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Roll on July 12th
Posted by Brian Jones
1 July 2002 – I am working on a new report for the Refugee Nutrition Information System (RNIS). The reports cover a variety of emergency contexts (mostly complex emergencies) in sub Saharan Africa but with a component on the current crisis in Afghanistan (see below). The report should be finished by the 12th of July and I leave my current position as coordinator of the RNIS at the end of July for a month's holiday before going back to the field once again with Oxfam.
With time so short I am getting a little anxious and have a suspicion that there could be some long nights ahead before this next report is off my desk and away to the printers. For futher information on the RNIS
The already existing crisis in Afghanistan was further compounded by fears of retaliatory action by US led forces following the terrorist attacks in the United States on 11 September 2001. This resulted in huge movements of population both within the country and to neighbouring countries, in addition to the withdrawal of all foreign humanitarian staff, greatly complicating the delivery of much needed assistance. The ensuing American led military campaign began on 7 October 2001, targeting both the Taliban authority and the Al Qaeda network. Given the scale of emergency prior to the military campaign there has been considerable concern over the fate of nearly nine million Afghans, including over one million internally displaced, all deemed to be acutely food insecure and in dire need of lifesaving humanitarian assistance (UN 01/02).
The humanitarian situation
The drought crisis of the past three years has further added to the severity of the situation, with current estimates foreseeing a further 12-18 months of drought (Feinstein 02/02). This has profound implications for the food and livelihood security of the population and is likely to mean that many will remain dependent on external assistance to meet their basic subsistence needs. The most drought-affected areas remain the rain fed areas of the north and central regions but all parts of the country are affected. It is estimated that the drought has resulted in a 50 % drop in staple grain production (UN 01/02). The drought continues to have a profound impact on the health situation in the country as people rely increasingly on contaminated water sources. It is important to note that the summer period is normally associated with an increase in diarrhoeal disease and the potential for epidemic outbreaks is high. This could have serious implications for the health and nutritional status of the population.
The security situation has improved considerably as the main thrust of the coalition led military campaign is drawing to a close, ending months of acute nationwide insecurity. This is facilitating access to areas which have been previously inaccessible, however insecurity still remains and continues to pose problems of access for humanitarian agencies. One cause of continued insecurity is factional fighting between various armed groups, particularly around the cities of Gardez, Khost, Kunduz and Mazar-e-Sharif. Fighting has also been reported in the northwest and in the Kandahar area (USAID 29/03/02). This has prevented access for assessment missions to the areas and the implementation of humanitarian programmes. The continued insecurity is also restricting the return of both IDPs and refugees to their areas of origin. In Eastern Afghanistan, UNHCR has recommended that up to 18,000 Afghan refugees halt returns as a result of violence along the road from Torkham to Jalalabad (UNHCR 09/04/02). The continued insecurity has also been sited as a direct reason for the continued large numbers of people seeking refuge in Pakistan.
The insecurity has also led to the looting of aid and the targeting of aid workers. WFP have reported incidences of their trucks being looted and armed men have also been reported to be disrupting food distributions in Maslakh camp near Hirat (WFP 23/11/01; MSF 06/02/02). There have also been concerning incidences of aid workers being targeted directly. In February, a UNICEF employee was shot in the northern city of Mazar-e-Sharif whilst, in a separate incident, another employee in the same area was abducted (IRIN 18/02/02). The general security situation continues to be of great concern to the international community but it is anticipated that the establishment of the Interim Government will lead to a centralised and stable political structure, which will facilitate greater security and begin the task of rebuilding the country.
The drought and the continued insecurity continue to affect large sectors of the population, with current estimates suggesting that up to 9 million people remain acutely vulnerable within the country (UN 01/02), including 920,000 (420,000 in the south and 500,000 in the north) internally displaced (USAID 19/04/02). The majority have moved from rural areas, particularly in the north, to urban centres in search of some form of employment and relief assistance. The current situation is characterised by very large movements of population both within the country and to areas outside as people either return to their areas of origin or flee further insecurity and drought. It is difficult to know how many have fled externally, but UNHCR reports that a further 250,000 entered Pakistan since the September attacks on the US (UNHCR 19/02/02). In 2002 agencies are preparing for the return of 1.2 million people from surrounding areas, with a total of 320,000 having returned to date (UNHCR 23/04/02).
