Hospital on the edge

This post contains graphic images.

Above, toddlers slept two or three to a bed in the children's intensive care unit at Mirwais Hospital, Kandahar.

I spent some time at southern Afghanistan's biggest public hospital working on another development story for National Public Radio. Read and listen to Soraya Nelson's NPR report here. The story was part of an end-of-the-year, in-depth series on the direction Afghanistan is going as a whole.

As security has deteriorated in Kandahar, many international NGO's have pulled their staff from the area or shut down their regional offices, cutting off the flow of money and people in a region where they are badly needed.


Despite the worsening security situation, development continues at Mirwais Hosptial, where the International Committe of the Red Cross (ICRC) conducts training and assists the local staff. ICRC is one of the few humanitarian NGOs with a foreign staff living and working in Kandahar.

Mirwais is a vital health treatment center, the only public hospital serving five southern provinces. If they are able, wounded and sick people travel from Helmand, Zabul, Uruzgan, Paktyka and throughout Kandahar province to reach this group of buildings near the edge of town.


Above, children's ICU.

The hospital has six departments: surgical, infectious diseases, pediatric, ophthalmology, obstetrics/gynecology, and emergency/intensive care. Two-thirds of patients come to the emergency department and around 50 percent of all clients are trauma patients. (That's a lot.)

By documenting daily life inside, I wanted to give an idea of what life is like outside the hospital walls--why development is both difficult and so very needed. Mirwais Hospital is in the middle of a war zone where Afghans are kidnapped and injured by bombs, and the violence makes development work dangerous. But poverty and under-development create a desperate need for clean water, health care, roads, electricity and sanitation.


Mirwais has a tiny neo-natal intensive care unit, with three or four incubators. Above, ICRC nurse Kristina Alho of Jyvaskyla, Finland, prepared an underweight baby girl to see her mother.

Infant mortality and maternal mortality rates are among the highest in the world. In rural Afghanistan, women sometimes start having children at a very young age, don't have access to birth control and are often the last to receive health care. It's a lethal combination for mothers and babies.


Accompanied by two female hospital staff members, Nurse Alho carried the baby girl through hallways to see her mother in the women's intensive care unit. Alho was on a six-month ICRC contract to work at Mirwais.


The preemie baby was delivered by Caesarian section and had been unable to breast feed, and the family had no money for milk. Convinced that the baby's weight and overall health would improve dramatically if the mother, Jana, could just get her milk to come, Nurse Alho tried to help.


But the milk wouldn't come.


Jana looked despondently at her baby girl, shortly before offering the child to NPR correspondent Soraya Nelson, my colleague.


A dimly-lit hallway on a women's floor.


Shakofa, 2, recovered from burns to her chest and feet in a children's burn unit. Many Afghans use open fires, propane or oil for cooking and heating.


The fires sometimes cause severe burns, especially over the winter. Above, 18-year-old Abdul Rahim, of Shawali Kot District, Kandahar Province, tried to rest in the men's burn unit. Two months earlier, Rahim was standing too close to a fire in his home when his clothing caught fire.


A toddler played on the floor next to Abdul Rahim.


A man was wheeled into the emergency department.


Regular people, civilians, get caught in the crossfire of Afghanistan's conflict and end up at Mirwais after being wounded in kidnappings, roadside bombs, by landmines and air attacks.

Above, Mohammad Nassim, 35, lay bruised and groaning in bed. Nassim and another man, 28-year-old Sher Mohammad, were kidnapped by Taliban from a municipal water wheel construction site where they were working, in Takhtapoul District. They said they were blindfolded and tortured for four days, before being released to warn others against working with the government.


Sher Mohammad's bruised back.


I was standing near the entrance to the hospital one morning when something unexpected happened. A truck carrying the dead bodies of two Afghan border policemen arrived.

And that's how I found myself in the hospital morgue.

The day before, Ahmad Shei, 25, and Hamidullah, 22, were in an unarmored truck carrying material to a checkpoint in Zabul Province. A roadside bomb detonated near their vehicle. Ahmad Shei and Hamidullah were killed; four other border policemen were injured and taken to Kandahar Air Field to receive medical treatment at the foreign military hospital. The two dead were taken to the morgue at Mirwais Hospital before being transported to their home provinces in the North for burial.

The second man from the left facing the camera, helping to lift the body of Ahmad Shei, is Atullah, 20. His brother was Hamidullah, the other dead policeman. Atullah told me he and his brother were from northern Baghlan province, and their parents had died much earlier. Their other siblings were working in Iran, and for quite some time, it had been just the two of them.


