Afghanistan
Pakistan
Iran
There has been conflict in Afghanistan for the last twenty years, leading to massive displacements both within Afghanistan, and as refugee movements, into Iran and Pakistan. Ten years after the withdrawal of the last soviet soldier in 1989 an armed conflict between opposing political factions still continues. Currently the Taliban control approximately 85% of the country and the Northern Alliance forces, led by Commander Ahmad Shad Masood, about 15%. Fighting has been reported in the front-line areas of the Central and North regions including Bamyan and Faizabad during the reporting period. The fighting has resulted in civilian casualties and humanitarian assistance to these areas has been interrupted (WFP - 23/04/99, 30/04/99).
As a consequence of the war, several million refugees are scattered throughout the region, mainly in Pakistan (1.2 million) and Iran (1.4 million). Repatriation is ongoing. WFP estimates that there are up to 2.5 million IDPs in Afghanistan: the agency assists some 1.25 million people in the country (WFP - 29/09/98).
UN presence is returning slowly to Afghanistan. WFP, FAO, UNHCR and UNICEF have all increased their presence and some NGOs are beginning to return. WFP continues to run bakeries in Kabul and other areas, as well as food for work programmes. An emergency feeding programme is underway in Bamyam province targeting the landless and female-headed households as well as IDPs in Panjao (OCHA - 02/06/99; WFP -23/04/99). The recently returned UN staff have undertaken several assessment missions around the country, the results of which are summarised below.
Food Security
Initial results from an FAO/WFP crop and food supply assessment mission suggest that the country's crop production is likely to be low for 1999, particularly in the northern regions. The main problem seems to have been a lack of snow and rainfall in the surplus crop production areas. In addition, there are indications of a serious problem of rust infection in the north and reports of red locusts in the north-east (WFP -04/06/99). Anecdotal reports from Mazar (a province in the north of the country) indicate that the food security situation of the most vulnerable people is deteriorating. Household assets are continuing to be sold and begging is on the rise. Labour wages have decreased as a result of an increased amount of labourers available. Although crop prices are currently low, preliminary indications are that many households are finding it difficult to buy enough (OCHA - 27/05/99).
A WFP food security study for Jalalabad reported that the most vulnerable families are those without a male wage earner. Without assistance these households earn only 70% of the minimum cash income required for food and non-food items. Thus they cannot afford to buy essential items such as fuel and clothing. Households with only one man, working in casual labour or as a government employee, were the next most vulnerable group. This group earn about 85% of their minimum requirement. In these circumstances WFP food boosts the low income and allows poor households to achieve minimum income requirements. Begging and the sale of assets in Jalalabad are reported to be less visible than in Kabul or Mazar (OCHA - 27/05/99).
In the provinces of Parwan and Kapsia (central region) market prices for cereals are now reported to have increased by 100% over normal inflation since a military-blockade was set up by the Taliban in 1997. Due to a lack of agricultural input and rust infestation of the wheat, the 1998 crop production was much below average in this region. If the 1999 crop production does not improve families dependent on purchasing their food will be unlikely to maintain their minimum needs (WFP - 04/06/99).
A recent report from WFP stated that the agency is preparing to introduce corn-soya blend (CSB) into selected programme activities throughout Afghanistan in order to "improve the nutritional status of the people in Afghanistan". Acceptability testing in Kabul suggested that CSB is well accepted by Afghan beneficiaries. In order to ensure the correct use and understanding of the commodity WFP's implementing partner's are conducting information campaigns which highlight CSB' nutritional value and show the various ways it can be used (WFP-02/07/99).
