Before the war, the health situation in Afghanistan was among the worst in the world primarily because the health infrastructure was grossly inadequate and mostly limited to urban centers. Protracted conflict since 1978 worsened the inequitable distribution of health manpower and services. The estimated infant mortality rate was 163 per 1000 live births (1993); the under five mortality rate 257 for every 1000 live births (1994); the maternal mortality rate 1700 per 100,000 live births (1993); and life expectancy at birth was 43.7.
Since infant and under five mortality rates are frequently used as reliable overall indicators of community health and development, these figures underscore the appalling state of the health sector in Afghanistan. Most children die of a variety of infectious and parasitic diseases, including acute diarrhoea, respiratory infections, tuberculosis, diphtheria, poliomyelitis, malaria, measles and malnutrition, in addition to disorders allied to pregnancy and delivery.
The tragedy is that 80 to 85 percent of these diseases can be avoided by preventive measures and by the provision of proper health care, or cured at an affordable cost. However, currently there is only one health center to care for every population group of approximately 100,000. Only 12 percent of pregnant women have access to maternal and emergency obstetric care; only 38 percent of children under one year are fully immunized. These problems are compounded by the fact that fully three-quarters of the nations physicians have left the country resulting in a physician/patient ratio of over 95,000/1. Because of the inadequacy of the health delivery system, a majority of the population relies on indigenous healers such as traditional midwives, herbalists, bone setters and barbers who circumcise, let blood, pull teeth, and perform other curative procedures. Mullahs, sayyids and other specialists prepare curative and protective amulets.
The war and deteriorating economic, social, and physical conditions in both rural and most urban areas, have impaired housing and environmental sanitation facilities in general and added sinister dimensions. By the end of 1996, it was estimated that 1.5 million men women and children were physically disabled by war injuries, including amputation, blindness and paralysis, as well as debilitating infectious diseases, such as poliomyelitis and leprosy. Birth complications causing disabilities such as cerebral palsy and mental retardation also increased. Another 10 percent of the total population representing families and associates of the disabled are directly affected by these disabilities. They require information and instruction not only regarding physical care, but also in ways to integrate disabled persons into communities as respected and productive members.
Sadly, the number of disabled increases daily because of an estimated 10 million landmines and unexploded ordnance (UXO) that contaminate the landscape, the largest concentration in the world. A 1993 national survey revealed there were over 465 square kilometers of minefield, of which 113 square kilometers were high priority areas directly affecting residential areas, farm lands, grazing pastures and canals; subsequently further high priority areas totalling more than ninety square kilometers were identified; and, as refugees return, new minefields continue to be uncovered raising low priority areas to high priority. By the end of 1996 some 158.8 square kilometers were cleared and 300,000 mines destroyed. The UN Mine Clearance Programme in cooperation with eight NGOs, includes 50 demining teams and 10 mine dog groups, as well as male and female mine awareness teams, staffed by some 3,000 Afghans. Due to continuing hostilities, however, several de-mined areas have been re-mined. It will be many years before Afghanistan will be free of this menace.
Assistance to enhance the capacity and increase the accessibility of health services, emphasizes basic preventive and curative primary health services, with special attention to strengthening Mother Child Health and health man power development at all levels, including Traditional Birth Attendants and community health workers. Providing safe potable water sources and sanitation facilities is also a high priority since contaminated water sources are major causes of high morbidity and mortality. Upwards of 60 NGOs, in addition to the International Red Cross Committee and the International Federation of Red Cross and Red Crescent Societies, WHO and UNICEF have been active in the health sector over the years, assisting everything from regional, provincial and district hospitals to basic health clinics, as well as specialized services in physiotherapy, drug detoxification, TB and malaria control.
The Mass Immunization Campaigns launched by WHO and UNICEF, in partnership with the Ministry of Public Health, utilizing a cadre of more than 15,000 vaccinators, health workers and volunteers throughout the country, are singular successes accomplished with the active cooperation of all parties to the conflict. In 1995, 2.6 million were vaccinated against DPT and measles; in 1996 2.3 million children under five received oral polio vaccine; during 1997, the nation-wide goal is to reach approximately four million children under five, in addition to 60 percent of women of child bearing age. The ultimate aim is to totally eradicate the polio virus in Afghanistan.
As in the case with the education sector, however, the overall results are generally spotty. New and refurbished buildings intended to dispense medical care stand empty because of lack of personnel or equipment; some have been commandeered by political groups for offices. Of the thousands trained in various medical fields, few find employment. Databases list increasing numbers of "discontinued" projects and facilities. This is particularly disheartening because the lack of medical facilities is a major deterrent to refugee repatriation.
REFUGEES AND REPATRIATION
Eighteen years after the 1978 coup by the PDPA, the refugee problem remained a significant issue for Afghanistan and its neighbors. The refugee flow began as a trickle in April 1978, reaching a peak during the first half of 1981 when an estimated 4,700 crossed the Pakistan border daily. The flow ebbed and surged in response to Soviet offenses, so that by the fall of 1989, the number of Afghan refugees was estimated at 3.2 million in Pakistan, 2.2. million in Iran, and several hundred thousands resettled in scattered communities throughout the world. Afghans represented the largest single concentration of refugees in the world on whom an estimated $1 million a day was expended in 1988.
