Omar Gul was on duty at a remote police checkpoint in Helmand's restive district of Sangin when the station came under fire.
It was a warm night in mid-September and the battle between Afghanistan's government forces and Taliban militants had been simmering in the southern province all summer.
Around sunrise, Gul recalled, he was shot in the leg. For the next twelve hours he bled, and waited, and bled some more, until the fighting died down long enough for a colleague to hoist Gul onto his back and take him to get help.
In the end, it was not his employer – the government of Afghanistan – who saved his life. After carrying him out of the checkpoint, Gul’s colleagues drove him to a first-aid post run by an Italian NGO called Emergency, whose own ambulance ferried him to the group's hospital in Lashkar Gah, Helmand's capital.
Lying in the hospital two weeks later, Gul said he owed his life to Emergency. If it wasn’t for them, “I would have died,” he said.
© REUTERS/Omar Sobhani Wounded Afghan policemen sit in a police hospital bed in Kabul August 27, 2014. Picture taken August 27, 2014.
Once the International Security Assistance Force (ISAF), the NATO-led coalition in Afghanistan, ends its combat mission next month, the 350,000-member Afghan National Security Forces will bear responsibility for fighting an increasingly organized and ambitious Taliban insurgency. ISAF’s departure will leave wounded men like Gul dependent on a thinly spread medical system with unreliable supply chains and insecure routes for evacuating the injured.
Interviews with senior Afghan and NATO military officials and local medical staff show some civilian hospitals are scrambling to treat an increasing number of injured soldiers and police. There are also cases of security personnel being treated with poor quality drugs and orders of medical supplies not reaching frontline clinics. If the new Afghan government under President Ashraf Ghani can’t effectively fight the war within its borders and care for its forces, it risks demoralizing the army and police and pushing more young men into the ranks of the Taliban.
"[The government] can't afford to give proper treatment to the police and army," said Faizullah Mohammadi, a surgeon who has been working at Emergency hospital in Lashkar Gah for 10 years.
UNPRECEDENTED CASUALTIES
Since the Afghan National Security Forces, comprising the Afghan National Army, the Afghan National Police and the Afghan Air Force, took the lead in security operations across the country in mid-2013, the Taliban and other militant groups have not succeeded in taking control of any province or provincial center. But Afghan forces have been suffering unprecedented casualties this year. Whereas 1,400 soldiers were killed in the Afghan calendar year from March 2013 to March 2014, 950 were killed in the six months from March through September this year. The government did not provide figures on the number of wounded.
The police have been hit even harder. More than 2,200 of them, including members of the Afghan Local Police, were killed in the first five months of the Afghan calendar year. That compares with 1,680 in the first seven months of last year, according to the Ministry of the Interior, which oversees the police.
Too often these deaths are the result of a lack of basic medical care, said Brig. Gen. David Glaser, deputy director of the ISAF-led advisory team to the Ministry of Interior. "They're bleeding out. They're not getting treated for shock. They're not applying tourniquets correctly," said Glaser, who is a member of the U.S. military.
At its peak in the fall of 2011, there were over 800 military installations being operated by the NATO-led coalition across the country. By the end of December, there will be fewer than 30. Late last month, the last U.S Marine unit in Afghanistan and the last British combat forces were airlifted out of their regional headquarters in Helmand.
"Is it going to be perfect before we leave? No," said Col. David Ristedt, who serves as the medical advisor for ISAF Joint Command.
But Ristedt is cautiously optimistic. The remaining coalition medical facilities have been seeing fewer injured Afghan soldiers and police because their own health care has improved, he said. And Afghan Ministry of Defense spokesman General Zahir Azimi told Reuters the government was fully prepared to care for its own troops. “For the last 18 months, we have been operating independently,” Azimi wrote in an email.
Some senior Afghan military commanders aren’t convinced. They said they have deep concerns about the implications of not being ready to take care of their own troops.
