A Country That Can't Catch You When You Fall

And Pakistan's deportation campaign has been massive, right?

We're not talking about a trickle.

Masiva es quedarse corto.

Massive is an understatement.

Desde finales de 2023, Pakistán ha expulsado o presionado a más de medio millón de afganos para que regresen, muchos de ellos personas que llevaban décadas viviendo allí, que habían construido sus vidas en suelo pakistaní.

Since late 2023, Pakistan has expelled or pressured more than half a million Afghans to return, many of them people who had lived there for decades, who had built their lives on Pakistani soil.

El argumento oficial es seguridad nacional y presión sobre los recursos.

The official argument is national security and pressure on resources.

La realidad es bastante más compleja.

The reality is considerably more complex.

More complex meaning, this is partly about domestic politics inside Pakistan.

The economy is struggling, there's pressure from nationalist groups, and Afghan refugees have become a convenient target.

En parte, sí.

Partly, yes.

Pero también hay una dimensión geopolítica.

But there's also a geopolitical dimension.

Las relaciones entre Islamabad y Kabul son tensas.

Relations between Islamabad and Kabul are tense.

Los talibanes tienen sus propios aliados y enemigos dentro de Pakistán, hay acusaciones cruzadas sobre quién está financiando a quién en la zona fronteriza.

The Taliban have their own allies and enemies inside Pakistan, there are mutual accusations about who is funding whom in the border zone.

Los refugiados quedan atrapados en medio de todo eso, como siempre.

Refugees end up caught in the middle of all of it, as always.

And here's the thing that gets me: many of these people being sent back have never actually lived in Afghanistan as adults.

Some of them were born in refugee camps in Pakistan.

They're being returned to a country they don't know, that doesn't know them, and that physically cannot care for them if they get sick or hurt.

Eso es lo que los demógrafos y los especialistas en salud pública llaman una doble vulnerabilidad.

That's what demographers and public health specialists call double vulnerability.

Primero, la vulnerabilidad de ser refugiado, con todo lo que eso implica en términos de acceso a servicios.

First, the vulnerability of being a refugee, with everything that implies in terms of access to services.

Y encima, el sistema al que te devuelven también está roto.

And on top of that, the system you're being returned to is also broken.

Es como cerrar la puerta del avión y luego quitar la escalerilla.

It's like closing the plane door and then removing the stairs.

That's a brutal image.

And accurate.

What does the WHO presence in Afghanistan actually look like right now?

Because I know they've tried to maintain some kind of foothold.

La OMS sigue operando allí, sí, y también algunas ONGs internacionales, pero con recursos muy reducidos comparado con antes de 2021.

The WHO continues to operate there, yes, and also some international NGOs, but with significantly reduced resources compared to before 2021.

El problema estructural es que muchos donantes institucionales, la Unión Europea, Estados Unidos, no pueden canalizar fondos directamente a un gobierno que no reconocen.

The structural problem is that many institutional donors, the European Union, the United States, cannot channel funds directly to a government they don't recognize.

Así que el dinero llega de forma fragmentada, a través de intermediarios, y mucho se pierde por el camino.

So the money arrives in fragmented form, through intermediaries, and a lot is lost along the way.

Which creates this absurd situation where Western governments are simultaneously refusing to legitimize the Taliban and refusing to fund healthcare through channels that would require recognizing them, while Afghan civilians pay the price for that principled stand.

Es una contradicción que los expertos en salud humanitaria llevan señalando desde 2021 y que no tiene una solución fácil.

It's a contradiction that humanitarian health experts have been pointing out since 2021 and that has no easy solution.

Porque canalizar fondos al sistema público afgano significa, en cierta medida, pagar los sueldos de funcionarios nombrados por los talibanes.

Because channeling funds into the Afghan public system means, to some extent, paying the salaries of officials appointed by the Taliban.

Y eso genera un rechazo político legítimo en muchas capitales occidentales.

And that generates legitimate political resistance in many Western capitals.

But the alternative is what?

Let people bleed out on a highway in Laghman because nobody has a functioning ambulance service?

Ese es exactamente el dilema.

That is precisely the dilemma.

Y no es teórico.

And it's not theoretical.

El accidente de ayer lo ilustra de una manera muy concreta.

Yesterday's accident illustrates it in very concrete terms.

Laghman es una provincia al este de Kabul, no es el fin del mundo, tiene cierta infraestructura heredada del período anterior.

Laghman is a province east of Kabul, not the end of the earth, it has some inherited infrastructure from the previous period.

Pero las capacidades de respuesta de emergencia son mínimas.

But emergency response capabilities are minimal.

Si tienes una hemorragia interna en esa carretera, la distancia hasta una sala de operaciones funcional puede costarte la vida.

If you have internal bleeding on that road, the distance to a functioning operating room can cost you your life.

Let's go back a bit further historically, because I think there's a pattern here that people forget.

Afghanistan's healthcare has been in a state of almost perpetual crisis for fifty years, not just since 2021.

Totalmente.

Completely.

La invasión soviética en 1979 destruyó gran parte de la infraestructura que existía.

