Here in Afghanistan, Carmen, Hakim, Faiz and I went to Kabul’s Emergency Surgical Center for Victims of War to donate blood. “Emergency” isn’t just an apt description of the hospital’s cases; it’s also the name of the Italy-based charity that runs war hospitals and clinics across Afghanistan. Emanuele Nannini, the program coordinator, and Giacomo Menaldo, the chief logistician, spoke with us for several hours about the work done in their facilities and the desperate emergency in health care which Afghanistan faces. Besides its Kabul center, “Emergency” operates two other major hospitals in Afghanistan, one in Lashkar Gah and one in Panjshir. They also operate 43 clinics, some of which treat as many as 2,000 people each month. All patients are treated free of charge. Hakim noted that it’s remarkable that the locals, the Taliban, and the government all want the work of these hospitals to continue. It’s a testimony, he says, to the neutral humanitarian service “Emergency” provides.
Emanuele, who has worked at the Kabul hospital for five years, says that the violence in Afghanistan is worse than ever. We felt deeply impressed by his and his colleagues’ determination to continue working under extremely stressful conditions even as they realistically predict a rise in fighting and possible massacres during weeks and months ahead.
Nearly every bed in the Kabul hospital is filled. Sometimes, during past months, when they were overwhelmed with patients needing emergency care, they had to narrow their criteria for receiving patients, accepting only those who required vascular, abdominal and thoracic surgeries. Anticipating future violence, the Kabul hospital is now building a new surgery theater plus a wing to accommodate 20 new beds. At the hospital in Lashkar Gah, where every possible space is being used for beds, the staff even had to convert the pharmacy into a new ward.
“Emergency” has about 45 ambulances moving between ten provinces of Afghanistan, constantly traveling roads through war zones and sometimes having to find new routes to avoid armed groups that are fighting.
Emanuele says that there are many front lines in the fighting. It’s not a “guerilla war.” It’s a full-blown war, with multiple sides heavily armed and battling. It’s not what most people, including journalists, see here in the capital.
“Kabul is like another country,” Emanuele says, explaining that although the Afghan government controls Kabul and the main roads leading into Kabul, it has lost control over many areas in the east and south, which are now split among warlords. The current divisions of control resemble conditions prevailing in 2000, before the U.S. invaded. He noted that in rural areas, it is the warlords who collect taxes, and less than 20% of the country’s population is urban.
In Helmand, in 16 days, 400 people were killed. “It’s like Gaza, but no one speaks about it,” said Emanuele. There is less that can credibly be called “fighting” in Israel’s massacre of Gazan civilians, but civilian casualties don’t suddenly become acceptable even in the heart of a war, at least not to the medical staff charged with caring for and attempting to save the survivors. “4,000 Taliban are fighting in Helmand, and this is just one of 34 provinces.”
Somewhat hopefully, Giacomo and Emanuele wonder if the current peak in fighting might represent a last-ditch effort before negotiations. Are various parties intending to enter negotiations but attempting first to establish facts on the ground that will give them a better bargaining position? Emanuele doesn’t believe the Taliban want to fight for another ten years. Nor does he believe they can sustain it.
Emergency’s commitment to sustain its invaluable care for victims of war is financially supported, primarily, by Italian families. “Pensioners and retirees take from what they have,” says Emanuele. “They believe in this work, want to be part of it.”
With assurance that Emergency will one day turn the hospital over to the state, the Afghan government now pays 20% of the hospital’s annual 6 million dollar budget. We told Emanuele that the U.S. now spends 2.1 million dollars per soldier, per year in Afghanistan. Emanuele quickly pointed out that Emergency’s entire operating budget equals the budget for keeping 3 U.S. soldiers in Afghanistan for one year.
He can’t help but laugh softly and shake his head when he compares their modestly-funded work with gargantuan multi-billion dollar health care and infrastructure projects funded by the United States over the past decade.