Brig. Gen. Dr. Mohammad Asif Bromand sits behind a large desk in a hospital at Camp Thunder, an Afghan base in the eastern province of Paktia, listening on a speakerphone to a call for staff from military hospitals across the country. The air is heavy with the tang of cigarette smoke.
In the hospital wards - there are seven army hospitals across the country - injured soldiers and police lie staring at the ceiling. A soldier in one room has been shot in the throat. Another has had a leg amputated after he was hit by an improvised explosive device (IED).
"I don't know what the politicians think, but as an Afghan general, I think it's too early to transfer the security responsibility from the U.S. to Afghanistan," he said. "From each and every aspect, the Afghan army isn't ready."
ISAF says coalition troops will continue to assist with air evacuation even after it ends its combat mission, but there will be fewer areas where they can help, leaving the task to the fledgling Afghan Air Force. Ground evacuation is more readily available but also more dangerous, with the wounded having to be transported along often unsafe roads.
“Five, six, seven years ago, the whole of Afghanistan was covered by coalition force MEDEVAC rings,” Captain Julie Thain-Smith, ISAF’s chief medical advisor, told Reuters in late October, referring to the areas where coalition forces could reach the wounded by air within an hour. Today there are only five major coalition bases left – in Kabul, Kandahar, Mazar-e-Sharif, Herat and Jalalabad – from which security forces can be reached in that timeframe, said Thain-Smith, a member of the Royal Navy who recently completed her assignment in Afghanistan.
`YOUR SYSTEM SUCKS’
On a morning in August, a convoy pulled out of the ISAF Joint Command base attached to Kabul airport and headed to the Afghan army's central supply depot. In one car, two soldiers scanned the streets as the convoy passed the concrete skeleton of a half-built apartment building pocked with bullet holes. A few weeks earlier, insurgents had used it to launch an attack on the airport.
Inside the supply depot's barbed-wire perimeter fence, the convoy slowed to a halt. Lt. General Joseph Anderson, the American who heads ISAF Joint Command, hopped out and strode toward Maj. Gen. Abdul Basir, the Afghan army’s logistics commander.
With ISAF’s mission winding down, Anderson said a sense of urgency was building in the coalition to help the Afghan military get its supply chains running more smoothly. His inspection of the depot didn’t inspire confidence.
The generals walked side by side, peering into rows of shipping containers stacked with military supplies. Basir explained why the movement of goods from Kabul to troops in the field was slow, blaming his colleagues around the country for not placing their orders correctly.
"Your system sucks," Anderson said, affably resting a hand on Basir's shoulder.
Later, looking at neatly stacked boxes of counter-IED robots, Anderson was less amicable. "What good is this shit doing in a container?" he asked. "Absolutely nothing. Guys are dying out there."
Maj. Gen. Mohammad Mussa Wardak, the medical commander of the Afghan army, told Reuters in August that procurement and distribution of medical supplies remained a weakness. He pointed to delays in supplies reaching hospitals and bureaucratic obstacles when importing morphine, an essential narcotic. "It's not a good system," he said.
As a backup, regional military hospitals can buy medicines on the local market. But that fix exposes soldiers to often poor quality medicines that flood much of the Afghan market, said Wardak, who was recently removed from his post.
More broadly, there are concerns over how international aid money to the military is being spent. An August 29 report by the U.S. Department of Defense Inspector General found that Afghanistan's previous government under President Hamid Karzai had failed to effectively track billions of dollars in direct contributions to the Afghan defense forces.
VITAMIN C INSTEAD OF BANDAGES
© REUTERS/Omar Sobhani Afghan policemen arrange medical boxes at a police medical warehouse in Kabul, August 27, 2014. Picture taken August 27, 2014.
Inside the police medical warehouse complex in Kabul, the long shelves are stacked with medicines and equipment for the main police hospital in the capital and 129 small clinics around the country.
It’s late August and fighting is unfolding across fronts in several provinces, but the compound is not particularly busy. A single truck is parked in front of a warehouse, picking up supplies for a medical facility in Kabul. Inside one of the buildings, a worker arranges supplies on a table.
