By Krista Mahr
KABUL (Reuters) - The U.S. air strike in Afghanistan that killed at least 22 patients and staff at a Medecins Sans Frontieres hospital wasn't the first time the escalating war has affected an aid-run medical facility. There have even been instances since.
Foreign aid workers and Afghan colleagues shaken by the weekend tragedy in Kunduz, one of the worst incidents of its kind in the 14-year war, say increased violence around the country makes it harder to provide basic services in a country where NGOs help provide the vast majority of healthcare.
In recent months, local and international non-governmental organizations (NGOs) have seen equipment and ambulances damaged in suicide attacks, raids by Afghan security personnel and threats to their lives from militants, staff members told Reuters this week.
"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.
According to Sagot-Priez, in mid-August intense fighting broke out near a remote clinic operated by Premiere Urgence in Kunar, in the east. The staff evacuated with their patients and none too soon: that day, the clinic was damaged in the shelling.
"We expect this kind of event to happen more and more," he said.
The Afghan government recognizes the growing risks.
"Staff no longer feel safe in any health facility anywhere in the country," the Ministry of Public Health said in the wake of the Kunduz attack.
CAUGHT IN CROSSFIRE
Afghanistan was the most violent country for aid workers last year, according to the Aid Worker Security Database, and international medical NGOs have been targeted before.
In 2004, five MSF staff were killed in Badghis province, prompting it to pull out of the country temporarily. In 2013, a ICRC staff member in the eastern city of Jalalabad was killed.
But changing tactics by Taliban insurgents this year, coinciding with the withdrawal of most foreign troops that made the country less stable, has seen district and provincial centers targeted more frequently and across a broader area.
"My staff always tells me the situation is deteriorating," said Qudratullah Nasrat, chief executive of Organization for Research and Community Development, operating government clinics in Ghazni province. "They say it's getting worse, day by day."
Health clinics and hospitals, particularly in remote areas, can be affected by both sides of the conflict.
On Monday, just two days after the MSF hospital in Kunduz was hit, members of Afghanistan's National Directorate of Security intelligence agency broke into an ambulance at a clinic in Wardak province, west of Kabul, operated by the Swedish Committee for Afghanistan, staff reported.
The agents, who said they suspected explosives were hidden inside, detained two SCA staff members overnight, according to Khalid Fahim, SCA's program director in Afghanistan.
The NDS was not immediately available to comment.
On Thursday, the same charity received news that the head of another clinic in Wardak was kidnapped by unidentified armed groups. His kidnappers told local elders he would be released on condition he left the district within a month, SCA said.
Fahim said that "all warring sides" have used the group's facilities as shelter at some point during the long war.
Meanwhile, in the eastern province of Nangarhar, 11 clinics have closed in recent months due to threats from fighters loyal to Islamic State, which has gained a foothold in the province despite the broader Taliban offensive.
They have accused staff of being government spies, said Mohammad Jan, the monitoring and evaluation coordinator for Agency for Assistance and Development of Afghanistan (AADA), which operates medical facilities in five provinces.
One has since reopened, he said.
"The clinics were also benefiting them. (For us) there is no difference between Daesh, the government and the public," Jan said, using the local name for Islamic State. "But they don't know what impartiality means."
AADA, like MSF and other medical aid groups working in Afghanistan, practices strict neutrality and treats patients on all sides of the conflict.
No group Reuters spoke to said Saturday's air strike had prompted them to scale down their operations. MSF told reporters on Thursday it was taking stock of its activities and would seek assurances from the government that it could carry on.
But the incident has taken its toll on some staff members, particularly those working in remote and insecure areas.
On Wednesday, aid coordinator Hekmat Zadran received a call that staff were panicking at a health facility in Farah, in the southwest, one of the facilities that French NGO Medical Refresher Courses for Afghans operates in three provinces through contracts with the government.
"There was a rumor that there was going to be an attack in the city," said Zadran. "They were thinking it was going to be like what happened in Kunduz."
Even before the Kunduz attack, uncertainty about safety had prompted SCA's expatriate staff to temporarily leave the country as of Sept. 27, SCA's Fahim said.
Others are staying for now.
Luca Radaelli, program coordinator for international NGO Emergency, said the group had no plans to scale back, even at first aid posts in the southern province Helmand which have seen intense fighting in recent months.
"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?"
(Additional reporting by James Mackenzie and Mirwais Harooni. Writing by Krista Mahr; Editing by Mike Collett-White)