MSF Surgeon Recalls Kunduz Strike: 'I Didnt Need Convincing That I Was Going To Die That Night'

Doctors Without Borders (MSF) surgeon Dr. Evangeline Cua was working at the Kunduz Trauma Center when U.S. airstrikes destroyed the hospital in Oct. 2015. Here, she describes her ordeal.

Aurelie Baumel

On October 3 2015, MSF’s trauma hospital in Kunduz, Afghanistan, was destroyed by precise and repeated U.S. airstrikes. The attack killed 42 people, including 14 MSF staff members, 24 patients, and four caretakers, and wounded dozens more.

Since 2011, the hospital had been providing free, high-quality surgical care to victims of general trauma, such as traffic accidents, as well as patients with conflict-related injuries. It was the only facility of its kind in the northeastern region of Afghanistan.

The attack has had devastating consequences for the victims, their families, MSF teams and Kunduz. Six months later, the hospital remains closed until further notice, leaving thousands of people without vital medical services.

Dr. Evangeline Cua is a surgeon from the Philippines who was working in MSF’s Kunduz Trauma Center in Afghanistan when US airstrikes destroyed the hospital on October 3. Here, she shares her story of surviving that horrific night.

Cua said she went through multiple debriefings, consults with psychiatrists and meditation techniques after the hospital attack.

MSF

It happened again last night. I woke up sobbing and disoriented. It had been three months since I went home from Afghanistan and, except for a fading scar on my right knee, that awful incident at the Kunduz Trauma Center was almost forgotten, suppressed to memory.

Debriefings, consults with psychiatrists, meditation techniques, pages upon pages of journal entries to unload myself of the horror of that night — all of these were swept aside when memories came rushing back, triggered by a firework.

The acrid smell of smoke, the burning bodies and hair, the smell of fresh blood mixed with hospital cleaning agents, and the terror I felt that night became so real again that I had to resist the urge to panic, to run, to seek shelter. Reminding myself that I am home now, I am safe, and nobody can hurt me, I started questioning why I was in the hospital on that awful night.

Fire burns in the MSF hospital in Kunduz following the airstrike. Cua still remembers the "acrid smell of smoke, the burning bodies and hair, the smell of fresh blood mixed with hospital cleaning agents."

Anadolu Agency via Getty Images

We were like two headless chickens running in total darkness -- me and the surgeon who assisted me in an operation. The nurses who were with us a moment ago had run outside the building, braving the volley of gunshots coming from above. I was coughing, half-choked by dust swirling around the area. Behind my surgical mask, my mouth was gritty, as if somebody forced me to eat sand. I could hear my breath rasping in and out. Layers of smoke coming from a nearby room made it hard to see where we were. Blinking around, I caught sight of a glow, from a man’s hand holding a phone. He seemed mortally wounded but was still trying to send a message… perhaps to a loved one?

I stood transfixed, not knowing where to turn or what to do. All around us, bombing continued in regular intervals, shaking the ground, sending debris sweeping and flying. One. Two. Three. I tried to count but there seems to be no abatement to the explosions. I stopped counting at eight and silently prayed that we could get out of there alive.

Fire licked at the roof at one end of the building, dancing and sparkling in the dark, reaching towards the branches of the trees nearby. The ICU was burning. We decided that we had to go the other way, towards what had recently been the lobby of the hospital, where we could see a faint gleam of light.

Trash crackling loudly under our feet as we headed in that direction. Loose debris continued to fall on us. Wires were hanging from the ceiling, and we were surrounded by mounds of trash, broken glass, wood, paper, cement, plastic, shreds and chunks of God-knows-what.

Pure chaos.

Fuck! The word came unbidden from my mouth. We had not made it very far when I tripped and fell down on something soft. A dead human body…or bodies? Oh, dear God! Stifling a scream and fearing the worst, I slowly got up. There was a sticky wetness on the front of my operating room gown and my gloved hand. Hurriedly examining myself, I found a big gash on my right knee. Tiny pieces of glass were clinging on the surface of my OT gown. I ached all over. No major injuries, though. Good.

