Access to health care under threat in Afghanistan
Authors: Sharmila Devi
Journal: The Lancet (2020)

Attacks on hospitals and high numbers of COVID-19 cases among health workers could hamper access to health care. Sharmila Devi reports. Millions of people are at risk from rising violence in Afghanistan including attacks on health-care facilities amid the COVID-19 pandemic, the International Committee of the Red Cross (ICRC) warned on June 17. An assault by gunmen on the Dasht-e-Barchi hospital in Kabul on May 12 that killed 24 people, including 16 women and two newborn babies, prompted Médecins Sans Frontières (MSF) to announce on June 15 that it was ceasing its activities at the hospital. The government blamed Taliban insurgents for the attack while the USA blamed so-called Islamic State, saying the group was opposed to Washington's efforts to resolve more than two decades of conflict between the Taliban and other Afghan groups. A report published on June 21 by the UN Assistance Mission in Afghanistan said that 12 deliberate attacks on health care were recorded between March 11 and May 23, the first 2 months of the pandemic. “At a time when an urgent humanitarian response was required to protect every life in Afghanistan, both the Taliban and Afghan national security forces carried out deliberate acts of violence that undermined health-care operations”, said Deborah Lyons, the UN secretary-general's special representative for Afghanistan. Afghanistan had 28 297 confirmed COVID-19 cases and 548 confirmed deaths, WHO said on June 20. The total of 925 confirmed cases in Kabul included 346 medical staff, officials told Reuters last month, and the high rate of infection prompted some doctors to close their clinics. However, it was unclear whether the high rate was because medical staff were more likely to be tested than the public. The true number of infections in Afghanistan is thought to be much higher, given that millions of vulnerable people have no access to health care in a country wracked by conflict, even before the pandemic. Afghanistan had only 172 hospitals and four doctors per 10 000 people, according to a 2019 government report. Around a third of the 37 million population has no access to a functional health centre within 2 h of their home, says the UN Office for the Coordination of Humanitarian Affairs (OCHA). Authorities imposed nationwide restrictions after the first COVID-19 cases were reported in February, but people have largely ignored the regulations because many are forced to work to survive. The price of staple foods, such as flour, pulses, rice, cooking oil, and sugar, continues to increase, making it harder for families to feed themselves. Even before COVID-19, 93% of Afghan households survived on less than US$2 per day, said OCHA in its June revision of the UN's Humanitarian Response Plan, which appealed for $1·1 billion to help 14 million people in need of assistance. The number of people who needed aid was 9·4 million just 6 months ago, it said. MSF said that in the month after the May 12 attack on Dasht-e-Barchi hospital, no group had claimed responsibility for it. “Today, we have to accept reality: higher walls and thicker security doors won’t prevent such horrific assaults from happening again”, said Thierry Allafort-Duverger, MSF general director, in a press release. “To remain [at the hospital] would mean to factor in such loss of human lives as a parameter of our activity, and this is unthinkable.” The organisation was looking into ways to support local initiatives aimed at improving access to health care. With almost 16 000 deliveries in 2019, the Dasht-e-Barchi maternity centre was one of MSF's biggest such projects worldwide. More than 70 MSF staff and patients in MSF health-care programmes have been killed in Afghanistan over the past 16 years. “The recent trajectory in Afghanistan is of great concern. After the hope brought by a relative reduction in hostilities in February and March, we again see more violence”, said Juan-Pedro Schaerer, the head of the ICRC delegation in Afghanistan, in a press release. “Civilian casualties are on the rise while the country is battling against COVID-19.” Years of international aid and development had been starting to pay off before the pandemic, in areas including record numbers of children in school and progress on child labour, poverty, and child marriage, said Save the Children. “The COVID-19 pandemic means these hard-won gains could roll back in a matter of weeks unless there is a rapid escalation of humanitarian support”, said Milan Dinic, Save the Children's country director in Afghanistan. “In its latest Afghanistan plan, the UN is asking the world for more than $1 billion to help meet the basic needs of Afghans. This is a big ask during a global economic crisis. But such crises always hit the poorest countries and the poorest families the hardest.”