KABUL (Reuters) - Plastic surgeon Abdul Ghafar Ghayur is practicing his own brand of welfare in Afghanistan, where access to healthcare is limited and many cannot afford private treatment.
The money he makes from the hundreds of nose jobs and Botox injections he performs on wealthy Afghans allows him to perform life-changing surgery on low-income patients at a discount or sometimes for free.
Ghayur's practice in the capital Kabul offers a microcosm of Afghan medicine, where doctors, driven by a sense of civic duty, try to fill huge gaps in a public health system devastated by decades of war.
The surgeon ticked off parliamentarians, business directors and other "rich people" among his clients, who got their ideas online or during trips abroad and were prepared to pay thousands of dollars for cosmetic surgery. The average Afghan monthly wage is around $35.
Income from such treatments, a relatively new phenomenon in Afghanistan, allows him to make a good living as well as treat low-income patients who turn up unannounced seeking reconstructive surgery to treat disease, congenital disorders and post-traumatic wounds.
Many of these patients arrive with late stage illnesses and require urgent attention.
"If a patient comes and says 'I can only pay $100', I can do it for $100. Or $20, or $30," Ghayur told Reuters during a recent morning consultation.
"Because if we decide to wait until the patient has the money, the patient will have no chance of survival."
He added: "I have treated lots of skin cancer patients for free, because some of them had small tumors that were 100 percent curable."
Healthcare in Afghanistan has improved since the hardline Islamist Taliban movement was ousted in 2001, according to the World Health Organization, but key indicators like infant and maternal mortality still rank among the worst in the world.
Public hospitals are also chronically under-funded and patients are expected to cover basic medical supplies like bandages, medicine and even wages.
Nose jobs are the most popular cosmetic surgeries, Ghayur said. He performed over 500 since opening his practice in 2013, many on members of the Hazara ethnic minority who wanted to elongate their distinctive Asian noses.
Bibi Zara, an ethnic Pashtun who had come to have the bridge of her nose raised with silicone, said her husband wanted her to look more beautiful.
"God made my nose so I am happy with it, but my husband wanted it," she said, smiling widely, her eyes the same opal blue color of her burqa.
Breast procedures were comparatively rare, Ghayur said, and cost around $3-5,000, depending on the patient's economic status. He has performed five such operations since 2013, when he returned home from his studies in neighboring Pakistan.
Plastic surgery in Afghanistan is a particularly neglected field. The health ministry counts just half a dozen registered practices and says it is not offered as a discipline at medical school.
"Most surgeons who perform heart, kidney and other surgeries carry out cosmetic surgeries too," said Mohammad Ismail Kawusi, a spokesman for the Ministry of Public Health.
Ghayur said low-income patients often arrived after one or more botched operations, performed by doctors who were the only practitioners in the area and trained to deal with war wounds.
"Usually if patients arrive, doctors will try. They won’t say, 'this is not my field,'" Ghayur said.
He spent six years studying plastic surgery in Pakistan and received further training abroad from the German Cleft Children's Aid Society.
The group has since covered costs for him to treat hundreds of children, including many without access to medical care in less stable parts of the country.
Ghayur performs most operations in Kabul, but also works elsewhere. His latest trip was to Kunduz, a province partially under the control of Taliban militants and battered by intense fighting this summer.
"I operated in the city, and there was no fighting," he said of the provincial capital. "Outside the city there was lots of fighting at night, while I was sleeping, about a kilometer away."
Reporting by Jessica Donati; Editing by Mike Collett-White