Afghanistan Region
Afghanistan continues to be a major complex emergency. Years of conflict in the country, coupled with frequent environmental disasters, have resulted in chronic social and economic hardship that have seen much of the population increasingly struggling to cope with the situation. This chronic emergency has been further exacerbated by three years of drought that has resulted in the almost complete failure of much of the country’s rain fed agriculture and the degradation of vital water resources. The years of insecurity and impoverishment have led to the internal displacement of many Afghans unable to cope in their places of origin, with many moving from rural areas to the urban provincial capitals in the hope of being able to secure employment and assistance. Many have also sought assistance outside of the country in neighbouring Pakistan and Iran, where they constitute the world’s largest refugee community at an estimated 3.6 million people.
The already desperate situation came to a head as a result of the September 11 th terrorist attacks on the United States and the subsequent military action within Afghanistan against the Taliban and Al Qaeda network. This resulted in the evacuation of aid agencies from the country and a dramatic increase in the number of internally displaced, which exceeded one million people. The fall of the Taliban regime in November 2001 opened up much of the country and a massive humanitarian intervention was implemented to provide emergency food and assistance for up to nine million people.
Recent events
The overall situation within Afghanistan has stabilised significantly over the duration of 2002, with particular strides in the political process of defining the future Afghan government. An interim Afghan Administration was created in December 2001, which governed the country until the convening of the Loya Jirga from 10 - 16 June 2002. The Loya Jirga brought together representatives from all over Afghanistan to form a nationally endorsed government, with Hamid Karzai voted in as head of state by an overwhelming majority (UNOCHA 14/06/02). Despite various tensions prior to the Loya Jirga, the outcome is extremely positive and bodes well for continued development of a stable political environment. It is hoped that the new government will oversee the regeneration of the country’s infrastructure and economy, both of which are essential for the mitigation of the current crisis.
Humanitarian situation
The humanitarian situation in Afghanistan continues to be extremely precarious. The effects of years of conflict and the recent three years of drought have resulted in the destruction of the country’s infrastructure and economy and have destroyed the livelihoods of much of the population. As a direct result, much of the population suffers from impoverishment and reports from across the country indicate that emergency needs remain extremely high. It is clear that many people have all but exhausted traditional coping mechanisms and are relying on non-sustainable coping strategies and on external assistance to meet the most basic of subsistence needs.
Humanitarian needs are expected to remain extremely high over the coming months and it has been suggested that the drought crisis could continue for a further 12-18 months (Feinstein 05/02), requiring continued humanitarian efforts. The period from April to July is seen as particularly critical as it is the pre-harvest hunger season when food stocks are normally at their lowest point, which is particularly concerning given the poor harvests of the past few years. As a result, the overall emergency food needs are at their highest during this period, with an estimated nine million people requiring assistance (WFP 03/05/02). The humanitarian response to these needs has been considerable, however it is worrying to note that the humanitarian appeal remains considerably under funded. WFP have estimated that they will require 544,000 MT of food for their current nine month operation from April to December 2002 and have recently reported that they face a shortfall of 175,000 MT, or 102 million US dollars (WFP 28/06/02). This has already resulted in some of WFP’s sub offices reporting pipeline breaks since early May 2002. The degree of under-funding and the projected pipeline breaks have worrying implications for the future of some programmes such as the Food for Asset Creation (FoodAC), Food For Work (FFW) and Food for Education. It is also concerning to note that the funding shortfalls are likely to affect key programmes designed to help with the reintegration of newly returned Afghans.
The situation has been made more difficult for the humanitarian community by the much greater than expected rate of return of IDPs and of refugees from neighbouring countries. Original planning figures estimated that up to 800,000 refugees would return during 2002, however this number was superseded in the first 15 weeks of the programme. At the end of June 2002, UNHCR estimated that 1,109,394 refugees had returned from neighbouring countries and it is now estimated that up to 2 million may return during the year (UNHCR 29/06/02). It is also estimated that there are still approximately 920,000 IDPs in various parts of the country. This is placing enormous strain on the already stretched resources and it has been suggested that rations, which make up a part of the essential return package for returnees, will be cut by up to a third of the intended amount (WFP 30/06/02). As a result, there is considerable concern over what will happen to people returning to areas with very little in the way of resources, infrastructure and essential livelihood opportunities, who will remain heavily dependent on external assistance.