Walking slowly now, we decided to crouch near a wall in the only lighted area and waited for the bombing to stop. The silence was unnerving. Everything was askew — the door was on the floor, a wheelchair was in the middle of the hall, papers everywhere.

Outside, the constant humming from above pointed to the presence of something. Was it an aircraft? Was this an airstrike? Why the hospital? Why us?

Then, without warning, another tremendous, earsplitting blast shook the building. The ceiling came crashing down on us and the last remaining lights were turned off, sending us into total darkness. I screamed in terror as wires pinned me to the ground. That was the last thing I could remember.

"The ceiling came crashing down on us and the last remaining lights were turned off, sending us into total darkness. I screamed in terror as wires pinned me to the ground," Cua wrote.

MSF

I was 12 years old when I read a famous woman surgeon’s biography. I dreamed of becoming a surgeon since then. “I am going to wear a scrub suit,” I thought to myself. “With a scalpel in my hand, I’ll make a difference in other peoples’ lives.”

The desire to work in a war zone came later but it was prominent in my bucket list. I feel like I won the lottery when I got accepted by Médecins Sans Frontières as a field surgeon. Doctors Without Borders! Despite the reminders and warnings from well-meaning friends and relatives about the dangers of working in a conflict zone, I eagerly prepared for my first mission.

In a 100-bed trauma center in a war zone, I was expecting to be inundated with patients, operating day in and day out, to be so exhausted that all I could do was crawl into bed and fall into a deep slumber each night. I wanted to do complicated cases. Bomb blasts. Gunshots. Cases I had only read in textbooks. Anything.

But I felt useless in my first few weeks in Kunduz. Except for the occasional liver injury sustained during motor vehicle accidents and some elective general surgeries, the majority of cases I encountered involved bones and fractures, something I have minimal knowledge about. And there were eight Afghan orthopedic surgeons who were so adept at what they were doing that I began questioning if I was of any use there at all.

I was bored. I wanted to operate on patients. I wanted to do more. It was the reason I was there, after all. I only had two weeks before the end of my mission and, with a few exceptions, my life in Kunduz was one monotonous routine.

That is, until the fighting began.

At the time of the airstrike, operating theaters were in use, and surgeons and anesthetists were attending to patients. This photo shows an operating theater destroyed after the airstrike.

Dan Sermand

“Car doors… windows unlocked…. jump….. car…. stray bullets. No…. contact… stopped… the way.”

It was a few days before the bombing. Last minute instructions were being given to us. I couldn’t concentrate. The field coordinator’s voice drifted in and out of my consciousness. My stomach was growling and I hadn’t had any sleep since last night.

“Okay?” Four heads simultaneously nodded. I was hardly paying attention. Trying to fix my head scarf with one hand, I was also busy writing a message to send back home.

Surgical team going to the hospital. No wifi there. Will call once I’m back in the staff house. Tell mom and dad not to worry. We’re safe. :)

Message sending failed.

Darn! Securing my backpack, and trying to hide my frustration, I hurriedly climbed into the vehicle where a female nurse supervisor was already waiting. The male orthopedic surgeon and anesthetist were in the other van.

Heart pounding and pulse racing, I tried to position myself as low as possible near the door, ready to spring up and jump out of the car if necessary. I had lots of questions in my mind — what are we going to do if a bomb was thrown our way, if they wouldn’t let us pass, or worse, if we were kidnapped? I chose to be silent, to maintain an appearance of calmness, to focus instead on the journey to the hospital. The sun was already rising in the east when the sound of explosions temporarily stopped and the surroundings became relatively quiet. When the go signal was given, the gates of the staff house were opened and two vehicles entered the deserted streets of Kunduz.

