In late 2008, refugees from Farah province, Afghanistan, told Médecins Sans Frontières (MSF) aid workers in Iran about the horrific levels of violence they faced inside their country. Some even said that the violence that summer was worse than at any time during the Soviet occupation in the 1980s. One year later, the UN reported that 2009 was the deadliest year for Afghan civilians since the current war began in November 2001.

Today, this violent reality – fuelled by fighting between international coalition forces and opposition groups like the Taliban, as well as a complex mixture of corruption, criminality, the opium trade, and rising tensions in Pakistan’s tribal zones – continues to inflict a heavy toll on civilians and their ability to access health care. A survey conducted for the International Committee of the Red Cross (ICRC) estimates that more than half the population has little or no access to basic services. For secondary health care, only two hospitals – in Kandahar supported by ICRC, and in Lashkargah supported by MSF – provide a complete range of services for the entire south, forcing people in need of care to go hundreds of miles through a war zone. Afghan officials are not able to manage services in an increasing number of locations due to targeting of staff by armed opposition groups.

MSF is providing medical care at the Ahmed Shah Baba hospital in eastern Kabul and the Lashkargah Provincial Hospital in Helmand Province. In Kabul, the influx of both returnees from Pakistan and displaced people fleeing war in other provinces has nearly quadrupled the population. Despite high needs and low health-care coverage, Kabul has so far been neglected because it is not a priority for the current counter-insurgency strategy.

The growing insecurity in Helmand Province is forcing people to go to extreme lengths to seek either routine or emergency care at often dysfunctional health structures. After the MSF team arrived at the hospital in Lashkargah, a woman nearing the full term of her pregnancy arrived more than 48 hours after being seriously wounded when her village was shelled. She survived but her baby later died of sepsis. Another woman brought in her child who was suffering from measles, revealing how the war has made it virtually impossible to carry out vaccination programs against easily preventable childhood diseases. The mother said eight other children in her village had similar symptoms but could not get to a hospital.

Paradoxically, Lashkargah hospital is piling up with advanced medical equipment – digital x-rays, mobile oxygen generators, scialytic lamps – donated by a range of states including the US, China, Iran, and India or through the Provincial Reconstruction Teams (PRTs). This equipment is usually dropped off with little explanation and no anticipation of maintenance; most of it sits in boxes, collecting dust, unopened and unused.

For several decades MSF provided medical care throughout Afghanistan. In the 1980s, teams set up a network of clinics in areas under the control of a variety of factions. MSF continued to work after the Soviet withdrawal, during the subsequent civil war, the rise and fall of the Taliban, and during the initial stages of the current conflict.

However, ensuring acceptance has been a challenge throughout our presence in Afghanistan. The Soviet Union refused to allow our operations and subsequently bombed several of our health structures, and in 2004, MSF left Afghanistan following the targeted assassination of five staff members. When the organization returned in 2009, teams found that the conditions needed for strictly impartial medical assistance had deteriorated almost to the point of disappearing.

One factor contributing to this deterioration in independent humanitarian assistance has been the deadly lack of respect for health care workers and facilities shown by all of the belligerents involved in the conflict. Hospitals, clinics, and medical personnel have been targeted by armed opposition groups like the Taliban, while Afghan government and international forces have repeatedly raided and occupied health structures. A second, related factor has been the co-optation of the aid system by the international coalition – at times with the complicity of the aid community itself – to the point where it is difficult to distinguish aid efforts from political and military action.

In short, the space to provide neutral, independent, and impartial humanitarian assistance in Afghanistan has been lost, given away, or taken, and this is having dire consequences for the population. Whether it is possible to regain and defend this space will not only affect the provision of assistance in Afghanistan, but in other conflicts as well.