Following the terrorist attacks of September 11th, Afghanistan has become the focus of world attention as the target of retaliatory American air strikes against the ruling Taliban authorities and the terrorist network assumed responsible for the events of September 11th. This has very profound implications for the scale of the humanitarian emergency within and around Afghanistan and the ability of the humanitarian community to provide essential humanitarian assistance where it is most needed.
Afghans constitute the largest single refugee population in the world with an estimated 3.6 million people, representing thirty percent of the global refugee population (UNHCR 02/10/01). Large numbers of Afghan refugees have been present in neighbouring countries particularly Iran and Pakistan, as a result of more than twenty years of conflict within the country, which has left much of the state infrastructure destroyed and has brought the economy to an almost total standstill.
For a country that has consistently remained near the bottom of human development indicator tables, the past year has seen a further alarming deterioration in the overall humanitarian situation. The affects of long-term internal conflict have been worsened by three years of severe drought, claimed to be the worst in thirty years, which has resulted in the wide scale failure of much of the countrys staple wheat production. Successive years of crop failure, conflict and a critically poor economy have left many Afghans increasingly unable to meet their basic nutrition and health needs. For many, the last resort has been to use increasingly unsustainable forms of coping such as the selling of important assets. For many the final coping mechanism has been migration to areas both within and outside the country in an attempt to seek assistance and sustain themselves and their families. The most recent estimates available to the RNIS are that over one million people internally displaced in the country with at least 200,000 having crossed into neighbouring areas, although these are likely to change daily as a result of the rapidly changing context (OCHA 27/09/01).
As previously reported (RNIS # 34) the most drought affected and vulnerable areas of the country are the northern and central regions close to frontlines which are heavily dependent on rain fed agriculture. However, the mass internal displacement of population, that has occurred pre September 11th, and universally poor harvests have affected the entire country. Within this context the humanitarian community has been conducting a major aid effort hampered by increasingly bad relations with the ruling Taliban authority that has seriously hampered access to vulnerable populations. The increasing severity of the situation prompted WFP on 6th of September, to launch a new appeal for an emergency operation to address the needs of an estimated 5.5 million people for a twelve-month period. The appeal was a substantial increase over the original plans to feed 3.8 million people in the country until the end of March 2002 and reflected the urgency with which the humanitarian community viewed the deteriorating situation (IRIN 06/09/01).
Increasing numbers of vulnerable people
As a direct result of the rapidly emerging crisis in Afghanistan the numbers of people either partly or fully dependent on international assistance for their survival, has now increased by two million to a total of 7.5 million both within and outside the country (OCHA 27/09/01). Six million of these people are expected to remain in Afghanistan and 1.5 million are expected to become refugees in Pakistan and other neighbouring countries (OCHA 27/09/01). This represents almost a quarter of the entire population. Areas of particular vulnerability remain the northern and western, rain fed agricultural regions of the country such as Herat, Badhgis, Balkh and Takhar in the Taliban controlled areas and the north eastern province of Badakhstan in the Northern Alliance controlled area.
The current conflict brings new threats to those living near front lines between the Taliban and the northern alliance, particularly in the north eastern region of the country but also in Ghor and Bamian provinces in the central region. The escalation of fighting has seen a major shift in the front lines, which appear to move on an almost daily basis. The American bombing has also forced many people to evacuate the cities with WFP reporting that up to 50% of Kabul have fled the city and in Jalalabad only 20% of the population are still resident (WFP 05/10/01; 12/10/01). Over the past year, the pattern of displacement has been from badly affected rural areas to the cities, in an attempt to find work. It is therefore concerning that recent displacement is a reversal of previous trends and is taking people into already badly affected rural areas unlikely to be able to sustain the growing population.
Limited Humanitarian Access
Highly restricted humanitarian access, particularly beyond the main cities, is seriously affecting the ability to get much needed assistance to the most vulnerable populations within the country. The security situation is now critical as a result of American air strikes and an increase in ground conflict. This is causing panic and a break down of order across the country.
International UN staff were evacuated immediately following the terrorist attacks of September 11th. Increasing insecurity, has meant all international staff were evacuated from the country for a while, although some have now been able to return (IRIN 01/10/01). In their absence, international assistance programs are usually run locally by national staff, with support from neighbouring countries. However, this has been severely hampered by a break down in communications, which has also made it extremely difficult to get information on what is happening on the ground. Poor security is also preventing many national staff from working, either as a result of displacement or out of a fear of being associated with western international organisations. There appears to have been a breakdown in law and order in many areas and there are reports of the looting of both UN and NGO offices and other resources, further destroying existing agency infrastructure and their operational capacity (IRIN 19/10/01). MSF have reported that the looting of several of their compounds in Mazar-ISharif and in Kandahar forced them to suspend relief activities in six provinces for a while (OCHA 19/10/01).
