Cologne, August 5th, 2002. Dr. Monika Hauser, a gynaecologist and founder of the women's relief organisation medica mondiale, returned from her trip to Kabul, Afghanistan highly alarmed by the state of affairs she encountered.
There she mainly accompanied the start of a medica mondiale project in cooperation with female Afghan doctors in exile and got a first hand impression of medical care in Kabul. Her synopsis is sobering: "I am shocked at the state of their clinics. Their equipment and the standards of medical care are beyond description. Even in the light of the promised international help amounting to millions of dollars, I can hardly believe what I've seen."

"All in all, I have to say that I'm shocked at the conditions of the clinics I've visited. Those who can afford it seek help at one of the countless private medical practices anyway, where incompetent pseudo-doctors make comparatively large amounts of money."

• Rabia Balkhi Women's Clinic

  This hospital is the worst I have ever seen. Minimal equipment, unmotivated, personnel who seem somewhere between indifferent and apathetic. It serves a huge region and has the poorest of clientele. The doctors earn about 20 US-dollars a month - certainly not enough to get by. The doctors are all traumatized themselves and appear to be suffering from depression. Most of them are completely lethargic. They complain that 30-40% of their patients are not really sick but merely undernourished and simply looking for handouts.
  Every day between 9 am and 1 pm three to five doctors see 70 patients with all kinds of symptoms at the general out-patient centre for women. This means that about 30 to 40 women - all in blue burkas - are waiting in the completely overcrowded square in front of the ground level centre. An old man guards the narrow entrance door to the centre - a cramped, stuffy room of about eight by three meters.
  Four tables are lined up along one wall. Doctors and two assistants are seated behind them. A filthy plank bed is put up far in the back where the only currently existing blood pressure gauge gets used once in a while only in extreme cases. This device, by the way, was given by medica mondiale. Our doctor Najiba brought it in her medical kit. There is supposed to be another one somewhere at the hospital. The women are let in individually and go to one of the available doctors. While standing, the woman tells the doctor about her complaints. The doctors ask no more than two questions - then the woman either receives some iron tablets laid out on the table in small sacks or a prescription. None of the patients, however, can actually use the prescriptions because the pharmacies charge money for it. Oftentimes the pharmacies simply give out what they have. The whole procedure takes no more than two minutes. It is an atmosphere ruled by indifference or even aggression.
  For a while I sat next to the only male doctor (there were three other female doctors) and watched the scene. Although he had seen around ten patients during the time I was there, only once did he halfway get up out of his chair--to look at a red and swollen calf. Iron tablets were prescribed for that, too. Then a woman came in whose serious heart problems and high blood pressure even he could not ignore. He actually got up to check her blood pressure. He kept the results to himself but said, with an emphatically important tone in his voice: "high blood pressure." From a dirty container underneath the table the assistant gave him several pill bottles to choose from. He was about to give one of them to the patient but changed his mind in the last moment and gave the bottle instead to me. Somewhat puzzled I told him that this was an anti-depressive. The only high blood pressure drugs we found had unfortunately expired last year. (Afterwards our Afghan doctor Najiba told me that he said to the assistant he would take the anti-depressive for himself!). The woman was likewise sent out with iron tablets. When she insisted that she was really not doing well the doctor signalled to an attendant. The attendant used the switch she was carrying to usher out the patient.
  
  Internal Medicine Unit
  In the rooms the beds are overcrowded. Sometimes two patients share one bed. Everything is covered with dirt - from the bed sheets, to the full chamber pots under the beds to the walls.
  The intensive care unit looked the same. (Apart from the severity of patients' conditions there was actually no difference to the other rooms as far as the equipment was concerned). Najiba asked why one of the beds was empty which only the day before had been given to a patient who had suffered a stroke and was paralysed on one side after apparent bleeding into the brain. Najiba was told that the patient's family wanted to bring her to Pakistan because there was no access to computer tomography in Kabul. How this woman was supposed to survive the long trip over bumpy streets escaped me.
  We then retreated into the doctor's office with four other female doctors for a talk. They became a little livelier and it turned out that three of them had just returned from Pakistan four months ago.
  This is something I noticed over and over again: The degree of depression depends on whether or not someone had been "outside", had had a job, whether anything had happened to her family etc. Many of them are paralysed by the sufferings of recent years and have built up self protection mechanisms between themselves and their patients.
  