Some of the main coping mechanisms have been the borrowing of money on future harvests and the taxing of kinship social networks, which have traditionally ensured the redistribution of resources. There is also evidence of people turning to illicit income generating activities such as opium production. The general impoverishment of the population as a whole has meant that both debt and kinship networks are less and less accessible, particularly to those already heavily indebted. As a result, people have increasingly been forced to turn to non-sustainable crisis coping strategies. Some of these strategies include the reduction of dietary intake, skipping meals, eating “poverty foods”, forgoing medical treatment, and sacrificing hygiene practices. As the crisis has unfolded many have turned to selling their productive assets such as their land, remaining animals and their houses (Feinstein 02/02). This is an extreme survival strategy because, although aiding immediate survival, it leaves people without the means to sustain their livelihoods in the future.
The immediate food crisis is likely to continue for some months. The period from April to July is traditionally seen as a hunger season as it precedes the July harvest and reliance on emergency food aid will be high (WFP 15/02/02). Furthermore, the harvest is expected to be poor due to drought and to the lack of access to land and crucial agricultural inputs such as seed and fertiliser. The period of most intense military action and large-scale population movement in October and November coincided with the last planting and land preparation period (RNIS #35). Whilst so much of the population remains critically impoverished there is likely to be poor accessibility to what food is available and the presence of emergency food distributions will be very important until people are able to rebuild livelihoods. The presence of insecurity is also likely to be a considerable constraint to food security. Insecurity is expected to prevent humanitarian agencies accessing some vulnerable population groups and may discourage the return of people to their land.
The current situation does not appear to have resulted in greatly increased levels of acute malnutrition although some pockets of nutritional decline do exist. As an indicator of the current situation the use of anthropometry on the under five population has been called into question, particularly as mortality rates do appear to be high and are possibly masking declining nutritional status. Several surveys and assessments have also highlighted high levels of maternal malnutrition, possibly as a result of mothers preferentially feeding their children to the detriment of their own nutritional status. Worryingly, there is increasing evidence of micronutrient malnutrition and there have already been reports of an outbreak of scurvy (vitamin C deficiency) in Ghor province in northern Afghanistan (WHO 16/04/02). This is particularly concerning as the outbreak would suggest a far wider problem of micronutrient deficiency in the area, which will have an effect on levels of both morbidity and mortality. The poor food security, the widespread water shortages and extremely poor health environment all combine to make the marginal nutritional status extremely alarming. It is likely that without considerable outside assistance, the nutritional status of large sections of the vulnerable population will continue to decline.
Vulnerable population groups
1 April 2002 saw the beginning of a new nine-month, 285 million US dollar operation for WFP, which will continue until the end of December 2002. The operation is designed to address the needs of 8.8 million people in Afghanistan. This is an increase of 2 million people from the previous six-month programme that began in October 2001 and reflects the increased needs during the “hunger season” until July 2002. The programme will address the immediate emergency food needs of the population but will also start to shift the emphasis of interventions from relief towards recovery. It is estimated that food requirements until the end of the year will be 544,000 MT (WFP 05/02/02). It is concerning to note that the overall cash and commodity resources remain far below the immediate requirements. WFP have announced that the appeal requires immediate funding in order to avoid a major food shortfall in June (WFP 19/04/02).
An important element of the food and nutrition response has been the establishment of a nutritional surveillance programme involving many agencies, with UNICEF taking a lead role. The aim of the surveillance is to monitor nutritional status, food security and other important indicators in order to identify and explain any deteriorating trends (SCNS 01/02). Work has already begun by UNICEF through CDC (UNICEF/CDC 03/02). Another important element has been the use of helicopters by WFP for the purpose of conducting Emergency Food Needs Assessments. Many assessment missions have taken place in the north and west of the country, allowing WFP to investigate particularly inaccessible areas and assess the true needs of vulnerable populations (WFP 07/02/02). This has greatly improved the capacity to identify pockets of acute needs requiring immediate humanitarian intervention.
