By Malalai Shinwari in Paktika (WP No. 3, 16-Jun-05)
We could hear the women's moans very clearly outside Paktika's only hospital, where relatives of the patients waited in the cold, windy weather. Esmatullah, 55, wiped dust from his eyes with the end of his turban. He told me that his daughter was inside, and that he had brought her here from his home in Khair Koot, a remote part of Paktika. Travel in the mountainous south-eastern province is difficult and expensive - the trip had cost him fifty US dollars.
"We have neither doctors nor hospitals in our area, and people die from minor illnesses," he said, leaning against the hospital wall. "I do not know why the government is not paying attention to Paktika -- we are also part of Afghanistan."
Paktika's hospital is situated in Sharana, the provincial centre. It is only one-storey tall, painted yellow, with a metal roof. But residents of Sharana are proud of the facility, which is the only cement structure in the whole province. Even though there is no running water, and no electricity except that created by the hospital's own generator, the building stands out as a beacon of modernity. There is a surgical ward and an X-ray machine, and there will be a laboratory sometime in the future.
Health care in this remote province of Afghanistan is rudimentary at best. There is a serious shortage of doctors, because medical graduates are reluctant to leave the capital, especially for a region as difficult as Paktika. Located in Afghanistan's south-eastern corner, it still has pockets of Taleban and al-Qaeda activity that make working there dangerous as well as challenging.
For women, of course, the difficulties are compounded. A UNICEF study released in 2002 called Afghanistan "the worst place in the world to become pregnant". Half of all deaths of Afghan women between the ages of 15 and 49 are due to complications surrounding pregnancy and childbirth. Paktika was not part of the study but Badakhshan, another mountainous province in the northwest part of the country, showed the highest maternal mortality rate ever recorded globally -- 6,500 maternal deaths per 100,000 births.
Most were preventable, the study showed. Only seven per cent of the documented deaths occurred when a doctor or qualified nurse was in attendance. Afghan women are highly unlikely to go to a male doctor, and the Taleban's prohibition on female education ensured that the supply of women doctors would be virtually nil.
In Sharana, there are ten doctors on the hospital staff, but only two are women. Out of 20 rooms in the hospital, two are devoted to female patients. The imbalance is stark - while the male wards were half empty on the day IWPR visited, the women's rooms were full to overflowing.
Each ward has ten beds. Most of the patients had come from remote areas of Paktika, and were waiting to be seen by one of the female doctors. When this reporter walked in, I was besieged by women asking me to check their pulse, telling me their symptoms. When I told them I was not a doctor they moved away, disappointed. But some were eager to share their stories with a journalist.
"My sister got pregnant and when we tried to take her to the hospital she died on the way. The roads are very bad. This is how women live in our province," one woman told me, covering her face with her headscarf.
Dr Zainab is one of the two women physicians on the hospital staff. She lives at the hospital with her eight-year-old daughter, and is concerned over the lack of schools in the region. "These women really need me, but the future of my daughter is also important, and I want to go back to Kabul," she said.
Many of the women in the ward complained that their husbands had gone abroad to seek work. Given the Afghan tradition of a bride moving in with her husband's family, these women were dependent on their in-laws, who may not attend to their needs.
Women are brought to the hospital only when matters have reached a crisis point, "We get a lot who are in a coma -- these are usually women whose husbands are abroad," the doctor added.
Gulab Mangal, the governor of Paktika, agreed that health care in his province was well below par, but was quick to assign blame elsewhere. "The media publishes bad information about Paktika, saying it is dangerous and no one wants to work here," he said. "International organisations have come, but they have not done enough."
The health ministry also confirmed that Afghanistan's women are facing a health crisis of major proportions. "Nearly 50 women lose their lives every single day," said Health Minister Sayeed Muhammad Amin Fatemi.
As bad as the situation is in Sharana, it is much worse once you leave central Paktika. The roads are so bad that our heads were hitting the roof of the car, and I tried to imagine how it would be to bring a sick person along this route. We passed caravans of Kuchis (nomads) coming from Pakistan. The minute I got out of the car I was surrounded. "Please, give me a pill," said one old woman. "I have had a fever for a month."
When I told her I was not a doctor, she shrugged, and said, "Then I must be going. I need to follow my camels."
I asked another Kuchi woman what she will do if she gets pregnant and delivers a child during her travels. She just smiled, uncomprehendingly, "We will take the child with us, of course."
We headed towards Sar-rozai, a village to the south of Sharana. There we met more of the same. One widow showed me her hands. She had fallen during the winter and broken her wrists. A village healer had tried to help, but no professional care had been available. "Now my hands are so weak I cannot work," she said.
Abdul Rahman, the district chief of Sar-rozai, said that all of the area's problems could be solved if the government would pay more attention to Paktika. The media was also to blame, he added, for publishing reports that made doctors afraid to come to the province.
But there is one bright spot on the horizon - Sar-rozai will soon have its own hospital. All they need now is doctors brave enough to go there.
Malalai Shinwari works for the BBC in Kabul.