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

Afghanistan Region
For decades Afghanistan has suffered from the effects of environmental, political, social and economic hardships brought on by an interplay of conflict, destructive political processes and natural disaster. This has led to the breakdown of basic infrastructure such as health and education facilities, as well as transportation and trade networks, and has led increasingly to the impoverishment of large portions of the society. The situation has worsened over the past three years as a result of a wide scale drought widely acknowledged to be the worst in over thirty years. The drought has compounded the effects of years of insecurity and impoverishment, and has resulted in a very profound deterioration in the humanitarian situation within the country. The result for many has been the breakdown in “normal” patterns of coping and an increasing reliance on unsustainable crisis coping strategies. As a direct result, there has been an ever-increasing reliance on external assistance for many poor Afghans. One example of this has been the number of people displaced both within the country and externally to neighbouring areas. Afghanistan has the world’s largest refugee community with an estimated 3.6 million living in Iran, Pakistan and other neighbouring countries (UNHCR 02/10/01).

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).

Recent events
The situation has changed enormously over the past months since the beginning of the military campaign. The Taliban began to collapse in November 2001 with the key towns of Mazar-e-Sharif falling on 9 November2001, Kabul on 13 November 2001 and the southern Taliban stronghold of Kandahar on 7 December 2001 (USAID 19/04/02). International humanitarian agency staff began to return on 17 November 2001 (WFP 23/11/01) enabling the scale of the humanitarian operations to increase considerably. The political situation has further developed with the establishment of an Interim Afghan Administration at an important meeting in Bonn, Germany on 22 December 2001 (UNSC 31/01/02). The Bonn agreement also led to the establishment of an International Security Assistance Force (ISAF) to be stationed in Kabul. The ISAF reached its full operational capacity of 4,500 troops on 18 February 2002 and has been mandated to assist the Interim Authority in maintaining peace in Kabul and the surrounding areas (UNSC 15/03/02). The final stage in the development of a new Afghan government will be the convening of the Loya Jirga, or “grand council”, from 10-16 June 2002, where 1,450 representatives, two thirds of whom will be elected, will convene to vote in a Transitional Afghan Government (USAID 05/04/02).

The humanitarian situation
The humanitarian situation has changed considerably over the past months but remains extremely serious. The years of conflict and drought preceding the most recent crisis have resulted in the breakdown of coherent political structures, social networks and the economy. As a result, the country remains at the bottom of human development indicator tables and the ability of the population to cope with both old and new crises is considerably constrained. Basic infrastructure is almost non-existent in many areas with up to one third of the population having no access to primary health care and the remainder chronically under supplied. Afghanistan has the second highest maternal mortality rate in the world with an estimated 16,000 deaths per year due to pregnancy related causes. One quarter of Afghan children do not live to their fifth birthday and are dying from preventable causes such as respiratory infections, diarrhoea, measles and malnutrition (WHO 05/12/01). It is further estimated that only 23 % of the population have access to safe water and only 12 % to sanitation facilities?. Over 50 % of the existing 3000 Km of primary road network requires rebuilding, severely limiting transportation. Afghanistan remains the country most affected by mines and unexploded ordinance (UXO) (UN 01/02). It is estimated that over 800 Km2 of potentially productive land is currently inaccessible due to mines (UNDP 15/01/02).

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).

Food insecurity
The food security situation remains extremely precarious. The extremely poor humanitarian backdrop has resulted in a population that has been living in a “coping economy” where the aim has been to employ diverse livelihood strategies in order to avoid the possibility of living in a high risk environment (ILO 03/01). As the humanitarian situation has deteriorated with the continuation of the drought and increased insecurity, the ability to cope has been further eroded. The drought has had a huge impact on food security for the whole population as access to adequate water has become increasingly difficult. It has especially affected 85 % of the population estimated to be reliant on agriculture for their subsistence. This has made access to water a key element in food security with households having to make key choices between sufficient water for survival and water for their animals and crops (Feinstein 02/02). As a direct result, many people who were previously self-sufficient are being forced to rely on the market for food, fuel and income. However, as the availability of food has diminished, so too has the accessibility. This is primarily a result of the loss of income and the general erosion of livelihoods.