Traditionally, much of the food entering Afghanistan has been trucked across the border from Pakistan and Iran but this has become extremely difficult as commercial trucks are increasingly afraid to load or unload food, to drive deep into Afghanistan or to stay overnight in cities or towns (Oxfam 17/10/01). Islamic Relief have announced that they have 1000 MT of food in Quetta, Pakistan, designated for Afghanistan but are unable to find commercial truckers prepared to carry it into the country. WFP were seriously constrained in their capacity to transport food as a result of truck shortages in September and some of October. At one point they announced that they required 190 trucks to transport the 52,000 MT they needed per month, but only had the use of 90 (IRIN 19/10/01; WFP 18/10/01). Food assistance must be prepositioned before the onset of winter, which is in little more than a few weeks, as bad weather, snow and ice will seal off roads in many areas, especially the central region. However, the magnitude of the needs compared with the volumes that can realistically be moved in the current circumstances, indicates a crisis of epic proportions is to come, much of which will unfold unseen by the outside world. This has prompted a call by a group of NGOs to have a pause in the bombing to allow humanitarian agencies to be able to access the country with much needed food aid (Oxfam 17/10/01).
Worsening Food Security
In June 2001 the FAO/WFP Crop and Food Supply Assessment mission observed that rain fed crops had almost totally failed as a result of another year of severe drought (RNIS # 34). This is particularly serious as more than 85% of the country are dependent on agriculture for their livelihoods. As a result many families are both acutely and chronically food insecure and coping mechanisms which in normal years would have allowed many to find alternative modes of generating income have been exhausted, leaving many unable to meet basic food and non food needs. A series of surveys and assessments over the last year (see RNIS 32/33 and 34) have documented increased evidence of emerging famine conditions in the country with food stocks in many areas exhausted. Some of the observed coping mechanisms have been; the widespread distress sales of livestock and other forms of household assets, a dramatic increase in the number of people taking out high interest loans, the migration of males of working age, increased consumption of wild foods and as a final resort, distress migration of entire families to areas where they hope to receive assistance (FAO/WFP 08/06/01).
Many of the observed coping mechanisms are non sustainable and whilst providing short term income and access to food, will leave families close to destitution and unable to meet future needs. The sale of livestock is particularly worrisome as livestock products, including milk and milk products, traditionally contribute to dietary diversity and improved nutritional intake. The RNIS reported on cases of scurvy (vitamin C deficiency), possibly complicated by other micronutrient deficiencies in RNIS #s 32/33 and 34. All cases of scurvy occurred over the winter months when dietary quality was at its lowest. In the current circumstances further outbreaks of micronutrient deficiencies are highly likely, with associated increased morbidity and mortality. Loss of livestock also limits access to dried animal dung which is an important fuel source. Its absence for many is likely to be critical during the sub zero temperatures of winter (Concern 09/01).
The increase in insecurity within the country has come at a time when people would normally be putting aside provisions for the winter period and planting the winter wheat crop for harvesting in May 2002 (FAO 20/09/01). Food stocks for winter are crucial because the harsh winters provide very little opportunity to acquire fresh sources of food. Living in lower temperatures increases dietary energy requirements i.e. people need to eat more food. The current insecurity has and will continue to force many people to move and disrupt what coping mechanisms remain. There are also reports that the agricultural activities that normally take place at this time of year have also been disrupted meaning that the total planted area and production of cereals will be further reduced. This will have profound implications for peoples food security for next year and is likely to mean that widespread reliance on food aid will continue for some time to come.
Particularly vulnerable groups
With the extent of the present crisis the entire population remains at greatly elevated risk but the most vulnerable remain the internally displaced. The majority of the IDPs are no longer able to cope with their situation without substantial assistance and must somehow find the means to survive during the winter months when temperatures are below zero. One such group are the Kuchi nomads who lost large numbers of livestock which are the basis of their livelihoods, providing both food and income. It is important to note that they are generally not thought of as IDPs because of their nomadic lifestyle and this has left them particularly vulnerable in the current situation. There is also concern for women and children because of the subordinate and severely oppressed position of women in Afghan society, and also because many families have lost men folk to the war and enforced conscription. Males are the major income generators in Afghanistan and severe restrictions on female work in Afghanistan make it very difficult for families without male members to sustain themselves.
