Return of refugees to Afghanistan catches agencies by surprise

Peter Moszynski looks at the problems that Afghanistan is facing a year after the United States started its war against al-Qaeda

A year after the United States began its campaign to remove the Taliban from power, Afghanistan still has some of the worst health indicators in the world. Despite concerted international aid programmes and massive funding pledges, lack of infrastructure and trained personnel mean that substantial progress is likely to take years or even decades to achieve.

“Developing a functional healthcare system must be a top priority in the reconstruction of Afghanistan,” said Dr Mohammed Jama, regional coordinator for the World Health Organization. “As long as hundreds of thousands of Afghans continue to die from preventable diseases, a stable future for the country cannot be guaranteed.”

A recent report from the WHO said: “Afghanistan suffers from one of the poorest health conditions in the world. Six million Afghans have no access to medical care. Women are particularly vulnerable, with more than 16000 women dying each year from pregnancy-related causes. One-fourth of Afghan children die before their fifth birthdays, often from preventable diseases such as measles.”

A massive return of refugees from neighbouring countries such as Pakistan and Iran caught agencies by surprise, and continuing insecurity in the provinces has led to an over-concentration of services in Kabul. Currently 50 of the country's 220 districts have no medical facility available and half of Afghanistan's 44 hospitals doing surgery have no means of testing blood for infectious diseases such as hepatitis.

Ann Clwyd, Labour MP for Cynon Valley, returned from a fact finding mission this week. She told the BMJ: “We weren't allowed out of Kabul for security reasons. Things are bad enough in the capital. Lord knows how much worse things are in the provinces. A major problem is the huge number of returnees that no one appears to have expected back so soon.”

At the start of 2002, Pakistan and Iran exerted increasing pressure on refugees to return. In Afghanistan, One Year On, the charity Médecins Sans Frontiàres warns: “The sudden, relative freedom in their country had inspired optimism, but the host countries had also given them a push.

“As a result, so many people returned that UN organizations such as the World Food Program (WFP) and the UNHCR [United Nations High Commissioner for Refugees] could barely cope. This year, over 1.5 million Afghans have already returned. No one had anticipated such high figures. All these people need food, shelter, drinking water, and jobs to support themselves. The country is nowhere near capable of handling this. Many have simply exchanged one calamitous situation for another and are desperately searching for any means of survival.”

Dr Egbert Sondorp, senior lecturer in public health and humanitarian aid at the London School of Hygiene and Tropical Medicine, told the BMJ: “It's far too soon to see significant changes. Local people are beginning to get disillusioned, but there are plans under way to try to get a minimum health package to all Afghans.

“We can either try to rehabilitate hospitals—most of which are in a very poor condition and are mostly situated in Kabul, along with almost all of the health professionals—or we can try to roll out basic healthcare packages to meet the needs of as many people as possible. The Ministry of Health and key donors have set out a new policy to push health services to the peripheries.”

A major problem is that under the Taliban most women were prevented from working or even attending primary education and those who have been trained or educated are still reluctant to leave the relative freedom of Kabul for the more conservative provinces.

Dr Sondorp maintains: “The key bottleneck at this stage isn't money but a lack of trained workers at all levels, ranging from community health workers and midwives to high level public health officials. It's still difficult to recruit appropriate people as most women lack even primary education. We can't expect things to happen overnight—it will take 15 years to really redress. In the short term there's no shortage of funds, but in the long term far more will be needed to expand the very basic health package to more normal standards, which cost 10 or 20 times more.”

The basic package that international agencies are trying to help the Ministry of Health to supply includes maternal care, immunisation, micronutrients, childhood diseases, family planning, malaria, and tuberculosis. It is estimated to cost $2 (£1.30; €2.10) per person. The package costs $50m (£32.3m; €51.4m) a year but excludes rehabilitation, reconstruction of facilities, and hospital care. The WHO and other agencies appealed to donors for $129m for the health sector in the 2002 immediate and transitional assistance programme.

A network of non-governmental organisations has been involved in primary health for over a decade and is able to overcome some of the shortages in supply. Major players include the local health charity Ibn Sina, the Swedish Committee for Afghanistan, Health Net International, Médecins Sans Frontiàres, Médecins du Monde, Mercy Corps, Merlin, the International Committee, and the Federation of the Red Cross.

But they have a huge mountain to climb. Diarrhoea kills an estimated 85000 children a year, and a recent report by the Physicians for Human Rights, Maternal Mortality in Herat Province: The Need to Protect Women's Rights, documented 593 maternal deaths in every 100000 live births.

“The rate of maternal mortality in a society is a critical indicator of the health and human rights status of women in a community,” said Dr Lynn Amowitz, one of the organisation's doctors. “What appears to be simply a public health catastrophe in Herat Province also speaks of the many years of denial and deprivation of women's rights in Afghanistan. Promoting rights such as access to adequate health care, food, shelter, and clean water will directly improve their health.”

Dr Nayeem Azim of the UK Afghan Medical Association is trying to gather primary health equipment to ship out before the onset of winter. “There has been some progress, but things need to be speeded up. People are going to die in large numbers this winter.

“After over 20 years of war people don't know peace. We need to change from gun culture to living with education, health, and prosperity. We also need stable long term projects, not just emergency relief. It will take a long time, but we'll get there, provided we're not abandoned by the international community.”

A spokeswoman for the UK government's Department for International Development told the BMJ:“As we move from emergency humanitarian assistance to long term reconstruction, Afghanistan remains very high on our list of priorities. Our Tokyo pledge of £200m is for a five year programme, and our attention will not be relaxed.”

Figure.

DR POESJEUX/WHO/CDS

This Afghan girl is one of 200000 people in Kabul with cutaneous leishmaniasis, which is caused by a parasite transmitted by insect bites. The World Health Organization and the Afghan government are appealing for $1.2m (£0.8m; €1.2m) to bring the outbreak under control