Zarsanga, a tiny 5-year-old with serious eyes who, like many Afghans, uses a single name, was inside her home in rural Ghazni province, playing on the floor with a 3-year-old cousin, when a firefight broke out nearby between Afghan soldiers and insurgents.
Now she’s in a war trauma hospital in Kabul run by the small international charity Emergency, the victim of a major reason that civilian casualties have jumped sharply in the first half of the year: getting caught in crossfire between insurgents and Afghan soldiers and police.
The United Nations Assistance Mission in Afghanistan reported Wednesday that the number of civilians wounded in the war here during the first half of the year rose 23 percent compared with the same period last year. The increase was even higher among women and children, up 61 percent for women and 30 percent for children.
No single reason is responsible for the full increase. In many cases, insurgents have struck targets such as police highway checkpoints, courthouses or government offices without regard to the presence of civilians or they’ve used improvised bombs indiscriminately.
However, the report says a major cause is that as the U.S.-led coalition has closed hundreds of small bases in outlying areas, insurgents have become more bold. That’s led Afghan security forces to attack, according to the report, and civilians often are caught in the ensuing fighting.
Zarsanga’s bullet entered her right hip and smashed the femur just below the joint. X-rays show that what’s left of the top of the bone sits at a 90-degree angle, and is mending that way.
"My cousin is fine. It was only me who was injured," Zarsanga said, dangling her legs in a wheelchair that was built for children but was still too large. "I can’t walk, but it doesn’t hurt right now."
It’s unclear how much she understands about how her life will be different.
The doctors are trying to partly fuse the joint, but that leg will always be shorter than the other, said Luca Radaelli, the hospital’s medical coordinator. At best, Zarsanga will walk with a slow, swinging gait.
Just inside the door of Zarsanga’s ward, a whiteboard bears the name and cause of wound for each patient.
"Bullet, bullet, shell, bullet, shell, bullet, bullet, knife, shell, bullet," Emergency’s Afghanistan program director, Emanuele Nannini, read on a recent day, hitting a rhythm as he worked down the list.
There are whiteboards like that one in all six wards of the hospital, and more in Emergency’s hospital in Lashkar Gah, in Helmand province, where the fighting has been particularly fierce. These days, those boards stay full.
Emergency admits only patients with severe trauma. Nearly all are civilians, though there also are police officers, and even Taliban. Its admissions are up 59 percent for the first half of the year, including an 89 percent increase at its hospital in the violent south.
Nannini said the spiking seemed to be in part because the fighting had moved closer to towns and villages in many areas. Also, government clinics in the most dangerous areas have been closing or seeing members of their staff flee, so Emergency is getting patients the Afghans can’t handle.
The U.N. report looks at deaths and injuries across the country, not just in the worst-hit places, where Emergency works. It says that all told there were 1,319 civilian deaths and 2,533 injuries. That reverses a decline last year.
The bulk, 74 percent, are still caused by insurgents and other "anti-government forces" such as criminal groups.
Improvised bombs remain the largest cause. In some cases, they’re triggered by the weight of vehicles, which can be minibuses carrying locals just as easily as they can be Afghan army Humvees.
"And if a bomb hits a minibus, who’s inside? Often, it’s women and kids," said Georgette Gagnon, a representative of the Office of the U.N. High Commissioner for Human Rights in Afghanistan.
For women, the ground fighting between insurgents and Afghan security forces was the most common cause of death or injury. For children, it was improvised bombs, then ground fighting and then accidental detonation of munitions left behind by fighting or the closing of a coalition base.
The U.N. mission called on the Afghan security forces to develop proper methods for tracking and reducing civilian casualties. It blamed government forces directly for 9 percent of the casualties.
For Afghans who are badly wounded, Emergency is widely regarded as the safest place to go. Even Afghan hospitals send deteriorating cases there that they’ve treated but cannot save.
Despite the fact that Emergency gets some of the worst cases, if a patient makes it there alive his or her chances improve instantly: Ninety-five percent of those who reach the Kabul hospital survive.
Emergency has three hospitals and about 40 clinics across the country, and a lean staff with a few foreign doctors and nurses and a few from Afghanistan.
In Kabul it has what was the first CAT scan machine in the country, and its facilities are among the best in Afghanistan, though it’s modest by Western standards.
The nonprofit is aggressive in maintaining its neutrality. It asks no questions about which side patients might have been fighting on or the circumstances of their wounds, other than what’s necessary to treat them.
The history of the organization’s Kabul hospital is a reminder of the seemingly endless chain of violence in the country for the past few decades.
It was a kindergarten, built by the Soviets before CIA-backed insurgents ran them out of the country.
During one of the various phases of civil war that followed, Taliban leader Mullah Mohammad Omar gave the building to Emergency at the group’s request to help underline its neutrality. That balanced the earlier gift of a hospital by Ahmad Shah Massoud, the famed Northern Alliance commander and fierce Taliban opponent.
Now it’s a quiet, almost gardenlike oasis from the tumult of the city around it. But there’s a sign on the grounds near a small monument that dates to its days as a kindergarten.
"A rocket landed in this place in 1992 and killed five children," it says.
A few feet away, in the women’s and children’s ward, the beds around Zarsanga are filled with other children. A boy, 8, who’d been hit in the abdomen by shrapnel. A boy, 10, who’d lost much of a hand to a land mine. A boy, 7, with a shell injury to his back. A girl, 10, who’d been hit in the buttocks, left thigh and right leg by shrapnel from a shell or bomb. A 5-year-old boy hit in the right leg with a bullet.
His leg had been amputated just two days earlier, but he was grinning and laughing with another patient.
Watching, Radaelli just shrugged. Afghan children are tough, he said. After they’ve been in the ward for only a few days, it becomes their community.
In the hospital’s intensive care unit, two other wounded children lay. One, a 5-year-old boy, had taken a shell blast to the abdomen, shoulder and groin. Doctors had removed part of his intestines and were monitoring his condition carefully.
The other, a 10-year-old boy, had been struck by a bullet that entered his skull low, from behind, and passed out the upper left front. Initially, he was unable to breathe without a respirator, his eyes had rolled back and he twitched rhythmically. A few days later, almost miraculously, he was able to breathe again, though how much function he will have is unclear, Radaelli said.
For every name on the whiteboards at Emergency, for every person in a bed, there are plenty who don’t get the chance, Nannini said.
"It’s hard to say this, but those we actually get are the lucky ones," he said. "We have no idea how many patients don’t reach us."