Gunshot wounds, the result of frequent, ongoing clashes between rival Northern Alliance commanders, and mine injuries, a legacy of the past Soviet occupation (1979–1989), were a daily occurrence (Box 6).

Afghanistan is the most heavily mined country in the world, with an estimated 10 million mines sown. As the front lines have shifted over time, so has control of the minefields, and complete confusion now reigns about the size, content and disposition of these fields, which kill or wound seven to 10 people in Afghanistan every day.

Baharak was a Soviet garrison during the occupation, and had been particularly heavily mined in an effort to deter mujahidin attacks. Now, these mines accounted for many injuries and deaths we saw, particularly among children attending their animals in the surrounding fields.

We generally provided first aid, with wound surgery conducted in the provincial city, Faizabad, three hours away by road. However, when the road to Faizabad was cut for security reasons, we needed to conduct surgery as best as we could manage at Baharak. With no formal surgical training, no x-ray machine, no blood, and only ketamine for anaesthesia, management was restricted to debridement or amputation and was very much a case of "flying by the seat of one's pants".

I had known to expect injuries from land mines, but on only my second day in the clinic I also met with the unexpected. A man was brought to the clinic in extremis. He had been subjected to public stoning for adultery. His condition was incompatible with survival and a solemn reminder of the country's profound cultural standards. There were two other stonings (also for adultery and also fatal) during my time in Baharak.

The leading cause of child mortality was diarrhoeal illness and dysentery, which related to the absence of safe water and poor sanitation. In summer, the incidence of both dysentery and typhoid escalated dramatically; sporadic cases of cholera were also seen (Box 7A). The simple use of oral rehydration salts was lifesaving for many. Malaria accounted for about 35% of all the summer admissions.

On our arrival, the tuberculosis program was almost non-existent. Poor compliance and the inappropriate use of drugs of poor quality, that had made their way from Pakistan to the local bazaar, also contributed to the problem. The disproportionate number of extrapulmonary cases confirmed our fears that the more infective active pulmonary cases were either not presenting or being missed (Box 7B).

Leishmaniasis is endemic in Afghanistan, but invariably in the cutaneous, self-limiting "oriental sore" form (Box 7C). A few cases of the more serious visceral leishmaniasis, kala-azar, had been documented in the past, and we saw many patients with remittent fever and grossly enlarged spleens who often did not fit the patterns of chronic malaria, brucellosis or myeloproliferative disorders. More than likely, several of these patients were dying of treatable visceral leishmaniasis. The absence of any antimonials usually used to treat kala-azar related to the lack of information on the prevalence of this condition; the absence of any firm epidemiological work on this and other infectious diseases significantly hampers the development of an effective health strategy in Afghanistan.

On occasions, I was confronted by rare but life-threatening conditions.

Anthrax, a significant part of the germ warfare repertoire, is endemic in Afghanistan, and usually seen as the relatively benign cutaneous form. The systemic form is anything but benign. One unfortunate patient, who had handled a dead sheep a few days earlier, presented to our mission with the typical black eschar and oedematous swelling over one eye. He developed frighteningly progressive respiratory distress and died some hours later, despite aggressive doses of intravenous antibiotics. For me, pneumonic anthrax is now a case of "once seen, never forgotten".

Then, one afternoon, I was asked to review a patient with uncontrollable epistaxis. The two health workers who were attempting to stem the bleeding were heavily contaminated with blood. Of greater concern to me was the fever, haematuria and petechial rash over the patient's body, including his soft palate.

An infectious diseases colleague had warned me of the existence of Congo-Crimean haemorrhagic fever (CCHF) in Badahkshan and the serious risk of nosocomial transmission. Everyone was disinfected and the patient barrier-nursed as best we could manage. As always, treatment was fairly pragmatic. If the patient did have CCHF, there was little we could offer.

The only treatable cause of such a presentation I could think of was a coagulopathy due to fulminating malaria and typhoid, so the patient was commenced on quinine and chloramphenicol. He survived, but developed paraplegia, presumably from a secondary spinal bleed.

On completion of my mission in Afghanistan, I took a sample of the patient's serum back to Geneva (despite some misgivings about the ethical and legal implications of carrying such potentially biosensitive material about the world); immunofluorescence confirmed the presence of IgG antibodies to CCHF.

During the July offensive, Taliban forces advanced rapidly on two axes nearby, one towards Faizabad and the other along the Panjshir Valley. At the same time, reports were received of a large group of Taliban gathering at Shah Salim Pass, on the border with Pakistan to the south. All United Nations flights to Faizabad were cancelled, so any rearward evacuation of our missions to Tajikistan was potentially threatened.

In our MSF vests, my Swiss physician friend, Philippe, and I felt secure. We both thought we were about to witness a defining moment in Afghan history, but a brilliantly executed counterattack by the Northern Alliance commander Ahmed Shah Massoud thwarted the Taliban advance (Box 8).

We shared a meal with commander Najmaddin Khan, at that time the second most important commander in the Northern Alliance after Massoud. I remember that he had a nervous tic and that the meal was interrupted frequently by calls on his satellite phone to other alliance commanders.

On one occasion Massoud arrived by helicopter to visit Najmaddin; two hours later a Taliban MiG fighter plane bombed Baharak. Taliban intelligence was excellent; fortunately, their aim was not so good.

Najmaddin was ambushed and killed in Baharak a month after I left Afghanistan. Massoud was assassinated by suicide bombers (posing as journalists) on 9 September last year — two days before the terrorist attacks in the US.

One of the highlights of my time in Afghanistan was an exploratory mission into Wakhan, the poorest and most remote district of the country, located in the far northeast bordering Tajikistan (to the north), China (to the east) and Pakistan (to the south). If, in shape, the map of Afghanistan is thought of as resembling an irregular leaf hanging from a stem, then the stem would be the Wakhan Corridor.

The district has an average altitude of 3000 metres and is subject to harsh climatic conditions. It is also devoid of any infrastructure, and the medical facility at Ishkashem is up to 10 days' travel by donkey from the more remote areas of the district.

The first stop of our trip was to pay respects to the local Shah, who seemed a very reasonable man with the best interests of his people at heart. From there we travelled with his opium-addicted uncle, who facilitated our entrez to the villages (Box 9).

Afghanistan is currently the world's leading supplier of illicit opium, providing a significant source of revenue for arms for military commanders, or, as one farmer put it, "the West sends us weapons, we send the West our white powder with respect" (Box 10).

It soon became apparent that opium addiction was common in Wakhan, primarily as a substitute for non-existent health care. Its analgesic, antitussive and constipating effects provided a panacea for many of the area's endemic diseases.

The final phase of my time in Afghanistan was spent assisting with the newly established mission in Faizabad (Box 13), aimed at developing the inpatient capability of Faizabad Hospital.

This hospital was the only formal surgical facility in a district of 700 000 people, with a grand total of one operating theatre and two trained Afghan surgeons. The challenge of working there was made all the greater by the lack of blood cross-matching reagents, and the amazing situation whereby the more experienced of the two surgeons was only permitted to operate on the most difficult cases. Between times, he was kept in jail for the murder of his brother!