The Kabul Hospital That Treats All Sides

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Excerpt:

http://www.nytimes.com/2012/05/20/magaz ... wanted=all

Pacifists in the Crossfire
The Kabul Hospital That Treats All Sides
Pieter Ten Hoopen/Agence Vu, for The New York Times

An orderly at the Emergency Surgical Center for War Victims in Kabul with a victim after a suicide bomber killed and injured scores during an attack on a Shiite holy day in December.
By LUKE MOGELSON
Published: May 18, 2012 1 Comment

Several miles west of Kabul, the village Qala-e Naw sits deep in the barren foothills of barrener mountains that are perennially half-sunk in cloud. The ruins of old homes strafed by Soviet gunships crowd a gravel streambed that is dry most of the year but runs swiftly with snowmelt come spring. One morning early in December, a 12-year-old girl named Gulali followed the bed for almost an hour, along with her mother and little sister, in search of dry timber to fuel their stove. When they reached a steep rise with scattered saplings near its peak, Gulali scrambled up the slope and set to hacking at some of the skinnier trunks with a hatchet. In the small community of poor Pashtun farmers who inhabit Qala-e Naw, Gulali was well liked for her prideful and precocious work ethic, and true to form, when her mother said they had enough wood and it was time to go home, Gulali insisted on felling one last tree. Seconds later, she stepped on a land mine. The explosion hurled her through the air, nearly severing her right leg and pulverizing most of the left.

After being treated at two other hospitals, Abdul Nafeh, a Local Police officer, was brought to Emergency with fatally infected wounds.

Gulali’s mother ran to her and began to stanch the hemorrhaging stump with a head scarf. Two of Gulali’s uncles, Pasha and Sartor, were working a field about a mile away when they heard the explosion and saw the brown plume drift and dissipate. It took Sartor, the younger one, more than 30 minutes to reach the scene, and when he arrived, he found Gulali cradled in her mother’s arms. Sartor put his niece over his shoulder and ran back to where Pasha and a group of nomadic herdsmen were waiting. An old shepherd offered his winter shawl, which Pasha and Sartor used as a makeshift litter to carry Gulali another 20 minutes to the nearest Afghan Police post. Gulali, who remained conscious the entire time, never made a sound. When she was 6, she fell down a 30-foot well that was dry at the bottom. Her father found her hours later, both of her legs broken. He had to climb down a ladder and lash her to his back with a rope to get her out. During that ordeal as well, her father told me, Gulali remained spookily calm.

Now her mother was screaming for help as they approached a metal shipping container with a machine-gunner’s nest on its roof. The police officer in charge of the post flagged down a car, put them in the back seat and instructed the driver to take them to the Emergency Surgical Center for War Victims in Kabul. “Don’t worry,” he tried to reassure Gulali’s mother. “The food and medicine are free there.”


When they arrived at Emergency — a former kindergarten built by the Soviets — Tijana Maricic, the head nurse, rushed Gulali from the car into the operating theater, her nearly severed right leg bundled in her mother’s scarf and a huge open wound on the left. Mine injuries, especially traumatic amputations, are uniquely vulnerable to infection — the blast often forces dirt, shrapnel and other contaminants deep into the stump — and a priority for the Afghan surgeons working on Gulali was to excise foreign bodies and damaged tissue. In the end, they also had to complete the amputation of the leg, removing it just below the knee.

“She was very brave,” Maricic said of Gulali’s stoic reaction to her pain. “Here, even most of the very young children with severe injuries never cry.” Maricic, a Serb, worked as a pediatric nurse in Belgrade before joining a cardiac center run by Emergency in Sudan. Now she is one of three foreign nurses at the hospital in Kabul. Maricic and the rest of the small international staff — the nurses, one doctor and a few administrators, most of whom are in their 30s — divide their time between the hospital and a quaint house directly across the street, in Kabul’s “new city,” a lively neighborhood of butcher shops, electronics stores, kebab stands, vagrants and panhandlers.