The humanitarian response to the crisis has been huge. On the 27th of September the UN launched a global appeal for over half a billion US dollars (584,035,652 USD) to deliver emergency assistance to 7.5 million Afghans deemed acutely vulnerable, both within and outside the country (OCHA 27/09/01). Central to the appeal is the figure of 7.5 million vulnerable Afghans. It is assumed that six million of these will remain in Afghanistan whilst the remaining 1.5 million will cross borders into neighbouring countries. The response to the appeal has been huge but WFP have reported that out of the 230 million US dollars they require, they face a shortfall of 97 million US dollars (WFP 02/11/01). The response has also been severely constrained by the security situation, which has made access to many areas of Afghanistan extremely difficult. With the continuation of the US air campaign and advances made by the Northern Alliance, there is a possibility that areas will start to become more accessible to humanitarian agencies. To this end WFP has developed a series of humanitarian corridors through Pakistan, Turkmenistan, Tajikistan and Iran and has increasingly succeeded in trucking aid in to many areas. The transportation of aid has grown enormously but was severely constrained for much of September. By the 29th of September there were 500 MT a day going into the country and WFP reported that a convoy had reached Kabul on October 1st, which had previously proved difficult (IRIN 01/10/01; WFP 05/10/01). For the first part of October, WFP succeeded in transporting 900 MT and estimated that it had trucked 5,000 MT of food by October 16th. October saw the capacity for transporting food grow enormously and WFP have recently reported that they are transporting 1,525 MT a day (WFP 02/11/01). On November 9th WFP reported that they have delivered 49,000 MT of food to the country since the beginning of October and over 40% of that has been delivered since the beginning of November (WFP 09/11/01). The increased capacity is a result of greater access to commercial trucks, the use of different aid corridors, the local purchasing of food. WFP has calculated that it needs to be transporting 52,000 MT of food aid per month to meet the needs of six million vulnerable people (WFP 04/10/01).
Another aspect of the food response has been the use of air dropped humanitarian daily rations( HDR). These are packets of energy dense food designed to meet the daily nutritional needs of a moderately malnourished individual. The HDRs have been used extensively by the American military as part of the operation Enduring Freedoms Humanitarian Relief Mission. This has involved the snowdropping of the HDRs over areas of Afghanistan. As of October 16th the US Department of Defense had air dropped 397,020 HDRs, valued at 1,480,920 US dollars, into Afghanistan (USAID 17/10/01). This has been severely criticised by the aid community because the rations cannot be targeted at the most vulnerable. There is very little way of following up on their impact and most worryingly they are contributing to a link between the military action and humanitarian aid. This is likely to severely compromise the independence and neutrality of aid agencies and could affect their ability to work freely inside Afghanistan.
The humanitarian response in neighbouring countries has also suffered from poor security as a result of anti American sentiment particularly in the North West Frontier Province of Pakistan. In preparation for the influx of a possible 1.5 million refugees, UNHCR has been preparing camps along borders with Afghanistan, however these too have met with some opposition from local populations. The challenge remains to prepare sufficient sites in secure locations and with sufficient facilities to meet the needs of potentially hundreds of thousands of refugees.
TALIBAN CONTROLLED AREAS
The central highlands and particularly the Hazarajat area have been designated as being at particular risk. OCHA have reported that security in Hazarajat is currently stable and aid offices in the region are able to function. However, the humanitarian situation in the area is deemed to be critical because the ice and snows of winter will cut off access to roads in the area in mid November. This will leave 100,000 families, who are dependent on outside assistance, without sufficient food supplies (IRIN 19/10/01). There are also reports that night time temperatures are now below zero across all high altitude areas and OCHA is reporting that there are already reports of increased rates of mortality (OCHA 17/10/01). The central region has also received a great deal of in-migration from large cities such as Kandahar and Kabul with people moving to rural areas in search of safety (UNHCR 17/10/01). This is adding to the burden of areas already impoverished by conflict and drought. The RNIS has not received any recent reports on the nutritional status of people in this region but given the severity of the situation it is almost certain to deteriorate over the winter months without sufficient outside intervention.
Areas both within and around Kabul have been heavily bombed and the resultant fear and chaos in the city has resulted in up to 50% of the city having fled to safer rural areas. OCHA currently estimate that there are about 100,000 IDPs and 900,000 vulnerable people within the city (OCHA 20/09/01). There is no new nutritional information, but the humanitarian situation is thought to be extremely poor.
WFP have reported that food prices in the city have risen by 30% as a result of the insecurity (WFP 2/09/01). Humanitarian activities are ongoing with the continued arrival of WFP food and the continuation of bread distributions to 51,000 families as a part of the WFP General Bakery programme (WFP 05/10/01). Medical NGOs such as ACF are also reporting that their nutrition centres are still being run by national staff (ACF 19/10/01). ACF reports admissions of acutely malnourished children to their therapeutic feeding centres were 120 in July 2001 compared to 80 in July 2000, with the major causes being attributed to the poor economic situation and the low quality food being eaten (WHO 09/01). There have been numerous reports of UN and NGO offices being looted and the WFP warehouses in the city were commandeered by the Taliban for a while raising fears for the 5,300 MT of food they contained. They were subsequently returned (WFP 19/10/01).
