KHAN NESHIN, Afghanistan — Five-year-old Sadiq was not a casualty of war. He was simply unlucky. The boy had opened a sack of grain at his home early on Wednesday morning, and a pit viper coiled inside lashed up and bit him above the lip.
His father, Kashmir, knew his son was sure to die. With no hospital anywhere nearby, he rushed the boy to an American outpost to plead for help. By midafternoon, Sadiq’s breathing was labored. Respiratory failure was not long off.
The events that followed unfolded like a tabletop counterinsurgency exercise at a military school. On one hand, the United States military’s medical capacity, implanted across Afghanistan to care for those wounded in the war, could not be used as primary care for the nation’s 29 million people. On the other hand, would the officer who upheld this policy be willing to watch a 5-year-old die?
Since last year, Helmand Province has been the scene of the most intensive combat in Afghanistan. Marine patrols and the Taliban fight daily, and helicopters are needed to evacuate the wounded.
Under NATO rules, any Afghan civilian wounded as a result of military activity is treated in the Western military’s medical system. Black Hawk helicopter crews often scramble and collect them. But each day, Afghans seek help for other injuries and ailments — for heart attacks, for trauma from vehicle and agricultural accidents, for twisted backs, cut hands, spiking fevers, infections, insect bites or dental pain.
For these ordinary medical conditions, unrelated to war but often urgent, Marines and Navy corpsmen in Helmand Province provide first aid. Getting approval for a Black Hawk is another matter.
The helicopters are few. They are spread out. Picking up Afghan civilians with routine ailments puts aircraft and crews at risk. It could also put a helicopter out of position for a gravely wounded soldier or Marine.
Often the decision is made against the patient: helicopters cannot be spared. Many aircrews, and many officers on the ground trying to forge relations with Afghan villages, do not like this. The choice is not theirs; flight approval is made by higher commands.
Maj. Jason S. Davis, a pilot and the commanding officer of Company C, Sixth Battalion, 101st Aviation Regiment, which provides a detachment of Black Hawks to fly medical missions in central and southern Helmand Province, described two conflicting truths.
“We can’t be Afghanistan’s E.M.S.,” he said. “But right now we are.”
Sadiq’s father appeared with him at a Marine outpost in southern Helmand. It was clear that local care could not save him. The Marines requested an evacuation helicopter.
At the Camp Dwyer airfield, to the north, Major Davis and a co-pilot, First Lt. Matthew E. Stewart, saw the request posted on their operation center’s electronic message board. With an escort aircraft trailing behind, they soon lifted off from Camp Dwyer and headed south, expecting that the mission would be approved.
After flying perhaps 15 minutes, they were called back. The boy was not eligible for care. Sadiq was on his own.
A few hours later, a new request for medical evacuation, or medevac, appeared on the screen, this one from another Marine outpost. A small boy, it seemed, had been bitten on the face by a viper.
Everyone knew what this meant: Sadiq’s father had brought his dying son to the next Marine position and had started over.
There were no other medevac missions under way. While the pilots stared at the message board, wondering whether this time the mission for Sadiq would be approved, an officer at the second outpost issued a blunt challenge: would whoever denied the mission, the officer wrote, acknowledge that they knew the boy would die?
The typed answer came back on the screen. The mission was approved.
The Black Hawks lifted into the air at 2:25 p.m. Soon they were flying through a dusty haze a few hundred feet up. “Ten minutes out,” Major Davis said. Halfway to the rescue, and they had not been called back.
While the desert dominates Helmand Province, the contest between the Marines and the Taliban plays out elsewhere, in belts of farmland along the river and in irrigated villages kept alive by pumps.
The military calls these areas “the green zone,” a nickname derived from how they appear from the air — pockets of vegetated terrain that end abruptly where the irrigation stops. It is in these areas where almost all the fighting takes place, and where helicopters come under fire.
Up ahead, a crosshatched pattern of pale fields appeared. “Entering the green zone,” Major Davis said. “Tell them to pop smoke.”
Beside a fortified compound, a Marine lobbed a smoke grenade.
Major Davis banked the aircraft in a wide circle and landed beside the billowing plume.