The atmosphere that dawn was in stark contrast to the previous weekend. Eid had just ended, which is a happy and celebratory time in the Muslim world. Not a single shot was heard that weekend. Roses were in full bloom and the weather was perfect. Afghan men were shaking hands and hugging each other; kids in their finest clothing were playing in the streets, candies in their pockets; food was shared; people were freely walking in the streets, going to relatives’ houses to pay visits.

It had been a delight to see children, and even adults, waving at us as our vehicle passed through the streets of Kunduz going to the hospital. The local staff and caretakers greeted us with smiles. Eid Mubarak! Happy Eid, doctor!

But two days after that idyllic weekend, after fierce fighting between government troops and the opposition, the city of Kunduz, after 14 years, was once again back in the hands of the Taliban.

I lost track of time. The clock on the wall reminded me that it was already late afternoon. A barrage of gunfire and explosions continued in the distance. I had just finished my sixth surgery and was slowly drying my hands with a piece of cloth. My scrub suit and shoes had splatters of blood on them. I probably got them from the pregnant woman who was hit by a stray bullet in the neck, I thought to myself.

I was exhausted. I had been on my feet for almost nine hours already and my legs were aching. All I wanted to do was to eat a hot meal and sleep.

From somewhere, I heard a nurse saying that armed men were outside the gates of the hospital — but had respected our “no guns” policy. “That’s good,” I shouted to his direction, trying to sound cheerful. Hurrying to the empty office, I opened my locker and got a packet of instant oatmeal. I missed breakfast and lunch; if casualties would continue arriving at the hospital, there was little chance that I could have a meal on time that night. So, I slowly ate, savoring every morsel of my food. A big “EATING IS NOT ALLOWED HERE” sign on the wall was the only witness to how hungry I was. I stayed in that spot for what seemed like an eternity, fighting off sleep, mentally reviewing the cases I did that day.

Then I heard my name being called.

“Doctor, can you see the patients at the ER and tell us who’s going to surgery first?” There was urgency in his voice.

“Now?”

“Yes, now.”

I was immediately given a white doctor’s gown to put over my soiled scrubs. Following him outside the operating room, it was a moment or so before I realized the strangeness of the scene before me. There were at least a dozen people on the floor. More were lying on stretchers parked on both sides of the ER lobby. There were women with blood-spattered shalwar kameez, one of them pregnant, another staring blankly at the ceiling; men with tattered, bloody clothes; and a little kid moaning in pain, blood pooling where his legs should have been.

Men. Women. Kids. All were victims of violence.

I was shocked at the scene I saw. I walked gingerly between patients, swaying lightly, feeling light-headed. Wounded people were everywhere. And more were still coming in. I didn’t want to look and yet I had to.

Overwhelmed, I asked one of the local surgeons to accompany me to check patients’ injuries and their vital signs. We decided whom we should prioritize and wrote it on their respective charts. “This one goes to the OT first, this one’s next. The one with the bomb blast on the abdomen is next at room two. And tell the caretakers we need blood.” And on and on we went. Twelve patients needed immediate surgery; the rest could wait.

It was going to be a long night for all of us.

MSF's trauma center was the only facility of its kind that provided high level life- and limb-saving trauma care in the whole of Afghanistan's northeastern region. Here, Qudus brings his four-year-old daughter to the MSF hospital.

Andrew Quilty

I walked slowly back to the operating room with a forlorn look on my face. I was startled when an old wrinkled man with a full beard and kind eyes stopped me, and uncharacteristic for an Afghan man, tried to touch my arm. With a pleading voice, he asked me in halting English, “Doctor, please. My son is out there. Could you please take a look at him?” pointing to the black zone.

Oh, no! The black zone is where fatally wounded patients who have very slim chance of survival are placed in the triage area. I wanted to send him away, to gently tell him to ask the assistance of nurses nearby. I was aware that I could not do anything more for his son — and unsure if I could stand the grief on his face if I told him about his son’s condition.

But I went with him, asking him what happened.

He was trying to evacuate. Hit by a bomb. No vehicle. Took them a long time to bring him to the hospital.

