War aggravates chronic humanitarian crisis in Afghanistan

Decades of civil war, five years of oppressive Taliban rule and three years of drought had forced millions from their homes in search of safety and food.

During the months following the September 11th attacks, many more fled from the retaliatory military action taken by the US-led coalition, and from fighting within the country. Vital humanitarian assistance, the only source of food and medical care for thousands, was cut off when Taliban forces compelled all international aid organizations to leave the country. Borders were closed, trapping civilians inside Afghanistan. The coalition dropped food packages as well as bombs - a propaganda move that was not only ineffective in meeting the needs of hungry people but also a dangerous fusion of military and humanitarian agendas.

Eventually the Taliban was driven from power. However, by July 2002, as a new government tried to establish itself in Afghanistan, the situation for most people remained precarious. Access to areas in the south was limited, dangerous or impossible. Malnutrition remained ever-present. Refugees were returning from neighboring countries even though the war was not yet over. And access to health care for most Afghans remained extremely limited.

The events of the last year illustrate the vulnerable position of civilians in conflict situations and the dangers of letting political objectives, and not the needs of the people, shape the aid that is given.

MSF has worked in Afghanistan since 1980, and medical aid programs were underway in 13 of the country's 32 provinces when the events of September 11th took place. In early 2001, having witnessed growing numbers of people displaced as a result of the civil war and the ongoing drought, MSF urged the international community to act. By summer 2001, everything was pointing to a worsening humanitarian situation in the country. The events from September onward only intensified this dire situation.

In conflicts, MSF relies on its neutrality to ensure the safety of its workers, but it soon became clear that anyone perceived as a "Westerner" could be in danger. With US-led military action imminent, MSF project leaders were informed by the Taliban that they should leave the country. By September 14th international volunteers had been evacuated from Taliban-held areas.

MSF activities, however, continued. International staff remained in the Northern Alliance-held areas, and MSF national staff throughout the country adapted to the crisis. They continued most programs in the Taliban-held areas, even as the conflict escalated around them.

From outside Afghanistan, MSF tried to negotiate reentry. Communication with local teams was difficult, and crucial supplies were cut off due to the fighting and the closure of international borders. Hospitals and clinics began to run low on food and essential medicines. MSF responded by shipping medicines, medical material and other relief items to strategic points in Pakistan, Tajikistan, Turkmenistan and Iran, where ongoing projects facilitated the emergency preparations. MSF met with Taliban representatives but was denied permission to return.

US and British forces began bombing Afghanistan on October 7th. At the same time, they began dropping food rations as part of a "bread and bombs" military campaign. Not only were the few thousand daily rations dropped insufficient to feed the millions of hungry people, but they were also the same color as cluster bombs being used in the offensive. These cluster bombs will be an enduring legacy of the conflict. Furthermore, through its 30 years of experience in delivering aid, MSF has learned that untargeted and unmonitored aid, particularly food aid, rarely reaches those who need it most, and this was the case in Afghanistan.

MSF strongly condemned this mix of military and humanitarian action as dangerous, ineffective and detrimental to future humanitarian aid. As long as humanitarian workers are recognized as neutral, they are safe to work in conflict areas. Once aid is linked to military action, humanitarian organizations become targets: future attempts to provide aid are suspect and new barriers exist between the most vulnerable and the international aid organizations trying to reach them. (See the Year in Review on page 6 and the essay on page 70, for more on MSF's concerns about linking
military and humanitarian action.)

International borders remained closed - Afghans able to reach the border were often trapped inside, denied the right to flee. Thousands waited for assistance near the border with Iran, digging holes to protect themselves from the sandstorms and the freezing cold. Others were trapped near the Pakistan border. MSF called on the international community to find an immediate solution for those who could neither flee to another country nor be reached inside Afghanistan by international organizations.

As the Taliban regime crumbled, MSF teams were finally able to return - first to Kabul on November 13th, then to Herat, Mazar-i-Sharif, Taloquan and other places in the following days and weeks. Many operations had been looted during the fighting, resulting in the loss of radio equipment, trucks and other supplies. As military strikes continued in parts of the country, MSF teams evaluated immediate needs and returned to supporting clinics, hospitals and camps for displaced people, building on existing programs and adding projects to meet new needs.

The consequences of the military operations on civilians as well as the critical health situation continued to be of concern. In December 2001, MSF transported civilians who had been wounded in the bombing of Tora Bora, and spoke out against the high number of civilian casualties. Half the country was still inaccessible in February 2002, and access to people in need continues to be a serious problem. A nutritional crisis in northern Afghanistan had become critical, and by March 2002 MSF had more than 4,000 children in emergency feeding centers.

By July 2002, about a million Afghan refugees had been repatriated from Pakistan and 150,000 from Iran; the conditions of their return have varied from area to area, depending on the security situation and the international assistance provided. MSF is monitoring the return and reinstallation of Afghans from points in Afghanistan, Iran and Pakistan, and in many project areas providing returnees with basic health care assistance.

Even as the new regime tries to establish itself and bring brighter prospects to a country so long at war, the situation in Afghanistan remains fragile. Conflict continues, especially in rural areas, and MSF teams work with isolated communities that have no access to health care and little food to survive the winter. In some places, the people have retreated into caves in the mountains. MSF also works in camps for people who have been displaced, vaccinating against infectious diseases and providing emergency medical care. Natural disasters, such as the series of earthquakes that struck the country in the first half of 2002, continue to take a heavy toll (MSF assisted people affected by the tremors).

Many projects specifically address the needs of women and children who would otherwise have no access to health care. Feeding centers continue to receive malnourished children.

As of July 2002, MSF was running medical and nutritional aid programs in many parts of Afghanistan, with support to hospitals, clinics, health posts, and therapeutic and supplementary feeding centers in cities and villages in the provinces of Badakhshan, Badghis, Bamyan, Faryab, Herat, Ghazni, Kabul, Kandahar and Takhar, as well as the cities and regions of Garden Dewal, Karai Valley in Faryab province, the Panjshir Valley/Shamali Plain and Yakawlang. Projects were ongoing with internally displaced people in Balkh, Baghlan, Herat, Kandahar and Kunduz provinces, while nutritional aid in Nimruz and Sar-i Pul provinces came to an end in May 2002. MSF also continued its work with Afghan refugees in Pakistan and Iran (see page 66).

International staff: 134
National staff: 906