Shirin has paid heavily for both Afghanistan’s conflict, and its abrupt end in Taliban victory. Three years ago her husband lost his leg when a roadside bomb hit his bus. Then in the summer the militants’ victory brought peace to her corner of Helmand, but a halt to the foreign aid funds that paid her salary as a hospital cleaner and kept the family afloat.
They fell behind on rent, were evicted from their home and began running out of food. Three weeks ago, worn down by cold, hunger and disruption, Mohammad Omar died from wounds that had never fully healed, leaving her a single mother to their four children.
“He died because of a lack of money. No one would even give us a loan,” said Shirin, 50. “We are suffering too much, but if we just got our salaries, everything would be solved.”
But even when she wasn’t being paid, she kept coming to the Gereshk district hospital to work at the maternity unit. “We are needed here,” she said, as a newborn girl was rushed off for oxygen and she prepared to move the mother into a recovery room and sterilise her bed for the next patient.
The wards need a cleaner in order to remain as safe as possible for new mothers, even in a hospital starved of cash and slowly grinding to a halt, like this one. Last month the operating theatre had to shut down, because there was no money for fuel for the generator – there is no grid power in this rural corner of Helmand near former Camp Bastion – or any gas to sterilise their equipment.
So women whose lives depended on having a caesarean, a car accident victim who needed open chest surgery, and people with inflamed appendixes all had to be sent off in taxis with a prayer that they would survive the hour’s drive to Lashkar Gah, where the Boost hospital supported by charity Médecins Sans Frontières still had power and supplies.
The roads may have been clear of the bombs and gunfights that prevented so many people in Helmand’s villages from reaching medical care, but the hospitals and clinics were no longer functioning properly.
“I could tell you about many cases,” said surgeon Karim Walid. “There was a woman who needed a caesarean because of the baby’s position. She had no money so we went round collecting a few thousand Afghanis for a car to take her to Boost.”
The lab ran out of test equipment, for diseases from malaria to HIV, for blood counts or blood sugar levels. “All we had left were pregnancy and TB tests,” said lab manager Bashir Ahmad Majar.
Eventually, even gloves ran out for midwives on the labour ward. “We asked those who could afford them to buy their own,” said Malalai, a midwife who worked with Shirin. For the others, the hospital went into debt. “I get calls every day from the shopkeepers, asking me why aren’t you giving us the money you owe us,” said Haji Mohammad Barak, director of the Gereshk hospital until early November, now provincial manager for a healthcare programme.
Fortunately, they had managed to patch up a hole in the inpatient ward roof, made by an air strike in the last days of fighting, before money totally ran out, he said. The bomb miraculously landed just between the five beds lining the walls of the ward, without causing any serious injuries.
The head of the World Health Organization, Tedros Adhanom Ghebreyesus, visited Kabul in September and warned the whole healthcare system was on the brink of collapse, prompting the UN to arrange payment of one month’s salaries.
The operating theatre in Gereshk has reopened, the lab is restocked and medical staff say they have been promised another three months of pay. But these are temporary solutions that will run out in the middle of Afghanistan’s bitter winter.
“We need something permanent; we can’t manage just getting a few months’ salary then everything goes again,” said the midwife, Malalai, who is the family’s main breadwinner. “Don’t leave us here without hope.”
Western governments that had supported the health and education sectors and were stunned in August by the unexpectedly rapid victory of a group they had sanctioned as terrorists, cut off all funds without making plans to support schools and hospitals that had been built to rely on overseas aid.
They worried about giving legitimacy to a government that has brought in sweeping restrictions on women’s rights to work and study, and been linked to other human rights abuses, including targeted killings and mass displacements.
But it is not senior Taliban officials who are paying the price for the freeze on funds. “Don’t make the mistake of thinking that I will suffer from sanctions,” said one senior Taliban official in Kabul. “I will always get my salary, my meals, and money to keep my office warm.”
It is the lives of ordinary Afghans that are on the line. Tedros warned that the abrupt halt in international funding had left health providers to make terrible decisions about “who to save and who to let die”. The reality in Gereshk was even worse.
With the hospital barely functioning, they could only tell patients in serious need to head to the Boost hospital. It was the only fully functioning medical centre for at least 1.5 million people in the province, and unofficially for hundreds of thousands more in neighbouring provinces. On some days more than 700 patients crammed into an emergency room designed for little more than half that number.
