In humanitarian terms, the front line in Afghanistan is the Yellow Desert, where thousands of refugees live in flimsy tents in a barren, cold, inhospitable landscape. Illness is rife and the only hope of staying well for many is treatment provided by the charity Médecins sans Frontières. Jonathan Steele reports
Tuesday December 23, 2003
A few miles to the west of Kandahar, the former capital of the Taliban, up to 40,000 people are living in a minefield. Even without the danger of losing lives or limbs if they stray beyond the confines of the small area cleared by the UN refugee agency, this camp's inhabitants face some of the grimmest conditions in the world.
Their home is known as Zhare Dasht, or Yellow Desert, and at this time of year, the bitter wind blows blasts of cold air as well as sand into people's faces and their flimsy tents. At night the temperature drops below zero.
Earlier waves of Afghan refugees moved to Pakistan and Iran, where they gradually built mud-brick homes instead of tents or moved to cities in search of work. The people of Zhare Dasht are a new wave of victims. Some were put to flight in 2001 by a third summer of drought which left their crops parched and forced them to sell their sheep, but most because of the US bombing campaign or its aftermath.
Thousands of Pashtun, who lived in northern Afghanistan where they were a minority, were harassed or even killed in the turmoil that followed the fall of the Taliban. The survivors fled. Changing its previous policy of accepting refugees, Pakistan only allowed a limited number across the border, and a huge mass of displaced people was left in no man's land until the UN urged them to move to Zhare Dasht.
In this bleak wilderness, illness is rife and every day dozens of patients used to wait their turn outside the clinics run by the only medical agency working there, Médecins sans Frontières (MSF). Not any more. Attacks on aid workers across southern and eastern Afghanistan led MSF to take the hard decision to suspend operations in Zhare Dasht earlier this month. "We used to have eight to 10 vehicles taking staff to and from Kandahar every day. The camp is still safe but the roads have become too dangerous. Twelve Afghan and foreign aid workers have been killed in the region this year, and 10 were attacked while travelling", says Vickie Hawkins, MSF's project coordinator in Kandahar.
It would be easy, and perhaps comforting, to fall back on a stereotype of Afghanistan as an endemically lawless place where banditry and tribal conflict have always made travel hazardous. The facts do not bear that out.
MSF has been working in Afghanistan for 20 years, often straddling the shifting front lines of civil war, in support of its policy of helping the sick impartially, whatever regime they live under. "But we've never previously experienced such a degree of targeting. Under the Taliban - and before them, the mojahedin - we could work normally. There was a recognition of the neutrality of aid workers. What's happening now is new," Hawkins says. Reasons for the change can only be guessed at, since no one is sure who the attackers are or why they have started to pick on soft targets such as humanitarian workers. The Americans tend to point the finger at Taliban supporters who, they say, want to create chaos in the hope of exploiting it to return to power. They also accuse other Pashtun fundamentalists such as the former mojahedin prime minister, Gulbuddin Hekmatyar.
But the attackers could be non-political criminals linked to drug producers or to local warlords struggling for control of turf. Whatever the truth, one demonstrably new ingredient in southern and eastern Afghanistan is the presence of a large foreign occupation force, around 11,000 US troops who are hunting for al-Qaida sympathisers. Designed to bring stability, they appear, to be doing the opposite.
Even without crass blunders such as the killing of 15 children in two recent US bombing raids, the sight of US troops angers some Afghans. They may identify UN and non-governmental humanitarian workers as aiding and abetting the intruders, as some Iraqis do.
MSF has always been fiercely independent and although it accepts financing from governments it does not take it for projects in countries where that particular donor has influence, whether it is a former French colony in Africa, or a US-dominated area like Iraq and Afghanistan. Some NGOs responded to the new threats by asking Nato, which is currently in charge of the 5,000 international peacekeepers in Kabul (separate from the 11,000 US troops hunting al-Qaida), to deploy troops in the south. MSF firmly resists that. Afghanistan is a tale of two countries. The non-Pashtun north and west are relatively safe, and although it has pulled out of Zhare Dasht and another southern project in Ghazni where it was working in the town's hospital, MSF still runs 17 projects in several Afghan provinces.
With 99 international volunteers, Afghanistan is one of MSF's biggest "destinations". The organisation sends about 2,500 expatriates abroad every year, usually on six- or nine-month contracts. This is not just another example of the north intervening in the south. The volunteers represent about 45 nationalities, many of them from developing countries themselves.
