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Afghans Face a Loss of Health Care
Medical Teams Scale Back As Attacks on Them Rise

By Griff Witte
Washington Post Foreign Service
Friday, June 29, 2007

JALALABAD, Afghanistan -- This month, two Afghan medical workers drove off into the hazy blue mountains that rise above this dusty provincial capital. They have not been seen since.

No one knows who took them, but their disappearance has had far-reaching consequences. With security in doubt, other health-care workers have been ordered off the roads. Clinics are fast running out of medicine because supplies can't be delivered. Doctors are searching for safer places to work.

The problems here mirror a developing crisis across Afghanistan. Just as violence is heating up, with civilian casualties rapidly escalating, the health-care system is breaking down, according to Afghan and international medical experts.

The deterioration has been especially pronounced in rural areas, scene of some of the most intense fighting between Taliban and international forces. In those places, clinics are shutting their doors because the medical workers have become targets.

"Day by day it's becoming worse," said Nadera Hayat Burhani, a doctor and the government's deputy health minister. "In each country, it's a rule that you let the medical staff do their work. Unfortunately, in Afghanistan it is not that way. Here, they kill the medical staff."

Insurgents have been campaigning for years to prove to Afghans that their government has little to offer. Police officers, schoolteachers and local political leaders have been targets of violence. Now medical workers fear that they are in danger as well.

The International Committee of the Red Cross recently said it faces a more restrictive environment than it has in two decades of work in Afghanistan. "It's not a conflict where there are clear front lines," said Franz Rauchenstein, the agency's deputy chief in Kabul. "It's more complicated than in the good old days, when you had Party A controlling one area and Party B controlling another. Now that can change every day."

Rauchenstein said his organization has had to pull back from many areas because it has not been able to get security guarantees. Other groups have pulled back, too. The ones that remain in the most dangerous regions are reconsidering their operations with each new attack.

There has been a series of disturbing episodes in recent months. A nurse was beheaded by Taliban fighters, who blamed his death on the government's failure to turn over the body of their former commander. Six medical workers in the northeastern area of Nuristan have been taken hostage. Overall, 39 government medical workers have been killed in less than two years, according to Health Ministry statistics.

Mohammad Naseem, a doctor who manages health care in the Jalalabad area for HealthNet TPO, a Dutch nonprofit organization, hopes his two workers aren't added to the list.

The two -- 35-year-old Shiraz and 40-year-old Wali Jan -- were helping with an immunization drive in the remote district of Shirzad when they were abducted June 13. Since then, the kidnappers have periodically used Jan's cellphone to make demands and to threaten to kill their hostages if they don't get what they want.

HealthNet TPO has worked in this eastern Afghan province for 12 years, but this is the first time its workers here have been seized. Now the organization, which runs 54 health facilities in the province, is contemplating getting out.

"If something goes wrong, there will be a very, very negative impact on health care in this area," Naseem said. "At the moment, our health facilities are open. But the time may come when we will not be able to supply drugs, and the services will collapse."

Even before the kidnappings, health facilities in the area were showing signs of strain.

While up to 80 percent of Afghans have access to basic health care, about 70 percent -- 22 million people -- lack a nearby hospital capable of treating more serious conditions.

That's why the health facility in the Shinwar district, a rural outpost an hour's drive from Jalalabad amid corn and poppy fields, has become so popular. The campus of spare concrete buildings looks rudimentary from the outside, but the two surgeons inside -- along with a pediatrician and a gynecologist -- are enough to draw patients from 50 miles away along rough mountain roads. Many die making the journey.

The facility is equipped to receive 1,800 patients a month; these days, it gets 6,000. Lately, more and more of them are war wounded.

On March 4, a patient arrived at the clinic with a gunshot wound to the neck. A second showed up minutes later with a bullet hole in his jaw. Over the next several hours, 21 additional trauma patients arrived -- victims of an attack by U.S. Marines that the military later called "a mistake" and apologized for.

The staff was overwhelmed. Anyone in the area who knew basic lifesaving skills was brought in to help. The local pharmacy was emptied of medication. Patients who were not in imminent danger had to give up their beds.

"If two or three trauma patients come in at once, we can cover that very well," said Aman Gul Amani, a doctor and the hospital manager. "But 23 is too much."

Similar mass-casualty events have been reported across Afghanistan in recent weeks. According to an Associated Press estimate, NATO and U.S.-led forces have killed 203 civilians this year; Taliban fighters have killed 178 civilians. Hundreds more people have been wounded.

NATO and U.S.-led forces say that they do everything they can to provide care to civilians and that they routinely offer medical evacuations by helicopter or plane.

But the areas where airstrikes occur are often exceptionally remote, and some are even beyond the reach of international forces.

Such was the case this month in the southern province of Uruzgan. There, 120 people were wounded and more than 60 killed over three days of intense clashes between NATO and Taliban forces.

Jan Mohammed, who is in his late 50s, was asleep at 4 a.m. in the Uruzgan district of Chowreh when a bomb tore through his home. Lying amid the wreckage, he could see the bodies of his wife, children and grandchildren. Overall, 22 members of his family were killed.

He was barely alive himself, with severe bleeding from his arm, abdomen and legs. For four hours, he lay there, desperately hoping for help. It finally arrived, but not in the form of an ambulance or military convoy. Instead, it was his neighbor, who put together a makeshift rescue squad to ferry the injured on the treacherous two-hour journey to the nearest medical facility.

"The hospitals didn't help us. The government didn't help us. The foreign people didn't help us," said Mohammed, breathing heavily through tears. "Only my neighbor came to help me."

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