KANDAHAR, Afghanistan — As soon as the Taliban bullet struck 24-year-old Afghan Sgt. Nazir Moradi’s leg, the men in his unit began brainstorming a way to get him off the battlefield.
The roads were too dangerous for an army ambulance. The Afghan soldiers, in several calls to their commanders, repeated one plea: They needed a helicopter.
The Afghan air force didn’t have any working aircraft available. The U.S. military, in the midst of drawing down its air support, denied a request for help. Instead, Moradi was carried for miles and eventually put in an unarmored ambulance impeded by rough terrain and the threat of roadside bombs.
By the time Moradi arrived at the Kandahar Regional Military Hospital, more than three hours away, he had bled to death from a minor wound. Hospital workers carried him to the morgue in a flag-draped coffin, the ritual they perform each time a soldier arrives too late.
“We kept waiting for a helicopter, either American or Afghan. But it never arrived,” said Pvt. Morabuddin, Moradi’s best friend. “He did not have to die.”
For the past decade, the Afghan army has relied on hundreds of American helicopters to pluck wounded soldiers from remote battlefields and outposts. Now, the U.S. helicopters are leaving Afghanistan just as the country’s army embarks on its toughest fight, assuming formal responsibility for security this summer. The Afghan air force has 60 helicopters, but many are out of commission at any given time, and none is dedicated solely to casualty evacuation.
The war here is full of asymmetries between one of the world’s strongest militaries and one of the world’s newest forces, dependent entirely on foreign aid. The staggering gap in air evacuation capacity raises questions not only about how Afghan troops will defeat a resilient enemy, but how they will avoid countless unnecessary deaths. About 250 Afghan soldiers and police officers die every month, a toll far higher than that suffered by Western troops in their deadliest period.
The United States has invested millions of dollars in training and supplying the Afghan air force, but American officials acknowledge that Afghan pilots will be able to evacuate only a fraction of wounded soldiers and police officers. Last year, the United States evacuated 4,700 Afghan soldiers by air, compared with the Afghan air force’s 400.
With American air support vanishing, the rest will have to rely on unarmored ambulances, even though soldiers are often wounded hundreds of miles from an adequate hospital, separated by roads peppered with homemade bombs, known as IEDs.
“Your helicopters are our life support, and they’re leaving,” said Ahmad Zia Safai, a surgeon at the Kandahar hospital.
When its troops are wounded, the U.S.-led International Security Assistance Force (ISAF) has long relied on a massive fleet of Black Hawk helicopters operating 24 hours a day. Rapid air evacuation is credited with saving hundreds of lives in the past decade of war. The coalition deems transporting its own casualties from the battlefield in ambulances too dangerous.
The Afghan air force, meanwhile, has about six working helicopters in all of the restive south. Afghan pilots don’t have the resources, such as night-vision goggles, necessary to fly after sunset, and their weakness in ground combat means that they are seldom able to land in hostile territory.
The Afghan fleet is expected to require NATO support until at least 2017, according to U.S. officials, due in large part to concerns about maintenance.
“There’s no way the Afghan air force will be able to cover what we’ve been covering,” said Col. Michael Paston, the U.S. 438th Air Expeditionary Advisory Wing surgeon general. “Are they going to be surprised when they call on ISAF [to evacuate a casualty] and ISAF says no? That’s happening now.”
That new reality has prompted a crisis of confidence in many Afghan units. Some commanders worry that troops might be less willing to put their lives at risk knowing that they lack once-dependable medical support.
“How can we fill the gap as the U.S. withdraws? It’s impossible. We can’t grow fast enough,” said Col. Asrail Wardak, the deputy commander of the Afghan air force’s southern fleet.
As the Taliban’s summer fighting season went into full swing this month, the dead and critically wounded soldiers poured into Kandahar Regional Military Hospital in almost equal number. All the men who arrived with life-threatening injuries had been evacuated by U.S. helicopters.
After performing a double amputation on a soldier who had stepped on a makeshift bomb, Khadir Tajik, a physician, emerged from the operating room with beads of sweat on his forehead.
“Without a helicopter, there’s no question he would have died. An ambulance would have taken way too long,” he said.
The recovery room was full of patients who said they knew that the helicopters that saved their lives were leaving Afghanistan. With the NATO withdrawal accelerating, they could be some of the last Afghan casualties to be evacuated by international forces.
Lt. Tamarac Dyer, an ISAF spokesman, said coalition forces “will provide assistance when needed, but not on a routine basis,” at bases shared with Afghan forces, which are rapidly diminishing in number.
In most cases, like Moradi’s, Afghan soldiers are injured while on missions at which no foreign forces are present.