Despite the improvements in security in the country, Afghanistan is still in a state of emergency and many areas of the country remain extremely insecure, which serves to hamper agency activities and humanitarian access. There has been a considerable rise in factional fighting, particularly in the northern regions of the country in the city of Mazar-I-Sharif and the surrounding districts of Sar-e-Pul and Sholgara. Much of the fighting has been between various warlords over control of key areas, and whilst the UN has served a key role in negotiating cease-fires, it has limited authority to enforce them (HRW 07/05/02). It is also alarming to note that rising insecurity in many areas has also resulted in increases in direct attacks on humanitarian aid workers and Afghan civilians, threatening the continued delivery of humanitarian aid. The attacks have included armed robbery, firing on clearly marked UN and NGO vehicles and the gang rape of a female NGO worker on 8 June 2002 (HRW 27/06/02). In some areas, notably in the north, this has resulted in the withdrawal of aid staff, the suspension of aid programmes and the complete withdrawal of at least one NGO from the country. The insecurity also severely threatens the fragile peace in the country, increases the possibility of more people being displaced, preventing returns of the population to their areas of origin, and could also serve to undermine the authority of the new government. The fragility of the current humanitarian situation coupled with the poor economic outlook and the number of people returning to the country could also serve to provoke further insecurity.
Food Insecurity
The food security situation in the country remains extremely poor. A pattern of general impoverishment within the population as a whole is emerging as a result of the drought and general degradation of livelihood activities. Numerous food security analyses have indicated that the traditionally robust coping mechanisms are breaking down and that nearly all medium and poor households suffer food insecurity, with land less and female headed households being the most vulnerable (WFP 05/02). In rain fed areas, those most affected by the drought, people are almost totally reliant on food aid. This reliance decreases slightly in the irrigated villages but the general lack of labour opportunities in all areas undermines people’s ability to purchase food (WFP 05/02). Indebtedness, a normal coping mechanism for many, is now widespread and many people are increasingly unable to repay debts or to take out new loans. As a result they are being forced to turn to increasingly untenable coping mechanisms involving the sale of essential livelihood assets such as land and livestock. This has very profound implications for people’s ability to restart livelihood activities in the near future. There are also widespread reports of people reducing their dietary intake and turning increasingly to wild "famine" foods in a bid to feed themselves and their families (AFSU/VAM 25/04/02; 05/05/02). The current state of indebtedness is concerning as many are unable to repay debts and this is thought to be one of the reasons for IDPs to become displaced whilst also preventing some from returning to their areas of origin (FAO 06/02).
Given the widespread food insecurity and the resultant emergency needs, it is surprising to note that there does not appear to be a greatly elevated prevalence of acute malnutrition in the population. However, there does appear to be a serious problem of chronic malnutrition, indicative of the long-term nature of the nutritional insult in Afghanistan. There is also increasing evidence of widespread micronutrient deficiency, which is of considerable public health concern as it contributes to increased morbidity and mortality. It is also important to stress that Afghanistan is entering the summer diarrhoea season, which has been clearly demonstrated to correlate very closely to increased levels of malnutrition in the under-five population (see RNIS 32 and 33) (ACF-UK 30/04/02). The current drought and scarcity of potable water sources has exacerbated the problem of diarrhoea and WHO estimates that between 20-40 % of all child deaths are due to diarrhoea (WHO 26/05/02). It is therefore likely that there will be an increase in rates of malnutrition over the summer period.
Central Afghanistan
The situation in the central highlands continues to be of great concern. A series of WFP rapid assessments have indicated that food insecurity is prevalent in many areas and reliance on external assistance is extremely high. The assessments indicate that people in many of the central regions have traditionally relied on their own agriculture and livestock as their main mode of livelihood. Surplus production was often sold, as were traditional handicrafts. The drought and conflict have resulted in the wide scale loss of harvests, livestock and essential assets and as a result most families now rely heavily on the need for cash to meet subsistence needs. Most income is now generated through labour and many men have left the area in search of work in order to provide for their families. This has left many landless and female-headed households who appear particularly vulnerable to further livelihood insecurity (AFSU/VAM 05/05/02).