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
As a result of the severity of the situation many people remain vulnerable to acute food insecurity and nutritional status decline. An overview of WFP Rapid Emergency Food Needs Assessments (REFNAs) conducted in the north and west of the country indicate that all medium and poor families suffer from food insecurity, with the landless and female-headed households being the most vulnerable (WFP 04/02). Rain fed villages, where both food availability and access is at a minimum, are also acutely vulnerable and people in these areas remain almost totally reliant on food aid. IDPs and returning refugees are also vulnerable because many do not have access to land or other livelihood activities. The Kuchi nomads, many of whom have lost their livestock, which represents their main productive asset, are also acutely vulnerable. Female-headed households are also considered vulnerable because many do not have adult male household members to provide income and family support. They are particularly vulnerable because they are often unable to access kinship and social networks which offer an essential form of assistance. There is also growing evidence to suggest that vulnerabilities are also falling along political and ethnic lines with Pashtun groups in some northern areas suffering from harassment and persecution. This is seen in the large number of Pashtuns currently seeking to move to Pakistan, fleeing violence in the areas from which they have been living. The Taliban were predominantly Pashtun and it is thought that this represents a backlash against associated population groups (WFP 08/03/02; 04/02).

Humanitarian response
The humanitarian response to the current situation has been enormous. In response to continued needs, the UN has released its largest ever humanitarian aid appeal of 1.8 billion dollars for 2002 (IRIN 05/03/02) and has indicated that the requirements for the next five years are likely to be 10.2 billion dollars (UN 01/02). A crucial element of the emergency response has been the provision of food assistance and WFP has done an incredible job of both maintaining and increasing the food pipeline under very difficult security and climatic conditions. WFP have brought 407,643 MT of food into the country since October 2001, 326,230 MT of which have been distributed (USAID 19/04/02). This is particularly impressive given the constraints imposed by the harsh winter conditions that have effectively cut off areas, in addition to the continuing insecurity. This has been possible as a result of cooperation from surrounding areas that have allowed multiple routes into the country to be opened using trucks, rivers and planes.

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.

Central Afghanistan
The Central Highlands and, in particular, the Hazarajat area are considered to be particularly vulnerable to food insecurity. The traditional livelihood activities of the area have been the sale of livestock and labour, either locally or abroad. However, both of these activities have been curtailed by the drought and insecurity. The Hazara populations of central provinces, such as Bamyan, have traditionally suffered from economic, political and social oppression from the Taliban authorities and faced a series of blockades from 1996-98 (WFP 01/02). There was grave concern for the area over the winter months, as it remained physically inaccessible, with many villages lying in remote mountainous valleys. Winter temperatures are reported to have plunged to between –10 and -15ºC. Recent months have seen the return of some Hazara, but conditions still remain extremely poor with little food availability other than from humanitarian aid. Reports also indicate that up to 80 % of houses in the province have been destroyed (IRIN 18/02/02). The RNIS does not have any recent nutritional information for the area but the population is believed to remain extremely vulnerable to the effects of continued acute food insecurity and nutritional decline.

Kabul
As the capital of Afghanistan, Kabul has remained at the centre of humanitarian activity in the country. Humanitarian agencies evacuated in the days immediately after the September 11th bombings, making the continued provision of aid and control of programmes extremely difficult. Many residents fled in fear of US reprisals, with the city subsequently suffering extensive bomb damage during the US led bombing campaign. , Kabul was recaptured on 13 November 2001 and humanitarian staff returned on 17 November 2001 (WFP 23/11/01). The creation of the Interim Government and the ISAF has brought some stability to the area and laid the foundations for a secure administration. However, problems with security do still exist and there have been reports of plots against the Interim government and attacks against ISAF. The security fears have implications both within the city and for other areas of the country.

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).

Northern Afghanistan
The north is home to 30 % of the national population and has traditionally been the breadbasket of the country. The region is considered to be one of the areas worst affected by drought and conflict. The three-year drought has seen the wide scale failure of all rain fed agriculture and, as a result, decimated food production. It is estimated that production of the staple, wheat, has fallen by over 50 % since 1999. This has had very profound effects on food security in an area dependent on the sale of agricultural products as the chief source of income (WFP 01/02). As a result of acute food insecurity, many people have resorted to distress migration to find employment or food. Much of the displacement has been from rural areas to large towns such as Mazar-I-Shariff. It is estimated that there are 450,000 IDPs with a further 900,000 acutely vulnerable (UN 01/02).

