The Washington PostDemocracy Dies in Darkness

With aid slow to enter Afghanistan, public health facilities are turning many patients away

Fauzia Raouf, the senior midwife at 100 Beds Hospital, with a baby boy several hours old. Like many public hospitals, this one is facing acute shortages of staffers and medicines. (Pamela Constable/The Washington Post)

KABUL — The wail of a newborn baby echoed plaintively in the silence. In the labor room one day this month, a lone woman groaned and sighed. In the recovery ward, two new mothers were dozing, but a long row of beds stood empty, each with a small plexiglass bassinet at its side.

For years, Dasht-e-Barchi State Hospital, popularly known as 100 Beds Hospital, was one of the busiest public health facilities in the Afghan capital, delivering thousands of babies each year. With substantial aid, staffing and expertise provided by the international charity Doctors Without Borders, it offered high-quality maternity care at nominal fees.

Today, 100 Beds is a subdued shadow of its former self, with the staff cut by two-thirds, some equipment inoperable and patients’ families required to purchase medicines outside. Last year, Doctors Without Borders withdrew its large local staff after a gruesome bombing and shooting attack that killed 24 people, including two infants.

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Since August, when Taliban militants took power in the country, conditions have deteriorated further. International donors suspended aid that had funded the bulk of public services in Afghanistan, concerned that the new rulers would severely curtail human rights and revive cruel punishments for those who disobeyed their religious dictates. The hospital's budget was slashed, and many staffers resigned.

"Security is much better now, but our capacity to pay for salaries and supplies has been greatly affected by the economic situation," said Atiqullah Kariq, the hospital director. "We used to deliver 70 babies a day, but now we are down to less than 15. We used to have more than 100 midwives; now we have six. We are trying our best, but without more international help, we cannot recover."

Across the city and the country, health-care facilities are facing similar struggles to provide basic services, especially in rural areas, humanitarian groups report. Although some private medical charities continue to operate in Afghanistan, they reach only a fraction of the population.

In an interview, Abdul Bari Umar, a Taliban deputy health minister, said the "main factor" in Afghanistan's struggling health-care system was that the world had abandoned the country for political reasons.

"If things are deteriorating day by day, we are not the responsible party," he said. "The entire responsibility will be with the international donors."

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Umar did not say how the new government plans to address the health crisis, but he asserted that it has made strides to improve health care by stopping widespread corruption and nepotism. He said doctors had been pocketing extra fees for lab tests and other public services, even as international donations poured in.

"We are going to create a fair and accountable health system," he said. "We promised the people we would bring a peaceful and stable government, and we will fulfill our other promises. For everyone who comes here to help, we will ensure their safety. For every 10 afghanis [12 cents] someone donates, we will be accountable for how it is spent."

For weeks, humanitarian aid groups have warned that a health crisis is sweeping the country, with millions of people jobless or displaced and poorly fed as winter nears. Already one of the world's poorest countries, Afghanistan suffers from high rates of infant mortality and inadequate nutrition, and it is marked by other indicators of poor health.

As international donors and agencies debate restoring significant amounts of aid, they have arranged several emergency measures. The United Nations announced Monday that it has obtained Taliban permission to launch a polio vaccination campaign next month. The U.N. Development Program will pay at least 25,000 Afghan health-care workers, using a World Bank system and a special authorization from Washington. Last week, the European Union pledged 1 billion euros in aid to Afghanistan and several neighboring countries.

 The Biden administration, which has frozen almost $10 billion of Afghan government assets, plans to contribute $64 million in emergency supplies to a U.N. special appeal, but made no move to release the assets after meetings between U.S. and Taliban leaders in Qatar last week.

So far, there has been no indication from Taliban leaders that they will soften their rhetoric or actions, but at 100 Beds Hospital, an on-site Taliban representative insisted that the new government is not a threat to anyone. In a gesture of confidence, he said he ordered the removal of the blast walls erected after the 2020 hospital bombing.