Humanitarian organisations have been implementing various emergency programmes in the area, including the distribution of emergency rations. The period between April and July is particularly critical as it lies in the hunger season prior to the harvest in August. In general the security situation has been relatively stable but there have been various incidences of attacks on NGOs over the past three months and this has hampered the delivery of assistance in some instances (UNAMA 30/04/02).
Kabul
Since the ousting of the Taliban regime, Kabul has been the hub of humanitarian activities within Afghanistan. However, it remains heavily affected by years of war within the country and suffers from an economy that lies in ruins. The southern and western quarters of the city have been particularly affected and lie largely in ruins. The establishment of the new Afghan government is an encouraging step in the rebuilding of both the city and the country at large. Security in the city and its surrounding area has been tense, with reports of various attacks on the city itself, possibly by parties attempting to destabilise the fledgling administration and government. One of the greatest challenges ahead is the regeneration of the economy, which has been reduced to small traders and scattered market stalls. Industry is non-existent and much of the population remains unemployed. The enormous number of displaced and returnees are also serving to put additional pressure on the city’s already over stretched resources. In particular, the issue of water has been highlighted as being especially important, with much of the city suffering from vastly inadequate access to potable water. This is particularly concerning as past data has clearly demonstrated a clear correlation between diarrhoea, particularly during the summer months, and an increase in malnutrition (ACF 30/04/02). The RNIS does not have any recent nutrition surveys from the city but the situation is assumed to be poor and a rise in malnutrition over the summer period can be expected.
Shomali Plains and the Panjsheer Valley
The Shomali Plains and Panjsheer Valley have been at the centre of some of the fiercest fighting in Afghanistan. The area was, for a long time, a front line area between the Taliban and Northern Alliance and the various offensives resulted in the displacement of vast numbers of people. The conflict and displacement severely affected what was once a highly fertile area of the country, however the presence of large numbers of land mines continues to prevent access to some of the fertile farming land.
The area is much more accessible than previously and it now takes two hours to reach Kabul, whereas before it took at least 12 hours. The area is less drought-affected than other regions but the level of destruction and the large amount of land mines mean that many families find it difficult to meet their basic needs. ACF conducted a nutrition survey in the area during March and April 2002. The survey followed standard cluster survey methodology to measure children under the age of five years and found an estimated prevalence of acute malnutrition (W/Ht <-2 Z scores and/or oedema) of 10.5 %, including 1.6 % of severe malnutrition (W/Ht <-3 Z scores and/or oedema) (see table below).
Acute malnutrition rates (in Z-scores), from ACF survey in Panjsheer-Shamali
|
|
Acute |
Severe |
|
August 2000 |
18.2 (14.8-22.2) |
2.8 (1.5-4.9) |
|
March 2001 |
8.3 (6.0-11.4) |
1.8 (0.8-3.6) |
|
March/April 2002 |
10.5 (7.7-13.3) |
1.6 (0.5-2.7) |
Northern Afghanistan
Northern Afghanistan has been one of the worst affected areas of the country. Both the conflict and drought have taken a considerable toll on livelihoods in the area and decimated food production. As a result, many people remain extremely food insecure and, unable to support themselves in their places of origin, have resorted to distress migration to urban areas in search of charity and employment opportunities.
There has been a considerable humanitarian response to the crisis in the area, with agencies addressing both food and non-food needs of needy populations. The area has always been prone to insecurity as a result of factional fighting, however, it is concerning to note that the past three months have seen a deterioration in the overall security situation as a result of a security vacuum. Much of the insecurity has been around the town of Mazar-I-Sharif and surrounding areas, and is a result of conflict between various warlords. The insecurity has disrupted aid programmes and resulted in the withdrawal of some aid agencies in light of various incidents and attacks on the aid community. As a result of the insecurity, UNHCR has also suspended some of its return activities to parts of the north(IRIN 02/07/02).