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
SCF-UK conducted a rapid MUAC assessment in Arzana and Rhor Dhor camps in Mazar-I-Sharif in January 2002. The assessment indicated that the prevalence of acute malnutrition was not above emergency thresholds but that the general public health environment of the camps and lack of access to food made the population extremely vulnerable to nutritional decline. The camps had not received food assistance for several months although a registration exercise had recently taken place. The camp occupants were undertaking petty trading activities and begging in order to raise cash for food purchases and there were also reports of the collection of wild food plants for consumption. Manure, cotton branches and roots were being collected for fuel. A retrospective mortality assessment was undertaken and under-five mortality rates did not appear to have exceeded emergency thresholds. Needs in the camp appeared high but, whilst the population remains vulnerable, it is hoped that their proximity to Mazar–I-Sharif and various operational agencies will ensure that they receive important food and health assistance.

Faryab and Sar-e-Pol Provinces
MSF carried out a series of assessments in six areas of Faryab and Sar-e-Pol provinces in late 2001 and early 2002 (MSF/Epicentre 01/02). The assessments indicated an extremely serious situation where the majority of both the displaced and non-displaced had exhausted their coping mechanisms. An MSF nutrition survey in August 2001 had already indicated a poor nutritional situation with reports of extensive micronutrient deficiency (RNIS 35). A WFP food security assessment in August 2001 classified the areas as acutely food insecure, where the population was only able to cover between 0 and 50% of their annual food requirements. This highlights the nutritional vulnerability of the populations. This vulnerability has been exacerbated by insecurity, inaccessibility to these areas and harsh winter weather conditions. As a result, general food distributions have been irregular. The assessment indicated that the availability and access to food sources was extremely poor and that household food stocks were negligible. In an attempt to retain access to food sources many households have sold their livestock as well as household items, and girls were being sold for marriage at a much earlier age than is normal. As a last resort many families had turned to distress migration in search of food and employment. The population of Sar-e-Pol displaced camp grew from an estimated 15,000 in November 2001 to 23,000 in January 2002 (MSF 21/02/02).

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
The humanitarian situation in northeastern Afghanistan has been of concern for some time. It has been badly affected by drought, conflict and natural disaster and recent assessments indicate a very poor situation for IDPs, returnees and non-displaced local populations. The area is extremely inaccessible and there has been little humanitarian agency activity in many areas. Concern conducted an assessment in the provinces of Baghlan and Takhar in November 2001. The first assessment was in Khost wa Fereng in Baghlan province, where means of access is via a road that crosses a mountain pass at about 4,000 m. The population in the surrounding area is approximately 80,000 people and WFP’s VAM unit has estimated that 80 % of the population face a food deficit. The assessment highlighted the vulnerability in the area, where large proportions of those questioned had very small food stocks, little access to land or livestock and very poor economic opportunities. In response, many males had left the valley in search of work, leading to a high rate of female-headed households, which represents a considerable risk factor for both food insecurity and nutritional decline. The situation was further exacerbated by a lack of access to water and the risk of decreased supplies in the coming year. Health infrastructure was also extremely poor with only one clinic in the area, inaccessible to most due to distance. Illness was considered to be a problem with reports of diarrhoea, ARIs and malaria. An examination of nutritional status indicated that prevalences were not highly elevated in the under-five population but were worryingly high amongst mothers. It has been suggested that this is a result of preferential feeding of children by mothers. This may partially explain the relatively low levels of acute malnutrition amongst children under five, however it has also been suggested that high infant and under-five mortality rates may be masking the extent of acute malnutrition (Concern 12/01).

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.

Western Afghanistan
The situation in Western Afghanistan remains extremely grave and has continued to suffer the effects of the devastating drought and insecurity. This has made it one of the worst affected areas of the country, with the most severely affected being the small scale farmers from drought affected rural areas in Ghor, Badghis and Hirat. The severity of the situation in many areas has resulted in the virtual depopulation of rural areas, with an estimated 400,000 displaced possibly living in and around the regional city of Hirat. As a result of the acute needs of the populations in Mazar-I-Sharif, the area has received much attention from humanitarian agencies. In January 2002, the WFP launched a major food distribution to the city, targeting 78 % of the population who received 50 Kg of wheat to last for one month (UN OCHA 08/01/01).

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).

Badghis
The situation in Badghis is extremely concerning and many people have left to find assistance in IDP camps such as Maslakh in Hirat. The area relies on rain fed agriculture and has suffered the failure of most food crops as a result of the drought. An exploratory mission by MSF in February 2002 confirmed that the humanitarian situation is extremely poor with the majority of people relying on donated wheat and the gathering of wild leaves to survive. Most people have also sold all valuable assets to procure food (MSF 12/02/02).

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.