Minutes later Atullah wept outside the morgue while his brother's body was washed and prepared for burial. He had just lost his best friend, brother, parent and comrade. I shot a couple of frames and then sat quietly next to him for a few minutes. I told him that I have a big brother too.

I couldn't help wondering how these two guys from way up north had found themselves in Zabul of all places. Had they been serving their country? Earning a paycheck? Keeping each other safe?


Imam Gul, 25, stood next to the body of Hamidullah, while the body was washed inside the morgue.

I don't know why they let me in. Maybe they wanted their sacrifice to be recorded. Maybe they didn't know what to do with the random foreign woman with a camera. Maybe they were too tired and shocked to care.


Imam Gul and Amanadin watched while a white shroud was pulled over their fellow policeman Hamidullah's body.

This picture is still hard for me to look at. The look on Amanadin's face mirrors my own shock.

I feel like most editors would think a photograph of a dead man with his legs blown off was unnecessarily graphic and would turn people off in a bad way. I guess this is the only place I feel like I can share this image and how it felt to be there, taking it.

Because this is the cold, hard truth.

Village by village

I know I haven't posted anything in a long time. Maintaining a blog is tough! Trying to get back on track, and taking you back to Afghanistan...

Above, a seventh-grade class in the girls' high school in Farghamanch, Jurm district, Badakhshan province.

This photograph was part of a story about the moderately successful National Solidarity Program in the impoverished but peaceful province. I had the pleasure of working with Sabrina Tavernise and our Afghan colleague Sangar Rahimi on this one.

(Please read Sabrina's New York Times story here. She did a great job. Also a slideshow by me.)

Through this program, villagers can apply directly for small development grants for whatever it is they feel their community needs most. Over the past five years, the people of Jurm have implemented a large drinking water project, come together during a flood disaster and built schools for girls, like the one above.

The keys to these small successes stem from the community-based approach and patience--change happened incrementally over a period of years. Local staff from the Aga Khan Development Network worked carefully with the villagers in Jurm set up councils, or shuras, who then acted as a group to apply for and implement the grants. This took the power out of the hands of the local commander and spread it out among the people.

It took a long time for the people of Jurm to accept help from the outside. Years of war and isolation made them initially hostile to the program, but the local development NGO worked patiently to build trust and credibility.

This story started as a report on the effects of illiteracy and evolved, as stories often do, into something much bigger. Illiteracy is a huge factor, because it's so much easier for a powerful commander or corrupt government officials to take advantage of people who can't read. However, one of the beautiful things we learned is that within this structure, even illiterate community leaders were able to come together and take charge.

We spent three bone-jolting days traveling the dirt roads of Jurm, visiting villages and projects.


Our journey into Jurm started with these guys: local shura leaders from all over the district. Jurm now has 68 shuras (or in the lingo of Aga Khan, community development councils, CDC's).

Notice the guy on the far right. His name is Shamsullah and he is the mullah, or religious leader, from Farghamanch, the village with the new school. Very powerful guy.

Sabrina wrote about him for At War, New York Times' blog about Post-9/11 conflict zones. To see just one example of what the Aga Khan Development Network was up against, read her post here. It's disturbing.


When I say isolated and remote, I mean this: Badakhshan has one paved road less than a mile long in Faizabad, the provincial capital. In Badakhshan's rugged mountainous terrain, winter storms routinely cut off entire districts from the outside world. Very few people own their own cars, traveling instead for miles by foot or donkey on paths cut into the sides of cliffs. It is under-development incarnate.


Traditional farming techniques in practice. Going into rural Afghanistan can feel like going back in time.

Actually, places with lots of arable land for agriculture, like the area above, are considered relatively affluent in Badakhshan. The people are more able to provide for themselves and less likely to depend on the commander with the most guns for their livelihood. Thus, areas with lots arable land were more open to Aga Khan, the shura idea and the National Solidarity Program. More impoverished communities, i.e., villages without arable land, like Farghamanch, were less open.

An interesting side-note: just a couple years before, the entire area was covered with poppy fields. A combination of falling poppy prices and an Afghan government crackdown led the farmers to plant wheat instead. And maybe a little nudging from Aga Khan helped too.


I managed not to get run over by the oxen.


Yes, that is a 9-year-old (who looks 5), preparing his family's fields for wheat planting, in the light of sunrise. BUT, he attends school in the afternoon. His name is Aziz, and he will hopefully grow up to be a literate farmer.