Unlike the army, which sends medical supplies to its regional centers by convoy, staff at the police clinics travel to Kabul to stock up because they don’t have regional warehouses. It's an often dangerous journey along insecure roads.
ISAF advisors also worry about the quality of medicines the police are receiving. Of 23 police clinics that Reuters contacted by phone in 20 provinces, the overwhelming majority said they were routinely short of medicines, that they often didn’t receive what they ordered or that the medicines they did get were regularly of poor quality or had expired. Only two of the clinics said they did not have problems with supplies or delivery.
A staff member at a clinic in Logar province outside Kabul said they routinely received medicines for inpatient use even though they were an outpatient facility. And a staffer at a clinic in the restive eastern province of Kunar, who said the clinic treats 40 to 50 wounded police a day, recalled receiving a delivery of Vitamin C instead of bandages that were needed. Only a few bandages arrived, he said.
Dr. Assadullah, the surgeon general for the Ministry of Interior, told Reuters there were “security problems” when medical staff traveled to Kabul for supplies. A shipment of medical supplies for Herat, some 800 kilometers (500 miles) west of Kabul, has been stuck in the capital for the past two months because of security restrictions on the roads, he said.
To help address this problem, the government has plans to build six regional police hospitals, each with its own warehouse, Assadullah said.
As coalition facilities close down and the number of soldiers and police wounded in battles with the Taliban rises, Afghan security forces are increasingly turning to civilian hospitals for help. With the number of civilian injured also going up as the insurgency intensifies, these hospitals are already strained.
To be sure, there are bright spots. Afghan surgeons are saving the lives of soldiers and police at hospitals run by their security forces. ISAF advisors say some Afghan medical facilities that were previously criticized by the U.S., including the army’s largest hospital, the Kabul National Military Hospital, have improved.
In August, the Afghan army opened a trauma center in Helmand where the quality of surgery is “remarkably good,” according to Navy Captain Jim Cole, the ISAF command surgeon for the region. “Their survival rates have dramatically improved,’’ he wrote in an email.
Foreign troops also won’t disappear completely. While combat operations will end next month, starting in January as many as 12,000 troops will be part of a new NATO-led mission called Resolute Support that will train and advise Afghan security forces. And the international community will continue to help finance the Afghan military.
`THEY CAN’T HELP US’
At Emergency hospital in Lashkar Gah, where civilians, security forces and insurgents are treated side by side, the impact of the war is inescapable in the hospital's hushed, white wards. The injuries are evidence of an increasingly ruthless conflict.
In the hospital's A Ward, where patients are transferred from ICU, 16-year-old Abdul Qawe lies on his side. His thin torso is swaddled in white bandages that cover a wound running down the middle of his abdomen like an open zipper.
Grimacing, Qawe explains how he was shot when insurgents ambushed the police checkpoint he was guarding.
Qawe is resigned to the fact that his own police force wasn’t able to treat him. "There is so much fighting in Sangin," he said. "They can't help us."
(Reporting By Krista Mahr.; Additional reporting by Kay Johnson, Mirwais Harooni, Hassib Sayed, Hamid Shalizi and Saman Basir in Kabul. Editing by Peter Hirschberg and Michael Williams.)
© REUTERS/Daniel Becerril Mexico's Attorney General Jesus Murillo Karam (3rd L) walks with others after a meeting with relatives of the 43 missing students of the Ayotzinapa teachers' training college, at a hangar at an airstrip of Mexico's Federal Police in Chilpancingo… 
© REUTERS/Daniel Becerril Relatives of the 43 missing students of the Ayotzinapa teachers' training college leave a hangar after a meeting with Mexico's Attorney General Jesus Murillo Karam at an airstrip of… The confessions of the gang members pointed to the murder "of a large number of people," Murillo said, showing a video of one suspect saying the victims had said they were students.