Not all are doctors or nurses. Every project has at least one logistician to handle transport, communications, and supplies as well as a "coordinator" who functions as team leader. Psychic rewards are what count, and "pay" is only a tiny fraction of what the UN agencies give their staff. The MSF UK office, which sends an average of 170 volunteers abroad every year, provides them with around £400 a month. The newly opened MSF station in the Afghan provincial town of Sar-i-Pul in the northern foothills of the Hindu Kush is typical. On one side of the unpaved and dusty road is the office compound, on the other hand the guesthouse, a four-roomed bungalow with an outside loo and two indoor showers heated by woodstoves.
Dr Inga Sandqvist, on a six-month contract from Sweden, lives here with a Belgian logistician, a Kenyan coordinator and a Belgian nurse. On most days, two of them make the two-hour drive to even more remote villages, at Tibir and Gosfandi, which have small health clinics.
The buildings belong to the ministry of health, and were painted and furnished by other NGOs. MSF took on the responsbility for making them work. The aim is not to have foreign doctors practise medicine directly, but rather to use their skill and experience to help Afghan doctors and nurses to improve their own services. MSF provides drugs and the refrigerators to keep them cool, as well as other essential medical supplies.
The two primary health clinics opened this summer, serving a population of around 100,000. They are not hospitals. They perform no operations. But they provide a lifeline for ordinary Afghans, particularly the poorest and most vulnerable. Although Afghan doctors get nominal salaries from the ministry (currently £110 a month), the money is rarely paid, so doctors prefer to treat patients for a fee in their own surgeries, usually a single room in the bazaar.
MSF offers an "incentive" of an extra £50 a month to get doctors to see patients at the clinic at no charge for at least half a day. They are hoping to extend that to six or even eight hours a day. MSF also works hard to persuade doctors not to over-prescribe drugs. "People often feel they haven't been properly treated if they haven't had three or four different drugs. Doctors have a financial incentive because they may have their own pharmacy, or know the pharmacist next door. We try to cut it down," says Sandqvist.
Vaccination is a key element of the work in Tibir. Three times a week, a group of Afghan health educators mount rickety bicycles and set off from the clinic to any one of a score of villages. With small cool-boxes full of vaccine strapped behind their saddles, they pedal along narrow roads where donkeys and camels provide the commonest form of transport.
Arriving at today's chosen village, one of the vaccinators climbs a ladder to the roof of a mosque. Through a loud-hailer he invites people to bring their babies for injection. His colleague lays a carpet on the ground under a tree and takes out papers to prepare to register the children.
Coming for injections seems to require little propaganda. Their value is well understood and a crowd soon develops in the yard of the mosque. But a large section of the population is strangely absent. Although the Taliban have gone, ancient taboos about women's dress and their right to appear in public are still powerful throughout Afghanistan. Rural Afghan women rarely leave the home. So usually it is older siblings or young fathers who bring the babies. Clumsily fumbling to find the buttons or laces of babies' cardigans and shawls, the men reveal that childcare is not one of their regular chores.
In the clinics the same problems arise. Male doctors are restricted in examining female patients. In extreme cases women decline to remove the all-encompassing burka from their faces, making it impossible to look into their throats, eyes, or ears. Even women who are prepared to lift the veil usually draw the line at having stethoscopes applied to their stomachs. Gynaecological examinations are completely rejected. So male doctors have to work entirely on the basis of the woman's statement of her symptoms.
Nevertheless, women come eagerly to the clinic. Attendance figures for Tibir show that visits by women outnumber men by almost two to one. The commonest complaint, according to the register, is peptic disorders followed by pneumonia, coughs and diarrhoea. Looking for medical help is one of the only legitimate reasons for women to leave the home. As a result many female patients' primary aim is to get tea, sympathy and some companionship in the segregated waiting room. Traditional customs die hard, and although Afghan women have been fighting bravely at the constitutional convention currently under way in Kabul to get their demands for equal rights heard, it is in the countryside that the biggest struggle is needed. The battle long preceded the US military intervention and will last after it has ended. MSF is on the real front line. It has shown it has the staying power, and it is getting results.
What your money buys
£17 cholera treatment for one person
£76 medical kit for 50 minor dressings
£79 village midwifery kit
£173 basic health kit for 1,000 people for 3 months
£63 treatment for tuberculosis for one patient 6 months
£1,450 shelter kit for 100 families
· Tomorrow in the broadsheet, Rory Carroll reports from Congo on the work of MSF.