“The health system of Afghanistan was very donor dependent, and the donors withdrew their support,” said Emmerson Gono, project coordinator for MSF in Helmand. The implications of that cut-off are tragic, and felt immediately.
“We are getting overwhelmed with the workload, people are coming from all over the province and even other provinces,” he said. “We go far beyond our capacity, because we will not turn away someone we see is critically ill.”
It is perhaps hard to picture a healthcare system “in collapse”, but you can see the human cost of the funding cuts at Boost hospital, in the fragile bodies of children racked with disease and malnutrition, or being wheeled to the morgue.
On a bright, crisp morning last week, hospital orderlies wrapped the small body of a six-year-old boy to take away. He had just lost a battle with bacterial meningitis, which he should have survived.
“We gave him a very strong antibiotic, but it was too late,” said the lead Afghan doctor on the ward, whom MSF asked not to be named. The clinic in Garmsir district where ther boy first went for help had no capacity to test his blood, mistook his illness for poisoning and tried to treat him for that.
Outside, a 12-year-old diabetes patient, paralysed from the waist down, was soaking up the sun as he slowly recovered from bed sores that had reached his bones and left him in the intensive care unit.
Zabihullah’s family is caught in a cycle of poverty and poor healthcare, said nurse Alyssa Tianna Ranger. The family have to travel to Lashkar Gah to get insulin for his treatment, because no local clinics can provide it and because the family struggle to feed him well, and manage his blood sugar, sores develop easily and rapidly.
“It is expensive for our family to get here,” said his mother, Marzia, as her son smiled despite his pain. “We were already poor before his diagnosis three years ago. Now things are worse, but we have no other choice.”
Like many of the poorest, they have been hit with multiple crises. Taliban control sent the economy into freefall: it contracted by at least a third. The government is not paying wages, internationally funded jobs have vanished, and food prices have soared. The impact is felt particularly on the badly overcrowded malnutrition wards, where the number of painfully skeletal children has soared. Autumn usually brings some respite because dehydration is worse in the summer, heat, but not this year.
Children who get little nutritious food are extremely vulnerable when other diseases – stomach problems, respiratory illnesses – ravage their small bodies and leave them unable to eat.
Nazdana came here in a desperate effort to keep three-year-old Khalida alive, after clinics in her home village of Yakhchal couldn’t stop the vomiting that was wasting her child away.
To get the money to travel, she had weigh up the value of two daughters’ lives, and make a betrothal contract for the girl’s five-year old sister. The wedding won’t be for 10 years, but Nazdana got a 15,000 Pakistani rupee (£63) advance on the 600,000 rupee dowry payment, enough for the journey.
“I spent some of the money to come here the very next day,” she said. In a working health system, Khalida should eventually be discharged to the care of local clinics which hand out feeding supplements like calorie-rich “plumpy nut”. Without these operating, some children are trapped in a cycle of malnutrition that sees them returning to the ward again and again.
As the international community weighs up whether to commit to long-term funding for the healthcare system again, they are likely to look with particular concern at the decision to put senior Taliban into all administrative positions overseeing clinics and hospitals.
Most were fighters just a few months ago, and Gereshk district health commissioner Mohammad Nasim admits that he has no background or expertise in the sector. “It is a decision of the Islamic emirate, I don’t know why they chose me for this position,” he said, using the group’s name for itself. “It is time for me to serve the people.”
But problems were also reported with the officials they had replaced; several healthcare sources said they found the new Taliban director for the province, Ahmad Alghazi, easier to work with and less corrupt than his predecessor under the Republic government.
He pledged in an interview that female medical staff would remain in their roles, and female patients would be able to access healthcare without a guardian, and that polio vaccination campaigns – which the Taliban have sometimes opposed in the past – would continue.
But he also warned the west against throwing away goodwill by cutting off the hospitals in their hour of need. “The international community should prioritise the needs of poor people, who have seen too many problems,” he said. “This is a good chance, because there is no corruption now, to support the health sector. It won’t be there for ever.”
From the Boost hospital director who works below him, there was a simple plea to donors to put Afghan patients’ lives ahead of their dispute with the new government.
“I hope the international community won’t mix health and human rights up with political issues,” said Faizullah Mohammadi. “We strongly need your support, and as a fellow human being, I ask that you don’t leave Afghanistan alone in this disaster.”