KUNDUZ, Afghanistan – A frontline hospital in Afghanistan already stretched by rising war casualties is facing another, invisible danger that is only beginning to come to light: highly contagious strains of drug-resistant bacteria which are making treatment harder.
While drug resistance is a problem in hospitals the world over, early evidence from tracking by Medecins Sans Frontieres (MSF) in the last two years suggests it may be acute in Afghanistan.
At the trauma center in the northern city of Kunduz, where Afghan forces are battling Taliban militants, staff have identified nearly 100 cases of multi-drug resistant bacteria, or nearly 30 percent of samples tested, since last year.
That is putting extra strain on the MSF-run facility already struggling to cope with wounded combatants and civilians.
One hot morning in mid-June, the halls of the clinic quickly filled with wheeled stretchers carrying around a dozen bloodied Afghan security personnel hurt in a mortar attack by insurgents.
One man struggled for breath, and a waft of iron hung in the air as staff wiped blood stains from the white-tiled floor.
Not far away, teenager Zemairy, one of whose legs had to be amputated after a mortar round went off in his back yard several days before, lay in a quiet isolation ward.
His wounds had become infected and the drugs he was taking were not helping. Staff tested the wounds for resistant bacteria and started treating him with a different drug, after which his health began to improve.
By late June, he had been hospitalized for nearly 40 days.
"I thought I was going to lose him, or that maybe he'd lose his other leg," said Ameer Muhammad, Zemairy's father.
Doctors in Kunduz do not have enough comparative data to chart the long-term trajectory of the problem, but they are worried.
The hospital plans to expand its laboratory to test patients' blood in order to better pinpoint which organisms are causing infection and what drugs to use to treat them; at present, the lab can only test pus from openly infected wounds.
"I'm sure the rates are higher, but we can't see it," said Kathleen Thomas, head of the hospital's intensive care unit (ICU) and the emergency room. "I think it's a big problem."
In the southern province of Helmand, another Afghan region where militant violence is common, staff at an MSF-supported hospital noticed patients with respiratory tract infections and diarrhea were not getting better.
An ensuing 2013-14 study showed high levels of resistance to widely used antibiotics among those being treated at the hospital.
Doctors say the probable causes of the problem include over-prescription and patients not finishing courses of treatment. In Afghanistan drug resistance may be made worse by medicines of suspect quality being illegally imported into the country.
"The general population has a big problem of resistance because of self-medication and patients putting pressure on doctors (to prescribe drugs)," said Abdul Qayoum Wardak, who oversees MSF's laboratories in Afghanistan.
Nearly 60 percent of medicine in Afghanistan enters through illegal channels, said Abdul Khalil Khakzad, head of the Avicina Pharmaceutical Institute in Kabul, possibly contributing to what doctors suspect is a glut of ineffective drugs on the market, including antibiotics.
Though many of the smuggled drugs may be fine, the lack of information may already be contributing to drug resistance, as some doctors try to over-correct for presumed low quality.
Officials in Afghanistan's health ministry blame the country's porous borders with Pakistan and Iran for the proliferation of unregulated drugs.
"We can control drug stores, but we can't control the highways," said Abdul Hafiz Quraishi, head of the General Directorate of Pharmaceutical Affairs.
President Ashraf Ghani's government has worked to rein in the sector, and Pakistan's drug regulatory authority said cross-border cooperation was improving.
"The (Afghan) complaints are not going into the filing cabinet," said Muhammad Aslam, head of the government-run Drug Regulatory Authority of Pakistan. "Either (the companies) will be given time to improve themselves or they will be shut down."
For hospital staff in Kunduz, trying to control life-threatening bacteria in the midst of an escalating conflict requires extreme measures, including flying in expensive drugs from thousands of miles away.
Like other MSF facilities in Afghanistan, the clinic only prescribes medicine from the organization's own stocks, and does not use drugs from the local market.
It also means finding space to isolate patients in wards that are treating nearly twice the number of war casualties as last year.
Earlier this month, doctors had to isolate two patients they suspected had different strains of resistant bacteria in the ICU's only isolation room and keep a third with ICU patients, potentially exposing others.
Staff suspect some of the resistant bacteria are passed between patients whose immune systems have been compromised, a common problem in hospitals.
But the fact that the center treats so many victims with open wounds means some may be already contaminated by the time they arrive, suggesting the resistant bugs could also be living outside, in the community itself.