In Afghanistan’s Paktia province, the U.S. built a modern hospital called the Gardez Provincial Hospital, but because the province lacks electricity, the hospital can’t possibly function. During normal functioning the “Emergency” hospital draws a total of 170 kilovolt-amperes, whereas the new Gardez hospital requires a whopping (and completely unavailable) 900 kVA. The new state of the art hospital, which is completely useless, looks good in photo shoots; donors might be pleased. But back in 2013, a Time Magazine article compared Gardez’s already existing hospital with the one under construction, noting that “the existing Gardez hospital has annual operating costs, including fuel, of about $611,000 … fuel costs alone for the new hospital could be as much as $3.2 million.”
Why would any group have continued building a hospital which clearly could never open? Giacomo pointed out that the Afghan construction companies are making money. Certain U.S. companies make money. Layers of subcontractors all profit, skimming some 10%-15% of the funds that have made it down to them, while U.S. media outlets spin fictions of how the war is helping Afghans.
In some of the more remote Afghan provinces, health care is non-existent or has collapsed. In July, 2014, when a bomb killed 89 people in a market in Paktika, about 28 wounded survivors were driven over difficult roads for the 7-to-12 hour trip to Kabul and its “Emergency” hospital.
The general state of Afghanistan’s hospital system helps maintain a thriving industry: the travel agencies that send Afghans to India in search of adequate medical care. The Indian embassy in Kabul issued 32,200 medical visas in 2013.
Before donating blood, we visited an “Emergency” ward where we paused at the bedsides of Farshaid and Jamshaid, twelve year old boys who were injured when a suicide bomber attacked NATO troops and Afghan police near the Bagram Airbase in Afghanistan’s Parwan province. Ten civilians, four Czech soldiers and two Afghan police were killed. The boys had been standing outside their school when the attack happened. Farshaid’s leg was amputated. At first we thought Jamshaid, his friend, was better off, having suffered a broken leg, but then we learned that he has lost much of his vision. One of their school friends was discharged the previous day, and he also lost one leg. Jamshaid and Farshaid were sad and listless.
“Ah,” said Michaela Paschetto, a young Italian nurse, “today was a bad day for them. Maybe they miss their friend.” She said she has been affectionately calling them “the gang” because sometimes they race about in their wheelchairs. Then she paused. “Really, I don’t ask so many questions,” she continued. “It becomes too much.” Over the past five years working with “Emergency” in Afghanistan, she has seen so many broken-hearted young boys whose bodies are maimed by war.
We asked Giacomo how he and the staff cope with the stress involved in their work. He recalled a day, not long ago, when the hospital received 46 new patients in one half hour. 100 family members were outside the gate. One of them became like a superhero and made his way past Giacomo and four security guards trying to restrain him. He wasn’t an attacker; he was only desperate to find his children. “We see so much trauma and death,” he said. “We need breaks.”
Emergency recommends its staff take a 15-day holiday every six months. But they must also find daily ways to disconnect. It’s hard because they must always have a live radio with them, ready to order them into surgery. Giacomo watches films or reads books. Too often they must remind each another to stop talking constantly about “the work.” “Play ping pong,” says Giacomo, “have a Bar-B-Q, have one free day every week. You have to balance the bad energy.”
Walking through the hospital grounds, with Giacomo, I recalled, over the years, watching the Emergency staff in Kabul play volleyball with local teams. “What happened to the court?” I asked. Giacomo stood still and let out a long sigh. “Ahhh, yes, over this I nearly resigned.” He’s joking. But to build the new wing, they had to destroy the court. He apparently led a great volleyball team.
An emergency – an emergent situation – is a situation that confronts us, that comes out where we can see it and have to deal with it. In the U.S., we tend to punctuate lives of entertainment with moments of concern for people abroad, moments, even, of activism. The “Emergency” staff here in Afghanistan struggles to find moments of entertainment to remove them, briefly, from the emergency.
In my home country of the U.S., ten time zones out beyond the sunset here, the war in Afghanistan doesn’t emerge into everyday life for most people. It doesn’t arise, it doesn’t come up — it’s a war that has generally been forgotten before it has ended.
To the families and neighbors of the bereaved here, to those suffering illnesses without treatment, for those whose bodies are maimed by shrapnel from U.S. munitions or from the weapons of forces the U.S. government has prodded into relentless battle — to these people, and to the doctors and nurses who’ve chosen to work here among them, what’s happening is an emergency. The people who are suffering emerge, always, as real human beings.