The Soviet invasion in 1979 destroyed much of the infrastructure that existed.

Luego vino la guerra civil de los años noventa.

Then came the civil war of the nineties.

Después el primer régimen talibán entre 1996 y 2001.

Then the first Taliban regime between 1996 and 2001.

Y luego veinte años de intervención internacional que construyeron algo, sí, pero sobre unos cimientos que nunca fueron sólidos porque dependían de la presencia militar extranjera y de fondos externos para funcionar.

And then twenty years of international intervention that built something, yes, but on foundations that were never solid because they depended on foreign military presence and external funding to function.

I wrote about this in 2010, actually.

The optimistic version of what was happening in Afghanistan.

Clinics being built, vaccination rates improving.

The numbers looked good if you didn't look too hard at where the money was coming from.

Y eso es lo que la mayoría de los informes oficiales hacían.

And that's what most official reports were doing.

Había métricas reales de mejora, no era todo mentira.

There were real metrics of improvement, it wasn't all lies.

La mortalidad infantil bajó significativamente entre 2001 y 2019.

Child mortality dropped significantly between 2001 and 2019.

La esperanza de vida aumentó.

Life expectancy increased.

Pero todo eso estaba construido sobre una dependencia externa que, cuando se retiró, dejó un vacío que el sistema local no tenía capacidad de absorber.

But all of that was built on external dependency that, when it was withdrawn, left a void the local system had no capacity to absorb.

That's a lesson, by the way, that applies beyond Afghanistan.

The humanitarian sector has been arguing about this for decades: the difference between building a clinic and building a health system.

They're not the same thing.

No, no lo son en absoluto.

No, they are absolutely not.

Una clínica es una infraestructura física.

A clinic is a physical infrastructure.

Un sistema de salud es una red de personas formadas, de cadenas de suministro de medicamentos, de protocolos, de financiación sostenible.

A health system is a network of trained people, medication supply chains, protocols, sustainable funding.

Lo que se construyó en Afganistán durante veinte años fue, en muchos casos, más lo primero que lo segundo.

What was built in Afghanistan over twenty years was, in many cases, more the former than the latter.

Y eso tiene consecuencias directas cuando alguien cae herido en una carretera de Laghman.

And that has direct consequences when someone falls injured on a road in Laghman.

Now, the people in that truck specifically, refugees returning from Pakistan, are they a particularly vulnerable population health-wise even before the accident?

Considerablemente.

Considerably.

Los estudios sobre salud de refugiados en retorno muestran sistemáticamente tasas más altas de malnutrición, de enfermedades no tratadas, de trauma psicológico.

Studies on the health of returning refugees systematically show higher rates of malnutrition, untreated illness, and psychological trauma.

Muchos de estos afganos en Pakistán vivían en condiciones muy precarias, con acceso limitado a atención médica.

Many of these Afghans in Pakistan were living in very precarious conditions, with limited access to medical care.

No se van de Pakistán en perfecto estado de salud para llegar a un sistema afgano que tampoco puede atenderles.

They are not leaving Pakistan in perfect health to arrive at an Afghan system that also cannot care for them.

And the children.

What's the data looking like on child health in Afghanistan now?

Because that was one of the biggest gains of the post-2001 period, child survival rates.

Las cifras que publicó UNICEF el año pasado son, francamente, alarmantes.

The figures UNICEF published last year are, frankly, alarming.

La malnutrición aguda severa en menores de cinco años ha alcanzado niveles que no se veían desde los peores momentos de los años noventa.

Severe acute malnutrition in children under five has reached levels not seen since the worst moments of the nineties.

Hablamos de millones de niños en riesgo, no de miles.

We're talking millions of children at risk, not thousands.

Y el sistema que debería detectarlos y tratarlos, los centros de nutrición, las clínicas pediátricas, funciona a una fracción de su capacidad anterior.

And the system that should be detecting and treating them, the nutrition centers, the pediatric clinics, operates at a fraction of its previous capacity.

Millions.

That's not a figure you can sit with comfortably.

And it barely makes the news.

Porque Afganistán ha desaparecido de la agenda mediática occidental desde que se fue el ejército.

Because Afghanistan has disappeared from the Western media agenda since the army left.

Eso es algo que me parece profundamente deshonesto por parte de nuestro gremio.

That's something I find deeply dishonest on the part of our profession.

Durante veinte años, Afganistán era noticia porque había soldados estadounidenses, británicos, españoles.

For twenty years, Afghanistan was news because there were American, British, Spanish soldiers there.

En el momento en que se van, el país desaparece de las portadas.

The moment they leave, the country disappears from the front pages.

Pero los afganos siguen ahí.

But Afghans are still there.

That one lands.

Hard.

I've had that argument with editors.

The logic was always, where are our people?

Our people left.

So the story left.

And the story that remained, which was the health collapse, the women losing their rights, the hunger, that required a different kind of coverage that nobody wanted to fund.

Y así nos encontramos en 2026 con que un camión lleno de refugiados vuelca en Laghman, mueren veintidós personas, y la noticia ocupa un párrafo en los medios internacionales.

