In September, the World Health Organization issued a statement that the health care system in Afghanistan was on the verge of collapse.
"Unless urgent action is taken, the country faces an imminent humanitarian catastrophe," said WHO Director-General Tedros Adhanom Ghebreyesus following a visit to Kabul, Afghanistan's capital.
That has happened just as predicted, says Dr. Paul Spiegel, who returned in early December from a five-week trip to Afghanistan as part of a WHO team charged with investigating the emergency.
Medical staff aren't being paid. Hospitals are running out of medicine. And many hospitals couldn't even heat patient rooms.
Spiegel and other observers say sanctions imposed by the U.N. are the reason. Many countries that previously contributed huge sums to Afghanistan have stopped donating. The idea behind the sanctions is to encourage the Taliban, which took over in August, to abandon the kinds of human rights abuses that marked their previous turn in power.
But the sanctions, say Spiegel and other observers, have had another devastating effect: "Much of Afghanistan's health care system has collapsed," says Spiegel.
Spiegel is director of the Center for Humanitarian Health at the Johns Hopkins Bloomberg School of Public Health. He spoke with NPR of his personal experiences in Afghanistan and not as a representative for WHO.
Spiegel says that he saw a two-pronged collapse.
On Aug. 15, Afghanistan was in the midst of six concurrent epidemics—continuing polio cases, measles, malaria, dengue, cholera and COVID-19. Almost immediately, sanctions required that all outside funding stop, including funding for health care, to Afghanistan's de facto authority, the Taliban.
On the most basic front of health care, that meant money dried up for primary health care, family planning, immunization programs and nutrition services. That money had been provided by USAID, the World Bank and various nongovernmental organizations (NGOs). Those funds had previously been given to a countrywide organization of clinics and health centers called Sehatmandi, which means healthfulness in Urdu.
The second health care front to suffer is the country's larger hospitals. Once funded by international donations to the Afghan government, these facilities were just as suddenly cut off.
"That means no funding for salaries, for equipment, for medicines or supplies. Any medical need like trauma care, surgery or any kind of secondary care isn't available," says Spiegel. "It all stopped because of sanctions."
"The bigger hospitals that provide higher levels of care are not being funded," he says. "For example, the U.S. and other donors funded 39 COVID-19 hospitals. Only 8% of them are now functioning at all. Most lack basic services such as oxygen and the essential intravenous medications to treat COVID-19. The bigger hospitals that provide higher levels of care at the provincial and regional levels are not being funded."
Even the large infectious disease hospital in Kabul that takes serious cases from around the country is hardly functioning, he says, because of the lack of staff and supplies.
"By October and November, the basic Sehatmandi health systems started to be funded again through NGOs," says Spiegel.
The reason is the U.N.'s release of $45 million in emergency funds in September. Those funds go directly to NGOs — not through the Taliban de facto authority — to help prevent Sehatmandi from collapsing. At that time, only 17% of the country's 2,300 Sehatmandi clinics and health facilities were fully functional, according to the WHO.
That means that immunization programs, aimed at finally eradicating polio in the country, as well as attempting to control the epidemics of measles and COVID-19, can begin again. However, Spiegel says, in some areas immunizations are no longer provided in door-to-door campaigns because of Taliban restrictions on men and unrelated women being alone together within houses. In those areas, immunizations are provided by asking people to travel to the nearest mosque for immunization, with women accompanied by a male relative. The renewed funding also means outbreaks of dengue, cholera and malaria can again be addressed.
"So there's a bit of hope, with money once again getting to Sehatmandi, of providing basic health care," Spiegel says.
Government hospitals still face huge shortfalls of cash with no money from the U.S. and other wealthy countries coming in.
"What's amazing is that most of the staff are still coming in, despite not being paid for many months. I think they're hoping that eventually they'll be paid. It's demoralizing for them, as they're limited to no medicine and no bedding. Patients have to bring their own bedding, their own food," says Spiegel.
"There isn't even enough money to heat the patient rooms. In the infectious disease hospital in Kabul, they had to cut down trees in the courtyard to provide heat for patient rooms."
"And it's starting to get very cold in Afghanistan," he says. "When it gets really, really cold and the snow starts falling in winter, I don't think staff will continue to show up. When winter comes in earnest, it will get much, much worse."
"We went to the emergency regional hospital in Kandahar [in the south of the country]. It had few medicines and supplies," he says. And the emergency room, packed with people, didn't have enough masks to protect everyone from COVID-19 spread, he says.
"Overall, it's going to be very hard to estimate the short- and long-term damage to the health systems and the number of excess deaths. In the Ministry of Public Health, for example, no one is getting paid," he says.
What's more, new Taliban workers delegated to health care facilities often have no relevant experience. That means, for example, that COVID-19 surveillance figures are nearly impossible to interpret by international agencies trying to track the pandemic. In addition, he says, "Some directors of hospitals have little to no hospital administration experience."
Even with five weeks on the ground, the team that Spiegel was part of could not investigate differences in health care in every region and remote rural area. Nor could it assess the impact and extent of Taliban policies such as restrictions on where women can travel and work.
The Taliban have put severe restrictions on education for girls and placed restrictions on female health care workers as well. For example, some female midwives were not allowed to do home visits without a male escort, according to a September article in the medical journal BMJ's opinion blog. In addition, many Muslim women prefer female medical workers and some refuse to get care from a male provider.
Spiegel said he visited a comprehensive health center outside Kandahar. "I spoke with a female midwife and a female doctor. The midwife said that so far the Taliban were not stopping family planning in that facility. But in remote areas? I don't know," he says. So far, he says, it seems there are vast regional inconsistencies in how many female providers are allowed to deliver care and how female patients are treated.
His personal view: "We need more nuanced sanctions to help the most vulnerable while continuing to pressure the Taliban to be more inclusive, particularly to women and girls." That means letting more money in so medicines and medical supplies get in and health care workers get paid.
"It's urgent. It has to happen now."
Susan Brink is a freelance writer who covers health and medicine. She is the author of The Fourth Trimester and co-author of A Change of Heart.