The RNIS has received no recent nutrition information from the Eastern region. Jalalabad in the Eastern region lies close to the border with Pakistan and has been a major staging post of food and other aid deliveries from Pakistan. The UN estimates that there are currently 350,000 vulnerable people in the city (OCHA 27/09/01) and is expecting that a further 250,000 may become vulnerable. Already there are reports that many people are fleeing cities such as Kabul, Jalalabad and Kandahar seeking refuge in the Eastern area possibly as a result of its proximity to the Pakistani border and the prospect of being able to escape into Pakistan or at least be close to sources of humanitarian relief. WFP report that between 40 and 60% of the population of Jalalabad have fled the city to rural areas or to Pakistan (WFP 05/10/01). OCHA has also reported that the number of patients in rural clinics in the eastern region has doubled in recent weeks as a result of the inflow of people (OCHA 03/10/01). The continued insecurity and greatly elevated influxes of IDPs into the area are likely to increase the vulnerability of people in this region.
The southern city of Kandahar has been a centre for the Taliban for some time and has suffered heavily from American air strikes. It is estimated that up to 80% of the population of the town have fled to rural areas (OCHA 19/10/01). Prior to American attacks the UN estimated that there were approximately 700,000 vulnerable people including 200,000 IDPs. The number of vulnerable is likely to increase by a projected 310,000 people (OCHA 27/09/01). The RNIS has received no new nutritional information from the area but the humanitarian situation continues to deteriorate as a result of extreme insecurity, the drought and the poor economic status of many of the areas population. Commercial activities have reportedly decreased by 90% since September 11th (OCHA 03/10/01) and the price of flour has reportedly risen by 30%, which make access to food even harder for many within the city (WFP 05/10/01). Particularly alarming is the breakdown in law and order in the city with some reports of looting. International organisations have been particularly affected and this has had severe repercussions for their ability to remain operational. The Taliban authorities in Kandahar have also told the aid community that they are not in a position to assure their safety (OCHA 17/10/01). The Taliban occupied the WFP warehouse in Kandahar and the 1640 MT that it contained along with various vehicles, all of which are currently not available for humanitarian use (WFP 19/10/01). The extreme lack of humanitarian space to address the needs of the vulnerable and the deteriorating situation makes the population of Kandahar and the surrounding area extremely vulnerable to nutritional decline and further acute food insecurity
The northern region of Afghanistan is made up of eight provinces and has an estimated population of over six million (ACF 0/01) and is considered to be amongst the worst affected regions in the country. The region has suffered the brunt of the drought and conflicted related insecurity and the OCHA estimates that there are 1.4 million vulnerable people including 500,000 displaced (OCHA 27/10/01). Results of a WFP survey in August and September revealed that the areas most in need of assistance were Badghis, Faryab and Ghor provinces (WFP 28/09/01). WFP has also expressed concern that at least 400,000 people are imminently about to run out of food in Faryab and Balkh provinces (OCHA 03/10/01) and is trying to get urgent food aid to the region through Turkmenistan.
- Balkh Province
It is estimated that between 15 and 17,000 families (90-102,000 individuals) are displaced within Balkh province (ACF 08/01) and this is likely to have increased. The current situation is extremely serious as a result of American air strikes on Mazar-I-Sharif and the resultant push by Northern Alliance forces to take the city. The extreme insecurity in the area is hampering aid efforts to get food and essential supplies to many thousands of vulnerable people who have become increasingly dependent on outside assistance. It would seem likely that the insecurity it also forcing further displacements and curtailing what coping mechanisms existed. On top of the fierce fighting taking place in the province, there are many reports of looting of aid agency assets and on October 19th the Swedish Committee for Afghanistan (SCA) announced the closure of its offices in northern Afghanistan after offices in Mazar-I-Sharif and Pul-I-Kumbri were looted and in one case burnt (OCHA 19/10/01). Recently, there has been a Taliban edict ordering the return of stolen property and the UN has been able to retrieve some vehicles but looting has severely constrained the operational ability of humanitarian agencies.
The food security of the area has been poor for some time and a rapid assessment by ACF in August 2001, indicated that many of the displaced hoped to generate income and improve their access to food by finding jobs within the traditionally important agricultural sector of the province and in the city of Mazar-I-Sharif.
Some of the displaced moved in with families but many moved into more than thirty spontaneous camps in the province. A food distribution was available to those in camps and provided an average of 50kg of un-milled wheat per six person family per month (a full ration of whole grain cereals is usually 15kg per person per month, or 75kg for six people). Between ten and twenty percent of the wheat would have been lost during the milling process and a further ten percent on average went toward paying for the milling process. ACF estimated that only twenty percent of families received additional items to the food basket in the form of dahl (lentils), sugar and oil. As a result, the diet of many was extremely poor in terms of both quality and quantity with many reporting that they were eating bread and water with even tea being beyond their means (ACF 08/01). For the majority of the displaced, their arrival in the camps was a result of having eroded their household assets and having nothing left with which to survive. As a result they were almost totally reliant on begging and humanitarian aid (ACF 08/01).