And so we find ourselves in 2026 with a truck full of refugees overturning in Laghman, twenty-two people dead, and the news gets a paragraph in international outlets.

Imagina ese mismo accidente en Europa.

Imagine that same accident in Europe.

El ciclo de noticias no hablaría de otra cosa en días.

The news cycle would talk of nothing else for days.

What's the realistic path forward for Afghan healthcare?

Because I don't want to end on pure despair.

Is there anything that's actually working?

Hay cosas que funcionan a pesar de todo, sí.

There are things that work in spite of everything, yes.

Médicos Sin Fronteras tiene programas que siguen operativos.

Médecins Sans Frontières has programs that remain operational.

Algunas organizaciones locales afganas, dirigidas por afganos, han demostrado una capacidad de adaptación extraordinaria precisamente porque no dependían tanto de estructuras externas.

Some local Afghan organizations, run by Afghans, have shown extraordinary capacity for adaptation precisely because they were less dependent on external structures.

Y hay negociaciones discretas, muy discretas, entre algunas agencias de la ONU y el gobierno talibán para preservar servicios sanitarios esenciales.

And there are quiet negotiations, very quiet ones, between some UN agencies and the Taliban government to preserve essential health services.

Quiet negotiations, meaning pragmatism that nobody wants to say out loud because it looks like dealing with a regime that bans girls from school.

Exactamente.

Exactly.

Es la misma tensión que aparece siempre en la salud humanitaria: ¿puedes salvar vidas concretas hoy aun cuando eso implica, aunque sea de forma indirecta, dar cierta legitimidad a quienes violan derechos fundamentales?

It's the same tension that always appears in humanitarian health: can you save specific lives today even when that implies, even if only indirectly, lending some legitimacy to those who violate fundamental rights?

No hay una respuesta limpia.

There's no clean answer.

Hay gente honesta e inteligente en los dos lados de ese debate.

There are honest, intelligent people on both sides of that debate.

And meanwhile the trucks keep moving down those roads, carrying people who were pushed out of Pakistan, back to a country that doesn't have the operating rooms or the ambulances or the medicines to help them when something goes wrong.

Eso es lo que el accidente de ayer nos recuerda.

That's what yesterday's accident reminds us.

No es solo una tragedia de tráfico.

It's not just a traffic tragedy.

Es el resultado visible de decisiones políticas, de flujos de financiación cortados, de una expulsión masiva enviando gente hacia un vacío.

It's the visible result of political decisions, of severed funding streams, of a mass expulsion sending people into a void.

Y que haya pasado casi desapercibido dice mucho sobre cómo priorizamos el sufrimiento en el mundo.

And the fact that it passed almost unnoticed says a great deal about how we prioritize suffering in the world.

Listen, before we wrap up, I want to come back to something you said earlier, because I caught it and I've been meaning to ask.

You used the phrase "a duras penas" when you were talking about how the local organizations survive.

I know those words individually but the combination threw me.

Buena observación.

Good catch.

"A duras penas" significa con gran dificultad, a barely.

"A duras penas" means with great difficulty, barely.

La palabra "duro" aquí no tiene el mismo sentido que "duro" en el sentido físico o emocional, sino más bien el de algo que cuesta mucho trabajo.

The word "duro" here doesn't carry the same sense as "duro" in a physical or emotional sense, but rather something that takes great effort.

Por ejemplo: "El hospital funcionaba a duras penas con los suministros que le quedaban." Es una expresión muy habitual en la lengua escrita y también en el registro oral formal.

For example: "The hospital was barely functioning with the supplies it had left." It's a very common expression in written language and also in formal spoken registers.

So it's like saying "by the skin of its teeth" in English, that sense of barely making it through.

And the "penas" in there, that's not grief, that's more like struggles or hardships?

Exacto.

Exactly.

"Pena" tiene ese doble sentido: puede ser tristeza o puede ser esfuerzo, trabajo duro, dificultad.

"Pena" has that double meaning: it can be sadness or it can be effort, hard work, difficulty.

En la expresión "a duras penas", el sentido es claramente esfuerzo.

In the expression "a duras penas," the meaning is clearly effort.

Funciona como adverbio, modifica al verbo.

It functions as an adverb, it modifies the verb.

"Sobrevivieron a duras penas" no significa que sobrevivieron con tristeza, sino que sobrevivieron con mucha dificultad.

"Sobrevivieron a duras penas" doesn't mean they survived sadly, but that they survived with great difficulty.

Si dices "con penas" en otro contexto puede significar tristezas.

If you say "con penas" in another context it can mean sorrows.

El contexto lo es todo.

Context is everything.

Context is everything.

That might be the motto for this entire conversation, actually.

Afghan healthcare, Afghan refugees, the decisions that led to yesterday's accident, all of it comes down to context that the headline doesn't give you.

Y por eso estamos aquí, supongo.

And that's why we're here, I suppose.

Para darle el contexto que merece.

To give it the context it deserves.

Aunque a veces uno termina una conversación así y siente que el peso de lo que se ha dicho es mayor que las palabras que se han usado.

Although sometimes you finish a conversation like this and feel that the weight of what's been said is greater than the words used to say it.