On the morning of 11 September, Lorena Enebral Perez met with a 21-year-old polio patient at a clinic in northern Afghanistan with a simple, gracious task: to help the wheelchair-bound man to walk.
When she approached him, the patient pulled out a pistol and shot her in the chest.
Perez, 38, was the 10th International Committee of the Red Cross worker killed in Afghanistan since 2001. Seven have now died this year alone, a devastating blow to an organisation known for its ability to work in more conflict zones than perhaps anyone else.
Perez was also the 15th aid worker killed this year in Afghanistan, the world’s second-most dangerous country for humanitarians, surpassed only by South Sudan.
Fragmentation among militant groups, responsible for the majority of killings, has complicated both the Afghan conflict and negotiations for humanitarian access. But risks are compounded by government forces that violate health facilities.
“The intensification of the conflict seemingly goes hand in hand with a further erosion of respect by all parties to the conflict of their obligations under international humanitarian law,” said Dominic Parker, head of the UN Office for the Coordination of Humanitarian Affairs in Afghanistan.
The number of incidents related to health facilities and workers has spiked dramatically, from 41 last year to 86 as of the end of August this year.
“Health facilities have repeatedly been abused as fighting positions, and earlier this year armed groups forced health clinics to close, depriving half a million people from access to healthcare,” Parker said.
Government forces are suspected of orchestrating the worst incident of the war. In 2015, a US airstrike destroyed a Médecins Sans Frontières hospital in Kunduz, killing 42 people, including 12 staff. Evidence has suggested that Afghan forces called in the airstrike due to deep mistrust of MSF who, in line with international humanitarian law, did not refuse to treat insurgents.
Since that attack, 40 beds at the inundated regional hospital in Kunduz have provided the only trauma care available for civilians in four northern provinces.
Government hospitals are prone to interference. The Taliban does not admit its injured to government hospitals and, while the hospital observes a strict no-weapons policy, security forces brazenly disrespect the ban.
“It’s very difficult for us to stay here,” said Abdul Rauf, the hospital’s nursing director. “We are not safe. Government militias bring their guns here every day.”
On a recent visit to the hospital, the Guardian found armed soldiers at the entrance to a ward where doctors were treating Abdul Halim, a young bomb disposal specialist who had lost both legs to a mine.
Eyeing them, Mirwais Osman, a doctor, said: “This is why we don’t feel safe.”
Osman was one of a dozen staff who remained at the hospital when it was evacuated during the 2015 Taliban siege, to protect equipment and vaccines.
Last year, government special forces raided a clinic run by the Swedish Committee for Afghanistan in Wardak, allegedly accompanied by Nato troops, abducting three patients and executing them.
Insurgents regularly threaten health clinics, too, often claiming that populations in their areas are underserved. In June, the SCA closed 40 clinics in Laghman due to threats, of which only half have been reopened.
“The attacks have forced aid organisations to reduce their presence across the country,” said Parker. “This means no service and assistance can be provided to some of the most vulnerable communities.”
Incidents in the north have had countrywide repercussions.
In Helmand, the river that runs behind the three main medical facilities lends a sense of calm to the country’s most violent province. But as the Taliban amass in the districts, the river could end up as a frontline, putting hospitals in the line of fire.
As of the end of August, US warplanes had dropped nearly 2,500 bombs in Afghanistan this year, the highest number since 2012. Districts close to Helmand’s provincial capital, Lashkar Gah, are among the heaviest hit. Afghan forces have also moved artillery positions closer to town.
Since the US bombardment of MSF in Kunduz, local staff at Helmand’s main trauma clinic have felt unnerved every time fighting flares up.
“The government can’t keep us safe, and we’re not safe from the Americans either,” said Badam, a female nurse. “We don’t feel any safer here than we do in our homes.”
A newly built underground bunker, and the introduction of sandbags to fortify windows, have boosted security. But female staff, in particular, remain fearful that an incident like the bombing in Kunduz could occur again.
“I don’t think the government will care about the hospital,” Badam said. “We don’t trust the government. They injure so many civilians and they never come and ask how they are.”
The motives of the man who shot Perez, the ICRC physiotherapist in Mazar-i Sharif, are unclear. But for an organisation whose work relies on community acceptance, any such incident is highly destructive.
The attack came just as the ICRC was resuming activities after six of its Afghan members of staff were killed and another two abducted in an ambush in Jowzjan in February.
When the Guardian visited Helmand in July, most ICRC operations in the south were on hold, despite a rising need for the organisation’s services. The number of amputees visiting the ICRC to have prosthetics fitted or receive physiotherapy had doubled in two years, said Steven Van Damme, the head of office.
The ICRC said it had not yet decided how the recent killing would affect its Afghan operations, only that it would rather cease operations than shelter behind armed compounds.
“Building relations is more complicated than building walls,” said Van Damme.