Kabul
ACF undertook a study of the nutritional situation of mothers and children under-five in Kabul in February (see Annex). Amongst children under-five, the prevalence of acute wasting was estimated at 8.4%, including 0.7% severe wasting. Oedema was found 0.3% of the children surveyed. The level of stunting (height-for-age) was much higher: 61.3% of the children were stunted, including 32.2% severe stunting. The authors, however, cautioned that the validity of the data on the children's ages was questionable. The prevalence of acute wasting in infants who were longer than 49cm (n=132) was 6.1%. Amongst those infants who were less than 49cm long (n=20), most of whom were less than a month old, 85% weighed less than 3.5kg which is considered to be a "normal" birthweight. Of these, 4% were actually below the low birthweight cut-off (2.5kg).
Using the chronic energy deficiency (CED) classification scheme, 17.2% of the mothers were defined as undernourished (BMI < 18.5 kg/m2), 5.4% of these more severely undernourished (BMI < 17.0 kg/m2). Analysis of the mothers' MUACs gave a similar result, 20.2% were classified as undernourished (MUAC<22.0 cm). 10% of the women had both low BMI and low MUAC (BMI < 18.5 kg/m2 and MUAC<22.0cm). 10.3% of the women were classified as overweight (BMI > 24.9 kg/m2) and 2.3% as obese (BMI > 29.9 kg/m2).
For the month prior to interview, CMR was estimated at 0.74/10,000/day and the mortality rate of children under-five at 0.61/10,000/day. The main causes of death amongst the general population were heart disease, hypertension and complications arising from child delivery. Amongst the under-fives measles, heart disease and delivery complications accounted for equal numbers of deaths. The major (72.3% of all children surveyed) cause of morbidity in the under-five age group were acute respiratory infections (as would be expected in a survey conducted in the winter), diarrhoea (20.9%), measles (2.4%) and "other symptoms" (43%).
The graph below compares the results of this survey to others conducted in Kabul in previous years. It can be seen that the prevalence of malnutrition in children under-five has increased incrementally since December 1996. The prevalence of mildly undernourished women remains below that found in December 1996, but the number of severely undernourished (BMI<16.0 kg/m2) women has increased from 1.1% to 2.5% over the same time period.
The authors of the survey conclude that the nutritional situation of the population in Kabul remains precarious. The general standard of living remains low for the majority of households and their nutritional status does not appear to have improved since late 1996. In general, the food security situation is fragile. The markets in Kabul are well supplied, but the prices of basic food and non-food stuffs have been increasing continuously since 1995. This is partly due to the decreased value of the Afghani (local currency) compared to the dollar. Another reason is that many of the items in the Afghans' diet are imported from Pakistan and the closure of the border between the two countries pushed up the prices of many foods. In addition, some Pakistanis have been speculating on various foods produced within Afghanistan itself (e.g.: onions) resulting in an increased price of local foods. One result of these price increases is that the bakers have decreased the weight of a standard nan, the basis of most households' meals, from 200 to 120g whilst maintaining the price.
The prevalence of wasting and/or oedema in Kabul between November 1995 and February 1999
Concurrent with price increases are decreases in many households' income. Unemployment levels have risen dramatically and many households are now dependent on income earned on a daily basis. Government employees are vulnerable as they do not receive their salary (which has not been properly adjusted to inflation rates) on a regular basis. Thus the purchasing power of Kabul's citizens has decreased. This is evidenced by an increased amount of selling of household goods - an unsustainable coping strategy. The withdrawal of the NGOs and UN has also had a poor effect on the nutritional situation of this population.
Women and infants are at particular risk of malnutrition in this population because of social beliefs and traditions in Afghanistan. Weaning practices are not well-adapted to young children's needs: the supplementary foods traditionally given to children during weaning (tea, biscuits, bread) are not suitable or well-balanced in terms of nutrients for this age group. It was also observed that some infants are given tea which may increase their exposure to infectious diseases. There is some evidence that women, whose activities are restricted by the Taliban, may have a lower daily intake than men because of social constraints imposed on them.