  HIV
  One of the doctors said that if we really want to help we should make sure an HIV-Screening Laboratory is put up as soon as possible. Otherwise the people of Afghanistan will die even faster. Many of the necessary medications are not available, there are no means of diagnosis, no medical devices. The [current] laboratory, the doctor said, does nothing more than perform a small blood count and determine creatine levels. Also alarming in this respect is the fact that the [existing] laboratories cannot run tests on hepatitis - with it being very likely that there are a great number of those infected with hepatitis living in Afghanistan!
  
  

• Helping Others to Help Themselves
  Another doctor reported: A young 22-year-old woman came in a few nights ago with internal bleeding. She died the next morning. The doctors are eager to learn how to help themselves, in order to, for instance, re-establish the country's pharmaceutical industry and not always remain dependent on international help.
  Finally a conversation with the director. She seemed like a cold vestige from former overly-regimented times with her white hood and rigid face. She says that four years ago the WHO renovated the hospital (I wonder what it looked like before). Ever since they had not received any medications or vaccines. That of course is something I can not check or confirm. Neither do I know how much corruption actually takes place here. However, one thing is for sure: these wards have not received any help over the last few years.
  
  
  

• Noor Eye Clinic

  Golulei, our doctor from the "Doctorane Omid" project shows us around. The technical equipment is more than inadequate. They barely have any diagnostic devices. Especially problematic is the fact that there are hardly any disinfectants and the ones they have are not being used! Golulei has a dish with swabs dipped in disinfectant solution, but hardly anyone from the staff uses it regularly! With many patients coming here with bacterial and viral eye infections the staff themselves become transmitters of disease! As a preventative step, Golulei urged the nurses to exchange their long Tschadoris (excellent carriers of bacteria!) for white caps, this being also much more professional. Five women have already taken up the suggestion - it seems that what is missing is mostly education and encouragement from the outside to make a change.

  Help from the GTZ
  Later on I talk to a representative of the Society for Technical Cooperation (GTZ) of Germany. He tells me that the GTZ is momentarily renovating the old Noor Clinic. Right now they are only working in a temporary building. There is also going to be basic medical equipment. The contract has just been signed. However, he doesn't know when the building is actually going to be finished. What really frustrates me is that there is often (by the Germans) concrete work carried out - but what happens when it's finished? There has to be training and further education for the entire staff. Otherwise they might have this nice new clinic but will still be spread germs with their Tschadoris and hands. There is no general strategy and there are no set of measures to take.

• Khai Khona Hospital/ 52 Bed Clinic

  Suicide Attempts and Sexual Violence
  Our doctor Saliha Ferhat (Doctorane Omid) was greeted enthusiastically at the Khai Khona Hospital. The morale and hygiene have improved immediately because Maruf Nadin, the director of the clinic, has become much more attentive and motivated. He says that the hospital hasn't received international aid for the last six months. The "Save the Children" organisation was the only one that supported them occasionally. He says he is very happy to have Saliha there, as is the entire personnel. They all appreciate her efforts at further education and at real moral support. Nadin admits that the psycho-social problems of the women are enormous. Saliha has reported that four women have attempted suicide since she has been at the hospital. When asked, the women all deny having experienced (sexual) violence, claiming that they simply had fights with their family members. As a twelve-year-old arrives with a broken arm, it becomes clear that she received the injury as she defended herself against rape by her 20-year-old "husband" – the man whom her parents insisted she marry!

  Discussion in the Gynaecology-Obstetrics Unit
  I am led around by the very pleasant director of the unit, Dr. Nagiba Siamak. Soon the other doctors and midwives join us and look at me with bright smiles. Every day in the delivery room there are 24-30 births. I am told that pregnant young girls suffer the most health problems, both during their term and at delivery. All in all, 30% of those delivering in the unit are young girls with serious complications. As it is easy to imagine, the personnel has no access to ultrasound devices, CDG or other diagnostic equipment for properly handling normal births, let alone for dealing with C-sections. They only have their hands, their stethoscopes and their outdated instruments. In the delivery room there is only a partly functioning floor lamp, whose light cannot be focused properly. Currently they have few hormones left, such as Oxytocin or Methergin - drugs particularly important for women already having had several pregnancies to stop bleeding after delivery. A young resident, Dr. Pashtana, speaks some English that she learned in Pakistan. She seems highly motivated and is very interested in the training offered by medica mondiale.
  Then I speak alone with Ms. Siamak. Sabiha and Roya translate for us. When asked about violence against when, Ms. Siamak immediately tells me the story of the twelve-year-old girl with the broken arm. Ms. Siamak says that she tried to speak with the girl's parents, but there was no chance of helping her. The parents did not want the "disgrace" of their daughter returning home! She describes how even young girls are married off to very old men. These 80-year-old men are no longer fertile but take young women as wives in the hope they will bear them sons. According no one is willing to speak about it. Ms. Siamak believes that the recent requests of parents of girls and young women for hymen reconstructive surgery attest to the fact many were raped under the Taliban regime.
  We agreed that the hymen reconstructive surgery was not a technical problem, but a moral one. When asked, Ms. Siamak said that such surgeries could occasionally help the girls…She emphasises that these women and girls first need economic help.
  At the end of our meeting she told me that her own children were living in Hamburg with their grandparents - for the time being she herself had to be in Afghanistan in order to help her women!
  

