For a second I thought I must have misunderstood. I was looking at two children who were alive, conscious, and looking back at me. But I was also looking at their X-rays, which clearly showed that both of them had bullets in their heads.
In each case, the bullets had pierced the children's skulls, and were now floating inside — alongside or within their brains. The bullets were impossible to remove, at least in this hospital, so they would remain there for the rest of their lives, causing, at the very least, severe headaches.
I know a surprising number of people who have been shot in the head and are still alive, but they survived because they were wearing helmets. These two children didn't have such luxuries. No one in rural Afghanistan does.
Helmets, flak jackets, surveillance balloons, mine-resistant trucks — even simpler things like sunglasses, bottled water, and walking boots — all these modern accouterments that made life for foreign forces a little easier and safer are all gone. Visiting the southern province of Helmand today, it's hard to see any evidence that thousands of foreigners, with all their technology and promises, were here just a few months earlier.
A nurse sat down next to one of the children, who asked for her bandages to be removed. The nurse patiently explained that the bandages had to stay on. The little girl asked the nurse where she was from, but seemed not to recognize the answer.
"Lashkar Gah," said the nurse. "This is Lashkar Gah, where you are at right now, this hospital is in Lashkar Gah." There was no response.
"You are in the hospital, do you know that?" The little girl looked around, a slightly confused panic in her eyes and voice, but otherwise remarkably calm. "What is your mother's name?" asked the nurse.
The girl tried to reply, "My mother's name is…" She looked down her bed, then imploringly at the nurse, not knowing why she couldn't remember her mother's name. Her voice trailed off.
Dimitra Giannakopoulou, the long-serving medical coordinator of the hospital, told VICE News that such cases are normal. In the last few days alone, she said, five children had been brought in with bullets inside their skulls. All but one of them survived.
Lashkar Gah is the capital of Helmand, which is Afghanistan's most violent province. The hospital is run by Emergency, one of the best NGOs I have ever encountered. It was a normal facility before foreign troops were deployed here, but it has since become a trauma unit, treating nothing but severe war injuries.
The hospital and its staff are operating at full capacity. Every room that once served some other function — like the pharmacy and the playroom — has now been converted into a ward. And every ward is full.
The security situation in Helmand is so dire that the foreign medical staff is restricted to working behind the walls of the hospital and resting behind the walls of their communal house. The only time they step outside those walls is on the short journey between the two.
The other hospital in Lashkar Gar is officially state-run, but supported by Doctors Without Borders (MSF), another NGO. Despite all the talk of reconstruction and development — and the hundreds of billions of dollars spent by the US and other foreign governments — these are the only two hospitals in Helmand.
'Now we are just treating war injuries, and there are more mass casualties.'
Emergency treats everybody they can at their hospital. They were here long before the war started, and will be here long after it ends. Their entire nationwide operation (three surgical centers, one maternity center, and 40 first-aid posts) has a combined budget of less than $7.5 million annually. That's a miniscule fraction of the more than $1 trillion spent so far on the war.
I asked how many patients they were receiving. "On a bad day, 30 patients per day," said Giannakopoulou.
On really bad days they get a "mass casualty," perhaps from a suicide bombing. Sometimes they get two or three of those in a single day, and that's when they struggle to cope. Cleaners, cooks, and security guards have been trained to perform basic medical duties so they can assist during emergencies.
I asked how many times that had happened. "So many I can't remember," Giannakopoulou said.
As Britain and America withdraw from Afghanistan, civilian casualties are increasing. Giannakopoulou said the hospital had 2,100 admissions in 2013, a 70 percent increase on the previous year. They are on pace for another 50 percent increase in civilian casualties in 2014.
This trend is reflected across the entire country, where civilian casualties have already risen at least 24 percent on last year, according to the UN.
"Ground engagements and crossfire hit children and women with unprecedented force, with associated child casualties more than doubling in the first six months of 2014 and two-thirds more women killed and injured by ground engagements compared with 2013," UNAMA said in a July report. The types of injuries are also changing, the organization stated — casualties from errant shells and bullets are now the leading cause of civilian deaths and injuries, for the first time since the war began.
Having seen the Afghan security forces and the Taliban fight on many occasions, this is not at all surprising. Both sides fire wildly and indiscriminately, paying little or no attention to where their bullets and shells might end up. The UN report estimates that in the first half of 2014, 1,564 civilians were killed and 3,289 injured.
The situation is likely to get worse. The Taliban, no longer fearful of western air strikes, have started launching mass attacks, with hundreds of fighters launching sustained assaults against Afghan army and police bases.
Afghan soldiers told me many stories of how little they can do when they have just four helicopters for the entire province, when the police are cutting deals with the Taliban and handing them patrol bases, when most of their vehicles are damaged and can't be repaired, and when medical evacuations and resupplies are either far too rare or non-existent. Some described battles where soldiers fought down to their last bullets.
'Do you see the condition of the Afghanistan people? You have come and made us fight with each other.'
