During the first six months of this year, MSF collected malnutrition data through rapid assessment (measurement of mid-upper arm circumference) in three provinces of western Afghanistan: Herat, Badghis, and Kandahar.4 Drought in these areas has caused cereal harvests to fall by 50% in 1999 and 85-90% in 2000, and many livestock have died.
Between December, 2000, and July, 2001, children younger than five years were assessed during a large-scale measles vaccination programme in Kandahar province, and through random household surveys of villages. More than 10% of people in ten of the 11 areas surveyed were malnourished - an increase since the start of the year.
In May, 2001, a food distribution programme was done in three districts of Kandahar Province: Daman, Maywand, and Panjwai. Prevalence of malnutrition among under-5s was 22% in Damman, and 23·4% in Panjwai, with a modest improvement noted in the summer after the feeding programme.
Deteriorating nutritional status was reflected by a 400% increase in caseload at five supplementary feeding centres in these areas from January to July, 2001 (1,372-5,489 beneficiaries). An outbreak of scurvy in Gulran, Herat Province, in February this year indicated micronutrient deficiency. 155 cases were recorded, indicating an overall prevalence of 3.8%, rising to 9.8% in women of childbearing age.
Also reported were increases in malnutrition, diarrhoea, vomiting, fever, typhoid, and suspected malaria and cholera. Health care was a 5-6 hr walk away for most people.
An outbreak of scurvy in western Afghanistan at the beginning of this year was one small sign for aid agencies of the chronic food crisis that risked evolving into a famine. Afghanistan's past three years of drought - the worst in 30 years - have been catastrophic in a country where 85% of the estimated 21 million population are dependent on agriculture.
Harvests have failed for the third year in a row, livestock have been decimated, and coping capacities are severely impaired by an increase in food prices and the collapse of the rural economy.
In Kandahar, southern Afghanistan, rivers that are used as the main source of drinking water and irrigation are totally dry. A progressive decline in nutritional status has been seen since the beginning of the year. These desperate conditions have forced millions to flee their homes.
By late spring 2001, the number of Afghans taking refuge in neighbouring countries had been pushed to more than 4 million, and several hundred thousand more were displaced within the country. Interviews done with refugees in Iran confirm that conflict, drought, and the food crisis are the main reasons why people flee Afghanistan.
Between September, 2000, and mid-January, 2001, Médecins Sans Frontières (MSF) interviewed 570 refugee families in Gulshur (a district of Mashad, northern Iran) and the surrounding townships.
Of the 407 who stated why they had come to Iran, 87 (21%) had left because of the drought and 279 (69%) as a result of violence and insecurity. Refugee testimonies tell of arrests, beatings, forced enlistment, torture, lootings, and killings.
One elderly man from Bamian, central Afghanistan, had lost his two wives and three sons to the war, and his house had been destroyed by bombing.
He finally left Afghanistan when begging for food could no longer sustain himself and his 4-year-old daughter. Aid agencies have found it increasingly difficult to meet Afghanistan's vast medical and nutritional needs. Following the Sept 11 terrorist attacks, the United Nations has massively reduced all aid operations in Afghanistan because of an increased security risk.
MSF, who have been working in Afghanistan since 1979, have withdrawn expatriate staff from all but three locations in the north (Badakhshan and Takhar provinces and the Panshir valley), and while local staff continue to work in a further six provinces, many programmes have closed. Getting aid into the country is difficult at best, and in some locations impossible.
Almost all aid agencies have withdrawn from Afghanistan to neighbouring countries. Tonnes of food and medical supplies and hundreds of staff are on one side of the border; on the other are millions of people suffering. Before Sept 11, everything pointed to a worsening humanitarian situation in Afghanistan. The air strikes, lack of aid, and onset of winter will only magnify this catastrophe.
The food drops that accompanied the US air strikes on Afghanistan will have done little to help alleviate the food crisis.
More seriously, this act has damaged the effectiveness of humanitarian aid. Military involvement in delivering humanitarian assistance can be regarded by opponents as an act of war, and thus aid can be legitimately targeted, and so denied to people in need.
In war, aid agencies depend on their reputation of being impartial and neutral.Access to those caught in war depends on the man with the Kalashnikov understanding - by recognising the Red Cross or MSF logo on the t-shirt - that the worker is not on one side or the other, but is there to provide medical assistance to whoever needs help.
In Pakistan, some United Nations offices, theoretically a beacon of hope for war distressed people, have been looted, sacked, and burnt. Security fears have forced aid agencies not only in Afghanistan but also in Kashmir, Bangladesh, Indonesia, Kenya, and Somalia to reduce work, depriving many of much needed assistance.
MSF in Somalia is still paying the price a decade later for the confusion between military and humanitarian objectives in Operation Restore Hope. Confusion was created again during the Kosovo crisis by the presence of NATO troops in the refugee camps; the camps were subsequently shelled by Yugoslav forces.
When the bombing stops, and humanitarian agencies can move into Afghanistan, how will the warring parties tell them apart from humanitarian bombers? The military can provide help through, for example, logistical capabilities to respond to natural disasters, and peacekeeping operations to protect civilians.
But every time a military party involved in a conflict describes their actions as humanitarian, the definition of this word is eroded. The work of aid agencies can be increasingly frustrated, and civilians be less likely to be treated according to the rules of war that should give protection from aggression and the right to independent assistance.
The vast needs of the people of Afghanistan will only be met by a large-scale independent humanitarian relief effort aimed directly at reaching the most vulnerable. One option could be a response 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 agencies.
The Taliban and its allies have the same responsibility towards civilians during war. Aid must get into Afghanistan and must be delivered by people who are not involved in the fighting. So-called humanitarian airdrops by the US airforce may feed a few people, but they also damage the effectiveness of humanitarian aid in this and other conflicts.