme Coordinator. “It’s the result of great social, not just medical, change. Women come here both to work and to give birth, from Panjshir province as well as the neighbouring provinces of Parwan and Kapisa.”

The Maternity Centre in Anabah

In 2002, when EMERGENCY began working on the idea, Nazar says that “no one would have imagined women going to hospital to give birth. They were saying I’d have to go from mosque to mosque, explaining why a maternity hospital would be useful, but there was no need.” Already in 2007, Nazar recalls with pride, “we didn’t know where to put the patients, so we had to expand the facility.”

EMERGENCY has chosen not to publish photos of Afghan colleagues and patients to protect their privacy and safety.

“They were telling us it wasn’t a good idea, that it went against tradition, that women would never come, that they’d never be allowed to,” adds Najib, who has also been with EMERGENCY from the very start, in 1999. The result “was surprising. It was a radical change. Women came of their own accord, for check-ups. They trusted our work.”

Gino Strada, founder of EMERGENCY, says it makes him “proud to see what’s happening now in Panjshir. The changes have been enormous. Husbands bring their wives to us, to the gynaecology department. We have so many women working with passion and getting excellent results.” At the bottom of all this is the forward thinking of General Ahmad Shah Massoud. “Massoud, who I formed a bond with on the back of just a few words and a great deal of mutual respect, once told me, ‘If you want to help emancipate women, put aside the burqa issue and start thinking of creating education and jobs.’”

Literacy rate in Afghanistan in 2011

17%
Women
45%
Men

Literacy rate in Afghanistan in 2018

30%
Women
55%
Men
Source: United Nations Educational, Scientific and Cultural Organization – UNESCO

Pietro Parrino says the “forward-looking decision to open the Maternity Centre is the result above all of an encounter between General Massoud and Gino Strada, founder of EMERGENCY; the general asked him to build a women’s hospital.” The decision was also based on real needs: “The death rate for women and babies was high,” Parrino explains. In 2002, the year before the Maternity Centre opened, UNICEF declared Afghanistan the worst country in the world to be a pregnant woman, in light of its maternal death rate of 1,600 per 100,000 live births.

The facility is now dedicated to the memory of Valeria Solesin, ‘a friend of EMERGENCY who lost her life in the attack on the Bataclan in Paris [on 13 November 2015]’. When we began operations, the hospital in Anabah oversaw about 20 births a month. Now, “we do between 500 and 700 a month, depending on the year,” explains Hasina; at 40 years of age, she has a photographic memory of the hospital. “It was all very different years ago. It was almost impossible to find women working for charities, with foreigners, indeed outside their homes. Now, so many women come here every day asking if we have any free places.”

The Maternity Centre in Anabah is dedicated to Valeria Solesin

This is the ‘silent revolution’ that EMERGENCY wrote about in a recent report. Hasina has been a witness to and a leader of this revolution. Tough, energetic and always smiling, she tells us: “When we opened the hospital for war victims in 1999, it was just us four women. I was a refugee. I’d come with my family from Parwan province, fleeing the war. I was homeless, I had nothing to eat, I had nothing. I was sleeping in a tent. I heard there was an Italian organisation looking for staff. I applied. I had an interview with Kate Rowlands. Then I met Gino Strada and that’s where it all started.” Hasina finishes before going back to her patients: “We were naïve. We thought the conflict would be over soon. Now we know that was only an illusion.”

Photography by Giuliano Battiston