Mazar-I-Sharif
Mazar is the main city in northern Afghanistan and the second largest city in the country. The city has been target of much in-migration from surrounding areas hit hard by conflict and drought. As a result, there is a substantial IDP community in and around Mazar that began arriving from February 2001. The last survey to be conducted in the town was in November 2000 (see RNIS 32 and 33), which showed low levels of acute malnutrition. Access to the city had been difficult until earlier this year when ACF under-took a nutrition survey in March 2002. The survey indicated a prevalence of acute malnutrition (W/Ht <-2 Z scores and/or oedema) of 2.9 % including 0.4 % of severe malnutrition (W/Ht <-3 Z scores and/or oedema). The results indicate that the nutrition situation is under control with levels being well below emergency cut-offs. The results are similar to those of November 2000 (ACF 03/02). The survey also measured mortality and estimated that the CMR was 0.2/10,000/day and the under-five mortality was 0.7/10,000/day. The mortality is also well within emergency thresholds and indicates that the overall health situation is under control. Given the poor food security outlook for many in the area and the dependency on humanitarian assistance, the low levels of acute malnutrition are surprising. However, the city has received a great deal of assistance and there is an increase in the number and variety of imported goods in the city, indicating an improvement in the overall economy. It is important to note that the survey took place before the summer, which is associated with a seasonal rise in diarrhoea and malnutrition, and it can be expected that rates of malnutrition will increase during the summer period.
Sar-e-Pol
The population of Sar-e-Pol is regarded as acutely food insecure as a result of drought. This has resulted in many families being forced to turn to ever more extreme methods of coping with the lack of food and employment opportunities. Access to cash for food purchase has become increasingly necessary and increasingly difficult and has led to families selling all or part of their assets to survive. In general the coping mechanisms in the area appear to be very strong and have allowed many to "cope", albeit at the very edge of their ability. However, people’s ability to cope is stretched to the very maximum. Many have traditionally relied on systems of charity and borrowing but, as the entire population now feels the effects of the past years, access to this traditional redistribution network is also becoming more and more difficult. As a last resort many have been forced to move from their areas of origin in order to meet their subsistence needs.
The situation has been exacerbated by recent reports of violence and factional fighting that has continued to displace people and has prevented others from returning. It is certainly difficult to see how the situation can improve without considerable long-term input to rebuild people’s livelihoods and to ensure that the security situation remains stable. Recent nutrition surveys have indicated a poor nutritional situation in the area. In March 2002, ACF conducted a further survey in Sang Charak district of Sar-e-Pol that showed an estimated prevalence of malnutrition of 3.6 % (W/Ht <-2 Z scores and/or oedema), including 0.6 % of severe malnutrition (W/Ht <-3 Z scores and/or oedema) (ACF 30/03/02). The low levels of acute malnutrition are surprising given the extent of the food crisis in the area, the dependency on food aid and the findings of previous surveys and assessments in the area. However, the results appear to be born out by the mortality rates from the survey, which estimated CMR as 0.55/10,000/day and under-five mortality as 1.31/10,000/day. These both remain below emergency thresholds. The survey points to a number of factors including the very strong coping strategies practised in the area. The survey also points out that the last full nutrition survey, showing a poor situation, was conducted in August 2001, during the period when diarrhoeal morbidity is at its highest. There is a large seasonal variation in nutrition rates strongly linked to diarrhoea. It is likely that the poor food security of the area and the inevitable summer increase in malnutrition will lead to an increase in malnutrition rates over the summer.
Western Afghanistan
The situation in Western Afghanistan remains extremely precarious largely as a result of drought and insecurity. Many of the small-scale farmers in the area have been particularly badly affected and the emergency needs of both non-displaced and displaced populations are high. UNICEF and CDC recently conducted a nutrition survey in Maslakh camp, near Hirat, which has seen unprecedented numbers of people seeking shelter and assistance over the past few years. This number has grown enormously over the past year and today Maslakh is the largest IDP camp in Asia and Europe (UNICEF/CDC 04/02). The survey indicated that the estimated prevalence of acute malnutrition (W/Ht <-2 Z scores and/or oedema) was 2.9 % including 1.2 % of severe malnutrition (W/Ht <-3 Z scores and/or oedema). These prevalences are extremely low, particularly given the current situation, and in fact are not significantly different from the standard reference population (UNICEF/CDC 04/02). The survey also measured mortality and found that the crude mortality rate over the previous four months was 1.5/10,000/day and the under-five mortality was 6.1/10,000/day. The mortality figures are extremely alarming as they are above emergency thresholds and, in the case of the under five mortality, very greatly so. The main causes of death were determined to be watery diarrhoea and pneumonia, with malnutrition reported to be an aggravating factor among 51.4 % of the total deaths and 46.9 % of the under-five mortality (UNICEF/CDC 04/02).
