- Email: [email protected]
Internally displaced people—refugees in their own country
HEALTH AND HUMAN RIGHTS
in Kashmir, Bangladesh, Indonesia, Kenya, and Somalia to reduce work, depriving many of much needed assistance. MSF in Somalia is still paying the price a decade later for the confusion between military and humanitarian objectives in Operation Restore Hope. Confusion was created again during the Kosovo crisis by the presence of NATO troops in the refugee camps; the camps were subsequently shelled by Yugoslav forces. When the bombing stops, and humanitarian agencies can move into Afghanistan, how will the warring parties tell them apart from humanitarian bombers? The military can provide help through, for example, logistical capabilities to respond to natural disasters, and peacekeeping operations to protect civilians. But every time a military party involved in a
conflict describes their actions as humanitarian, the definition of this word is eroded. The work of aid agencies can be increasingly frustrated, and civilians be less likely to be treated according to the rules of war that should give protection from aggression and the right to independent assistance. The vast needs of the people of Afghanistan will only be met by a large-scale independent humanitarian relief effort aimed directly at reaching the most vulnerable. One option could be a response led by the United Nations with a clearly understood humanitarian mandate, in collaboration with independent aid agencies. All parties to the conflict must allow for the delivery of large-scale aid convoys by humanitarian agencies. The Taliban and its allies have the same responsibility towards civilians during war. Aid
must get into Afghanistan and must be delivered by people who are not involved in the fighting. So-called humanitarian airdrops by the US airforce may feed a few people, but they also damage the effectiveness of humanitarian aid in this and other conflicts. 1
2
3
4
MSF report on new Afghan refugees situation in Gulshur town October 2000–January 2001. Paris: MSF, 2001. Khabir Ahmad. Military strikes worsen desperate plight of Afghans. Lancet 2001; 358: 1248. Fiona Terry. Military involvement in refugee crises: a positive evolution? Lancet 2001; 357: 1431–32. Nutritional surveillance, Afghanistan: preliminary report. Amsterdam: MSF, 2001.
Nathan Ford, Austen Davis Médecins Sans Frontières, 124–32 Clerkenwell Road, London EC1R 5DJ, UK (e-mail: [email protected])
Internally displaced people—refugees in their own country camps in Kunduz province, and n a recent planning document, the 42 000 highly vulnerable stranded UN estimated that 5 million people in Faryab province in the Afghans, including 956 000 internorthwest. nally displaced people, were affected In the short-term, IOM’s priorities by the humanitarian crisis before the remain to manage camps for interSept 11 attacks on the USA. nally displaced people in Herat, According to the UNHCR (United Mazar-I-Sharif, Faryab, and Kunduz. Nations High Commission for The main aim is to deliver critical Refugees), 387 000 such people were located in Afghanistan’s northern regions controlled by the Northern Alliance, 200 000 were residing in the northwestern province of Herat, 200 000 were in southern provinces around Kandahar, 94 000 were in Badakhshan, and 75 000 in Hazarajat region. UNHCR also estimates that before Sept 11, there were 2 million refugees in Pakistan, 1·5 million in Iran, 15 400 in Tajikistan, 8300 in Uzbekistan, and 1500 in Turkmenistan. These figures exclude asylum seekers beyond Central Asia, Building tents in Maslakh Camp, Herat, Afghanistan including about 100 000 in shelter (blankets, tents, construction Russia, 36 000 in Europe, 17 000 in materials), food, and other essentials North America and Australia, and (household fuel, personal hygiene 13 000 in India. and sanitation items such as soap) International Organization for before the onset of winter to the Migration (IOM) has worked in camp-based populations of migrants. Afghanistan for many years supportAs one of about 100 Afghan staff ing voluntary returns of Afghans from still working for IOM inside Iran in close cooperation with Afghanistan, an IOM national medUNHCR. Before Sept 11, IOM ical officer continues to assist in assisted 150 000 people in six camps health-related tasks in two main in and around Herat city who had camps in Herat city: Shaydee and been displaced by conflict and Maslakh. His role involves monitordrought. IOM also assisted 30 000 ing disease morbidity and deaths Afghans displaced by conflict in two
based on information obtained from other agencies delivering health services, assessing new health-related needs, identifying gaps in health services with other partners, training health workers and community leaders in delivering health education messages, monitoring the distribution of food, hygiene, and sanitary rations, supervising the installation and maintenance of sanitary facilities, and providing medical support services to families voluntarily returning to their places of origin. The report compiled from health clinics for the week ending Sept 16, 2001, in Shaydee camp alone, includes over 65 malnourished children admitted to supplementary feeding centres, nine cases of malaria, 275 children receiving oral rehydration therapy, 139 immunisations, and five deaths. Disease morbidity was dominated by diarrhoea and urinary-tract infections, which is typical of the period following the end of the second annual rainy season. It was not possible to obtain more recent health statistics reports after mid-September because of various restrictions imposed by the Taliban on international agency staff. However, most health agencies anticipate a sharp rise in acute respiratory disease in children during the imminent winter months. Based on a survey in the camps on Oct 11, 2001, IOM’s field team in
1544
THE LANCET • Vol 358 • November 3, 2001
Jeff McMurdo/IOM 2001
I
For personal use. Only reproduce with permission from The Lancet Publishing Group.