WFP have undoubtedly done an amazing job of getting very large amounts of food aid into the country. However, an important issue surrounding the emergency food assistance is the apparent inadequacy of the current food ration in terms of both quantity and quality (UNICEF 05/02/02). The basic food ration consists of 50 Kg of wheat flour supplied per family, assumed to be made up of five people, to last for one month. Current international guidelines stress that the food ration for populations dependent on food aid should be 2100 Kcal with an extra 100 Kcals added for every 5 degree drop in temperature below 20 degrees centigrade (UNHCR/WFP). This would require a ration of at least 2500 Kcal for the Afghan population, particularly during the freezing temperatures of the winter period. The food ration should also supply a diet that is balanced in terms of both the major macro and micronutrients. An examination of the current ration indicates that it provides a total of 920 Kcal per person per day and does not meet the required daily intake of fat, proteins or micronutrients. This is extremely concerning given the current state of acute food insecurity and the extremely high dependence of many Afghans on emergency food assistance. The lack of fortified foods is also concerning given the increasing evidence of micronutrient deficiencies.
Another cause for concern has been the mixing of the military and humanitarian relief. In a letter to the US government, a coalition of U.S humanitarian agencies expressed their concern that the distinction between military and civilian humanitarian agencies was becoming increasingly blurred. Considerable concern was expressed over the US military’s use of army personnel dressed in civilian clothes to provide relief services (USAID 05/04/02). It is felt that this compromises basic humanitarian principles of neutrality and transparency and could compromise future humanitarian relief work.
The resumption of humanitarian activities in the city has resulted in continued food distributions to the population but the number of vulnerable groups remains high. UNHCR estimate that 64,750 IDPs and 41,900 refugees have returned to the city, whist a further 31,360 IDPs have left the capital (WFP 05/04/02). WFP has also restarted the women’s bakery programme, which provides subsidised bread to poor female-headed households. In general, the humanitarian situation has improved, however many groups in the city remain impoverished and find it very difficult to access food sources. As a result, food aid has been an essential source of food for large sectors of the city’s population. Reports indicate that people are heavily indebted and have resorted to selling essential household items to raise sufficient cash to purchase food and water. However, there is some evidence to suggest that the rates of distress sales are falling (Feinstein 02/02). Underemployment and high prices have continued to make life difficult for many impoverished groups.
For years, members of the civil service in Kabul have not received payment, leaving them extremely vulnerable as their livelihood options are greatly reduced in comparison to other groups. On 19 February 2002, WFP signed a letter of agreement with the Interim Authority to supply a monthly ration of 12.5 Kg of pulses and one can of cooking oil for 60,000 civil service employees. The rations are worth about 50 % of their cash salaries. WFP expect to extend this to other provinces where it is hoped that it will help foster stability in government structures (UN OCHA 21/02/02).
The massive destruction that the city has suffered over years of conflict has left many areas of the city in ruins with very little working infrastructure. This has important implications for the population of IDPs and residents alike. It is estimated that only 20 % of the city have access to clean water and 70 % are without regular access to water (UN OCHA 11/02/02). The poor water security and lack of adequate sanitation does raise the fear of disease outbreaks, particularly as there is normally a seasonal increase in diarrhoea during the summer months (RNIS 32/33 and 34).
The humanitarian situation is exacerbated by the continuation of insecurity in some areas between various groups. Typically this fighting has been between ethnic Uzbek and Tajik forces (AFP 17/02/02) and the relative ethnic diversity of the northern region makes the continuation of sporadic insecurity likely (Feinstein 02/02). This continues to have implications for issues of access to vulnerable groups by humanitarian agencies. The area also has a history of natural disaster. On 25 March 2002 and 12 April 2002 there were major earthquakes that caused wide spread destruction of property and loss of life (AFP 12/04/02; IRIN 29/03/02). A massive earthquake affected the same area in 1998, resulting in the death of between 10-14,000 people. This illustrates the vulnerability of the population in the north to all forms of external shock, including natural disaster.
IDPs in Mazar-I-Sharif
Faryab and Sar-e-Pol Provinces
Rapid nutrition assessments indicate that the nutrition situation is extremely poor in all areas and, although the assessment methods are not comparable with the previous MSF nutrition survey in August 2001 (RNIS 35), the assessment concluded that the nutrition situation appeared to have deteriorated. It is also worrying to note that the assessment also found indications that scurvy (vitamin C deficiency) was on the increase. This reinforces the observation that the diet is of extremely low quality and is worrying because it probably indicates a high prevalence of sub clinical deficiency, which is associated with increased morbidity and mortality. Assessments of both Crude and Under-Five mortality indicated that rates were significantly raised above emergency thresholds, again indicating the severity of the situation (MSF/Epicentre 01/02). The overall situation in the area is extremely concerning and further nutritional decline is to be expected unless additional external assistance can be provided.