A market in nearby Baharak. Cell phone towers and the phones that come with them arrived in Baharak and Jurm just two years ago. They've revolutionized life in a place where nonexistent infrastructure, poverty and winter weather make travel extremely difficult. Cell phones have allowed shura members to talk to one another in emergencies and when they are unable to meet in person.


Like most places outside of Kabul, Jurm district is still very conservative, especially with regard to women and family. Above, women depart a teacher training course.


I chased goat herder Abdullah, 18, and his posse up the side of a mountain. It was a hike! I realized you can't run after goats if you want to get closer to them, you have to sneak up on them. (Sigh. The things one learns in the field.)


Girls stopped collecting dung (used for fuel in these parts) to confront my camera. The girl wearing the red scarf was so confident she made me smile. In my haste I actually forgot to ask if they attend school. I hope they do.


Elected shura members listen intently during a leadership training workshop, Jurm district Aga Khan headquarters.


The workshop instructor talked about the qualities of a leader.


What is a workshop without a team-building activity? Actually, since most of the people in the workshop couldn't read or write, hands-on activities took on new importance--they were more likely to learn through doing.

The shura members were split into two groups and had to work as a team to hang a handful of nails from one big nail stuck into a wooden block. Different styles of leadership emerged as the group worked through the problem. It was something out of the NGO community development handbook, plopped down into the middle of rural Afghanistan. Not something I expected to see, but...


...they were really engaged in the task. They didn't find it silly or pointless. It was fun to watch them try to figure it out.


Success!


In Dashtak village, communal water taps are spaced every ten houses to ensure that everyone can get enough drinking water. Seven village councils banded together to facilitate drinking water for the residents. Such teamwork was unheard of before 2004.


Masura's eyes well up with tears while she talks about her husband who died of illness just days before in Farghamanch village. Many remote areas in Afghanistan, especially in poorer provinces like Badakhshan, still lack water, electricity, schools and health clinics.

In addition to seeing successful projects in villages where people were more receptive to change, we wanted to see a place where the Aga Khan and National Solidarity Program faced a real challenge.

This was Farghamanch.

One of the poorer villages, it was essentially ruled by the young radical mullah pictured near the beginning of this blog post. Shamsullah was one of the most resistant community leaders, according to local Aga Khan staffers. But, over time, the staff gained his trust and surprisingly, the community's top priority was a new school--for girls.

Actually pretty amazing.

Our first visit to the village was on a Friday afternoon, the day off, so we decided to just talk to some of the people living there.


As Shamsullah was away in another village, we met some very warm and receptive people. Sabrina conducted interviews while one of the women brought me into her home. Nagmi, right, a wife and mother in Farghamanch, looked through a practice notebook next to 14-year-old Madida, who attends the village's new girls' school. Nagmi attends a women's literacy class once a week, also held at the new school, another little victory in this outpost in the middle of nowhere.

Literacy in Afghanistan hovers around 28 percent, and is even lower for women.


Nagmi writes her name.


The following day started bright and early as we watched girls and boys walk to a school located between two villages in Baharak district, just west of Jurm. The school has 300 students and 13 teachers, some of whom walk two hours each way to school every day. Ninth-grade girls occupy two of the school's classrooms, a high grade for girls in this province. Ninth grade is marrying age.

It so happens that Shamsullah, the powerful mullah from Farghamanch, was a teacher at this school. So, let's see: he was the religious leader and shura leader of his own village, teacher at a school outside his district, and we found out that morning he was somehow involved in voter registration during the recent elections. And the other teachers at this Baharak school were afraid of him.


We decided it was finally time to visit the new girls school in Farghamanch, the one that the community had built with National Solidarity Program money.

Photographically, it was essential to shoot girls inside or outside of the school--a task much harder than it looks. This village was a place seen by few outsiders, and the school administrators and teachers were actually somewhat hostile toward us. Judging by the prevailing attitude of the mullah ("We not only hate Americans, we hate all foreigners."), let's just say we were not welcomed with open arms at the school.

One of the administrators took me into a ninth-grade classroom and the girls recoiled at the suggestion of being photographed. (I don't know why he started with the oldest girls. Some of them are already young women.) I went outside and in my desperation made some photos of the exterior.


I saw a pupil looking out the window of her classroom. She didn't seem horrified at my presence, so I went back inside and made a few photographs inside the seventh-grade classroom, including the one at the top of this post.