The RNIS does not have any nutritional surveys from this region but rapid assessments from a number of agencies indicate high levels of acute malnutrition in numerous camps (ACF 08/01). The ACF assessment also reports that micronutrient deficiencies appear to be a problem with wide scale anaemia and possible cases of scurvy. At the end of last winter MSF-B and Save the Children (See RNIS # 32/33 and 34) found numerous cases of scurvy in the area and it is extremely likely that this winter will produce even more cases. There is little access to health facilities in the area and there have been worrying reports of diarrhoeal outbreaks, including cholera, as well as widespread respiratory infections. The RNIS has not seen mortality figures for the area but agency reports indicate that they have been above emergency thresholds in many camps (ACF 08/01). Given the current insecurity, acute food insecurity of the area and dependence of many of the displaced on humanitarian assistance, the situation appears to be extremely serious and steep declines in nutritional status can be expected leading to greatly elevated morbidity and mortality.
- Faryab Province
The situation remains critical in Faryab and the latest nutritional survey information from the province is from an MSF survey in August in Qayser and Almar districts. The survey reports that a food distribution took place as well as a Food For Work program. The food distribution targeted 60% of the population, particularly vulnerable groups such as women headed households, and consisted of 50 Kg of wheat per family per month (MSF-H 06/08/01). The province has been suffering from both drought and conflict, and many people have been forced to move their families to other areas of the country such as Balkh province. The province has had two full nutrition surveys in the past year, which have both shown relatively low levels of acute malnutrition, particularly when compared to food security indicators. However the surveys have also shown mortality levels above emergency thresholds and have highlighted the presence of vitamin C deficiency (See RNIS # 32/33 and 34). The survey follows standard methodologies but was limited to villages within a four hour radius by car and donkey, from the towns of Qayser and Almar by insecurity and the rugged terrain. Because of the rugged terrain and insecurity, many areas of the country are extremely difficult to reach with any ease and this makes the implementation of a full nutrition survey in an open population extremely difficult. With clusters chosen at random it would be easily possible for a cluster to be chosen that was many hours or even days, by foot or donkey, from a logistical centre. This makes the implementation of surveys very costly in terms of both time and resources. The MSF survey illustrates the necessity of restricting the area of the survey but this does mean that some care must be taken when extrapolating the results to the wider area.
The survey estimated a prevalence of acute malnutrition (W/Ht < -2 Z-scores and/or oedema) of 9.8% including 0.8% of severe acute malnutrition (W/Ht < -3 Z-scores and/or oedema). These levels are not above alert thresholds and indicate that malnutrition is not a problem of public health significance. However, it is concerning to note that the ration of 50 Kg per family will work out at less than 10 Kg per person with no other food items included. This represents an insufficient ration and it is likely that in the absence of alternative food sources, the nutritional status of the population will decline. The crude mortality rate was estimated at 0.6/10,000/day and the under five mortality at 1.4/10,000/day. Neither of these figures are above alert thresholds but the survey authors make the point that it is likely that the most vulnerable have already left the area, possibly hiding a more serious situation. Many of the displaced have gone to Balkh province where the mortality rates have been considerably higher (MSF-H 06/08/01). The discovery of micronutrient deficiencies over last winter are a good indication of how marginal the nutrition of this population group is. The current situation in Afghanistan is likely to further compromise the nutritional status of this population and without increased assistance there is likely to be a severe deterioration in their nutritional status.
Herat has continued to receive some of the highest numbers of displaced with over 8,000 people arriving in camps a month. There are currently estimated to be 300,000 IDPs in camps in and around Herat city, many housed in little more than simple shelters affording very little protection from the weather. WFP has reported that the security situation is deteriorating in the region and that UNICEF and the International Organisation for Migration (IOM) have ceased all deliveries from Iran (WFP 19/10/01). The majority of the IDPs are almost totally dependent on humanitarian relief and regular food distribution have been taking place with a family ration of 65 Kg comprising of 50 Kg of wheat and 15 Kg of split peas. However, the ability of the humanitarian community to keep pace with the ever increasing numbers of IDPs has been severely constrained. The RNIS does not have any new nutrition survey information but MSF, who are running therapeutic feeding centres in Maslakh camp, have reported unacceptable levels of acute malnutrition and their centres saw a 3% mortality rate during July and August (WHO 09/01).
