Episode: "Country Nurse"

MSF in Afghanistan: Responding to the Effects of Perpetual War

In this episode, filmed in mid-2002, Logistician Sander Hammer is renovating the Mir Wais hospital in southern Afghanistan, which was damaged in war between US/Northern Alliance forces and the Taliban during late 2001. But Afghanistan’s health emergency extends far beyond damaged hospitals, and has been around for much longer than the ongoing US-led military campaign.

Even more disturbing, perhaps, is that as of August 2003 – long after the downfall of the Taliban and the transition of media attention to Iraq – Afghanistan’s emergency continues. Beyond expanded access to healthcare for women and the removal of a brutal and oppressive regime, the US victory in Afghanistan has brought painfully few improvements in the basic healthcare available to millions of Afghans. Afghanistan was a country in crisis before the war of 2001, and it remains a country in crisis now.

Country Background

Long before terrorist attacks in the United States thrust Afghanistan into the international media spotlight, the impoverished nation was mired in one of the world’s most destructive and intractable humanitarian crises.

Sitting astride a land route connecting India to Central Asia, Afghanistan has historically been a coveted territory for local and international forces that seek to control regional trade and travel. As a result, the country’s economic development has been stunted by a string of invasions extending back to Alexander the Great.

But the last quarter-century of unrelenting violence bears the most direct responsibility for the sorry state of Afghan public health. Beginning in 1979, a ten-year Cold War battle between the US-backed Mujahideen and Soviet forces took a terrible toll on the country’s infrastructure and forced millions from their homes. (At one point in the early 1980s, the United Nations estimated that half of the people in Afghanistan were displaced.)

A Neglected Disaster: Afghanistan Before 9/11

MSF opened projects in the country shortly after the Soviet invasion of Afghanistan, increasing its presence in the 1980s and through the succession of civil wars that swept the nation in the years following Soviet withdrawal. By the year 2000, 500 MSF aid workers were stationed in Afghanistan, the vast majority members of a highly skilled and effective national staff. Operating on both sides of the shifting frontlines, MSF was able to respond to a wide variety of health problems throughout the country.

In the late 1990s, under the Taliban, a regime of Islamic hardliners who placed particularly heavy restrictions on the behavior and movement of women, MSF escalated programs providing women with access to health care. During this time, MSF was repeatedly expelled from some locations by the Taliban and forced to evacuate other projects because of security concerns related to the regime’s war with the rebel Northern Alliance.

In the summer of 2001, just before the fateful events of September 11, MSF witnessed distressing signals that the situation in Afghanistan was turning from horrible to worse. Three years of perpetual drought had decimated crops and showed no signs of letting up. Five years of oppressive Taliban rule had deprived women, children, and ethnic and religious minorities of vital healthcare. And decades of civil war had forced people from their homes in search of food and safety.

In the northern city of Mazar-i-Shariff, for example, more than 60,000 people huddled in makeshift camps, vulnerable to breakouts of cholera and scurvy – a disease that was virtually eradicated in the 20th century. Meanwhile, Iran and Pakistan hosted a combined population of some four million Afghan refugees, the largest single refugee community in the world. Nevertheless, most aspects of the evolving humanitarian crisis rarely made it into newspapers and onto television screens in the West, even though the drought in Afghanistan was the worst that the country had seen in 30 years.

Post 9/11 Afghanistan: Unkept Promises and Continuing Needs

Not surprisingly, US bombings and ground fighting between Northern Alliance and Taliban troops exacerbated the refugee crisis in Afghanistan. Civilians fled before the violence, abandoning fragile livelihoods for a hand-to-mouth existence in the Afghan hills or in border areas where they sought assistance in neighboring countries.

No assistance was forthcoming, however. Pakistan and Iran closed their borders to the tides of refugees; thousands were trapped in a “waiting area” between Afghanistan and Pakistan and thousands more left to dig holes along the border with Iran – a crude and ineffective form of shelter against sandstorms and the coming winter.

Upon the fall of the Taliban, refugees flooded back into Afghanistan. By July 2002, when this episode was filmed, roughly one million people had been repatriated from Pakistan and 150,000 from Iran. The influx continues – 390,000 people have been repatriated from these two countries by the UN in 2003. The vast majority of these refugees are starting from scratch; they need food, water, and jobs to support themselves.

So far, less than $1 billion of the $4.5 billion in international aid promised to Afghanistan last year has arrived.

Project Update: Kandahar

Mir Wais hospital, where Rachel and Sander are working in this episode, is a project supervised through the Kandahar office of MSF. Much progress has been made at Mir Wais in the last year – after physical renovations and training of staff in the infectious disease ward and outpatient department, MSF now aids Mir Wais in a support capacity. But providing aid in southern Afghanistan has increasingly been a struggle, as a continued influx of refugees and perilous conditions for aid workers have complicated MSF’s efforts.

Many of southern Afghanistan’s returnees have ended up in a camp known as Zhare Dasht, or “Yellow Desert” – a windswept settlement lying one hour south of Kandahar that close to 40,000 Afghans now call home. In early August, an outbreak of diphtheria in the camp forced MSF to mount an emergency vaccination campaign. The intervention is expected to immunize every person in the camp by early fall.
In southern Afghanistan, however, MSF’s work has been jeopardized by the deliberate targeting of aid workers during the last several months. On March 27, a water engineer for the International Committee of the Red Cross (ICRC) was murdered in cold blood in Uruzgan province, southern Afghanistan. In April, grenades were thrown into UNICEF’s center of operations, in May several staff members of an Afghan non-governmental organization (NGO) were killed, and UN offices were also attacked with grenades. MSF has been forced to evacuate projects twice, in February and April.

An estimated 70% of medical care in Afghanistan is provided by NGOs. With continuing drought and displacement perpetuating the country’s plight, the safety of humanitarian aid workers is absolutely critical.