“He’s a nice man, doctor. My youngest son.” He was saying the words to me proudly, a hint of a smile on his face. I managed to suppress a gasp when I saw the man on the stretcher near the wall. He was young, in his early 30s perhaps. Multiple wounds of various sizes covered his extremities. Bomb blast. On his chest, a big gaping wound gave me a view to his partially exposed lung. He already had a glassy look in his eyes and had no palpable pulse. Trying to do something, anything, I adjusted his intravenous line. I gently covered his chest with hospital linen and, in a breaking voice, told the old man to excuse me and that I’ll ask one of the nurses to tend to his son.

The grateful look in his eyes, as if I had given his son a second lease on life, will haunt me forever.

The constant element of my nightmares was the roaring sound and panels of wood crashing down on us. And screams. Mine. Then me tripping and landing on the floor.

I vividly remember that moment. My ears rang and the wind was knocked out of me after the explosion. My heart was slamming against my chest. I was too stunned to move. Lying there stiffly, I became aware of a hand holding me, tugging at me.

“Get up! Come on.”

I slowly stood wincing in pain, trying to see him in the dark. “Stop pulling me!” I shouted. A thick cable was on my chest, restricting my movement. My body hurt, like somebody hit me with a lead pipe, yet I knew we had to get out of there. There was no time to waste.

I clumsily tried to free myself from the tangle of wires and cables, wondering where the others went. A moment before, while we were crouching near the wall waiting for the bombing to stop, a group of five kids and two women — each holding an infant — had joined us.

A hair-raising scream from a young voice shattered the stillness. Then there was another scream, of anguish this time. Running steps followed. Then, as if nothing happened, it was quiet once again. Oh, God, I said with dread. Somebody just got hit.

Freed from the cables, my colleague and I starting running out of the building. It was still dark outside. The outlying buildings were meters away and it was too dangerous to run in the open field and go there.

Where? Where? He seemed to be saying. He was looking at me, asking me which direction we should run. Doing a quick assessment, I realized that running towards the gate of the hospital, towards the streets, would be an unwise choice. We had no idea what’s going on beyond the gates. Then I saw the unmistakable slanting roof. The basement! Thank God.

“Left side. Going to the basement!” I shouted. We ran and jumped into the hole. To our horror, and big disappointment, we found ourselves inside the exhaust of the basement window. Surrounded with thick cement walls, about seven feet below the ground, it was covered only by a thin sheet of roof above. An abyss. A dark space. Dead end. The basement was on the other side of the wall.

We were like two mice who ran into a trap. Resigned to our fate, I silently reminded myself that we had done everything. If this is where we are going to die, then so be it. Settling down beside my colleague, I closed my eyes, hopeless, worn out, but feeling oddly safe and comfortable. Absent, dreamy. Must be hypoglycemia.

“It’s going to be alright. We will get out of here.” He was trying to reassure me but there was a hint of fear in his voice. I could hear his heart beating loudly. His breathing was fast. “Yeah, maybe,” I answered, trying to convince myself, too.

The wind was blowing to our direction, fanning the smoke towards us. Coughing, tears streaming from our eyes, we struggled to not inhale the smoke. The sound of crackling wood and leaves were the only other indication that there was a fire nearby. Bombs continued dropping in the hospital. At one point, the ground shook so hard we thought it was the end for us.

“Pray with me,” I heard him saying with terror in his voice. “Allah…” I only heard the first word of what he said.

“What? Say it again. Slowly.”

Patiently, like a teacher, he guided me through the prayer.

La…La, I repeated.
Ilaha…ilaha
Illa….illa
Allah…allah
La ilaha illa allah

I barely heard him from the cacophony of noise above us. In all honesty, I did not understand what I just recited but I prayed it with all my heart, holding on to any hope I was being offered. Maybe Allah, in his goodness and mercy, would keep us safe. “I am not Muslim but I pray for your protection. Keep us safe.” I silently begged Him.