In light of the poor food security of the population, it is concerning to note that there is a grave need for sanitation, health services and shelter. Many of the camps have suffered from high rates of diarrhoea with some cases of cholera being reported. The crowded conditions and lack of adequate sanitation make the camps ideal breeding grounds for cholera infection. MSF have suggested that conditions within the camps could easily see attack rates of as high as 5%, resulting in 7,500 cases in Maslakh camp alone (WHO 12/09/01). The other great concern for the camps is the provision of appropriate shelter and fuel for the upcoming winter. Last winter saw temperatures plummet to -25 °C with more than 150 people dying in one week (WHO 12/09/01). The supply of blankets, warm clothing and fuel will be critical. There have been reports of deaths from land mines as people venture out into areas of the countryside in search of wood for fuel. There is a grave need to provide people with basic food and non food needs in order to prevent excess loss of life.
NORTHERN ALLIANCE CONTROLLED AREAS
North Eastern Afghanistan
The province of Badakhstan in the north east of the country is under the control of the Northern Alliance. The province has been badly affected by both the drought and conflict but recent reports indicate that the security situation remains relatively calm with no reported movements of population or clashes reported. The current round of air strikes against Afghanistan are focused on the Taliban and their absence from Badakhstan has protected it from bombing and has made it slightly more accessible to humanitarian organisations. However, WFP operations are being affected by a lack of commercial transportation (WFP 19/10/01). There are currently estimated to be approximately 100,000 IDPs in the province with a further 200,000 vulnerable people (OCHA 27/09/01).
In August and September 2001, Concern Worldwide conducted a nutritional anthropometric survey in several provinces in the north of Afghanistan. The survey was interrupted by the events of September 11th and the survey was halted. However, data from the Khosh valley in Badakhstan had already been collected and an analysis was possible. The survey measured the nutritional status of non displaced children under five and their mothers. The estimated prevalence of acute malnutrition amongst these children was 11.5% (W/Ht < -2 Z-scores and/or oedema) including 3.2% severe acute malnutrition (W/Ht < - 3 Z-scores and/or oedema). Maternal nutrition was measured using MUAC (< 21.5 cm) corresponding to a BMI of below 16.0 Kg/m2 and was estimated to be 21.2%. The rates of child malnutrition are slightly above alert thresholds, and the authors conclude that this was a result of an extended and severe hungry season compounded by a poor public health situation. The results of the maternal survey are alarming and were attributed to limited availability of food. They are a good indicator that coping strategies are near exhaustion (Concern 09/01). The results are considered particularly alarming because the survey came after the end of the hunger gap with the availability of the summer harvest. It is also concerning to note that the next harvest is nine months away in May/June 2002. Prevalences of diarrhoea and fever were also estimated and found to be high and significantly associated with acute malnutrition. Diarrhoea was found to be an important cause of acute malnutrition and followed a seasonal pattern with the highest prevalence being seen over the summer months (see ACF data in RNIS # 32/33).
The survey also collected information on the food economy of the area and the coping mechanisms employed by the villagers. An agricultural assessment revealed that the rain fed winter and spring wheat crops had universally failed and any harvested grain was described as poor quality. Most farmers claimed that they did not have sufficient staple food to last them through the winter and had next to no seed to plant for future harvests. A food economy analysis examined the impact of different forms of coping strategies on the ability of farmers to access food over the winter months. In the worst case scenario, 80% of families will be without access to food by January 2002 and in the best case scenario, which included relief distributions covering 22% of the annual food requirement, 50% will be able to meet their food requirements by January of next year (Concern 09/01).
There were many coping strategies employed by families but it was striking how many are totally unsustainable such as the sale of household goods, livestock and land and the use of high interest loans. It was also widely reported that there had been a reduction in food intake and in dietary variety both of which have and will continue to have severely adverse effects on nutritional status.
From informal interviews with different groups, as a part of the qualitative study, it was acknowledged that there was considerable preferential feeding of children by mothers who reduced their own intake before that of their children or husbands (Concern 09/01). This observation can only be reliably be applied to the survey population but if it is a coping mechanism that is widely used in other areas of the country, then it would sheds some light on the relatively low levels of acute malnutrition amongst child populations that have been observed by numerous surveys across the country. The relatively low rates amongst the underfive population have been puzzling given the apparent severity of the food security situation, although few if any surveys prior to this have considered all three groups of underlying causes, including food, health and care practices. This finding clearly shows the importance of including care-giving behaviours in a nutrition survey.
