Last week’s devastating air strike by the United States on an Afghanistan hospital run by Medecins Sans Frontieres (Doctors Without Borders, or MSF) was not the first attack against an aid-run medical facility in the increasingly dangerous country – and nor has it been the last.
In the aftermath of the Oct. 3 tragedy in war-torn Kunduz, foreign aid workers say the escalating level of violence is making it difficult provide basic services in a country where healthcare is largely dispensed by NGOs.
Both local and international NGOs have sustained damage to equipment and vehicles in suicide attacks, been subject to raids by Afghan security personnel, and received death threats from militants, according to staff members.
"A few years ago the situation was much more stable," said Antoine Sagot-Priez, head of the Afghan mission for French aid agency Premiere Urgence Internationale, which has contracts through the government to run 80 health facilities in Kunar and Daikundi provinces.
"Now we have more and more casualties because the fighting is spreading all over the country," he added.
Sagot-Priez said intense fighting broke out in mid-August near one of Premiere Urgence’s remote clinics in eastern Kunar. The building was evacuated of staff and patients, and later that same day the shelling damaged the clinic.
"We expect this kind of event to happen more and more," he said.
The Afghan government acknowledges that NGOs face growing risks.
"Staff no longer feel safe in any health facility anywhere in the country," the Public Health Ministry said following the Kunduz attack.
Afghanistan was the most violent country for aid workers last year, according to the Aid Worker Security Database, and militants have previously attacked international aid organizations. In 2004, five MSF staff were killed in Badghis Province, leading it to pull out of the country temporarily. In 2013, a Red Cross staff member was killed in the eastern city of Jalalabad.
District and provincial cities have become more frequent targets following the withdrawal of most foreign troops and changing Taliban tactics that have destabilized the country.
"My staff always tells me the situation is deteriorating," said Qudratullah Nasrat, chief executive of Organization for Research and Community Development, which operates government clinics in Ghazni Province. "They say it's getting worse day by day."
Both sides of the conflict can affect health clinics and hospitals, especially those in remote areas.
Just two days after the Doctors Without Borders hospital was hit in Kunduz, members of Afghanistan’s National Directorate of Security intelligence agency broke into an ambulance outside a clinic in Wardak Province. The agents said they suspected that explosives were hidden inside the ambulance, owned by the Swedish Committee for Afghanistan. They also detained two staff members overnight, said Khalid Fahim, SCA's program director in Afghanistan.
The NDS was not immediately available for comment.
The SCA received news on Oct. 8 that the head of another clinic in Wardak had been kidnapped by an unidentified armed group. The kidnappers said he would be released on the condition that he leave the district within a month, according to SCA.
Fahim said that "all warring sides" have used the group's facilities as shelter at some point during the 14-year war.
Meanwhile, eastern Nangarhar Province has seen 11 clinics shuttered in recent months following threats from militants claiming allegiance to the Islamic State, which despite the broader Taliban offensive has gained a foothold in the region. Medical staff were accused of being government spies.
One has since reopened, Fahim said.
Doctors Without Borders told reporters on October 8 that it was evaluating its activities and would seek assurances from the government that it could carry on its work. But some staff members have felt the felt the aftershocks of the incident, particularly those working in remote and insecure areas.
Aid coordinator Hekmat Zadran received a call on October 7 that staff were panicking at a health facility in southwestern Farah, one of the facilities that French NGO Medical Refresher Courses for Afghans operates through contracts with the government.
"There was a rumor there was going to be an attack in the city," Zadran said. "They were thinking it was going to be like what happened in Kunduz."
Luca Radaelli, program coordinator for international NGO Emergency, said the group had no plans to scale back its activities, even at first-aid posts in southern Helmand Province, which has seen intense fighting.
"Obviously what happened to MSF makes you think, but what are we supposed to do?" he asked. "If you remove (NGOs), who will do the job? Who will treat the people?"
With reporting by Krista Mahr for Reuters