U.S. aid could have transformed Pakistan's largest maternity hospital, where rats run through the halls, patients sleep three to a bed, women who require C-sections aren't getting them because only one operating room is functioning, and premature babies risk death because of a shortage of incubators.
But the government of Pakistan's most populous province, Punjab, turned down an American offer of $127 million for health care, education and municipal services following the U.S. raid that killed Osama bin Laden. Sixteen million dollars was earmarked for Lady Willingdon Hospital in the provincial capital of Lahore.
The government's decision was thought to be an attempt to win votes by capitalizing on pervasive anti-American sentiment in a province with a significantly larger population than France and a bigger land area than Greece. Pakistan's federal government and other provinces did not follow suit, but they may also find themselves with less U.S. assistance soon.
Pressure is growing in the U.S. Congress to reduce the billions of dollars in annual military and civilian aid because of the government's alleged ties to Islamist militants. The money has failed to persuade Pakistan to target militants using its territory to attack U.S. troops in Afghanistan.
The experience in Punjab shows that the impact of an aid cut in this poverty-stricken country would be felt most acutely by the poorest citizens, not the army generals allegedly gambling with militant proxies in Afghanistan or wealthy politicians hoping to win votes with their anti-American gestures.
Pakistan's elite does benefit from U.S. assistance, either through lucrative contracts for NGOs or by allegedly skimming off money funneled through the government. The loss of these funds may crimp their lifestyle, but it is unlikely to affect whether their families get adequate medical treatment or their children a decent education.
"The decision of the Punjab government to turn down U.S. money was not in the best interests of poor people in Punjab," said Mohammed Sharif, a senior administrator at Lady Willingdon Hospital. "It was a high-level decision, and we are suffering for it."
Like many government-run hospitals in Pakistan, Lady Willingdon struggles to provide even basic care. The hospital, built by the British in the 1930s before Pakistan's independence, was meant to house 80 patients. The country's population has since boomed, forcing officials to cram 235 patients into a facility that is now run-down. Paint peels off the concrete walls and black mold covers the ceilings.
Patients are forced to share beds, and sometimes women who are close to giving birth have to sit on the floor for lack of space, said nurse Kaneez Akhtar.
The hospital also faces a shortage of critical medical equipment. There is only one functioning operating room, leaving women lined up to receive cesarean sections, said a senior doctor.
"We lose a lot of babies because of that," said the doctor, speaking on condition of anonymity because of the sensitivity of the issue.
There are only three working infant incubators, which were donated by NGOs, said Mohammed Athar, the doctor who runs the nursery for premature babies. The hospital is forced to use overhead warmers for other infants, leaving them more exposed to disease, he said.
"Without incubators, it's useless," said Athar.
The $16 million offered by the U.S. would have been used to purchase 10 incubators, build a new 100-bed ward and expand the nursery and emergency facilities, said Sharif, the hospital administrator.
The U.S. has financed similar efforts to transform two hospitals in southern Sindh province that treat tens of thousands of patients every year.
The head of the Punjab government, Shahbaz Sharif, tried to justify his decision to spurn American aid following the May 2 raid that killed the al-Qaida chief not far from Pakistan's equivalent of West Point. He said at the time that Pakistan needed "to break the begging bowl" and "get rid of the foreign shackles."
The U.S. operation outraged Pakistani officials because they were not told about it beforehand.
Sharif is a leading member of the main opposition party in the country, and many viewed his decision as a way to siphon votes away from the Pakistan People's Party, which controls the federal government. The Punjab government spokesman declined to comment on this interpretation.
Sharif and other members of his government are unlikely to feel much personal impact from the move to turn down U.S. aid.
Free government-run hospitals like Lady Willingdon are mainly used by the poor, who are already suffering from Pakistan's weak economy and surging inflation. Wealthier citizens opt for more expensive private institutions in Pakistan or abroad.
A large chunk of the American assistance, $100 million, was to be used to rebuild schools in southern Punjab destroyed by last year's devastating floods. An additional $10 million was meant to improve municipal services like clean water and sanitation.
The money will now be redirected to other areas of the country, said the U.S. Embassy.
Washington has continued several programs in Punjab that don't run directly through the provincial government, such as rehabilitation of power plants and small grants to female entrepreneurs in flood-affected areas, said the embassy.
The loss of aid for schools, water and sanitation also won't be felt acutely by the elite. Most send their children to private schools and live in leafy parts of Lahore dotted with Western restaurant chains, polo grounds and cosmetic surgery centers. The Sharifs own property in London worth millions of dollars.
The Pakistani military, which has received the bulk of U.S. assistance over the past decade, is also somewhat insulated from a reduction in aid. Its officers mostly live on well-manicured cantonments that have their own schools and hospitals that are much better than those available to the general public.
Life is very different for Pakistanis who live in Shamaspura, a dirt-poor part of Lahore filled with ramshackle brick houses separated by a narrow mud lane coursing with sewage. Most of the roughly 15,000 residents are fruit and vegetable vendors who make about $2 per day. They are forced to tie pieces of cloth across their faucets to filter out dirt and insects in the water.
"We have asked the government to pave our road and build us a sewer system, but they said they don't have any money," said Jumma Khan, a 55-year-old vegetable vendor.
Poor citizens could take out their anger at the ballot box, but Pakistani politicians often insulate themselves by bestowing favors on village elders and other influential people who direct ordinary citizens how to vote.
The U.S. may be unpopular in Pakistani neighborhoods like Shamaspura, but residents said it was crazy for the government to turn down aid that could have improved their lives.
"This is rich people denying aid meant for the poor," said Batool Akhtar, a feisty old lady wearing a dirty yellow shalwar kameez covered in white flowers. "The government should have taken the money."
(This version CORRECTS that there are three working incubators in the hospital, not two.)