As United States forces withdraw from Afghanistan, putting an end to the longest war in US history, a new era has begun again for a country that has seen invading forces come and go over the centuries. 

The news has been dominated by the Taliban forces swiftly taking control of the provincial capitals and seizing Kabul unopposed, as well as the sight of western embassies packing up, Afghans desperately trying to leave, the spectacle of foreigners fleeing en masse, and many NGOs ceasing to operate.

In contrast to these scenes, Doctors Without Borders/Médecins Sans Frontières (MSF) and a handful of other humanitarian agencies have maintained their presence and activities at the height of the fighting, providing lifesaving assistance to the sick and wounded. 

How has this been possible? Doctors Without Borders has had successes and failures in Afghanistan, but the core of our approach has remained the same: we would only work if we had the explicit agreement of all parties to the conflict. That included the Taliban, the US forces, the Afghan National Army, and in some cases local militia groups. Our principles of neutrality, independence, and impartiality, that can at times seem abstract, were operationalized by talking to all sides, refusing funding from governments, clearly identifying ourselves so as not to be confused with other groups that may have other interests, and by making our hospitals weapon-free zones. Whoever came to a privately funded Doctors Without Borders hospital had to literally leave their gun at the door. 

When working in Kunduz or Lashkargah hospitals, we regularly explained to US, Afghan, and Taliban soldiers that we would never turn away any patient, be they a wounded government soldier, a car crash victim, or a wounded Taliban fighter. Our hospitals triaged based on needs alone. We worked according to medical ethics, not according to who was deemed a criminal, a terrorist, a soldier, or a politician. We often had to request US and Afghan soldiers to leave and return without their weapons if they wished to visit the hospital. 

Our approach was often in contrast to the way in which the aid system – including humanitarian agencies – were being pushed by donors to build the Afghan state, to create stability in areas taken by Afghan forces and contribute to the legitimacy of a fledgling US backed government. Aid was the “soft power” to win over the population to the Afghan government, a key component of the hearts and minds strategy bolstering the “hard power” of military deployment. 

Tellingly, when meeting a western humanitarian donor in Kabul, they were unable to tell us where the humanitarian needs were the greatest but instead referred to a map of areas under control of coalition forces (in green), under Taliban control (in red), and contested areas (in purple). They were sending aid to green and purple areas to help boost the military effort. International NGOs taking government funding from western states involved in the fighting were shocked to see counter-insurgency language such as “clear and hold” creep into their funding grants. As one of the biggest government donors explained to us in Kabul: “The Taliban are making gains in this province; we told the aid agency to cover the province in wheat, and they did.”

But our approach did not always protect us. It was in 2015 that US special forces bombed our hospital in Kunduz after the province had been briefly taken over by the Taliban. It demonstrated to us the grey zones that exist in such conflicts: aid is tolerated and accepted when it boosts the legitimacy of the state, but it becomes susceptible to being destroyed when it falls into a territory where entire communities are designated as hostile enemies and when the state is on the back foot. This grey zone is cultivated by legal ambiguities between international and national law, creating environments conducive to what US authorities categorized as “mistakes.”

Following the destruction of our hospital, Doctors Without Borders engaged again with all parties to the conflict to clarify the respect for our medical activities. It was arguably our widespread public support and the political cost of the attack on Doctors Without Borders that ultimately served as our best safeguard against future so-called mistakes by US and Afghan forces. However, this form of deterrence through engagement and public pressure was of no use when our maternity hospital was brutally attacked in Dasht-e-Barchi, most likely by the Islamic State in Afghanistan who have remained out of reach of our dialogue. 

While Doctors Without Borders has been able to operate in provincial capitals we have been unable to go into rural areas to address needs there. This has been one of the failures of Doctors Without Borders’s work over the past years. However, two weeks ago, when the Taliban entered the cities, we were able to continue working to treat patients: the sick and the wounded were able to receive care in facilities which we adapted to cope with the intensity of the fighting.  In Helmand, Kandahar, Kunduz, Herat, and Khost, our teams continued to work. Our health facilities are today full of patients. 

This is why as Doctors Without Borders we seek to negotiate with all parties to a conflict. It’s to enable our teams to deliver assistance when needed the most. Often these moments are in the midst of changes in power and control. It’s also the reason we resist against efforts to incorporate our activities into political processes of state-building. It is why we speak out loudly when our facilities and staff are harmed. 

The future of Afghanistan is uncertain, and our activities will remain under pressure. The challenges we face will evolve and the security of our teams and patients remains a concern. But to weather future storms in Afghanistan, humanitarian actors would do well to firmly plot their own course based on the needs that exist, rather than being steered by the changing political winds. 

Afghanistan shows how foreign led nation-building can fail and how humanitarian actors’ contributions to such efforts are minimal. It also shows that our work can save the most lives when we are able to be as independent as possible, both when a state is being built and when it collapses. – Rappler.com

Christopher Stokes and Jonathan Whittall have both worked in Afghanistan.

Stokes was the Head of Mission for Médecins Sans Frontières (MSF) in Afghanistan in 1996 when the Taliban took over Kabul for the first time, and has returned regularly to the country over the past two decades to support and represent MSF operations in his previous capacities as Director of Operations and General Director of MSF’s Operational Center Brussels. He was most recently in Afghanistan in 2021.

Whittall helped to set up the Kunduz trauma hospital as a Project Coordinator in 2011/2012 and has also returned on multiple occasions, including to carry out research on access to health in Helmand as a Senior Humanitarian Advisor and to support the teams in negotiations at Kabul level after the attack on the Kunduz hospital in 2015. Whittall can be found on Twitter: @offyourrecord.