When he first started guarding the CURE international hospital, few at the West Kabul medical facility saw anything out of the ordinary about Ainuddin. And certainly, no one thought that only four days later the young man they described as young and fit, “like a Turkish soap opera star” would turn his gun on the staff of a hospital specializing in child and maternal health.

But that’s exactly what he did as five doctors entered the building on Thursday morning. In what is slowly becoming a trend in Afghanistan, Ainuddin chose his victims carefully. All of the dead were US citizens. 

At least one doctor, Jerry Umanos, a Chicago-based pediatrician who had been working at the Karte Seh facility since 2005, was among them. Two other Americans, Gary Gable a visiting lecturer at Kabul University and his son, John - both visiting Umanos at the time - were also killed. Gary’s wife, a nurse, was transferred to the capital’s Emergency Hospital, where she is receiving treatment for the injuries she sustained.

Though no motive has been given for the attack - the second targeting of foreign civilians this month - it has raised questions about the risks of a foreign presence in non-combat situations.

For the Afghans working side-by-side with foreigners, the shift from the so-called “green-on-blue” attacks, which saw members of the Afghan National Security Forces turn their guns on their foreign counterparts, to attacks on foreign civilians, presents a new threat to their lives and livelihoods.

Many of the local staff at CURE went from taking part in foreign-led trainings and fellowships to leading those programs themselves. 

To the family of one doctor I spoke to, the security implications of a hospital where international staff were said to work alongside local staff as they trained in the latest medical procedures, was foremost on their minds.

While visiting her only hours after the attack, several members of the doctor’s family asked: “Why do you keep working at that hospital?”

The doctor, who did not wish to be named, responded simply: “Where in Kabul should I work that’s safe?”

It is precisely this sense of fear that another doctor, an OB/GYN, said was so dangerous about attacks that target civilians — whether foreign or Afghan.

“The continual attacks create this sense that you can’t leave your house. They want to make you feel like you can’t go to a restaurant or the store. It’s like they want to recreate the fear and anxiety we lived in during the Taliban again”, the OB/GYN told me.

Though no group, including the Taliban, have claimed responsibility for the attack, the imminent announcement of their annual “spring offensive”, is likely to further the unease.

Thursday’s shooting is the third case of violence against foreign civilians in three months.

Earlier in April, a member of the Afghan National Police killed Anja Niedringhaus, a Pulitzer prize-winning photojournalist and injured Kathy Gannon, while they were reporting in the eastern province of Khost.

The assailant in that case was said to be acting in retaliation for the deaths of seven children and one woman killed in a NATO airstrike last year. 

In January, the Taliban claimed responsibility for an attack on the Taverna du Liban, a high-priced eatery in the capital’s diplomatic corridor. The January 17 attack, which killed eight Afghans - mainly drivers and restaurant staff - and 13 foreign nationals, was the most lethal attack on foreign civilians since the US-led invasion in 2001.

As foreign forces prepare to withdraw from the nation, these attacks could represent a shift in strategy from the  “green on blue” killings - which accounted for 15 percent of coalition deaths in 2012 - towards more easily accessible civilian targets.

More than 48 hours after the attack, national staff at the hospital remain in disbelief at an attack that would target medical professionals. 

“There is nothing more cowardly that what they did”, said the OB/GYN of the attack.

“When a physician comes here, no matter where they’re from, there’s nothing political about it. As doctors they are here to serve the sick, whoever that may be,” she said.

Further, the OB/GYN said patients often expressed their gratitude towards foreign physicians who would willingly bring their skills and experience to a nation at war.

“Patients wanted to be treated by the foreign doctors, they had trust in their work.” 

To her, the nature of the attack is proof that if the shooting was pre-planned, there was foreign involvement.

“No Afghan who sees women, children and the disabled walking in and out of these doors could ever do such a thing on their own. There had to be some kind of foreign influence on them. Only someone who wants the worst for Afghanistan, for us to continue to be sick and broken, would do something like this.”

Though it is still too early to gauge what impact, if any, the shooting will have on healthcare in the nation, recent reports had shown that despite gains, healthcare in Afghanistan can scarcely afford any setbacks.  

In a February report, Medecins Sans Frontieres, said 19 per cent of Afghans had a family member die due to lack of access to proper health facilities, another 12 percent had to travel for more than two hours to reach the nearest facility. In their annual budget, the government of Kabul had allocated only one percent to healthcare.

In a nation with an infant mortality rate of 71, CURE’s neonatal ICU, considered by many to be one of the only modern, functioning units of its kind in Afghanistan, is a valuable resource for the nation.

Looking at the shooter, who was later treated by CURE staff for wounds he sustained when other hospital guards opened fire on him, the OB/GYN said she was left to wonder how a young man who looked “so normal” could do such a thing.

“He was so young. You could tell he worked out. It just makes no sense, why would he throw all that away?”

Though they were initially hesitant to operate on a young man who still had undetonated explosives on his body, doctors ultimately decided to take Ainuddin into CURE’s operating room and treat his wounds.

With the blood of their colleague still fresh in the entrance corridor, it was their Hippocratic Oath and the disbelief at the act that led them back into the OR that day.

“We wanted to keep him alive to find out who would do such a thing.”