Despite Emergency’s central location, Maricic and her colleagues see little of the city outside the hospital grounds and almost nothing of the country. Inside the hospital, however, they see everything — the worst of what war can do.

“I prefer it here,” Maricic told me recently. “Sudan was closer to an ordinary life. You could go outside. You could go to the shop or for a walk. But here, we are more like a family, closer, and in this way it’s more like an ordinary life. After this, I don’t think any of us will be able to go back to a normal hospital.”



‘We Cannot be on One Side of the War’

Emergency is an Italian-based nonprofit that opened its first surgical center in Afghanistan in 1999, during the war between the Taliban and the Northern Alliance. One of its founders, Dr. Gino Strada, worked as a surgeon for the International Committee of the Red Cross in Kabul during the early ’90s, when the Soviet-backed government fell to rivalrous Mujahedeen factions. When Strada returned to Afghanistan in 1999, the Mujahedeen had been routed by the Taliban, and forces loyal to the Tajik commander Ahmad Shah Massoud had retreated north toward their mountain refuge in the Panjshir Valley. Sporadic fighting continued between Panjshir and Kabul. Massoud gave Strada a former police academy in Panjshir, which Strada and his team converted into a trauma hospital. “Immediately we thought, O.K., we cannot be on one side of the war,” Strada told me recently. “So I went to Kabul to talk to the Taliban and offered to balance our presence so that people could see we were neutral.”

Eventually, Mullah Omar, the leader of the Taliban, agreed to let Emergency open its hospital in the former kindergarten. Because of the ever-shifting front, Strada said, “we had Taliban fighters who were taken to Panjshir, and Northern Alliance fighters who were taken to Kabul. As soon as we discharged a patient on either side, he would be in trouble. So we started to negotiate with both sides.” Strada managed to persuade both Massoud and the Taliban to guarantee the safe transportation of discharged patients to their respective places of origin. Today Emergency’s commitment to neutrality endures: the Tajik policemen who guard the entrance to the Panjshir Valley still permit Taliban casualties to be taken to the hospital there, and insurgents are treated alongside wounded Afghan security forces at the surgical center in Kabul.

A vast majority of Emergency’s patients, however, are civilians. In 2011, the war in Afghanistan killed more than 3,000 civilians, more than any year since 2001. According to the United Nations, 77 percent of these deaths were caused by insurgents, who escalated their use of improvised explosive devices and suicide attacks. At the same time, the number of civilians killed by coalition airstrikes also rose in 2011. Because of the unconventional nature of the fighting — because the violence comes from all sides, in small doses, everywhere — it can sometimes feel not quite like a war at all but more like an interminable cycle of murder. In this war that is not exactly a war, Emergency represents one of the few places that offers something like an accounting.



Triage After the Bomb

Until she came to Emergency, Gulali grew up somewhat insulated from the conflict. For years, her father fought the Soviets in Qala-e Naw; the rusted carcass of a Russian tank, which one of his compatriots set alight with a rocket-propelled grenade, still sits on the bank of the stream near their house. But since 2001, Qala-e Naw has been relatively peaceful, and Gulali’s childhood was uncorrupted by violence. The Shiite holy day of Ashura, commemorating the martyrdom of the Prophet Muhammad’s grandson Imam Hussein, arrived during Gulali’s first week at Emergency, however, and that afternoon visited on the hospital some of the grisliest brutality that 11 years of fighting has managed to produce.

Shiites represent a small minority in Afghanistan, and they are mostly ethnic Hazaras. While Gulali was lying in bed, recovering from her operation, hundreds of Hazaras were congregating about a mile away, at the Abul Fazal Abbas shrine in Kabul’s old city. It was a clear day, and on the street outside the shrine, worshipers circled a group of young shirtless men lashing themselves with steel blades affixed to lengths of chain. Self-flagellation is a customary form of mourning Imam Hussein; as the men swung the blades against their backs, they shouted: “Ya Hussein! Ya Hussein!” There was an element of defiance in how fervently the Shiites exhibited their devotion. Soon many of the half-naked flagellants were covered in their own blood.

