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The boy was left for nearly 20 hours before the ambulance could reach him. He was unable to move because a bullet had torn a hole through his abdomen. When the fighting finally subsided, he was driven the 130 kilometers north from Ghazni to Kabul and a specialized hospital that treats the war-wounded.

The boy, 12, became one of 50 cases the Italian nongovernmental organization Emergency treats on a daily basis in what has become the surgical center’s busiest year on record.

At the entrance to the children’s ward, a whiteboard lists the injuries: shrapnel, mine, shrapnel, shrapnel, mine, shrapnel, bullet, bullet, bullet, shrapnel, shotgun, bullet, shrapnel, bullet, bullet, bullet, bullet. Children account for about 30% of all patients the hospital treats.

Doctors begin another round of surgery on a teen who had his arm torn off by a bomb. Surgeons say his is an average case.
Brent Swails/CNN
Doctors begin another round of surgery on a teen who had his arm torn off by a bomb. Surgeons say his is an average case.

The center treats victims from across the country, but in recent months, it’s been the increasing violence in and around the capital that has affected even the most hardened staff members.

“Even Kabul is not secure. When I’m coming from home and I say hello to my baby and wife, I am thinking sometimes there is no guarantee to be back at home,” says Najibullah Hekmat, a third-generation Afghan surgeon trained and working at the hospital.

ISIS claimed responsibility for Kabul’s latest attack on Wednesday, twin blasts that killed 20 civilians and wounded 70 more.

“Every day the situation is getting worse and the fighting is increasing. Honestly for me, I don’t have any clear future,” says Hekmat.

A view of Kabul, where fighting has increased in recent months. "When I'm coming from home and I say hello to my baby and wife, I am thinking sometimes there is no guarantee to be back at home," says surgeon Najibullah Hekmat.
Brent Swails/CNN
A view of Kabul, where fighting has increased in recent months. "When I'm coming from home and I say hello to my baby and wife, I am thinking sometimes there is no guarantee to be back at home," says surgeon Najibullah Hekmat.

As US Secretary of Defense James Mattis arrived in Afghanistan Friday to chart the future strategy with his new top commander Gen. Austin S. Miller, he was confronted with an unsettling truth: 2018 may be a bad year in America’s longest running war, but for Afghanistan, it is becoming its bloodiest.

An escalation in terrorist attacks and fighting between the Taliban and government forces has helped drive the number of civilian deaths this year to its highest point on record – 1,692 civilians killed by June 30, according to the UN.

In August, Taliban forces overran and briefly captured Ghazni. The attack was the boldest in a series of offenses. The US Special Inspector General for Reconstruction (SIGAR) estimates only around 56% of the country’s districts are under government control, and a third of Afghanistan is now “contested.”

This despite the $45 billion the US spends per year here, focused mainly on training Afghan security forces.

’All killed in a horrible way’

In Nangahar Province’s Kot District to the east of Kabul, Niaz Bibi walks out of her mud brick compound, down the steep hill to the graveyard. Bibi brings with her 32 young children that a woman of her years – she doesn’t know her exact age but estimates it as around 85 – shouldn’t have to care for. These are the children of her sons and grandsons who’ve been killed or wounded in the long-running conflict, some of whom are buried in the graveyard below.

A nurse walks down a recovery ward in Emergency's Surgical Center in Kabul. 2018 has been the hospital's busiest year on record.
Michael Millett
A nurse walks down a recovery ward in Emergency's Surgical Center in Kabul. 2018 has been the hospital's busiest year on record.

Three sons and three grandsons served in Afghanistan’s army and police, but they are all dead. One son, Kameen, was beheaded by ISIS as he attended a relative’s funeral ceremony. Four other grandsons are still alive, but all have been wounded fighting insurgents in Nangahar.

“They were all killed in a horrible way,” Bibi says. “Some of them were shot and some others were beheaded. I couldn’t see the dead bodies of some of them because we had escaped our village.”

Her sons and grandsons earned less than $200 a month to serve. Poor morale, drug abuse and never-ending combat have driven Afghan desertions and deaths so high that staffing levels are now classified by the American military.

In its July quarterly report, SIGAR reported the Afghan National Army was at 86% of its authorized strength, 31,084 soldiers short of its goal.

But NATO sources on the ground say the real numbers could be much worse. One frontline government brigade is more than twice as bad, 30% below strength, according to the sources.

Bibi says her sons and grandsons expected to be killed when they joined the security forces.

“It’s obvious that when you defend your homeland, you get killed.”