Médecins Sans Frontières has started to work again in Afghanistan after an absence of five years. MSF's General Director Christopher Stokes, has extensive work experience in the country, and he has recently been back to take stock of the MSF projects.

In this article, he explains why it is crucial for MSF to base its activities in the country on three pillars; providing free medical care, not accepting funds from governments, and keeping all weapons out of the hospitals.

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

MSF has just started working in the only public general hospital still functioning in Helmand, 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. Generally 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 only work in the mornings – in the afternoons they leave to work in their private clinics. Medical practice in the hospital is out-of-date; drugs are routinely over-prescribed – at times seven different antibiotics are prescribed when one would suffice.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 – whilst the consultation may be free, patients are nearly always sent out to private pharmacies to buy drugs. The cost of these can be prohibitive for poor families, particularly when you add in the cost they incurred travelling to the hospital in the first place. Even if they have the means, the drugs 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.

Whilst I was there, 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 led to a dangerous risk of cross infection. Nevertheless, this is where he was brought. Meanwhile we counted at least six mobile oxygen generators gathering dust in the basement! The child is a victim of this 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 donations from governments and "dumping" of medical equipment, the hospital is still not ready to receive patients and treat them properly.