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"We have no budget, because the foreign groups broke their contracts and left early. We still need more staff, but everyone here is happy and safe now. Those groups should come back," said the representative, Hassan Gul, who keeps a military rifle next to his desk. He accompanied Kariq and a reporter on a tour of the hospital, taking notes on the reporter's conversations with the staff.

Several staff members expressed frustration over their scaled-down service. They said they repeatedly run out of lifesaving drugs and have not performed any Caesarean sections in the past two months. They are also turning away pregnant patients with high-risk conditions because they cannot ensure that scarce oxygen and a skilled surgeon will both be available during delivery. Instead, they said, such patients are sent to private clinics.

Fauzia Raouf, a supervising midwife who has worked at 100 Beds for 16 years, survived the bombing last year. She said she heard an alarm, then rapid gunfire followed by a huge explosion. "A woman in delivery was killed, and another one hid in the bathroom, but they shot her, too," she said. "We are safe now, but we need help. Please, please tell [Doctors Without Borders] to come back."

Dasht-e-Barchi has many private medical clinics, but they, too, are experiencing a severe drop in the number of patients, including many who have lost their jobs since the Taliban takeover. Abdul Qadir Noori, a dentist who owns a general practice clinic, said he may have to close it because so few patients are coming in. In his office, expensive dental equipment was gathering dust.

“A few weeks ago, a man brought his wife one evening. She was about to give birth, so we attended her and the baby,” Noori recounted. “Then at 3 a.m., the husband suddenly said they had to go home. Our fee was only 1,000 afghanis [$12], but he had no money. He left me his driver’s license as collateral. I still have the license, but he never came back.”

At another clinic, a couple came in with their infant son, asking to have him circumcised. The father, Ali, said he had first gone to a public hospital but was turned away because it no longer had a staffer with the necessary skills. Informed that the clinic’s fee would be 800 afghanis ($10), he shook his head in consternation.

“I feel so hopeless,” said Ali, who spoke on the condition that only his first name be used out of concern for his safety. An engineer for a construction company that had contracts with the U.S. military, he said he had lost his job and was worried that the Taliban would come after him. “I have no income, I am afraid for my safety, and I cannot even give my son something that Islam requires me to do for him.”

One of the few advantages at 100 Beds and other public health-care facilities is that Taliban authorities still allow women to work there while so far banning them from many other government jobs.

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But the rules and practices of mixed-gender work interactions can be complicated, and the reduced availability of skilled medical services has been exacerbated by the exodus of Afghan professionals since August. Hundreds of midwives continue working in Kabul and many provinces, but most highly trained or specialized doctors are male, and many have fled abroad.

One local doctor said he took an impoverished female patient to a public hospital to have a hysterectomy, which she needed because of bleeding and cysts. At a private clinic, the procedure would cost more than $100; at a public one, only about $12. He said she was turned away because there was no female doctor with the necessary skills, and no male doctor was allowed to perform the procedure.

“Midwives are fine for normal births, but for more-complicated surgeries, you need more skills,” said the doctor, Gul Anis. He said Afghan families still tend to steer daughters away from higher medical training. “They assume the investment would be wasted when they marry and start having children.”

At 100 Beds, Gul, the Taliban representative, said the male and female staffers attend meetings together but work in separate areas unless a special need or emergency arises. But some staff members said they had been told that a male doctor should not treat a female patient.

At the Health Ministry, Umar denied that hospital staffers or patients are being segregated by gender. “We want men to treat all patients and to work with women, as long as they are wearing hijab,” he said. “In intensive care units and operating theaters, they all work together.”

At a vegetable market outside the entrance to 100 Beds one recent afternoon, a woman was holding out an unfilled prescription order and asking for help. A crowd of men and women soon gathered at the spot, jostling against one another as they thrust medical documents and X-rays at a reporter.

“My child is sick. I paid 25 afghanis [20 cents] to get inside but they didn’t give me any medicines,” one woman said.

A grizzled man in his 70s chimed in.

“I brought my son’s wife here to have her baby, but they had no facilities,” he complained. “I had to take her to another hospital that charged almost 5,000 afghanis.”

Then he stopped and smiled, adding, “It was a boy.”