Ghor
Ghor province has also suffered from drought and insecurity and many people are known to have left rural areas to go to cities such as Hirat in search of food and possible employment. In early March, reports were received of a possible outbreak of scurvy (vitamin C deficiency) and in response a WHO investigative team was dispatched to the area. Scurvy has been noted in Afghanistan before, with an outbreak occurring last year in Faryab province. The investigation concluded that an outbreak had occurred in the two districts visited and that a substantial number of people were affected, including a number of mortalities. Scurvy is indicative of an extremely poor diet devoid of fresh foods, particularly vegetables. This would appear to correspond to diet histories taken from amongst the affected communities, which indicate that people have been surviving over the winter months on a diet of bread and tea (WHO 16/04/02), and with observations of little food available in the market. The investigation noted that very few animals were present and that the only food available was from food distribution. It was also noted that up to a quarter of some of the villages had left the area for the camps in Hirat (WHO 16/04/02). The emergence of spring plants gives greater access to potential sources of vitamin C and a distribution of vitamin C tablets will be conducted this sentence doesn’t make sense. However, the emergence of overt clinical deficiency is a strong indication of the nutritional vulnerability of the group and, without improved access to food, sub clinical deficiencies are likely to remain high and are associated with increased morbidity and mortality.

Southern Afghanistan
The preceding months have seen a general improvement in the situation in the south of Afghanistan. Pockets of insecurity still exist but, in general, the security situation is better and the higher reliance on irrigated agriculture has meant that the area is less affected by the drought of the past three years. At the end of February 2002, UN OCHA announced that out of the 300,000 people that had fled from Kandahar, an estimated 98 % had returned. Food security remains a concern but aid agencies do have access to the area and food distributions are taking place (UN OCHA 21/02/02). The south of Kandahar province, close to the border with Pakistan, has high numbers of remaining IDPs in camps such as Spin Boldak and Killi Faizo. Many are Kuchi nomads or farmers from the provinces of Kandahar, Zabol and Nimruz who have collected in displaced camps, having exhausted their coping strategies in their places of origin. Many IDPs are waiting to cross into Pakistan in the hope that the situation will be better there and there is a fear amongst agencies that if the drought continues many will be unwilling to return home. It is currently estimated that 250,000 people remain displaced in the southern provinces (IRIN 14/03/02). The RNIS does not have any recent nutritional information for the area.

Mekaki and Mile 46 camps, Nimruz Province
ACF conducted nutrition surveys in the IDP camps of Mekaki and Mile 46, which lie close to the Iranian border, in January 2001. The camps were established when Iranian authorities refused to open the border to people fleeing the U.S led bombing campaign. The surrounding area of Nimruz has suffered from huge reductions in livestock and agricultural output as a result of the continued drought. This has also had implications for water availability for consumption and for hygiene. The camps are well served in terms of food distribution with a well-balanced general ration calculated to supply 2427 Kcal. There is also relatively good access to water and to health services. In Mekaki camp, the prevalence of acute malnutrition (W/Ht < -2 Z scores and/or oedema) was calculated from an exhaustive survey and found to be 4.7% including 0.6% severe (W/Ht – 3 Z scores and/or oedema). In Mile 46 camp, the prevalences were 4.9% acute and 0.7% severe acute. The prevalences do not indicate a nutritional problem and on 4 March 2002 the Iranian government announced plans to close the camps and begin repatriation in April 2002.

Eastern Afghanistan
The eastern region of the country remains food insecure and recent WFP assessments indicate that 46% of the population in Nangahar province will require food assistance for the next 3 months. In response, WFP is planning to use a range of food for asset creation (FOODAC) projects and general food distributions in Nangahar, Lagam and Kunar provinces (WFP 05/04/02). The area continues to receive a large number of returnees from Pakistan and other areas of the country. The large number of returns can potentially prove a problem for existing resources in the area but so far they are being assisted as they transit through towns such as Jalalabad, Assadabad and centres in Nangahar, Kunar and Lagman provinces. One of the major constraints for the returns has been the emergence of insecurity, with reports of UN staff being threatened and violence erupting along important transit roads. The tension has resulted in roadblocks and UNHCR has recommended that 18,000 potential Afghan returnees should delay their return (UNHCR 09/04/02). The RNIS has received no recent nutritional information from this area.