HEALTH AND HUMAN RIGHTS
Herat will attempt to supply wood for cooking and heating, kerosene for lanterns, winter clothes and shoes (especially for women and children), in addition to an increased food ration. During the week ending Oct 12, 27 of 50 latrines were rehabilitated in Shaydee camp and 26 100 laundry soap bars distributed as well as various items of clothing for women and children. In addition, 3500 kg of beans, 3000 kg of cooking oil, and 2500 kg of sugar were distributed to support the 20 000 people in Shaydee camp. Food rations are designed to provide full daily require-
ments of protein, carbohydrates, and fats through a diet consisting of wheat, beans, sugar, and cooking oil. The UN’s Inter-Agency Regional Contingency Planning Framework (Oct 4, 2001) analysed the situation in the aftermath of the Sept 11 attacks on the USA and subsequent military strikes against targets in Afghanistan. The UN estimates that the ongoing strikes will potentially lead to an outflow of 1·5 million refugees to Pakistan, Iran, Tajikistan, and Turkmenistan. Within Afghanistan it is anticipated that the military strikes will result in at least another
100 000 internally displaced people moving to Herat and 200 000 moving towards the camps in the northern region. The UN also expects about 500 000 refugees in neighbouring countries to return to pockets of stability within Afghanistan. Assisting their return and helping them reintegrate and re-establish their lives will pose another challenge to the international community. Akram A Eltom IOM, 17 route des Morillons, CH-1211, Geneva, Switzerland (e-mail: [email protected])
Aid workers in Afghanistan: health consequences he work of bringing food and development aid to Afghans at risk of starvation now depends on the Afghan aid workers of local and international non-governmental organisations (NGOs) and UN agencies. International co-workers were evacuated from Afghanistan in the wake of the Sept 11 attacks in the USA. Afghan aid staff have always been the mainstay of aid efforts in the country. They travel throughout Afghanistan, face the gravest dangers, and take the greatest risks. Recently, Human Rights Watch reported that aid offices and staff have been attacked by the Taliban and other groups. On Oct 14, 2001, an Afghan NGO told The Lancet that “Our staff called from Kandahar and told us that the Taliban have taken over all offices of the aid agencies and put their guns on the roofs.” Afghan aid workers face emotional stress from providing aid and relief. We know little about the psychosocial effects of long-term war on a population, but we have even less information on how war affects caregivers in such circumstances. Aid workers are at risk of stress-related illnesses, including mental health problems. In interviews with Afghan aid workers, most spoke about the trauma they had faced during war and the difficulty in doing their work now because of flashbacks, intrusive thoughts, non-directed anger and depression, and fear of the future. Many of the men have been imprisoned and beaten or tortured and found difficulty in keeping resulting anger and other emotions out of their family life. Female staff have also been harassed and beaten. Afghan aid workers face danger, trauma, and frustration, with profound mental health and psychoso-
T
THE LANCET • Vol 358 • November 3, 2001
cial consequences, and effects on their personal health and relationships with their families and communities. War has amplified the conflicts within their families and joint family systems. Debriefing, a process of helping aid or disaster relief workers cope with the emotional stress of their work, is standard procedure for disaster relief workers in the western world. Such treatment for workers is rare in Afghanistan. An informal survey of NGOs working with refugees in Pakistan and in Afghanistan showed that only a few agencies are addressing staff mental health needs. The
