The women’s cancer ward at the Jamhuriat Hospital in central Kabul is full. Each one of the 12 beds is taken, but the ward is silent, save the gentle rattling of prayer beads. Some patients arrived today, others have been here for nearly a month.
In the far corner of one room lies 25-year-old Azma, the ward’s youngest patient. Her tiny figure is dwarfed by the rust-flecked oxygen tank towering over her bed.
“She fell unconscious two days ago,” whispers Najia Niazi, peeking through a window from the hallway. For the last three years, Niazi has been the lone psychologist working here at Jamhuriat. “She is stage four, and her breast cancer is too advanced.”
Niazi has come to meet Azma’s mother for counselling sessions. “Azma is suffering,” Niazi tells VICE News. “She has lost so much weight and strength, and her mother is witnessing the change in her physical appearance. The mother is seeing the pain, so she needs emotional support as much as Azma needs it.”
Outside the ward, a dozen women lie curled up on the corridor floor on blankets. Some of them have been waiting over two weeks for a bed to free up. Cancer patients from all over Afghanistan are referred to Jamhuriat – the only public hospital in a country of 38 million people with a dedicated cancer centre.
Niazi says she is the only psychologist in the country working with cancer patients and their families. “There are some short courses that train psychologists, and the ministry of health organised a one-year psycho-social counselling course, but this course only covers basic counselling, it doesn't cover the complexities of depression or anxiety in cancer patients,” she explains. “Afghanistan is in desperate need of psychologists. We have seen 40 years of war, and people are very traumatised. Most suffer from PTSD or depression, but they are not diagnosed because they can’t reach hospitals – and those that do reach hospitals are not treated appropriately.”
“Culturally, women are brought up [to feel] that they should not make a fuss over how they feel emotionally or mentally, and most haven’t shared their story with anyone in their life,” Niazi adds. “So, for them, this is the first time someone has really listened. The majority of women who reach the cancer ward are already stage three or four, and do not have the option for chemotherapy or alternative treatments. Some are depressed, and when they start opening up about their feelings around their cancer, they start opening up about their whole life.”
Struggling with an overwhelmed and under-equipped healthcare system after four decades of war, Afghanistan has no readily available chemotherapy medication or radiation-therapy at any of its state-run hospitals. Istiqlal, one of Kabul’s other large hospitals, has one of the only public mammogram facilities in the country that offers free clinical diagnoses for breast cancer.
Hard statistics are also in short supply, but the Afghan Ministry of Public Health estimates that approximately 3,000 Afghan women were diagnosed with breast cancer in 2018, of which 1,700 died. Around 60,000 people develop breast cancer each year in Afghanistan, according to a 2019 survey by the Afghanistan Cancer Foundation.
The challenges come on many fronts: from a lack of staff, facilities and medication to accommodate and treat the increasing number of breast cancer patients, to a complete lack of specialist doctors in rural districts with the training to correctly diagnose breast cancer.
In rural areas, where many people lack basic education, cancer is often a death sentence, with poorer patients having access to few diagnostic options and even fewer treatment possibilities across the country.
Afghanistan imports over 95 percent of its pharmaceuticals. Those who can afford it travel to places like Pakistan, India and Iran for treatment. But for the vast majority of Afghans, chemotherapy drugs remain prohibitively expensive and inaccessible.
Businessman Abdul has been working to make chemotherapy drugs more readily available to Afghans for the past decade. “The government is not paying attention to the increasing numbers of breast cancer patients to bring in the equipment, training and chemotherapy drugs needed,” Abdul says. “This is why we are importing the products from India. I can’t stop cancer in this country, and not everyone can be cured, but I will do what I can to help.”
Abdul says that about 90 percent of the chemotherapy drugs in Afghanistan reach the country through illegal channels, and some of his biggest customers are pharmacies in the grounds of government hospitals. “The chemotherapy drugs are shipped by air from Delhi to Kabul or Kandahar,” Abdul adds. “They also come by sea from several different routes. They are hidden from border police officers under other goods inside big containers.”
He continues: "In one batch of 2,000 ampoules of imported chemotherapy, the border police and airport customs will seize about 25 injections. They say it is for quality control, but sometimes they sell the drugs themselves for personal profit. If they don't take the medicine, they often ask for bribes instead. The pharmacies won’t accept these medicines without a bribe also, even when we show our official documents showing that we are registered and allowed to import medicine.”
On top of border police seizing large amounts of chemotherapy medicine, Abdul also accuses senior officials at the Ministry of Public Health of making private orders to pharmaceutical businesses and keeping the chemotherapy drugs for their personal use – a severe abuse of their public office. There have been recent reports of ministry staff stealing medications from the MOPH stockpile and selling them on to third parties at vastly inflated prices.
