Afghanistan: saving lives in one of the world’s deadliest conflict zones

Amanullah, a 32-year-old welder, worked in his shop near the Afghan capital Kabul when the neighbourhood suddenly rattled with automatic gunfire. People ran for cover as government troops engaged in heavy clashes with Taliban fighters in the streets outside.

“Bullets were flying everywhere,” Amanullah, who like most Afghans uses only one name, recalls. “Then someone fired a rocket that landed just outside my shop.”

Sakhi, Emergency Head Nurse, examines Amanhullah’s ex-rays showing shrapnel damage. ©European Union, 2020 (photographer: Peter Biro)

Amanullah was thrown backwards by the blast, hitting his head on a concrete wall. He woke up in the hospital four days later. The explosion had ripped off his right leg above the knee and sent jagged pieces of hot metal into various part of his body.

“When I woke up, I was wondering where I was,” he says, straining to speak due to damage by shrapnel to his lungs. “Then I looked down and my right leg was gone.”

Amputations are carried out only when it is lifesaving and absolutely necessary, but in a country dependent on manual labour and agriculture, the loss of a limb often means the loss of a livelihood as well.

“I worry a bit about the future,” Amanullah, a father of four, says.

A long-lasting conflict

Ordinary Afghans like Amanullah have long borne the brunt of fighting in a country that after more than 40 years remains one of the world’s deadliest conflict zones. Almost 6,000 Afghan civilians were killed or injured in the armed conflict, from 1 January to 30 September 2020, according to the latest report of the UN Assistance Mission in Afghanistan (UNAMA). September 2020 marks a 39% increase in the number of civilian casualties in comparison to the same period last year.

The toll has been consistent over the past six years, putting the total number of casualties in the past decade to over 100,000 people. The Afghan conflict remains the deadliest in the world for children. Child casualties were 31% of all civilian casualties in the first nine months of 2020, women 13%.

A patient is cared for by a nurse at Emergency’s facility in Kabul. The 35-year-old was carrying food along a secluded path near Kabul when he stepped in a land mine. He will require weeks of rehabilitation to be able to walk on the prosthetic leg. ©European Union, 2020 (photographer: Peter Biro)

Amanullah is now being treated in the surgical facility of an EU-supported aid group Emergency in Kabul, housed in a former kindergarten built by the Soviets. Emergency, based in Italy, opened its first surgical centre in Afghanistan in 1999, during the war between the Taliban and the Northern Alliance. The centre, with 120 beds, treats war victims from across Afghanistan and has seen has seen an increasing flow of civilian patients suffering from serious injuries as a result of war.

The US and the Taliban recently signed an agreement that could result in American troops leaving the country. However, the Taliban has continued its offensive operations against the Afghan government. Meanwhile, the staff at Emergency remain on a 24-hour standby to deal with the next suicide attack or roadside bombing, which often results in a high number of killed and injured.

“We see an average of over 400 patients per month,” says Sakhi, Emergency’s head nurse. “But when a suicide bombing or other large attack occur, we are of course flooded with patients requiring immediate life-saving treatment.”

Dealing with mass tragedies

In 2018, when an ambulance loaded with explosives detonated near a crowd of police in the centre of Kabul, Emergency’s facility received over 130 wounded patients in one instance, brought to the front gates in cars, taxis and the back of pickup trucks.

“In mass events, the injured are taken to a triage station by the main gate, where we prioritise the wounded,” says Dejan Panic, Emergency’s Programme Coordinator in Afghanistan. “They are then taken to our three operation theatres, where they are treated by highly experienced staff specialised in trauma surgery.”

Outside the wards, patients in wheelchairs relish the first rays of the spring sun and in the hospital’s rehabilitation room, a young man practices walking with a new artificial leg, his hands gripping rails running along a ramp for support.

One of the facilities where many patients relax with a relative in the hospital garden. ©European Union, 2020 (photographer: Peter Biro)

Violations of International Humanitarian Law abound amongst all parties to the conflict. In the first nine months of 2020, UNAMA verified a total of 52 attacks on medical missions and 45 attacks against education facilities.

In an adjacent room lies Parwiz, 13. Just two days earlier, he was collecting firewood in a small village in the eastern province of Logar when he found what he recognised as a landmine in the undergrowth. As he lifted it to throw it away, the device exploded, sending shrapnel into his abdomen.

“We’ve removed all of it and the accident could have been much worse,” says Sakhi. “We expect him to fully recover.”

In 2019, over 40% of casualties were caused by improvised explosive devices (IEDs), planted by anti-government forces, including the Taliban and Islamic State. According to the UN, 885 people were killed by IEDs, with nearly 3,500 injured. Last year also saw record-high levels of civilian casualties from airstrikes, mostly carried out by international military forces, with more than 1,000 killed and injured.

The side effects of conflict

As health facilities continue to report record-high admission levels of conflict-related trauma cases, the EU has stepped up its humanitarian support for emergency treatment and related psychological assistance to include nearly 5,000 people each month.

“Treating war trauma has become one of the EU’s largest priorities in Afghanistan,” says Luigi Pandolfi, who oversees the EU’s humanitarian programs in the country. “We spend almost 30% of our overall budget to equip healthcare facilities with trauma care capacity.”

Pandolfi says that the EU’s and its humanitarian partners have been able to provide these critical services not only in large urban centres but also in remote and conflict-affected areas.

Ali Sajad, 17, is learning how to walk again after a bullet damaged his bones and muscles in the upper leg. ©European Union, 2020 (photographer: Peter Biro)

Healthcare in all forms is badly needed across the country. A staggering 10 million Afghans — over a quarter of the population — lack regular and sustained access to basic health services. Specialised care, such as treating trauma patients and rehabilitating amputees, is even rarer in government-run hospitals and clinics. To ease the burden on the strained Afghan healthcare system, the EU is also supporting the training of nurses and other healthcare staff in first aid, mass casualty management and basic life support.

“We have increasingly seen patients suffering from serious trauma arriving in the hospital properly bandaged, on spinal boards and stabilized,” says Dejan Panic. “Training is literally saving lives.”

Story by Peter Biro, Regional Information Officer, EU Civil Protection and Humanitarian Aid Operations.

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