North Eastern Afghanistan
Concern also conducted an assessment in Rustac region of Takhar province, which was the epicentre of the 1998 earthquake. The assessment revealed a very poor nutritional situation with the nutritional status of mothers being of particular concern. Very few of the households were female-headed, but the area had not fully recovered from the devastating earthquake in 1998 and the environment appeared to be extremely hostile with little visible signs of agriculture. The nutrition situation is a result of poor food security and lack of opportunities for obtaining cash income. The assessment also noted that many IDPs had started to return to the area and were being supported by the local populations. This proved a further drain on existing resources (Concern 12/01).
Merlin undertook a follow up assessment in Khost wa Fereng in February 2002 and it was noted that no food distribution had taken place since mid November 2001. The assessment also indicated that the nutrition situation was extremely poor with particularly high prevalences of acute malnutrition amongst mothers. Crude and under-five mortality were also measured and were above emergency thresholds (Merlin 02/02). Although the two assessments used differing methodologies, it appears as if the nutrition situation had deteriorated in the intervening months. The reason for the continued decline was attributed to the lack of both availability and access to food sources. This is a result of drought, conflict and inaccessibility of the area. The lack of general food distribution is a concern. There was also a high burden of infectious disease with no access to medical services. It is concerning to note that mortality rates appear to be high and the population must be considered to be acutely vulnerable to further nutritional decline.
The IDP camp of Maslakh, some 20 Km outside of Hirat city, is the largest IDP camp in Afghanistan and was originally established by the ICRC in the winter of 2000. The International Organisation for Migration (IOM) has since taken on coordination of camp activities. The camp has received large amounts of relief assistance, with the WFP delivering 90 Mt of food aid a day to the camp. This was to fulfil the needs of an estimated population of 300,000 people. However, concern over the validity of the population figures prompted a re-registration of camp inhabitants in February 2002. The re-registration exercise indicated that the actual population figures amounted to less than half of the original number (IRIN 18/02/02). The readjustment of the population figures highlighted abuses of the registration and distribution system and the need for much closer monitoring of distributions. An MSF MUAC survey conducted in January 2001 found alarmingly high levels of acute malnutrition amongst the under-five population with a prevalence of acute malnutrition estimated at 26.4% (MUAC <124 mm) with 6.6% severe (MUAC <108 mm) (MSF-H 26/01/02). Despite the use of MUAC, the results indicated an extremely severe situation, although it was noted that weekly surveillance of the nutrition situation did not indicate such high levels and mortality in the camp remained low. The explanation for the high levels found in the survey was unequal access to food as a result of high levels of crime, corruption and ethnic tensions inside the camp. As a result, much of the food aid was not reaching those most urgently in need (MSF 06/02/02). This would seem to be corroborated by the results of the re-registration, which indicates that more than twice the amount of food needed was delivered to the camp.
The most recent developments at the camp have been the return of many of the IDPs to their places of origin. This has been facilitated by the supply of return kits to returning families. As of 14 April 2002, the IOM have reported that 20,800 IDPs have chosen to return to their places of origin (WFP 19/04/02). This represents a policy to prevent further distress migration to centres like Hirat and an attempt to support people in their own places of origin.
MSF conducted a further nutritional assessment in Shaidai IDP camp near Hirat. The camp is much smaller than Maslakh and relatively well served for health, sanitation and food. The survey was exhaustive and indicated a prevalence of acute malnutrition of 3.9% (MUAC< 125 mm) including 0.7% severe (MUAC < 110 mm). The results do not indicate a serious situation and morbidity and mortality statistics also reveal that the camp is stable in terms of both health and nutritional status (MSF 07/02/02).