  
  
• Maiwand Children´s Hospital

  Seriously Ill Children - Young, Fully Overburdened Mothers
  Maiwand Children´s Hospital primarily treats undernourished and improperly fed children, or resulting infections (in particular lung and intestinal track infections). Children with other medical problems are handled only on a secondary basis. Children are admitted to the hospital's intensive care unit based on certain criteria such as weighing 60-70% of normal body weight or on the severity of their hunger edema. After they have gained some weight, the children are transferred to the emergency care unit. But this does not mean they are safely on the road to recovery.
  The entire department is lead exceptionally well by a doctor who has worked here for the last ten years. It is clearly difficult for her to see that she cannot really help many of these children.
  Take, for example, a one-year-old child showing symptoms of a hyperactive thyroid. If properly diagnosed, the condition could be easily treated. The already existing progress of physical and mental retardation could even be reversed. But unfortunately because of poorly equipped facilities at the hospital and at the Kabul central laboratory, a proper diagnosis cannot take place. Soon the mother will have to return with her child to the northern regions of Afghanistan, knowing the child faces the prognosis of increasing disability. What will become of such a child in these devastated surroundings?
  At the Maiwand- Children's Hospital it was not only the dire situation of the children but of their mothers that became particularly evident. Still themselves very young, the mothers sit apathetically and disoriented on the beds of their critically ill child. Many have had to travel great distances from the provinces, leaving them emaciated and with little strength themselves, while having to worry about their other children at home. In the intensive care unit I met a young 16-year-old woman. Next to her was her little one-and-a-half-year-old son who was in a very bad physical state. Back home she had a three-year-old son and a 30-year-old husband. Her facial expression was that of a wounded animal, itself injured and heavily traumatised. She was far from being the caring and concerned mother one might expect. Her only protection seemed to be her indifference.
  It is clear how deeply important it is - and how great a chance we have - to reach out to these women and girls with further education and empathy. I find it to be a very hopeful sign that there is a teacher who greets the women and takes time to educate them about hygiene, child care, etc. We will have to see to what extent medica mondiale will be able to contribute to teaching women how to provide for themselves or to giving them psycho-social support and family planning counselling. In any case it would be an ideal opportunity to reach these women from distant provinces, all of whom experience daily sexual violence carried out by their spouses or family members.
  The possibilities for providing good family planning and sex education of course depend mainly on societal changes.
  Nevertheless: these young doctors and their director are women who have the potential to effect real change!
  

  It is these discussions, I must say, which work to counteract my otherwise deep horror at the actual situation in Kabul and the many layers of destruction and hate found there. These discussions are reason to think that change will come one day. But the path of change will surely be extremely difficult and the women of Afghanistan will need the help of vigorous supporters .
  
  

• Violence Against Women - the Facts
  1. Forced marriage: It is increasingly common in Kabul for young girls to be forced into marriage with very old men. When childless, men often take a young wife in the hope she will bear him children. This phenomenon is more and more frequent in Kabul, as the men there have money to pay-off the parents of their soon-to-be-wives.
  2. Serious problems with domestic violence: girls and women are being beaten by men, other women and older siblings.
  3. There is little help and solidarity among Afghan women. Social aid networks have been dismantled. This has resulted from physical effects through the breaking apart of families in war as well as from the effects of ruined psyches.
  4. Although officially not talked about, it is well-known that many young girls were raped under the Taliban regime. Now there are many requests for hymen reconstructive surgery.

Photos from Monika Hauser's journey in Juli 2002