A photographer’s return to Afghanistan after losing three limbs

A year ago, Giles Duley gave this TED talk:

In a magazine feature article for the New York Times published last May, Luke Mogelson described the medical care provided by Emergency, an Italian-based nonprofit that opened its first surgical center in Afghanistan in 1999. He also described the ‘criminal’ discharge policies being applied to Afghans who get treated at NATO hospitals.

In April, I traveled to Sayad, a town in Kapisa Province, to meet a 14-year-old boy named Zobair, who had recently been discharged from a hospital at Bagram Air Base, one of the largest American military installations in Afghanistan. Zobair’s uncle Nasir had taken him to Sayad in a borrowed Toyota hatchback, its rear seats folded forward to accommodate the green U.S. Army litter on which Zobair reclined. We were parked on the bank of a wide river with small wooden platforms extending over the water’s edge, where you could order lunch from local fishmongers. My interpreter and I arrived early and bought food for Zobair and Nasir — a gesture that felt ridiculous now, in light of Zobair’s condition.

Both of his legs were gone, and wounds covered his hands, arms and back. He was nauseated and fevered; every movement elicited a grimace. “Most of the pain is in my stomach,” Zobair told me as soon as we met. His eyes were half-shut, heavy with fatigue, and he spoke so softly that I had to lean close to catch his words. Without a wheelchair, Zobair had no way to reach the landing where we had set up the meal. When Nasir climbed into the back of the Toyota and raised Zobair’s shalwar kameez, he revealed a pouching system attached to a stoma and four pink tubes sticking out of Zobair’s sides. Fifty-two metal staples held together an incision running the length of his abdomen.

Zobair and Nasir were from Tagab District, where French troops have struggled for years to dislodge a deeply entrenched insurgency, without much success. In February, a French airstrike, mistaking them for insurgents, killed seven boys while they were herding sheep not far from Tagab. A few weeks later, according to Zobair and his family, Zobair was sitting outside his house with four cousins, watching the sun go down, when two low-flying helicopters approached from the distance. Helicopters have long been a daily occurrence in Tagab, but something about the way this pair hovered near the house made Zobair nervous. He said as much to his cousins, who mocked him for being overanxious.

Zobair stood up and began to walk away. He does not know what kind of ordnance or ammunition the helicopter fired. Given the damage, it was likely a Hellfire missile. Two cousins — ages 14 and 18 — were killed immediately. Zobair, who had taken about four steps before the explosion, was thrown into an irrigation ditch. Villagers rushed the survivors to the French military base in Tagab, where another of Zobair’s cousins soon died. In response to my questions about the helicopter strike, a representative for the French military told me that they had conducted an investigation, the conclusions of which were “full positive”: “On that day, after having checked there were no civilians in the area, one helicopter fired at a group of five insurgents with hostile intentions.”

The last thing Zobair remembers before losing consciousness was a foreigner sticking him with a needle. He woke up “in a white room with white walls,” he told me. “They wouldn’t tell us where we were.” Back in Tagab, no one from the base would inform Nasir where Zobair had been taken; it was generally known, however, that casualties from Kapisa were often airlifted to Bagram. “We came to Bagram several times to write our names and give them to the interpreter at the gate,” Nasir said. “Sometimes the interpreter told us, ‘Yes, he is here.’ Sometimes he told us, ‘No, he is not here.’ Zobair called us one time. He told us: ‘I am in a hospital, but I don’t know where. I’m not allowed to tell.’ ” When I asked NATO why Zobair was not allowed to speak with his family, a representative replied, “We know there is a policy on this and are seeking more information at this time.” I was later told that he should have been allowed to call home.

After 23 days, Nasir received a call from an interpreter at Bagram, who told him to come pick up his nephew. At the airfield, Zobair was carried out from the hospital and put into the ambulance, accompanied by an Afghan interpreter. The interpreter told Nasir that they should go to the Red Cross in Kabul so that Zobair’s amputated legs could be fitted for prostheses. She then handed Nasir some papers detailing, in English, the treatment that Zobair received.

