This article first appeared in the British Journal of General Practice in the November edition, 2001.
For years the people of Afghanistan have been caught in one of the worst humanitarian crises in the world. In all provinces where Médecins Sans Frontières (MSF) work, a clear degradation in nutritional status has been seen. In the first part of this year an outbreak of scurvy was detected and cases of cholera were on the rise.
The current drought, now in its third year, has been catastrophic. Harvests have failed and livestock have been decimated. Seeds have been eaten and rivers have dried up, leaving too little water for drinking or irrigation. The serious food crisis risks evolving into a famine.
The war, drought and food crisis has forced thousands of Afghans to flee their homes: 66,000 people were displaced to refugee camps in Mazar-i-Sharif out of a total of 150,000 in the northern provinces, 228,000 were displaced in two camps in Herat province in the West, and 100,000 more in Kandahar in the South. In August 2001, an estimated 100 - 200 people were arriving every day in the camps in Herat province. Already, one million refugees had fled to Pakistan, 400,000 to Iran and 100,000 to Turkmenistan, Uzbekistan and Tajikistan. The United Nations refugee agency, UNHCR is planning camps along the Afghanistan-Pakistan border for a further 1.5 million refugees.
Two decades of conflict have taken their toll on Afghanistan. The country's health system is among the worst in the world and all indicators -infant mortality, malnutrition, lack of access to water - paint a desperate picture . Médecins Sans Frontières (MSF) has been working in Afghanistan since 1979. But recently its work has been greatly reduced. Aid agencies, on whose work thousands of lives depend, have found it increasingly difficult to deliver assistance in recent years, as many regions are inaccessible due to the conflict.
The threats of war following the terrorist attacks in the United States on September 11 had greatly increased the security risk for expatriate workers and forced the majority of aid agencies to withdraw to neighbouring countries. The airstrikes at the beginning of October, the chronic lack of aid, and the onset of winter will only magnify the humanitarian catastrophe.
MSF's expatriate staff have withdawn from all but two provinces (Faizabad and Eshkashim in the north), although experienced local staff continue to work in many provinces. In the month since September 11, MSF has delivered 40 tonnes of medical and food supplies to its programms in northern and Western Afghanistan, but gettting aid into the country is difficult at best, and in some locations impossible. The US-airstrikes were accompanied by food dropped into Afghanistan. However, the amount of food dropped was vastly insufficient to meet the needs, and airdrops are in any case the least effective way of delivering aid. "It's a bit like throwing a bundle of £5 notes up in the air in Oxford Street," said Geoff Prescott, the head of MSF in Pakistan, said. "The people who grab the notes first will not be the needy and vulnerable."
Of far greater concern is the mixing of humanitarian aid with military objectives. If the military are involved in delivering humanitarian assistance, it can be regarded by their opponents as an act of war: aid and aid workers can be legitimately targeted, and so denied to people in need. This was seen during the Kosovo crisis when NATO troops were present in the refugee camps and the camps were shelled by Yugoslav forces. In Pakistan in early October some United Nations offices were attacked. When the bombing stops, how will the Afghans tell humanitarian aid agencies apart from humanitarian bombers?
The military can provide help to people in danger in certain circumstances. Logistical resources are frequently deployed to respond to natural disasters, and peacekeepers have an important role to play in protecting civilians caught in conflict. But every time a military power that is belligerently involved in a conflict describe their actions as humanitarian, this vital concept is eroded. Aid agencies are perceived as less neutral and less independent, and staff will find it increasingly difficult to work and will be increasingly targeted. Civilian victims are less likely to be treated according to the rules of war, which insist on protection from aggression and the right to independent assistance.
Today the people of Afghanistan are in desperate need and have almost no assistance. Millions are faced with starvation. The UN has massively reduced all actions and aid workers now wait across the border in preparation for either a massive refugee crisis, a return to Afghanistan, or both. On one side, tons of aid and hundreds of staff; on the other side millions of people suffering.
To bridge this vast gap, large-scale independent humanitarian relief effort is required, aimed directly at reaching the most vulnerable. This response could be led by the United Nations with a clearly understood humanitarian mandate, in collaboration with independent aid agencies. All parties to the conflict must allow for the delivery of large-scale aid convoys by humanitarian actors. The Taleban and its allies have the same responsibility towards civilians in war. Aid must get into Afghanistan and must be delivered by people who are not involved in the fighting.