The very high under-five mortality rate could be masking a more serious nutritional crisis in the under- five population, however other information on the nutritional situation in the camp would seem to indicate that malnutrition is not a widespread problem. The prevalence of micronutrient deficiencies was deemed not to be a problem of public health importance and the prevalence in women of reproductive age was also not seen to be greatly elevated. The main cause of both morbidity and mortality seems to be preventable communicable diseases, which would indicate that the camp suffers from an extremely poor public health environment (UNICEF/CDC 04/02). This is particularly concerning given the upcoming diarrhoeal season.
Southern Afghanistan
Almost one half of Afghanistan’s IDPs live in Southern Afghanistan, with the majority being drought displaced. A large proportion of these come from the Ethnic Kuchi population, traditionally nomadic pastoralists whose livelihoods have been decimated by the drought and conflict. Many of the IDPs and returnees are concentrated in camps in the south of Kandahar province. This includes about 40,000 people waiting in the Cha-man ‘no man’s land’ area, hoping to cross into Pakistan. They have been refused entry and it is hoped that they will be relocated to about 10 community-based settlements in Kandahar province (WFP 31/05/02). There are also estimated to be about 44,000 IDPs in five camps at Spin Boldak. The situation in the Spin Boldak camps is currently uncertain due to the withdrawal of the main NGOs from the camp. The UNHCR has stepped in for a period but suffers from its own funding constraints. The hope is that many of the camp residents will return to their areas of origin but many feel currently unable to do so as a result of continuing insecurity and loss of livelihoods. It has also been noted that there is considerable persecution of ethnic Pashtuns, which make up the majority of the IDPs in the south, and they are unlikely to return until it is clear that they are able to do so safely (UNHCR 26&06/02). The RNIS has not received any recent nutritional reports on the area but the nutrition situation is thought to be precarious.
The Iranian government finally closed the two IDP camps of Mekaki and Mile 46 in Nimruz province on 8 May 2002. The camps had been just one kilometre inside the border with Iran and were established because Iran would not open its borders to Afghans seeking refugee status. At their height, the camps housed approximately 10,500 people. The IDPs have since returned to their places of origin.
Afghan refugees in Pakistan
Years of conflict and drought have driven many Afghans to seek refuge in Pakistan in search of food and employment. This led to a total caseload of in excess of 2 million Afghan refugees in the country. Some of these refugees are based invarious camps in the North West Frontier Province(NWFP), particularly around Peshawar, as well as in Balochistan. Many more are dispersed around the country in various cities living independently or with urban host families.
The recent military action within Afghanistan resulted in further influxes of people into the country and UNHCR estimated that upwards of 250,000 people entered the country in the period after 11 September 2001. However, dramatic changes in the situation in Afghanistan have led to an unprecedented return of both old and new refugees. It is currently estimated that 1,038,000 refugees have been officially assisted to return since the beginning of 2002, with a further 180,000 returning spontaneously (USAID 03/07/02). As of 1 June 2002, UNHCR reported that there were 271,062 refugees in camps, with 146,735 in the Balochistan area and 124,062 in the NWFP.
MSF conducted a nutrition survey in the Roghani refugee camp in the Chaman area of Pakistan, close to the Afghan border. The camp is one of 5 camps opened in November 2001 and was officially closed in December 2001 when capacity had been reached with a total population of 17,112. The survey estimated that there was a prevalence of acute malnutrition (W/Ht <-2 Z scores and/or oedema) of 7.1 % including 1 % of severe malnutrition (W/Ht <-3 Z scores and/or oedema). This prevalence is not indicative of a major nutritional problem in the camp and is comparable to other surveys done in Afghanistan at around the same time. The needs of the population within the camp were relatively well catered for and refugees received a regular and adequate food ration of 2428 Kcal along with essential non-food items, access to medical care and water and sanitation. The CMR was estimated to be 0.35/10,000/day and the under-five mortality 0.68/10,000/day. Both these mortality rates are below emergency thresholds and reinforce the impression that the situation within the camp remains under control (MSF-H 12/01/02).