UNICEF and the Centre of Disease Control (CDC) recently conducted a nutrition survey in Badghis province to establish baseline data on malnutrition in women and children. The survey found an estimated prevalence of acute malnutrition (W/Ht < -2 Z scores and/or oedema) of 6.5% including 2% of severe malnutrition (W/Ht <-3 Z scores and/or oedema). Chronic malnutrition was also measured and the prevalence was found to be 57.5% (Ht/age <-2 Z scores) including 30.9% of severe chronic malnutrition (Ht/age <-3 Z scores). It is notable that a greater proportion of the children had severe chronic malnutrition than moderate (UNICEF/CDC 03/02). The results indicate that acute malnutrition is not an overwhelming public health problem in the area. However, the prevalence should be interpreted within the wider food security and public health context. The general food security situation in the area is known to be extremely insecure and the survey also showed that only 5.2% of households are using safe water sources. This is very probably a contributing factor to the high proportion of children reporting to have had a diarrhoeal disease in the two weeks prior to the survey. It was also noted that acute respiratory infections were common. Very few children with illnesses had been taken to health facilities and the coverage of childhood vaccination was very poor. Children were also assessed for micronutrient deficiencies and the signs and symptoms of vitamin A and vitamin D deficiencies were common. Other possible deficiencies were also noted but are difficult to confirm without biochemical testing. It was also observed that whilst breast-feeding practices were generally good, the introduction of complimentary foods was not well conducted, possibly explaining the relatively higher proportion of malnutrition in the 12-23 month age group.
Anthropometric measurements were also conducted on women of reproductive age but prevalences of acute malnutrition were not found to be greatly elevated. However, it was noted that there was a high prevalence of goitre (11.5%), indicative of iodine deficiency. This is related to the very low consumption of iodised salt and is worrying because it is associated to an increased incidence of cretinism. Crude mortality (CMR) was estimated and found to be 0.72/10,000/day and under-five mortality was 2.51/10,000/day. The CMR is not above emergency thresholds but is slightly elevated and the under-five mortality is above emergency thresholds, but not to the degree that it could account for the relatively low estimated acute malnutrition amongst children. In conclusion, the nutrition situation of the population is extremely marginal and the high rates of chronic malnutrition indicate that this has been the case for some time. The population should be considered to be extremely vulnerable.
Mekaki and Mile 46 camps, Nimruz Province
Afghan Refugees in Pakistan
The RNIS does not have any recent nutritional data from newly established camps, however PDH, UNICEF, UNHCR and Mercy Corps International conducted a nutritional survey in the long-term camps in Balochistan province in December 2001 (UNHCR 12/01). The camps have existed for some years but there has been a significant influx of new refugees since September 2001, fleeing the insecurity and drought. A previous nutrition survey in 1997 had revealed a low prevalence of acute malnutrition. However, it was felt that there was a risk of nutritional decline as a result of the extra burden on existing systems posed by newly arriving refugees. General food rations had been stopped 6 years previously. The survey revealed low levels of acute malnutrition, probably as a result of the well-established camp systems where many can be regarded as settlements. As a result, livelihood activities are well established and ongoing.
Although refugees are still trying to enter the country, there has also been a considerable repatriation movement back to Afghanistan. On 1 March 2002, a voluntary repatriation programme was established to facilitate returns and it is currently estimated that 370,000 people have repatriated to Afghanistan since 1 March 2002 (1992?) (UNHCR 30/04/02). The main factors governing the decision to repatriate are security and continued drought. There has been some concern that people will not be able so survive in some areas without considerable assistance and so UNHCR is providing a return kit which includes $100 per family, 150 Kg of wheat to last for three months and some essential non food items. Poor security, particularly in eastern areas, has hampered the return of some refugees
Afghan Refugees in the Islamic Republic of Iran
Afghan Refugees in Tajikistan
In general the prevalence of acute malnutrition is not greatly elevated, although there is some evidence to suggest that there are higher prevalences amongst adult women. It is important to question whether surveys, by concentrating on the under-five population, are concentrating on the wrong population group and that acute malnutrition is going unrecorded. It is also important to note that rates of crude and under-five mortality appear to be elevated and, in many instances, above emergency thresholds. This could be a mechanism for skewing observed prevalences of acute malnutrition.
The food ration being supplied to many people is insufficient, a reason for great concern given the degree of food insecurity. The recorded outbreak of scurvy and other micronutrient deficiencies is a strong indication of how fragile the nutritional status of parts of the population is. Finally, it is clear that many people have resorted to crisis coping and that their current survival has taken place at the expense of their productive assets and livelihoods, where the ability to cope has turned into the ability to survive.
From the UNICEF/CDC survey in Badghis province 03/02
From the Feinstein food security report 02/02
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