Ameenah, 13.

When I asked her what she wanted to be when she got older, she said in a wavering voice that she wanted to become a doctor. The other girls laughed when she said this and her face crumpled. I ignored the laughter and tried to encourage her, telling her she can achieve whatever she wants, if she works hard.

And I can only hope this is true.

Uruzgan germs

The next few posts will bounce back to Afghanistan, although I am now back in Cairo for a break.

The one and only embed I did in the entire three months was with the Dutch troops down in Tarin Kot, Uruzgan province, and I will forever remember it as the embed that gave me pneumonia. I started to feel under the weather the day Mark Magnier, of the Los Angeles Times, and I traveled to Uruzgan. It took a whole day (starting at around 6 a.m.) to get there via military transport flights.

The story was about how the Dutch are using development to improve security. We spent the following day with the Police Mentoring Team, as they conducted a traffic stop and training with local police. Take a look at Mark's story here: "Dutch troops' method in Afghanistan gains new prominence."

I admit I am a little divided on embeds. Some journalists spend the bulk of their time in Afghanistan embedded. While I think the military is a vital aspect of the story, it is nearly impossible to get to know regular Afghans while embedded. Some places are extremely difficult and dangerous to visit so hooking up with the military is sometimes the only way, and I admit I would not have been able to get to Uruzgan without embedding. I just try to take it as part, but not the whole, story.


I woke up with my throat on fire and feeling like my head was four times too large. Always a bummer when there's work to be done.

We left the base and convoyed through the provincial capital of Tarin Kot in these giant armored vehicles with little slits for windows. I guess they were similar to the U.S. Army's M-RAP (Mine Resistant Ambush Protected vehicle). From a safety standpoint, these are supposed to be more protected than a Humvee if an road-side bomb explodes nearby, which is great, but I couldn't see anything from inside. I asked one of the rear gunners if I could poke my head up for a few shots, but I also didn't particularly want to get in his way or obstruct his vision. Tricky.

The other downside is the vehicle doesn't take bumps well. At all. I could barely hang on to my camera.


Downtown Tarin Kot. Lots of men, kids, even some women out, all good to see. We were just passing through though to the other end of town. No time to stop and chat.


The soldiers parked in formation and got out at an intersection next to a gas station and across from an Afghan National Police station called Sar Sheykhil. Then the soldiers set up an impromptu traffic checkpoint so that the Afghan National Police could practice searching cars and people for weapons and explosives.


The idea was for the soldiers to mentor and supervise the police while they conducted searches, which is good since most of the police seemed to be unarmed.


It was a just another September day in Uruzgan: dusty and hot.


The foreign presence attracted lots of curious onlookers.


I like the eyes on the headlight. Classy.


Some people seemed to find the whole experience entertaining.


The police went inside the station to take part in a training on handcuffing and searching, so the Dutch soldiers continued searching the motorists and pedestrians outside.


These kids and their donkey walked by at least five times. (I have other photos of them.)


Inside Sar Sheykhil police station, Sgt. 1st Class Radjen Rampersad taught procedures for searching and handcuffing suspects. He also asked them basic civics questions, like "Why is it permitted for police to search and handcuff someone?" Most couldn't answer. They attempted the exercises with enthusiasm though.


The police don't have the tools they need to conduct their work, and they don't earn much money. This 40-officer station shares one pair of handcuffs. Most of the officers don't have their own weapons. Some don't even have proper shoes. Because of the complicated politics back home, the Dutch must get special permission to hand out arms. But, it's hard to figure out what part the Afghan government has in equipping and training them.

For their part, the police officers expressed frustration. They are starting from zero and they are putting themselves at risk for what seems like very little in return. Afghanistan is one of those places that needs so much it's hard to know where to begin.


That's the police station behind the HESCOs--the brown bunker-type things in the background. (Pretty sad I talk Army now.)

Almost time to cut out. By now all I can think about is my pounding head, clogged sinuses and the bed in the container back at the base. And I am coated in sweat and dirt.


Go inside, little guy. It's too hot.


Much of Uruzgan is desert, by the way. Mountains, valleys, very harsh terrain. Very little infrastructure. Did I mention it's like an oven?


Yes that is a windmill. It's actually a coffee bar inside of a container at the base in Tarin Kot, FOB Ripley.

And, with that full day's work, I crashed in my bunk. It took three days to get back to Kabul, and by that time all I could do was lie miserably in bed.

Ah yes Uruzgan. I won't forget you, or your dust.