Afghanistan has been in conflict for over two decades. Guerrilla warfare under a brutal Soviet occupation, civil war that quickly filled the vacuum after the Russian departure, and totalitarian rule of the victorious Taliban which now controls the vast majority of the country: the health of the Afghan people has been aggrieved by each of these stages of the country’s recent history.

Médecins Sans Fontières (MSF) has worked in Afghanistan since 1980, on all sides of the various front lines. Aid to women, men and children in hospitals, clinics and health posts throughout the country has taken many forms over the years, but has almost always been carried out in conditions of insecurity and quickly changing circumstances.

Maintaining an independent humanitarian presence

MSF is committed to carrying out an independent humanitarian mission in the face of pressure from both the Taliban government, which seeks to place broad restrictions on aid work in the country, and international organizations such as the UN, which has sought to be an umbrella contact between international NGOs and the Afghan government.

MSF is, above all, dedicated to maintaining its contact with the Afghan people. Of special concern are the problems experienced by Afghan women with regard to their access to health care: in the Taliban’s Islamic state, women are severely restricted in employment, movement outside of the home, and in where they can go to receive medical attention. For this reason, MSF seeks to give women access to both primary and specialized care.

The conflict intensifies

By mid-summer 2000, both civil war and drought were weighing heavily on the Afghan people. The conflict had intensified, with the Taliban (government) forces taking territory formerly held by the Northern Alliance, the group of opposition forces that has held part of northeastern Afghanistan for the last several years. When the fighting reached Taloquan, in Takhar province in the north, MSF was forced to evacuate its volunteers, who later rejoined the some of the many thousands of people fleeing the advancing front line. Mobile clinics were set up in the areas of Keshem and Dashti Qala to treat the displaced.

By the end of the summer MSF was also closely monitoring the effect of a drought on people in Faryab province, in the north, relying on a network of 19 clinics in five northern provinces to detect signs of cholera, a possible consequence of the drought. The drought is the worst to hit the country in 30 years. MSF works in three health clinics and two hospitals in the Panjshir Valley, long a stronghold of opposition forces.

The area is frequently touched by fighting (it was the object of a renewed government offensive in 1999), and is also home to many displaced people. Both the displaced and residents in this isolated region have limited access to health care. MSF provides primary care and responds to emergencies. In the province of Badakhshan, also held by the opposition, MSF works in the hospital in Faizabad and support

Work in Taliban-controlled areas

Kabul, the once-cosmopolitan Afghan capital, is often first hit by government restrictions that affect the well-being of the population and, often, MSF’s ability to provide health care. MSF teams were expelled from Kabul in July 1998. Work in the capital resumed in May 1999, in the poor areas of Dashte Barchi and slightly later in Khair Khana. Working in clinics in both areas maintains MSF’s contact with the city’s inhabitants.

MSF has a wide variety of programmes in government-controlled areas. In Ghazni, a city about 125 km southwest of Kabul, MSF supports the provincial hospital, works to fight tuberculosis and runs a nutrition programme. In Sarab and Garden Dewal, both in the Hazarajat region, clinics provide basic care.

In Oruzgan province, MSF concentrates on developing local capacity to manage infectious diseases and epidemics. In the western province of Herat, teams focus on primary care. A midwife visits several towns in the province, meeting with traditional birth attendants, health educators, and community health workers to try and improve care for women and children.

MSF works with local midwives to improve care of mothers, in an effort to reduce the high maternal mortality rate of 17 maternal deaths for every 1000 births. MSF also works in the pediatric ward of Herat hospital. At the Herat nursing school, MSF recently launched a project to train health workers in recognizing and managing mental health problems. Another programme focusing on primary health care for women and children has been underway in Badghis province since April 1999.

In addition to providing primary care, MSF has also been working on emergency preparedness in Kandahar province, and will be doing a tuberculosis assessment there as a basis for possible future intervention. MSF is running a network of primary healthcare clinics in the five provinces of Faryab, Balkh, Baghlan, Kunduz and Takhar to be able to respond to emergency situations.