Additional risk factors for poor health in this population include a low immunisation coverage. The immunisation programme coverage (all valid doses) was estimated to be 34.2% in children under two years old. Nearly half the children had not been vaccinated for measles. 69.5% of the children had BCG scars. 31.1% of the women interviewed had been immunised for neonatal tetanus. In general, it was noted that women were unaware of the benefits of vaccination for themselves. UNICEF, WHO and the Ministry of Public Health are currently conducting a country-wide immunisation campaign aimed at eradicating polio and giving vitamin A supplementation to children between 6-59 months of age. The most recent report suggests that they have reached over 3.6 million children out of a target 4.3 million (OCHA - 30/04/99, 02/06/99).
Returnees from Iran and Pakistan
UNHCR anticipates that 220,000 refugees from Iran and Pakistan will return to Afghanistan in 1999. WFP has allocated food for repatriation packages for 130,000 returnees expected in four areas of the country. The returnee package consists of 300kg of food aid to be shared between a family, no individual returnees are assisted. The returnees are expected to settle in the areas of Heart and Kandahar initially (WFP - 23/04/99, 07/05/99).
UNHCR provides indirect assistance to 1.2 million people in at least 200 refugee villages in Pakistan. The agency helps to sustain government activities in health and education by providing medicine and salaries etc. It s also active in other areas such as helping start community services run by the refugees or Pakistan government officials (UNHCR - 08/06/99).
There are no reports of a change in the adequate nutritional status of the approximately 320,000 Afghani refugees requiring food assistance in Pakistan. 20,000 of the newest (most recently registered) refugees are provided with a ration of 2,102/kcal/day by WFP and are given non-food inputs by UNHCR. One of the problems with this method of targeting is that it encourages the recycling of refugees, i.e., many of new arrivals are not new arrivals at all. A further 300,000 (targeted) vulnerable refugees receive assistance under a Social Safety Net and Environmental Rehabilitation Programme. A well organised community network which has been set-up identifies the most vulnerable groups which are then targeted. The remaining refugees have established themselves in Pakistan and are considered to be self-reliant and self-sufficient (UNHCR - 08/06/99).
There are some 2 million refugees in Iran including 508,000 Iraqi Kurds, 58,000 Iraqi Arabs and 1,425,000 Afghans. In most cases the refugees are not in camps and are allowed to live and work alongside Iranians; only the most vulnerable 94,000 are hosted in official camps (UNHCR- 02/99).
There is no new information on the nutritional situation of the refugees in Iran. A joint WFP/UNHCR mission which visited Iran in December 1998 reported that there were no discernible nutritional deficiencies (either observed or reported) amongst the refugees, although there were a number of vulnerable refugees who were housed outside the camp.
Overall, the IDPs in Afghanistan are considered to be at moderate nutritional risk (category IIb). The 40,000 refugees in Iran who outside the camps are also considered to be at moderate risk of malnutrition. The other refugees in Iran and those in Pakistan are considered to be at low nutritional risk (category IIc).
Recommendations and Priorities:
· A stronger UN and NGO presence is required in Afghanistan in order to fulfil the populations' humanitarian needs.Recommendations from the ACF survey in Kabul include:
· Continue the close monitoring of the nutritional status of mothers, children under-five, infants and the new born in Kabul to prevent a nutritional crisis situation developing.· Perform active Mother and Child health preventative activities, especially reinforce pre- and post-natal care follow-up.
· Screen all children under five (particularly those less than 29 months) for malnutrition when they pass through the Health Services clinics in Kabul. Refer those with poor nutritional status to the Therapeutic Feeding Centres or Day Care Centres in order to prevent them becoming more severely undernourished.
· Continue to constantly enforce/renew health education activities within all medical community based structures. Focus particularly on weaning practices, breast feeding and the prevention of diarrhoea and acute respiratory infections. Train mobile health workers and home visitors to give health education.
· Expand and strengthen the immunisation programme for women and children. Routinely check the vaccination status of women when they bring their children to a clinic. Make the benefits of maternal vaccination more widely known through an education campaign.
