Afghanistan has some of the worst health indicators in the world. In Helmand province the noise of war is heard around the clock; as helicopters take off in the night, gunfire and rockets are audible in the distance. Movement from villages to towns is very dangerous and in many places simply impossible. In this context ordinary health problems become medical emergencies.

MSF has just started working in the only public general hospital still functioning in Helmand, located in the provincial capital Lashkargah. This is a hospital that has over the last few years been the recipient of a great deal of overseas aid. Yet, when I walked through the different wards what I found most striking was the absence of patients.  Only a third of beds are occupied. On the morning of our visit we counted 40 patients for 124 beds.

Why so few patients? In truth, the medical services provided in this hospital have been patchy at best. Most of the medical staff work only in the mornings – in the afternoons they leave to work in private clinics. Medical practices in the hospital are out-of-date. Drugs are routinely over-prescribed; at times seven different antibiotics are prescribed when one would suffice. Then there is the cost of the medications – the consultation may be free, but patients are often sent out to private pharmacies to buy drugs. The cost of these drugs can be prohibitive for poor families, particularly when you add in the cost they incur travelling to the hospital in the first place. Even if they have the means to buy these drugs, what they do manage to buy can be of low quality or even counterfeit.

While the hospital may not be operating to its capacity it is nevertheless full of donations of sophisticated medical equipment. Digital x-ray machines from Europe and China, laboratory machines, surgical equipment and scialytic lamps, many still unpacked, are piled up in the basement. They were donated by governments, through the provincial reconstruction teams of the International Security Assistance Force (ISAF) or via direct bilateral aid – usually with little explanation or instruction.

While I was in the hospital a child with measles was brought in. His mother told us there were at least eight more children with similar symptoms in her village. Measles is a highly contagious disease that can be fatal if untreated. Her child suffered from complications and needed oxygen to get through the night. However, the only functional oxygen machine was in the medical ward where the presence of other children could lead to cross infection. Nevertheless, this is where he was brought. Meanwhile we counted at least six mobile oxygen generators gathering dust in the basement!

This child is a victim of the conflict and his plight encapsulates this war. He contracted an easily preventable communicable disease simply because he lives in a war torn region where vaccination coverage is scarce. The child's mother had no choice – she took a risk by coming to Lashkargah, but she had to wait until it was almost too late.  Even after eight years of receiving donations from governments and then ‘dumping’ this medical equipment, the hospital is still not ready to receive patients and treat them properly.

Earlier, a pregnant woman was injured in an explosion. She finally made it to Lashkargah 48 hours later.  Her unborn baby was also wounded in the blast. The mother survived the delivery despite a perforated uterus, but her baby died from sepsis. Had she been able to reach a hospital faster, perhaps both lives could have been saved.

After nearly five years of absence, following the murders of five of our colleagues in 2004, the return of MSF is cautious – balancing risks against needs. Our sole objective is to assist those most in medical need in order to help as many people as possible survive the conflict. In order to be accepted by all parties involved in a conflict a private medical-humanitarian organization should demonstrate and clearly communicate complete impartiality and independence. For MSF this means that we choose not to accept any funds from any governments for our work in Afghanistan or Pakistan and we reject any attempt from other forces to direct or control us.

The once clear distinction between armed forces, reconstruction, development activities and humanitarian actors has become very confused. Presently, all assistance actions, including “hearts and minds” initiatives implemented by armed forces, are labelled ‘humanitarian’. The key difference is that strictly humanitarian organizations such as MSF work to provide immediate life-saving care on the basis of medical needs alone, with no other objectives.

There is a practical need for clear distinctions to be made. Why? Because humanitarian organizations such as MSF should seek to help populations in need no matter where in the country they live or what battles are being fought there. An organization (of whatever political complexion) that aligns itself with one side through funding or otherwise simply will not and cannot do this. Second, choosing sides often requires relying on armed protection and that can make the organization or the structure they support a military target.

Currently, there are many medical facilities in Helmand that have been physically rehabilitated by ISAF and are patrolled by NATO and Afghan troops. They are viewed as military targets by armed opposition groups. Meanwhile, clinics run by local, independent NGOs, which are often intentionally left in a state of disrepair to avoid association with ISAF-supported health facilities, have come under attack by ISAF forces mistaking them for opposition hideouts. The result is that the clinics themselves have become a battleground, placing patients in danger and making them more reluctant to seek healthcare.

Central to restarting our work in Afghanistan has been the demilitarization of hospitals through the enforcement of a strict no-gun policy in the health structures where we work. We are asking all parties – the police, the coalition forces, and the armed opposition – to leave their guns at the gate.

In addition to the Lashkargah provincial hospital in Helmand, we are also starting to work in a hospital east of Kabul in a town whose population has mushroomed with the arrival of Afghan returnees from Pakistan and displaced people fleeing the war in the eastern provinces of Afghanistan. Despite the needs and low health service coverage, this area has been neglected by aid agencies because it is not a priority in counter-insurgency aid policies. Much funding is set aside for large infrastructure projects in Kabul, but few international funds are made available for immediate assistance.

We have medical teams made up of Afghan and foreign staff now working in both hospitals with the aim to  provide quality, life-saving and absolutely free medical care with effective drugs in all medical areas, including maternity, paediatrics, surgery and emergency care. The collaboration begins with getting the resident medical staff to agree on best practices. The next priority is to get these medical services running 24 hours a day, rather than for a few hours in the morning. MSF will seek to extend its support to hospitals and rural health centres in other provinces in 2010, but in such a dangerous environment progress will be slow.

Today in Afghanistan, there are not enough organizations independently assessing and responding to the needs of people in war affected areas. In a province like Helmand, access to care is extremely limited. Evidently, the delivery of aid for political rather than humanitarian objectives has its limitations: it can fill hospital basements with expensive medical machinery, but not fill beds with the patients in need of treatment coming from all sides of the conflict.

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