Afghan refugees in Pakistan
The current situation in Afghanistan is having a huge effect on the numbers of refugees seeking asylum in Pakistan. However, even before the crisis started, Pakistan had one of the largest Afghan refugee populations in the world with over two million people. Many of these have been living in the country for a number of years in camps such as Shamshatoo, or in cities such as Peshwar, in the North West Frontier Province. Many refugees have been driven by a mixture of drought and the protracted conflict within Afghanistan which has left them unable to cope with the resultant grinding poverty and insecurity. The safety, economic opportunities and the presence of an existing sizeable Afghan community have made it an important destination for refugees. It is estimated that over 200,000 new refugees have arrived in Pakistan over the past year with 60,000 alone settling in the Jalozai refugee camps near Peshwar (WFP 28/09/01). However, as the numbers of refugees have mounted, the position of the Pakistani government hardened. The government has increasingly stated that it is unable to accept further refugees and has closed the border with Afghanistan to further refugee influxes. For much of the year it has also prevented the screening, and therefore the access to humanitarian assistance, of refugees in the Jalozai camp near Peshwar. On the 2nd of August 2001, UNHCR and the government of Pakistan signed an agreement to initiate screening of 180,000 residents in the Nasir Bagh, Jalozai and the new Shamshatoo camps in and around Peshwar (IRIN 20/08/01).
With the advent of the current crisis in Afghanistan the number of Afghans attempting to enter the country is growing by the day and the UN regional appeal for the crisis has estimated that as many as one million refugees could enter the country, fleeing an increasingly desperate humanitarian situation with Afghanistan (OCHA 27/09/01). It is extremely difficult to keep track of numbers of refugees entering Pakistan but the UNHCR has estimated that over 1,000 a day (UNHCR 15/10/01) have been finding their way across the borders and from Friday 19th to Sunday 21st of October, an estimated 13,000 people crossed the Chaman border post between Quetta in Pakistan and Kandahar in Afghanistan despite the border being officially closed. A further 15-20,000 are reported to be waiting across the border (UNIC 22/10/01).
As a result, there is tremendous pressure on the Pakistani government to open its borders and allow refugees to cross but to date the borders remain closed. In preparation, considerable effort is being put into building camps to receive possibly hundreds of thousands of refugees in extremely poor condition. In the direct aftermath of the American air strikes, efforts to identify and develop the camps were severely hindered by the security situation which saw mass anti US protests. In some cases these turned violent and resulted in attacks on various international organisations (IRIN 11/10/01). The situation has since calmed and preparations are under way to create camps for new refugees in Baluchistan province, bordering southern Afghanistan and the North West Frontier Province (NWFP) bordering eastern Afghanistan. The Pakistani government has stipulated that sites must be situated close to the border to prevent the uncontrolled entrance of refugees to the rest of the country. As a result, numerous sites have been examined and many found to be unsuitable. Some of the constraints have been a lack of proximity to water sources, the insecurity of some of the tribal areas and objections by local communities (IRIN 11/10/01). As of 19th of October, three to four sites will be ready in Baluchistan province with a total capacity of between 70-90,000 people and further sites are being prepared in the NWFP to accommodate 150,000 people (WFP 19/10/01).
A recent meeting between WFP, UNHCR and the Pakistani government has greatly clarified the refugee situation in Pakistan. The meeting agreed the establishment of eleven new sites for refugees can be opened for use with three in Baluchistan province and eight in the North West Frontier Province (UNHCR 08/11/01). The sites in Baluchistan are all near the Chaman border crossing and are expected to have a maximum capacity of 70,000 people. The meeting also agreed to include the estimated 135,000 people who have entered the country since September 11th but who have not been officially recognised. A third category of refugee to be included are the refugees currently in the New Jalozai camp near Peshwar. Many of these refugees arrived pre September 11th but have been joined by others after September 11th. The status of the camp has been in doubt and now the entire camp will be moved closer to the border (UNHCR 08/11/01). The RNIS does not have any recent nutritional information on either refugees since or before September 11th but it can be assumed that they remain extremely vulnerable.
Afghan refugees in the Islamic Republic of Iran
Iran shares the brunt of the worlds Afghan refugee population with Pakistan. Very few of the refugees live in camps and many have been resident in the country for many years. However, the Iranian government has taken an increasingly hard line on the refugees in the country and many have opted to return to Afghanistan. The border with Afghanistan currently remains closed and there are no reports of influxes of refugees. Any possible refugee influx would be likely to come from Herat where there are 300,000 IDPs in makeshift camps. Iran is an important staging point in the current Afghan crisis, particularly for getting food and other relief items into the northern region of Afghanistan and is being used as one of the major food corridors for the transportation of humanitarian aid (IRIN 08/10/01). Relief agencies are currently stockpiling food, medicines, tents and blankets in the town of Mashhad which lies close to the border, in preparation for the influx of a possible 400,000 people who may flee violence and the worsening humanitarian situation in Afghanistan (OCHA 27/09/01). The Iranian government has been loath to create camps inside Iran but have identified sites on the Iranian side of the border opposite to Afghan areas where refugees are likely to collect. Taliban officials have also just given permission to the Iranian government to set up a refugee camp at Makhaki on the Afghan side of the border. The camp has a capacity of 7,000 people and there are currently estimated to be about 600 hundred people in the camp (OCHA 22/10/01). The RNIS has no nutrition survey information on refugees in Iran but it would seem likely that the nutritional status of new refugees entering the country would be poor.