Sometime shortly after noon, a suicide bomber infiltrated the ceremony and detonated himself. The explosion ripped through the heart of the crowd. It cleared a wide swath and at the periphery of its force created a semicircle of wrecked bodies piled along a strangely geometric arc. More than 200 people were injured or dead: crumpled improbably, heaped among odd scraps of clothes and limbs as if they had plummeted from a great height. In the carnage and confusion, the dying were hard to distinguish from the dead. Bodies in all manner of distress were taken to Emergency in taxis and cars and in the backs of pickup trucks. When Luca Radaelli, the hospital’s 35-year-old medical coordinator, opened the first ambulance’s doors, he found several dead infants stacked atop a mass of bloodied but breathing women and men. “I also found the head of what was probably the suicide bomber,” Radaelli later told me. “As I took out the first patient, the head fell down at my feet.”

A mob of distraught relatives and survivors began to form outside. Radaelli shut the hospital’s gate, allowing only patients to enter. Some of the bereaved tried to break down the gate, others to scale the walls. More victims continued to arrive. Soon gore and body parts littered the sidewalk. When I arrived at the main entrance, about an hour after the bombing, a brain lay on the street. It was perfectly intact and surprisingly white. An Afghan employee of the hospital, wearing heavy rubber gloves and equipped with a wheelbarrow and a hose, was hurrying to clean up the mess.

A mass-casualty triage tent was hastily erected on the lawn where the local staff members sometimes play volleyball. In Gulali’s ward, injured children came and went. She sat in her wheelchair, watching. It’s difficult to imagine what it all must have looked like through her eyes or how she understood it. At the time, no one understood it. Never before during the decade-old war had there been an attack targeting Shiites on such a scale. Within the maelstrom of ethnic, tribal, economic and political enmities churning the violence in Afghanistan, sectarianism simply didn’t rate. Even the Taliban condemned the bombing.

Late in the afternoon, the orderlies began collecting the bloody mattresses and backboards and stretchers that littered the lawn, scrubbing them clean with antiseptic. The nurses hurried from ward to ward, attending the dozens of moaning wounded in line for surgery. I went out to talk with some of the relatives crowded around the gate, where a list of names was posted on the wall. The sun was starting to go down, but dozens of Hazaras still anxiously awaited news.

When I asked whom they blamed, everyone said Pakistan. This was to be expected — many Afghans see Pakistanis as the ultimate source of all their woes — but what came as a surprise was their unanimous refusal to impugn Sunnis or ascribe a religious motive to the attack. “We don’t blame the Sunnis,” insisted a young man named Ali Bahram, whose nephew was inside. “Islam belongs to Sunnis and Shia both. It’s the I.S.I. who are the enemies of Islam,” he added, referring to Pakistan’s spy service. Several men had gathered around us, nodding in agreement. “The I.S.I. wants us to retaliate,” one of them yelled. “They want to create strife between the Shia and Sunnis in Afghanistan.” (The organization that eventually claimed responsibility for the bombing, Lashkar-e-Jhangvi, is in fact from Pakistan and once enjoyed the support of the government, though it has since been outlawed.)

Back inside, two teams of surgeons — five Afghans and one Italian — performed operations until 4 in the morning. For many of the Afghan employees, the day had been all too familiar. One senior surgeon, Dr. Hamed Nazir, was reminded of being a young physician in the northern city Mazar-e Sharif during the war between the Taliban and the Northern Alliance. When the Taliban finally took the city in 1998, they massacred thousands of people, mostly Hazaras. Every afternoon, wounded civilians would be dropped off by taxis and vans at the hospital where Nazir was working. “It was exactly the same this time,” Nazir told me. “Mostly dead children. It’s always like that.”