If Nasir had been able to read the papers, he would have learned that American surgeons at Craig Joint Theater Hospital saved Zobair’s life with a battery of sophisticated procedures. The incision on Zobair’s abdomen was from a laparotomy that enabled the doctors to repair his lacerated spleen, colon and kidney; the pouching system was to collect feces from an ileostomy, where a section of damaged intestine had been removed; and the four tubes sticking out of his sides were internal compression sutures helping to hold his abdomen together. Curiously, the only future treatment recommended for Zobair was to “follow up with a surgeon in six months to have the ileostomy takedown” — that is, to have the intestine reattached and the temporary pouching system removed. According to Nasir, he was not given any guidance about what to do for the internal sutures and 52 metal staples, though both were meant to remain in place no longer than a week or two, after which they posed a risk of becoming infected.

The ambulance took them to a Red Cross orthopedic center in Kabul. There, doctors saw immediately that Zobair was in no condition to have been discharged. He could not even sit up. (A spokeswoman for Craig Joint Theater Hospital said that “in accordance with accepted international clinical practice, the patient had recuperated well enough to be considered by his physicians for discharge.”) The Red Cross told the Afghan escort accompanying the ambulance that Zobair required further medical attention before the orthopedic phase of his recovery could begin.

When the ambulance left with Nasir and Zobair, the staff at the Red Cross assumed they were returning to Bagram. Instead they were taken to Kapisa’s provincial hospital, Mahmud-i-Raqi, where doctors informed Nasir that few if any public hospitals in Afghanistan possessed the special tool required to remove the metal staples that were used on Zobair. “They said they were not able to fix this problem,” Nasir told me, “and they sent us away.” Craig Joint Theater Hospital says that it previously arranged to transfer Zobair to Mahmud-i-Raqi and secured its consent to accept Zobair before his discharge. But the director of Mahmud-i-Raqi, Dr. Mustafa Faiz, says this is untrue. According to Faiz, no one from Bagram ever contacted the hospital about Zobair.

I visited Mahmud-i-Raqi twice. Part of the hospital is made of free-standing plywood and sheet-metal rooms with corrugated tin roofs, while the main building suffers from severe disrepair. Paint peels from walls; water creeps from ceilings; and the floors are covered in dirt. The first time I went there, I arrived at around 3 in the afternoon, but I was told that all the nurses and doctors had gone home early. The second time I visited Mahmud-i-Raqi, it was overrun with people jostling to be seen. Faiz, the director, gestured at the melee and asked, “Why would a hospital like the one at Bagram want to send a patient here?” He explained that Mahmud-i-Raqi could never accept a patient like Zobair for the simple reason that it had no surgeons. He then asked me if I could procure his staff some medical textbooks the next time I went to Bagram.

Nasir says that when Mahmud-i-Raqi refused to admit Zobair, the Afghan escort from the ambulance called Bagram and asked what to do. When he got off the phone, the escort told Nasir: “Zobair didn’t have much problems. He only needed his dressings changed. He said we could take him home.” The ambulance returned to Bagram, and Nasir hired a taxi to drive him and Zobair back to Tagab. The following afternoon, an elder from the village visited Zobair to help with his dressings. When he saw the incision, the elder told Nasir that he needed to get Zobair to a hospital immediately. They went to Emergency’s medical center in Panjshir Valley the next morning.

The only patients Emergency does not accept, however, are those who have already been operated on at NATO facilities. They adhere to this policy very strictly — some might say brutally. In the past, Emergency used to treat patients like Zobair, “but we stopped,” Emanuele Nannini, the program director for Afghanistan, told me. “They kept dying in our hospital.” Nannini describes NATO’s practice of discharging injured Afghan civilians requiring further care as an unethical one, which Emergency has opted not to participate in. “They don’t take responsibility for the patients,” he said. “They start a job, and they give all the complications to somebody else.” He added: “If they wanted to treat them, they could. That is the point. They have the capability.”

One nurse at Emergency who helped make the decision to turn Zobair away later told me: “It was a disaster. The incision was not clean. It was infected.” When I asked Radaelli, the medical coordinator, whether Zobair was in danger of dying from the infection, he said, “If someone doesn’t take him, for sure.” He added, “We see this all the time.” Nannini, the program director, is strident on the subject of NATO’s discharge policies, going so far as to characterize them as criminal. “They did nothing for this patient,” he said of Zobair. “It’s better to let him die than to suffer while going from one hospital to another.” [Continue reading…]

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