Following the fall of the PDPA regime in 1992, a new wave of refugees entered Pakistan; the takeover of Kabul by the Taliban in 1996 set in motion a lesser flow which continued in 1997 although refugee assistance, other than to those most vulnerable, was cut back drastically in October 1995. Only emergency assistance is available in hastily reconstituted camps for new arrivals around Peshawar.
Unlike earlier flows of refugees who fled from the consequences of war, recent arrivals are largely educated urban families fleeing because the economy has broken down and, most significantly, because education for girls is unavailable and that provided for boys is so poor. Arriving in Pakistan with high hopes, the new refugees find the situation as bad, if not worse than it is in Afghanistan. There are no jobs, housing and services are expensive as is admission to Pakistani schools, and the schools run by many Afghans are mostly shams. Immigration to third countries is all but closed. Most families, therefore, must depend exclusively on relatives which is psychologically destructive.
Less publicized, but equally disruptive, was the displacement of internal populations, from war affected rural areas to cities, and from bombed out cities to rural areas. IDPs or Internally Displaced Persons are estimated at about one million. UNHCR, ICRC and NGO-assisted camps were established in and around Jalalabad in the east, at Pul-i-Khumri, Mazar-i- Sharif and Kunduz in the north, and in Herat in the west. Other IDPs survived on the goodwill and support systems of local rural communities. This stretched the resources of towns and rural areas throughout the country, especially south and north of Kabul and in the Hazarajat. These movements could bring about changes in demographic balances with untold consequences.
To stem the flow of refugees, NGOs based in Pakistan led by the example of the Swedish Committee for Afghanistan in 1982, provided essential services in health, education and agriculture inside Afghanistan. These were known as cross-border programs. At the same time, UN agencies, delivered cross-line assistance into mujahideen-held from their offices in Kabul.
In July 1990 UNHCR started an assisted repatriation program in Pakistan, later extended to Iran. By the end of 1996 total repatriation reached 3.84 million. Many returnees were assisted by Quick Impact Projects. Designed to encourage repatriation and facilitate refugees when they returned, the QIP provided assistance for a limited period to support improvements in shelter, health and sanitation, and education, repaired roads and irrigation systems, and offered skills training related to income generation. Many Afghan NGOs also seek to support the sustainable return of refugees and IDPs by strengthening livelihood security, improving economic opportunities, providing basic social safety nets and restoring the environment.
Following Taliban takeovers of Jalalabad and Kabul in September 1996, the flow of returnees decreased dramatically - on some days none crossed the border - while the number of families crossing into Pakistan once again rose, despite the fact that they were officially discouraged from entering and that only minimum emergency assistance was available.
The background and origins of the refugees has changed over the years. The first to come in 1978 were members of the extended Afghan royal family, their associates, and political allies. Almost all resettled in third countries. By the mid-1980s, most refugees in Pakistan were rural, nonliterate pastoralists and farmers. The refugees who fled from Kabul in the 1990s included educated urban bureaucrats, uneducated laborers and high profile officials. Most of the latter were immediately given asylum in third countries. By 1996 the majority of arrivals were highly urbanized, skilled professionals and technocrats. In Pakistan they sit idle, representing a tragic waste of scarce human resources at the very moment in the nation's history when their skills are so desperately needed for reconstruction.
In the early years most refugees, with the exception of those from urban areas who chose to live in cities, lived in tented villages in the North West Frontier Province (NWFP), in Baluchistan Province, and in southwest Punjab. Over the years many of these villages became permanent settlements, with mud-brick dwellings and walled compounds replicating the rural villages inside Afghanistan. Pakistan government policies concerning refugees has all along been most liberal. No barbed-wire fences confine camps, and refugees are free to move anywhere to seek employment. Additionally, management of supplies and services provided by the Pakistan government, UNHCR and numbers of NGOs was exemplary. Remarkably, there were no epidemics, little malnutrition because of delayed or insufficient food, and no major outbreaks of violence between refugee and local populations.
Social life for most refugees in Pakistan retained many elements of life in Afghanistan, although settlement patterns in an alien environment with indiscriminate mixings of family, geographic, ethnic, sectarian and social groups strengthened inherent social and religious conservatism. Family bonds were strengthened, but the outward semblance of solidity masked an existence that was tenuous and subject to severe tensions, many of which marginalized traditional female roles and curtailed their freedom. Aggressive campaigns by mujahideen parties whose representatives largely controlled the refugee camps kept women from seeking employment and training opportunities. Many of these problems gradually disappeared in 1992 once the mujahideen took over the reins of government in Kabul.
On the other hand, although still physically restricted, women have widened their horizons and heightened their expectations, especially with regard to better health and education. Many women are thus reluctant to repatriate, citing an unwillingness once again to undergo the traumas of displacement, the inability of the authorities to provide even minimal services to which they have become accustomed, and the absence of guaranteed economic security. A million or more refugees remain in Pakistan, therefore, and the prospects for total repatriation are less than bright.