In the Kandahar recovery room, there was a 25-year-old commando whose unit had unearthed eight makeshift bombs before the ninth exploded beneath his feet. There was a 21-year-old police officer whose vehicle had stepped on a roadside bomb and whose right leg was amputated by doctors; when he couldn’t hear them, they whispered that his left leg would probably have to be removed, too. There was a 22-year-old soldier who was stabbed and beaten after he stepped out of his outpost to investigate suspicious activity.
Top U.S. and Afghan military leaders have met twice in the past year to discuss the future of casualty evacuation after NATO’s pullout. U.S. officials urged Afghan commanders to do ground evacuation, according to U.S. and Afghan officials. Gen. Abdul Basir, the Afghan army’s deputy medical commander, said he stood at the second meeting and spoke angrily.
“If a soldier is in serious condition — if he has lost his limbs — an ambulance will not get him to the hospital in time,” he recalled saying.
Like many of his colleagues, Basir was trained by American doctors and military officers over the past decade. His U.S. advisers taught him the importance of the “golden hour” — the window of opportunity to save a victim of severe trauma.
“Without helicopters, we lose the golden hour,” Basir said in an interview. “We lose an opportunity to save lives.”
Still, late last year, after the meeting with U.S. officials, Gen. Sher Mohammad Karimi, the Afghan army’s chief of staff, issued a memo to his commanders explaining the need to rely on ambulances as U.S. air support dwindles.
“Until now, the evacuation of the war wounded and injured was often carried out by the international coalition through air,” Karimi wrote. “Since this process has been gradually reduced . . . Afghan army units need to arrange their plans for ground evacuation.”
Recently, two Afghan Mi-17 helicopters flew over the rocky, inhospitable terrain between Kandahar and Zabul provinces. Each casualty evacuation amounts to a small triumph for the nation’s young air force. This one occurred after a hailstorm grounded the entire fleet for four days.
A few hours after a wounded soldier, Pvt. Lal Muhammad, was loaded, grimacing, into the helicopter and transported to the Kandahar military hospital, he spoke coldly from his hospital bed.
“It took four days for them to pick me up,” he said. “How is that possible?”
Muhammad’s injury wasn’t life-threatening — he had accidentally shot himself in the foot in the middle of a firefight. But the closest hospital with experienced medics was nearly 200 miles from his remote outpost. The road to the facility, Muhammad’s unit knew, was lined with bombs. The only solution was to wait for a helicopter, however long it took. If the injury had been more serious, he he assumes he would have died.
“You can’t replace a U.S. helicopter with an Afghan ambulance,” said Soor Gulab Ahmadzia, the flight medic who tended to Muhammad.
U.S. officials haven’t articulated what kind of air support they will provide to Afghans through 2014 — only that it will continue to diminish. That transition has been rocky, and U.S. officials acknowledge that they are letting Afghans down by denying requests for air evacuation.
The U.S.-led coalition made a similar change in 2009, when it largely stopped providing air evacuation assistance to Afghan civilians injured by the Taliban. Some in the U.S. military viewed that as a betrayal.
“Not only did the U.S. choose to escalate the war knowing that civilians would increasingly be killed and wounded — without proper trauma care in place — they also changed the medical rules of engagement, resulting in greater mortality,” said one U.S. official who is not authorized to talk to the media and spoke on the condition of anonymity.
U.S. officials say they are simply trying to find an “Afghan solution” as their resources diminish. But there are many stories, like Moradi’s, of Afghan soldiers and police officers dying of treatable injuries.
In March, Naqibullah, a police officer in Wardak province who had been injured by a Taliban mortar round, waited seven hours to be evacuated by air because his commander worried that an ambulance would be vulnerable to roadside bombs. The helicopter never came, and Naqibullah bled to death.
But the commander’s concern turned out to be justified: Hours later, a vehicle in the convoy transporting Naqibullah’s body from Jaghatu district to the provincial capital hit one such bomb, killing another officer.
“This brought down the morale of our officers one hundred percent,” said Wahid Tanha, the Jaghatu police chief. “It shows the weakness of our government.”
In an interview in Kandahar, Morabuddin said he traveled 500 miles with Moradi’s coffin to Badakhshan province, along the border with Tajikistan.
When he arrived, Moradi’s relatives opened the coffin and saw the minor gunshot wound. Morabuddin said he felt obligated to explain what had happened, how their son and brother had died of a treatable injury.
“After he was wounded, there was no way to evacuate him by ambulance,” Morabuddin recalled telling them. “There was no road. By the time he arrived in the hospital, he was dead.”
Morabuddin waited for more questions, dreading the answers he would have to give. But the family was silent. Finally, Moradi’s brother spoke.
“What we know is that he died for his country. It was his destiny.”