Logistically the Afghan security forces are extremely weak. Many are either brutally indifferent or even predatory towards the local population. Any claims that we have succeeded in training and equipping the Afghan security forces to anything like an adequate level are so far from the truth they are obscene. This is particularly galling when you witness the extraordinary and routine suffering many Afghan civilians are now going through.
One patient — his head, left arm, and left knee in bandages and his entire right leg wrapped in a huge plaster cast — winced in pain as he was lifted from his bed to a wheelchair. He was in his mid to late 20s, possibly a fighter for one side or the other. "Do you see the condition of the Afghanistan people?" he asked me angrily. "You have come and made us fight with each other."
The Afghan government stopped releasing their own casualty figures last year, because they are so bad. Unofficial estimates of at least 25 soldiers and policemen being killed every day seem conservative. Several districts in Helmand are in perilous states. A number of provinces in southern and eastern Afghanistan are regularly described as being on the verge of falling to the Taliban.
Dr. Shah Wali is one of four surgeons, all Afghans, at the hospital and he let me follow him on one of his daily tours. His scruffy hair and crumpled scrubs suggested a man who spends too much time at work and not enough at home.
He walked to the bedside of a young boy I had seen all over the hospital. It was the first time I'd seen the child in his bed. He mostly raced around in a wheelchair, which he skillfully used to appear to be everywhere at once. The boy had had a laryngectomy — the complete removal of his larynx — and could now only breathe through a plastic tube that had been inserted into the front of his throat.
He had severe scars along the right side of his jawline that you could only see when you were close to his face. He was incredibly handsome, with yellowy brown eyes that sparkled with mischief when he was happy. But he was also sad a lot of the time, and would often find a quiet spot somewhere and cry on his own. I also saw him swatting away a book that Afghan members of staff kept offering to him.
"He got multiple shell injuries to his abdomen, face and neck," said Dr. Wali. He pointed to the boy's throat. "One was a severe injury — he lost his epiglottis. So now he cannot speak, forever."
I asked if the boy knew that he would never be able to speak again, and the surgeon said he did. The book I'd seen him reject was a writing book. The staff members were trying to teach him to write in Pashto so that he would be able to communicate.
The rounds continued. We stopped at the bed of a man whose eyes were both swollen, whose cheeks were crossed with long and thick lines of stitches, and whose mouth appeared to be full of tissue paper.
"He got a shell injury to the face and mouth," said Dr. Wali. "We reconstructed the mouth a little bit but there is no mandible."
The doctor stretched his finger and thumb along his jaw to show me the bone he was talking about. The man's entire chin had been blown off. "There is no bone there, just tissue. His mouth was like that." The surgeon held his hands out in front of him then opened his fingers, simulating an explosion. "It was completely open. It exploded the mouth. I don't know what kind of thing did this."
Dr. Wali finished his rounds, examining patients who were paraplegic after being hit in the spine, or who had two, or even three, limbs removed after shells landed on their homes. One man had been shot in the head and his "brain was out" when he arrived, the doctor said. He would survive, but was hemiplegic — paralyzed across one side of his body. A female patient had suffered the exact same injury, and the surgeon lifted her right arm, looking for signs that she was regaining control of that side of her body. Each time the limb just flopped back down onto the bed, with everyone looking at it despondently.
'They are coming every day: bullet to the chest, to the skull.'
One little girl had lost most of her fingers and both of her eyes were dark blue and swollen shut. She had picked up a shiny, new-looking object she'd found — as kids often do — not knowing that it was an unexploded shell. The hundreds of cuts across her face painted a horrifically perfect picture of how the bomb must have exploded into her face as she brought it close to look at it.
"Today was a little bit quiet," said the surgeon, as he left the wards. All the hospital staff members I talked to were businesslike as they described these injuries, rarely showing too much emotion, and often appearing bemused by my ignorant questions and expressions of shock. But away from our interviews, I kept seeing them making constant gestures of tenderness, touching patients' heads, or stroking their arms as they walked past. This mixture of stoicism and affection made them appear perfectly heroic. Whenever I asked any of them how they kept going, they gave simple answers that they assumed were too obvious to even think about. "That's our job, we must do it," "Because these people need it," or simply, "Because I can."
I sat down on a wall outside the wards with Dr. Wali while he took a rare break. He told me he'd been a surgeon in Helmand for 13 years, almost as long as the duration of the current conflict. "It was quiet at the beginning, there was no war," he said. "We treated road traffic accidents, things like that, a few war injuries. Slowly the war injuries got worse, and now we are just treating war injuries, and there are more mass casualties." He listed the places he used to be able to visit without problems, including his home region of Marjah, but said that he and his staff are now prisoners in Lashkar Gah and can't travel anywhere.
I asked if he and his family were tempted to leave. "There is nowhere we can go to live in peace. All of Afghanistan is the same, so we'll stay here." I asked if the situation was now the worst that it had ever been and he said it was, adding, "And getting worse. They are coming every day: bullet to the chest, to the skull. The situation is getting worse and we don't know what will happen. There is no hope for the future."
Follow Ben Anderson on Twitter: @BenJohnAnderson
All photos by Jackson Fager/VICE