HEALTH

Before the war, the health situation in Afghanistan was among the worst in the world primarily because the health infrastructure was grossly inadequate and mostly limited to urban centers. Protracted conflict since 1978 worsened the inequitable distribution of health manpower and services. The estimated infant mortality rate was 163 per 1000 live births (1993); the under five mortality rate 257 for every 1000 live births (1994); the maternal mortality rate 1700 per 100,000 live births (1993); and life expectancy at birth was 43.7.

Since infant and under five mortality rates are frequently used as reliable overall indicators of community health and development, these figures underscore the appalling state of the health sector in Afghanistan. Most children die of a variety of infectious and parasitic diseases, including acute diarrhoea, respiratory infections, tuberculosis, diphtheria, poliomyelitis, malaria, measles and malnutrition, in addition to disorders allied to pregnancy and delivery.

The tragedy is that 80 to 85 percent of these diseases can be avoided by preventive measures and by the provision of proper health care, or cured at an affordable cost. However, currently there is only one health center to care for every population group of approximately 100,000. Only 12 percent of pregnant women have access to maternal and emergency obstetric care; only 38 percent of children under one year are fully immunized. These problems are compounded by the fact that fully three-quarters of the nations physicians have left the country resulting in a physician/patient ratio of over 95,000/1. Because of the inadequacy of the health delivery system, a majority of the population relies on indigenous healers such as traditional midwives, herbalists, bone setters and barbers who circumcise, let blood, pull teeth, and perform other curative procedures. Mullahs, sayyids and other specialists prepare curative and protective amulets.

The war and deteriorating economic, social, and physical conditions in both rural and most urban areas, have impaired housing and environmental sanitation facilities in general and added sinister dimensions. By the end of 1996, it was estimated that 1.5 million men women and children were physically disabled by war injuries, including amputation, blindness and paralysis, as well as debilitating infectious diseases, such as poliomyelitis and leprosy. Birth complications causing disabilities such as cerebral palsy and mental retardation also increased. Another 10 percent of the total population representing families and associates of the disabled are directly affected by these disabilities. They require information and instruction not only regarding physical care, but also in ways to integrate disabled persons into communities as respected and productive members.

Sadly, the number of disabled increases daily because of an estimated 10 million landmines and unexploded ordnance (UXO) that contaminate the landscape, the largest concentration in the world. A 1993 national survey revealed there were over 465 square kilometers of minefield, of which 113 square kilometers were high priority areas directly affecting residential areas, farm lands, grazing pastures and canals; subsequently further high priority areas totalling more than ninety square kilometers were identified; and, as refugees return, new minefields continue to be uncovered raising low priority areas to high priority. By the end of 1996 some 158.8 square kilometers were cleared and 300,000 mines destroyed. The UN Mine Clearance Programme in cooperation with eight NGOs, includes 50 demining teams and 10 mine dog groups, as well as male and female mine awareness teams, staffed by some 3,000 Afghans. Due to continuing hostilities, however, several de-mined areas have been re-mined. It will be many years before Afghanistan will be free of this menace.

Assistance to enhance the capacity and increase the accessibility of health services, emphasizes basic preventive and curative primary health services, with special attention to strengthening Mother Child Health and health man power development at all levels, including Traditional Birth Attendants and community health workers. Providing safe potable water sources and sanitation facilities is also a high priority since contaminated water sources are major causes of high morbidity and mortality. Upwards of 60 NGOs, in addition to the International Red Cross Committee and the International Federation of Red Cross and Red Crescent Societies, WHO and UNICEF have been active in the health sector over the years, assisting everything from regional, provincial and district hospitals to basic health clinics, as well as specialized services in physiotherapy, drug detoxification, TB and malaria control.

The Mass Immunization Campaigns launched by WHO and UNICEF, in partnership with the Ministry of Public Health, utilizing a cadre of more than 15,000 vaccinators, health workers and volunteers throughout the country, are singular successes accomplished with the active cooperation of all parties to the conflict. In 1995, 2.6 million were vaccinated against DPT and measles; in 1996 2.3 million children under five received oral polio vaccine; during 1997, the nation-wide goal is to reach approximately four million children under five, in addition to 60 percent of women of child bearing age. The ultimate aim is to totally eradicate the polio virus in Afghanistan.

As in the case with the education sector, however, the overall results are generally spotty. New and refurbished buildings intended to dispense medical care stand empty because of lack of personnel or equipment; some have been commandeered by political groups for offices. Of the thousands trained in various medical fields, few find employment. Databases list increasing numbers of "discontinued" projects and facilities. This is particularly disheartening because the lack of medical facilities is a major deterrent to refugee repatriation.