At the same time, I was thinking of my mom. What would she feel if I was returned home in an urn, just a mound of ash? Worst, if I would burn to death here and nobody would recognize my remains. Unidentified. Missing for eternity. I shuddered at the thought. I wanted to spare her from that agony. But how? How?

There was silence between us, occasionally interrupted by a burst of gunfire or a big explosion that seemed far away. I could only see his outline in the dark but I knew he was deep in thoughts, too. I was drifting in and out of consciousness. Dog-tired and hungry, all I wanted was to sleep.

My mind wandered to five days prior, when the conflict started. It had been a blur of surgeries, which sometimes meant staying at the operating theater for 16 hours straight. My arms were red and raw from constant scrubbing. I would wince in pain whenever I prepare for surgery. “You’re losing weight,” one of the local surgeons told me. I did. I lost appetite from seeing all the wounded day in and day out.

Sleep was a luxury. I tried sleeping in the dressing room whenever I could — on the narrow bench, even on the cold floor sometimes. There was no stopping the flow of injured people seeking treatment at our hospital. There was just too much to do and I feel like we were not doing enough. But the anguish on the faces of parents with injured children was enough to keep me going.

I was functioning like a robot on those days — emotions off, just concentrate on the task at hand and do as much as I could to save lives. There was no time to get emotional even if I wanted to cry. Crying was always bad for morale.

The day before the bombing, October 2, it was quiet at the hospital. We were woken up — me, the other surgeons, the anesthesiologist — from deep slumber. “Morning meeting guys, it’s already 8 a.m.!”

I woke up refreshed; eight hours of sleep, that was good! It felt like things were going back to normal. We could now walk across the open field to the hospital without fear of getting hit by a stray bullet. And there were very few patients’ names on the white board outside the OR. I did rounds in the outpatient department, something we had missed doing for almost a week.

Life was good in Kunduz, again!

We scheduled a young man at the ICU for surgery. Two more of my patients at the ICU also needed repeat surgery. We wanted to finish all the cases scheduled on the board that night.

We had been doing the first surgery for almost three hours and we were exchanging jokes and stories to break the monotony of the activity. It was already 2 a.m. when I glanced at the clock. I scrubbed out, asking the local surgeon to finish the operation while I wrote the operative technique. “Let’s eat after you finish. I have some food in my locker,” I said.

Then the bombing started.

"I am not Muslim but I pray for your protection. Keep us safe," Cua prayed to Allah with her colleague as bombs fell around them, she recalled. The remains of a bed frame in a room in MSF's Outpatient Department building.

Andrew Quilty

I was leaning on my colleague’s shoulder in the basement when he shook me hard, waking me in panic.

“What?!” I asked in alarm.

“Are you alright?’’ he asked, concern in his voice.

I nodded.

The smoke was becoming stronger and he was afraid we might suffocate. “Let’s get out of here.”

“No, I’m staying here!” I told him firmly. I’d rather die of carbon monoxide poisoning than be hit by a stray bullet outside. “Just close your eyes,” I absentmindedly added. In a normal circumstance, I might have laughed at my suggestion. Close your eyes? Genius solution!

“Okay, we stay here. But cover your nose with this,” gathering the hem of my OR gown and handing it to me. I lost my mask earlier. “I don’t want you losing consciousness.” And with a laugh, continued, “I might not be able to carry you out of here.”

Zzzzzziiiiiinng!

Out of nowhere, something tore through the roof and landed inches away from our feet. A stray bullet missed us by a few inches. A few freaking inches! The hair on my body stood on end. We could see the extent of the fire above through the hole the bullet made on the roof. I didn’t need convincing that I was going to die that night. There was just no way we were going to get out of there alive.

"I didnt need convincing that I was going to die that night," Cua wrote.

Stringer Afghanistan / Reuters

All traces of sleepiness now gone, we began discussing what we would do if we were still alive in the morning. We had been hiding in that hole for what seemed like an hour. Nobody knew I was there, that I was still alive. I asked if I could go with him.