Afghan refugees in Tajikistan
Tajikistan is currently suffering from its own drought emergency and WFP has recently launched an appeal for 67,000 MT of food to cover the needs of those most severely affected (WFP 19/10/01). To date the borders with Afghanistan remain closed and the government continues to move existing Afghan refugees from the capital Dushanbe. There continues to be refugees on islands of the Pyanj river which makes up the border with Afghanistan. The refugees have been in the location for some time and numbers do not appear to have grown in recent months or as a result of wider conflict within Afghanistan. AAH-UK and Merlin are currently addressing the nutritional and medical needs of the populations and a recent AAH-UK rapid assessment survey on Island # 13 indicated that malnutrition was not a problem of public health significance in itself but that the diet quality of the refugees was extremely poor and was exacerbated by the poor health status and food security of the population (AAH-UK 03/08/01). WFP report that a recent assessment indicated a need for food assistance for between 6-8,000 people along the Pyanj river, requiring an input of 128 MT of mixed food commodities monthly. The current refugee situation in Tajikistan seems very calm but the current drought crisis in the country would make a significant influx of refugees extremely alarming and it can be assumed that they would be at high risk of nutritional decline in the absence of significant humanitarian intervention.
The situation in and around Afghanistan has markedly deteriorated over the last year. The events of September 11th and the subsequent American air strikes have resulted in a massive further deterioration in the humanitarian situation. The already harsh food security situation of last winter has generally deteriorated. Growing numbers of displaced people, combined with restrictions on humanitarian access and immediately prior to the onset of winter, is having a very profound effect on the severity of the humanitarian situation. It will also greatly affect the ability of the humanitarian community to reach and address the needs of vulnerable populations. It is feared that excess morbidity and mortality will be the inevitable result of the harsh winter and a lack of access to basic needs such as food, water, shelter and health care, unless there is a major change in the current security situation.
Those displaced by drought and conflict within Afghanistan, and to neighbouring countries, are regarded as very acutely vulnerable (category I). The plight of the IDPs within Afghanistan itself deserves special mention because of the present lack of access to many of these groups. The refugees who have entered into neighbouring countries are equally vulnerable but are potentially better off because they are accessible to humanitarian agencies. However, the vulnerability of many is likely to remain high until appropriate facilities such as water and sanitation are established in the new and proposed refugee camps that are being built along border areas. The severity of the current situation is extreme, and likely to get worse. This means that many hundreds of thousands of people will not be able to satisfy their basic needs such as food, water, shelter and health care, over the winter period and will require some form of outside assistance to survive. The scale of the humanitarian appeal has been huge, but key UN agencies are yet to have their appeals met in full. The current situation is severely constraining the ability of the humanitarian community to provide sufficient support to the enormous numbers of vulnerable. The ability to provide assistance is highly contingent on how the security situation develops and its impact on humanitarian access to the Afghan population.
Recommendations and priorities
From the RNIS
· Funding appeals must be met in full to ensure that humanitarian needs are addressedFrom MSF survey in Faryab province (MSF 06/08/01)
· Every effort must be made by operational UN agencies to coordinate their nutrition activities on the ground
· Nutrition activities should be fully prioritised according to a comprehensive analysis of the needs on the ground
· In light of the strong link, made by the media, of the US and UK governments combination of military, diplomatic and humanitarian action, humanitarian agencies must endeavour to keep their neutrality and independence.
· Once security allows, assess the impact of food insecurity on all members of the household, in particular on household care-giving behaviours and also their anthropometric status.
· Food distributions should continue and be improved in terms of both quality and quantityFrom the ACF Rapid assessment report from the northern region (ACF 08/01)
· Selective feeding capacity should be boosted and should include outreach screening where possible
· Implement a full General Food Distribution and give people seeds and tools to facilitate planting for next years cropsFrom the Concern survey in Badakhstan (Concern 09/01)
· Implement an emergency intervention to provide urgently needed food before winter.From Refugees International (RI 16/10/01)
· Conduct a distribution of seeds prior to the planting period for spring wheat in March 2002. (It is already too late to provide for the planting of rain fed winter wheat and barley)
· Distribute blankets and winter clothes before the onset of the severe winter weather
· Develop safe humanitarian corridors to get food into Afghanistan
· Utilise the existing cross border trade routes. Central Asian traders are famously flexible and could be used to deliver aid. Monitoring mechanisms would have to be put into place
· Initiate an air service into some Afghan cities using planes from neutral countries
· Planning for air drops should go ahead as they may prove the only feasible way of getting food into the country