As the van passed along the bumpy road, groans could be heard coming from the three wounded passengers, but once on asphalt near Kandahar city, southern Afghanistan, only one person was still murmuring; the two others (teenagers) had passed away.
Driving Aleem’s wounded body from a district to the city took 12 hours, he said (Photo: Sarwar Amani/IRIN)
The three were injured in an air strike on their village in Shah Wali Kot District, Kandahar Province, earlier this month, according to Abdul Aleem, the surviving injured man.
"There is no clinic or doctor in our district so they brought me here," he told IRIN from his bed in a hospital in Kandahar. "I was in terrible pain on the road here."
Next to Aleem's bed is Juma Gol, 13, who said he was wounded in a roadside explosion in Kandahar's Panjwaye District. Gol endured three hours tied to the back of a motorcycle driven by his elder brother until they found a car to take him to the city for treatment.
"When I got wounded I did not feel much pain but I felt terrible pain when I was on the motorcycle," Gol said.
Bringing a patient from rural areas to Kandahar is not only difficult and risky but very expensive. Several patients and their relatives complained about improvised roadside explosions, demands for cash from insurgents and apparently indiscriminate shooting by international forces.
"In an emergency private drivers demand several times more money than usual," said Shir Mohammad, from Maiwand District.
Constant fighting and threats to health workers have forced the closure of at least 11 of the 38 health facilities across the province, the population of which is estimated at over one million, according to provincial health officials.
Women at greatest risk
The absence of health providers in rural areas makes things especially difficult for women who already have limited access to work and education.
Bibi Nanye, an elderly woman from Khakriz District in Kandahar, said: "Many women die during pregnancy and child delivery and from other diseases because men cannot, and do not, take them to hospital in the city."
Her concerns were acknowledged by Abdul Qayum Pokhla, the director of Kandahar's health department. "Women and children suffer more than anyone else from the lack of access to health care."
Afghanistan has one of the worst maternal mortality rates in the world: 1,600 deaths per 100,000 live births, according to UN agencies.
Influx of patients
Rapid population growth and lack of access to health services particularly in insecure rural areas have contributed to an influx of patients to the provincial capital, health officials said.
"We receive patients not only from all over Kandahar but also from [neighbouring] Helmand, Zabul and Uruzgan provinces," Daud Farhad, director of Mirwais Hospital in Kandahar city, told IRIN, adding that from March to August 2009 over 67,000 patients had been treated at the hospital.
Established in 1978 initially with 250 beds, the hospital's capacity has now been increased to 354 beds in order to meet increasing demand.
"Sometimes we give one bed to three patients with minor ailments because of space limits," Farhad said.
Lack of medical personnel
The shortage of qualified medical personnel and equipment is also affecting the hospital's response capacity.
"For the 180-bed surgery unit we should have 36 surgeons but currently we only have 18," said Farhad. "Although it's a main regional hospital we don't have equipment such as CT [computerized tomography] and MRI [magnetic resonance imaging] scans."
The International Committee of the Red Cross (ICRC) supports Mirwais Hospital with medical supplies, equipment, training and maintenance because it is a major health facility in the volatile south.
"Mirwais regional hospital is admitting more and more children with ailments that could easily be treated locally if only health posts and clinics were functioning. Patients with severe trauma are also on the rise. The number of civilians injured by improvised explosive devices is a cause for alarm," ICRC said in an operational update in July.
Security the key
Provincial health officials say there is an urgent need for the expansion of rural healthcare facilities and the establishment of a new hospital in Kandahar Province.
"We need a new 500-bed hospital in order to be able to respond to growing needs here," said Pokhla.
More qualified health workers are also critically needed in the province, he added.
However, officials concede that everything hinges on one important issue - security. "We can re-open the closed clinics and build new ones if only we had security," Pokhla said.
Taliban insurgents are believed to be present throughout the province, according to a report by the International Council on Security and Development.