No safe home

Recent fighting in Afghanistan has forced thousands of people from their homes. Many are left hungry, exhausted and vulnerable to disease. The latest fighting won the Taliban control of the province of Tahkar, leaving only the remote province of Badakshan in control of the Northern Alliance. Following fierce shelling and bombing of Taloqan, the capital city of Takhar, 70,000 people fled north into the mountains towards Faizabad and the border with Tajikistan. Most are now staying in the compounds of family and friends, but roughly 14,000 have had to take refuge in abandoned buildings such as schools.

"The people must be allowed to return to their homes, and soon, as winter is closing in," explains Dr Krist Tierlinck, the medical co-ordinator for MSF in northern Afghanistan. "The first snows have already fallen in the mountains and the temperatures are dropping fast. There will not be enough food for people to stay in the mountains through the winter, and it will be very difficult to reach those highest areas once the snows arrive."

Three MSF mobile clinics provide medical care to the displaced, and are carrying out approximately 1000 consultations a week. The main health problems are respiratory difficulties, diarrhoea and exhaustion. High-energy biscuits are given to the most vulnerable patients. MSF is also building latrines and providing the displaced with emergency items such as blankets, jerry cans and plastic sheeting.

In Taloqan, efforts are being made to reopen the hospital and clinics, but many of the experienced and educated medical staff have left, especially the women. "Although the Taliban said they would make an exception to their ban on female employment for medical staff, we still have a lot of negotiations, both with the Taliban, and with the women, to make this a reality. Female medical staff are absolutely essential if we are to provide medical services to the whole population - our mother and child health programme, for example, would be impossible without them," says Tierlink.

A looming food crisis

With severe drought affecting the south and west of the country, there is a danger of serious food shortages. Lack of food has already forced thousands of people to leave their homes and seek safety in the major towns such as Herat, which is currently hosting 10,000 displaced people. The camps there are poorly equipped to cope with the influx.

"We're not yet seeing a major food crisis, but there are worrying signs," says MSF's health advisor Christa Hook. "Normally, rural people prepare food stocks to last the coming winter - in several districts, people don't have enough supplies to do this."

MSF teams in Ghurian have noted that children treated in the mother-and-child health care programme are often failing to improve when they are sent home - a worrying indication that there is not enough food for them or their families.

Elsewhere in the country outbreaks of disease are causing concern. In the northern provinces of Jowzjan, Fariab and Badghis, a cholera epidemic has already claimed hundreds of lives. MSF is chlorinating water and has opened a network of treatment centres throughout the affected region - in Sherbeghan town alone 451 patients have already been treated. But despite the best reactive efforts of MSF and other aid agencies, the lack of a proper health system in Afghanistan, continued population displacement, and the absence of basic infrastructure means that people will remain vulnerable to outbreaks of serious disease.

Mandy Dougal, has just returned from nine months working in the infectious disease ward of Kandahar hospital: "We were treating diarrhoea, typhoid, hepatitis and meningitis as well as a few suspected cholera cases. The lack of access to health facilities, combined with the rampant and unregulated over-consumption of drugs from the bazaar, meant that often we didn't see patients until it was too late."

Despite these inhospitable and worsening conditions, the United Nations High Commission for Refugees (UNHCR) is currently repatriating Afghans back from Pakistan and Iran. These countries have been the destination of thousands of Afghans fleeing the war during the last ten years. But the current situation in Afghanistan is not suitable for people to return to Afghanistan in safety. MSF has called upon UNHCR to put the repatriation programme on hold until conditions in Afghanistan improve, and until assistance, protection and monitoring of returnees is in place.

Aid cut despite worsening crisis Despite an increasingly alarming humanitarian situation, the British government has withheld funding for the work of international nongovernmental organisations in Afghanistan for the last two years. Frances Stevenson is MSF UK's programme manager: "Thanks to the support of private individuals, MSF is able to continue working for the Afghans. However, many other aid agencies rely on government support, and they have had to stop some of their programmes. Some have even had to leave Afghanistan. As most of the basic services in the country are provided by aid agencies, this is having a real impact on the population."

MSF has been working in Afghanistan since 1980 on all sides of the various front lines and currently employs 470 people.