As Coalition Forces pull out of Afghanistan after 12 years, their leaders struggle to define the intervention's legacy. Alluring narratives of success - crafted to suit political and military agendas - abound. But any desire to package the intervention into a simple success story obscures the reality of an ongoing conflict. Last year was the second most violent one for civilians since the war began, and hardly a week passes without casualties or severe injuries from bomb attacks, shootings or landmines.
When it comes to healthcare provision, much investment and progress has undeniably been made since 2002. Official accounts of Afghanistan's health system however, habitually emphasise achievements, yet neglect unmet medical needs. It is remarkable how far the prevailing stories of progress differ from the reality. This brings to mind the fable of the doctor who, like the international community in Afghanistan, has declared their operation to be a success. The macabre reality, however, is that the patient has died.
During the second half of 2013, MSF interviewed more than 800 patients to better understand their experiences in accessing healthcare. The resulting report, "Between Rhetoric and Reality, The Ongoing Struggle to Access Health Care in Afghanistan," reveals a sobering fact: a majority of people across four different provinces often cannot reach critical medical assistance due to insecurity, distance and cost.
At least one in five patients reported violence to their relatives or neighbours over the past year. Within the previous 12 months, one in four people had either experienced violence themselves, or had a family member or friend who had experienced violence. One in four people had a family member or friend who had died as a result of violence within the preceding year. Over 80% of the violence reported was directly related to the conflict.
Beyond the statistics were the horrific stories we heard: an entire family blown up by a landmine as they travelled home from hospital with a new baby; of villages caught between rival armed groups; of people forced to hold night-long 'death-watches' over sick or wounded relatives as fighting raged outside, in the hope of reaching medical care safely the next day.
Patients trying to reach a doctor or medical facility told us about how they must risk government and opposition checkpoints, landmines, bandits and crossfire, and the majority are too afraid to travel at night, when all these obstacles intensify. All parties to the conflict bear responsibility for these obstacles and must ensure access to medical care is facilitated.
For those who do manage to reach health facilities, actual care often remains elusive because of cost. In Khost, in the east of the country, and in the capital, Kabul, roughly half the people surveyed by MSF borrowed money or sold what they could to pay for medicines or doctors' fees during a recent illness. Several sought care in neighbouring Pakistan.
These stories are from the people that managed to reach our hospitals. We know that many more who need medical care do not receive it. This is why the discussions underway about Afghanistan's future must recognise and address unmet humanitarian and medical needs.
Enough time has already been wasted.
In 2005, donors and policy-makers were abuzz with talk of reconstruction and post-conflict transition. This premature label suited the US-led coalition and the Afghan government it supported. Acknowledging the extent of the humanitarian crisis did not.
In the name of stabilisation, "force protection," or "winning hearts and minds," military and political imperatives have rendered as secondary the plain matter of what patients need. Priority needs have been overlooked, such as a functional referral system between basic health centres and district or provincial hospitals for people with serious injuries needing prompt surgical attention or women experiencing complications during labour.
So while government health services may have expanded in the country, they did so largely in areas deemed of strategic and political value to donor governments or where the security environment was stable enough according to international forces, not necessarily where the needs are actually the most acute. And where these facilities do exist, the trend of them being used for purposes other than the provision of health has been once again proven by a decision by the Afghan government to use hospitals as polling stations in the upcoming elections.
As donors renew and review their pledges, and politicians get ready to make new promises, medical care must be high on the agenda. And, crucially, aid in Afghanistan must be untangled from political and military considerations of all parties to the conflict, once and for all.
Assistance should be provided based on needs alone, and must not be obstructed by any armed group. If not, too many Afghans will continue to be denied the lifesaving medical care they need and Afghanistan will become known not only as the graveyard of empires, but also of humanitarianism.