“Of course! Let’s go to my house and hide there temporarily.”

“Okay. But do you have food? Basement? Is it safe there?”

“Yeah.”

“How could we go there?”

His car was in the parking lot, several hundred meters from where we were at the moment.

“We could run. Then you can hide in the car. I’ll drive fast”

“I don’t have any identification card or travel documents with me.” I left all my things at the OR. All I had in my pockets when we ran out were the keys to my room and locker.

“Don’t worry. My father and my uncle will find a way to get you to Kabul.”

Agreeing finally to what we should do next, we noticed fire darting in and out of the windows just above where we were hiding. Without notice and any hesitation, he hoisted himself up the wall and successfully jumped out of that pit and ran into the open. I was left in the dark… alone.

Following his example, I jumped and tried to reach the edge of the hole but was unsuccessful. I stood up and tried again, this time, placing my body against the wall and putting my feet on the opposite side to gain traction. I fell down with a loud thud. I was panicking. The fire was slowly eating the window above the roof covering the hole and I could feel the heat. I shouted for him to go back, to help me get out of there. I heard his voice calling back my name, telling me to get out of there immediately. Then, silence. Nothing. I was becoming desperate so I jumped again but failed miserably.

An MSF employee walks among the remains of the hospital after the airstrike. Cua said she was almost trapped inside a building as fire darted in and out of the windows.

ASSOCIATED PRESS

I slumped on the floor, weeping, all trace of hope now gone. I was weeping for myself, the dreams I had yet to achieve, all the plans for the future. For my family back home, for giving them so much heartache — I could have spared them the agony if I had chosen to stay at home and had a private practice instead. For my friends — I was not going to see them again. For the patient I just lost at the OR table — he was still so young. For the old man who lost a son. For all the work we poured into this hospital. For the people of Kunduz.

“I only asked You for one thing on my birthday, to keep me safe,” I cried into the darkness. “One wish and You could not even grant it.” I arrived in Afghanistan on my birthday and it was my sole wish. My heart was filled with bitterness.

I was angry. I wanted to lash out at somebody, anybody. I wanted to punch someone in the face. I was enraged. I hated both sides involved in this stupid war. I wanted them to see all the damage they have been causing to civilians and let them imagine that those are their families. Let us see then if they would still continue this senseless war.

I was also afraid. I don’t want to be burned alive.

The tears came in a torrent, bringing all my frustrations into surface.

MSF staff demonstrate in Geneva one month after the bombing of the Kunduz hospital. "Even war has rules," one of the banner reads.

Denis Balibouse / Reuters

Then, surprisingly, there was calm and clarity. I was back to being a surgeon again. “Okay, nobody will help me now but myself. What should I do?” After removing my shoes, I stood and studied the small space I was in. No crevice on the wall to put my foot into and the wall was really too high for me.

Then I saw a small piece of steel jutting out from the right corner, so small I hardly saw it the first time.

With all my might I jumped, aiming to grab it. It was hot but I didn’t let go. My shoulder joint threatened to dislocate but I didn’t mind. I didn’t know how or what else I exactly did but in a few minutes I was out of the hole. With a big sigh of relief, I saw my colleague sprawled on the ground near the rose garden, waiting, a big grin on his face when he saw me.

I ducked and ran to where he was, hearing him say, “Get down! Get down!” I felt my OR gown catching a small fire from the embers falling from the burning building. I rolled on the ground. When the volley of shots in the surroundings stopped, we started crawling towards a building several meters from where we were. We were halfway there when a figure came out from the darkness. Fear gripped me. I did not survive the fire to just be kidnapped! No, please.

Then the man, who was wearing traditional Afghan attire, uttered the words that I would always remember: “Follow me, there’s a safe place here.”

This story was originally published at The Development Set .

Read more about the attack on the MSF hospital in Kunduz:

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