Despite Abdul bringing in as many as seven batches of chemotherapy drugs each year – costing around $200,000 – these amounts are still not enough to keep pace with Afghanistan’s rapidly increasing rates of cancer, which are predicted to double over the next two years.
Dr Ramin Karim bustles across the courtyard of the Istiqlal Hospital, toward a large stained concrete block that houses the surgical ward. A row of women crouching in a sliver of shade call out to him for assistance as he passes, listing their health concerns.
Karim has just finished a night shift. He will compile the roster for the next team of doctors and decide which patients will have surgery over the next 24 hours. Although he’s off the clock, he will not be going home – today, he is scheduled to perform surgery on his sister-in-law.
He navigates his way through a group of women blocked by a security guard at the ward entrance. Karim is from Mazar-e-sharif in Afghanistan’s northern region, and has been working as a general surgeon at Istiqlal for six years.
A recent study found breast and oesophageal cancers to be the most common types among Afghans.
“Most of the patients who come here are stage three or four, because local doctors did not have the expertise to diagnose the cancer sooner,” Karim says. “Doctors in rural areas are not trained to recognise the symptoms. We get about 11 breast cancer patients admitted here each day. We carry out investigations on the lymph to see if it's a tumour or if it's benign, and diagnose breast cancer with mammography, MRI, ultrasound and biopsy.
“There are a small amount of chemotherapy drugs at Jamhuriat, but not nearly enough – and they are too expensive. People in rural areas will sell all their livestock just to come here for treatment. But most of the time, they run out of money and have to return home, where they will likely die.”
In a country where 83 percent of the population lives on less than $1.50 per day, one round of treatment can cost as much as 7,500 Afghanis ($98 USD).
Hasina is a patient at Istaqlal, and due to undergo a lumpectomy today.
“I didn’t know I had cancer. I didn’t even know what cancer was,” she says. Hasina was stage three by the time she reached Jamhuriat, but like many Afghans she did not have enough money for treatment and was forced to return to the provinces.
Hasina explains how, out of desperation, she had previously acquired illegal chemotherapy drugs at various black market pharmacies in Kabul. She says she had a bad reaction to this poor-quality medication.
Karim explains that not all of the chemotherapy drugs imported into Afghanistan are of benefit to patients: “Sometimes the medication is fake, and some people are buying chemotherapy on the black market. Even hospital staff are buying drugs illegally here. Others bring it into the country in their pockets, but chemotherapy drugs need to be stored at a specific temperature. Even the pharmacies are without the facilities to keep them cold.”
Despite the efforts of local doctors, a lack of cancer-specific medical training within Afghanistan limits the types of treatment they can administer.
“We can learn some things from books and YouTube, but we’re not specialists in chemotherapy,” Karim adds. “So, after a patient's surgery, we advise them to go abroad for chemotherapy or radiotherapy to finish their treatment, often to Pakistan and India. There, the doctors can set the dosage and send us the guide of chemotherapy to administer, and then we can treat the patients accordingly.”
On top of all this, breast cancer remains heavily stigmatised in the country. “According to our culture, it's shameful for someone to have an operation on their body,” Karim says. “As a result, people are often reluctant to come to the hospital. If they eventually do come, the cancer is often in its final stages. The condition is very advanced and the patient is in poor condition.”
Surgeons at Istaqlal offer two kinds of surgery: lumpectomy, to remove the lymph from the breast, and mastectomy, in which the breast is removed entirely. “In Afghanistan, we almost always perform lumpectomies, because for a woman it's very difficult to be without breasts,” says Karim. “Even if we advise a mastectomy as the best course of treatment for a certain patient, most women will still opt for a lumpectomy.”
Karim says the prevalence of breast cancer is increasing in Afghanistan at a rapid pace, and education is key to slowing it down. “Many Afghans cannot understand what cancer is or what it means for their health,” he explains. “We should have a centre to advise the people on how they can self examine. Unfortunately in Afghanistan, people don't know this. The Ministry of Public Health must improve awareness programmes to help women seek treatment at an earlier stage.”
Over the last five years, Karim has noticed a positive surge in the number of women seeking treatment, thanks to a rise in public awareness. “And some Afghan women know that they can treat their breasts, so we now have more patients at the hospitals.”
It’s the following morning on the Jamhuriat cancer ward, and a new patient is in Azma’s bed, after she was moved to a different ward. There is nothing that the doctors can do for her now, except manage her pain. Niazi and Karim continue their work. The wards are full, and a new influx of patients from the provinces have reached the capital and are lining up outside.