Afghan Refugees in Pakistan
The drought and years of civil war have resulted in many Afghans moving into Pakistan in search of security, food and employment. As a result, it is estimated that the total caseload of Afghan refugees in Pakistan is 2 million (USAID 26/04/02). The upsurge in insecurity saw a large rise in the number of people crossing the border and UNHCR has estimated that up to 250,000 Afghans entered Pakistan since September 2001 (UNHCR 12/02/02). A major issue for the humanitarian community has been where to accommodate the refugees. There has been considerable concern in Pakistan over an uncontrolled influx by Afghans into the country and as a result the border areas have remained very tightly shut, with the border crossing at Chaman being one of the only crossing points. The closures continue to affect potential refugees and there are frequently large numbers of people waiting on the Afghan side of the border for registration prior to entering the country. Despite the need to create new camps and provide for the influx of refugees, the humanitarian response has managed to address the needs of new refugees. Many of the new camps have been placed close to border areas and on 6 April 2002 there were 158,400 refugees residing in 9 camps in Balochistan. 41,000 refugees were reported as waiting to cross the border pending local authority approval (WFP 12/04/02).

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
Along with Pakistan, Iran has traditionally hosted the majority of Afghan refugees. There are currently estimated to be 1.5 million long-term refugees in the country. The Iranian government has taken a very strong stance on refugees over the past months. Afghan refugees have been stopped from officially crossing the border into Iran, with many staying in camps in Afghanistan situated close to border areas. This has facilitated the distribution of aid from Iran, as the refugees remain accessible close to border areas. With the change in government and improving security within Afghanistan, it has been hoped that many refugees will chose to return. UNHCR have estimated that 45,900 people have returned from Iran to Afghanistan since January 2002 (WFP 26/04/02). Some of these have been spontaneous repatriations but on 9 April 2002, a major effort to assist Afghan refugees to repatriate was started (IRIN 11/04/02). UNHCR report that 23,000 Afghans were repatriated in the first three weeks of the programme (UNHCR 30/04/02). The RNIS does not have any recent nutritional information from Afghan refugees in Iran but they are assumed to be vulnerable.

Afghan Refugees in Tajikistan
The overall humanitarian situation in Tajikistan is extremely poor as a result of the region wide drought. A recent nutrition survey by ACF indicates that the nutrition status of children under five years appears to be deteriorating when compared to similar surveys conducted in 1999 and 2000 (ACF 11/01). The RNIS will not cover the drought (this sentence doesn’t make sense) but it will have an effect on refugees in the country and the ability of already impoverished local populations to assist them. A voluntary repatriation of 10,000 refugees on the Tajik / Afghan border on island # 9 on the Pyanj river began on 8 April 2002. The refugees are receiving a return package of 100 Kg of wheat flour, hygienic items and plastic sheeting and assistance to return to their places of origin (UN OCHA 12/04/02). It is reported that aid to the area will cease and that any remaining refugees will be able to access aid from the Afghan side of the border. The RNIS does not have any recent nutritional information from this group.

Overall
There has been some improvement in the overall context of the Afghan emergency, particularly with the appointment of the Interim Authority and a general improvement in the countrywide security situation. However, it is clear that acute needs still exist and that an enormous proportion of the population will continue to require assistance to meet short term emergency needs and in the long term to restart livelihood activities. Insecurity does still exist in many areas as a result of fighting between factions and pockets of resistance to the Interim Authority and coalition led troops. The continuation of the three-year drought conditions will also have serious implications for the next 12-18 months. As a result of the insecurity and drought, acute food insecurity will continue in many parts of the country and displaced and non-displaced populations should be considered to be acutely vulnerable (Category I).

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.

Recommendations
From the RNIS
· Support the establishment of the national nutritional surveillance project.
· Improve the general food ration to include oil, beans and fortified blended foods.
· Support the regeneration of livelihoods by supporting agriculture and livestock and facilitate income generation.
· Standardise the collection of nutritional data through the adoption of common methodologies, indices and cut-offs.

From the UNICEF/CDC survey in Badghis province 03/02
· Regular supplies of food should be assured to acutely food insecure areas. One-off blanket distributions have little effect.
· Programmes should target both mothers and children.
· All wheat flour should be fortified with micronutrients.
· The iodine intake of women should be increased, possibly with the use of iodised oil.
· All edible oils should be fortified with retinal.

From the Feinstein food security report 02/02
· Agencies should prepare for at least one more year of emergency assistance to Afghanistan.
· Emergency water projects should be implemented to ensure the health and food security of poor and marginalised groups.
· Widespread cash for work programs are needed to ensure that people can access commercial food.
· There is a need for emergency livestock programmes that include health, water and fodder support.

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