Further nutritional surveys were recently conducted by UNICEF/UNHCR/PDH in April and May 2002 in the camps and urban areas in the NWFP. The NWFP has sheltered a large number of Afghan refugees since at least 1978 and it was expected that in excess of 600,000 new refugees would enter the region after 11 September 2001. However, it was estimated that 138,000 had crossed the border by late December 2001 (UNICEF/UNHCR/PDH 05/02). A total of nine new camps were erected in response to the new influx and to house relocated "old" refugees. The first survey assessed refugees living in camps and estimated that the prevalence of acute malnutrition was 4.7% (W/Ht <-2 Z scores and/or oedema) including 0.7 % severe malnutrition (W/Ht <-3 Z scores and/or oedema). CMR was estimated at 0.27/10,000/day and under-five mortality at 0.61/10,000/day. Both the prevalence of acute malnutrition and the mortality rate are not greatly elevated and do not indicate a particularly concerning situation. However, it is important to note that the refugees remain largely dependent on food aid and food purchase as they have no access to land for cultivation or livestock. Wage labour was the most common form of income generating activity and this has proven to be extremely seasonal.
The next survey was conducted amongst refugees in urban communities and estimated that the prevalence of acute malnutrition was 7.7 % (W/Ht <-2 Z scores and/or oedema) including 1.3 % of severe malnutrition (W/Ht <-3 Z scores and/or oedema) (UNICEF/UNHCR/PDH 05/02). The CMR was 0.21/10,000/day and the under-five mortality was 0.55/10,000/day. Again, the prevalence of malnutrition and the mortality are not above emergency thresholds. In general, the urban communities can be assumed to have slightly greater prospects for income generation. The surveys indicated that the incidence of diarrhoeal disease was high in the study population and that there was a problem of inadequate feeding practices that was directly linked to cases of malnutrition in young children. The overall conclusion from both surveys is that the level of malnutrition was not unusually high for the time of year and was unlikely to deteriorate in the near future (UNICEF/UNHCR/PDH 05/02).
Overall
The overall situation within Afghanistan remains extremely precarious with continuing drought conditions and an apparent increase in insecurity, despite the creation of a fully functioning Afghan government. Acute food insecurity continues to be a problem in many areas of the country and humanitarian needs will remain high for some time. IDPs and non-displaced populations, as well as returning refugees, are considered to be acutely vulnerable (category II). In general the nutrition situation is not critical, reflecting the robustness of current coping mechanisms and the magnitude of assistance that has been supplied. However, it is likely that there will be a seasonal increase in malnutrition over the summer months in line with the diarrhoeal season. As a result, the situation requires careful monitoring.
Recommendations
From the UNICEF/UNHCR/PDH survey of refugees living in camps and urban host communities in NWFP of Pakistan May 2000
· Conduct a Knowledge, Attitude and Practice (KAP) study on breast-feeding and weaning to address inadequate infant feeding practices.From the ACF survey in the Panjsheer valley and Shomali Plains, April 2002· Implement essential water and sanitation activities to address issues of poor hygiene in the camps.
· Strengthen the existing nutritional surveillance programme, including the continuation of growth monitoring beyond one year of age.
· Strengthen the referral system between clinics and feeding centres through staff training.From the UNICEF nutrition survey in Maslakh camp, Herat, April 2002
· Improve the outreach programmes and health screening for remote households.
· Implement a distribution of iodised salt.
· Further investigations are needed into the prevalence of diarrhoea and ARI.From the ACF survey in Sang Chark district, Sar-I-Pul Province, March 2002· All wheat flour distributed should be fortified with iron.
· Adequate preventive and curative health services should be available and accessible in areas of return of IDPs.
· There is a need for better mortality and morbidity surveillance.
· Conduct training for midwives and TBAs and on health and hygiene promotion.From the ACF survey in Mazar city, March 2002
· Introduce a nutritional surveillance system in health centres.
· Improve water and sanitation infrastructure in health centres.
· Distribute wheat seed for the coming October planting season.
· Continue monitoring of the nutrition situation, particularly with the onset of the diarrhoeal season.· Improve the use of maternal and child health services, in particular for per-natal care, immunisation and the treatment of childhood disease.
· Introduce Cash for Work or Food for Work activities targeted at vulnerable families.
· Improve the water and sanitation infrastructure.