“Our staff called from Kandahar and told us that the Taliban have taken over all offices of the aid agencies and put their guns on the roofs.” UN’s World Food Programme (WFP) has a peer counselling programme for their aid staff in the area. Selected local staff in each office are trained in peer counselling techniques by Dr Kamran Ahmad. Other local and international agencies said they had provided stress reduction workshops for employees. Cooperation for Humanitarian Assistance (CHA) has initiated a mental health programme for its staff. The programme started with a workshop in March, 2001. Follow-up was provided by an American professional counsellor, Nina Lawrence, who spent 8 days with CHA, during 3 months, assisting individuals and helping train the mental health team. As one staff member said: “I used to think I didn’t need any help. Now I can see how much difficulty I was
having all along and I know how to get the help I need.” The counselling method, called focusing, is closely linked to Sufi tradition and can be easily linked to Islamic models. It was chosen because it allows deep work on psychological issues to be done without breaching ethical dilemmas of trust and disclosure. Those being treated can work on their psychological problems or needs alone or with a listener, who merely reflects back what the participant says. The listener may never know the nature of the problem, which means that private issues do not have to be revealed, and breaches of trust are not a risk. Since the programme was initiated, staff have reported that levels of tension and anger at work have decreased because managers are better able to deal with their anger, and are acting on their frustrations less often. CHA’s director noted that the managers’ problem solving abilities have also improved. One manager stated: “Old family issues and old pain about the war were weighing me down, always increasing my tension and anger. Now that is much better. The pressure is less.” CHA staff are reporting a mix of emotions, including fear, frustration and hope, after the bombing started in Afghanistan. They have described how focusing has helped them to cope and feel hopeful for the future despite the worry and uncertainty of their situation. Aid agencies must address the mental health needs of their staff and enable them to feel hope, which is critical to mental health and wellbeing. Patricia Omidian (e-mail: [email protected]) Patricia Omidian is a medical anthropologist and was the technical advisor for the CHA mentalhealth programme.
1545
For personal use. Only reproduce with permission from The Lancet Publishing Group.
in Kashmir, Bangladesh, Indonesia, Kenya, and Somalia to reduce work, depriving many of much needed assistance. MSF in Somalia is still paying the price a decade later for the confusion between military and humanitarian objectives in Operation Restore Hope. Confusion was created again during the Kosovo crisis by the presence of NATO troops in the refugee camps; the camps were subsequently shelled by Yugoslav forces. When the bombing stops, and humanitarian agencies can move into Afghanistan, how will the warring parties tell them apart from humanitarian bombers? The military can provide help through, for example, logistical capabilities to respond to natural disasters, and peacekeeping operations to protect civilians. But every time a military party involved in a
conflict describes their actions as humanitarian, the definition of this word is eroded. The work of aid agencies can be increasingly frustrated, and civilians be less likely to be treated according to the rules of war that should give protection from aggression and the right to independent assistance. The vast needs of the people of Afghanistan will only be met by a large-scale independent humanitarian relief effort aimed directly at reaching the most vulnerable. One option could be a response led by the United Nations with a clearly understood humanitarian mandate, in collaboration with independent aid agencies. All parties to the conflict must allow for the delivery of large-scale aid convoys by humanitarian agencies. The Taliban and its allies have the same responsibility towards civilians during war. Aid
must get into Afghanistan and must be delivered by people who are not involved in the fighting. So-called humanitarian airdrops by the US airforce may feed a few people, but they also damage the effectiveness of humanitarian aid in this and other conflicts. 1
2
3
4
MSF report on new Afghan refugees situation in Gulshur town October 2000–January 2001. Paris: MSF, 2001. Khabir Ahmad. Military strikes worsen desperate plight of Afghans. Lancet 2001; 358: 1248. Fiona Terry. Military involvement in refugee crises: a positive evolution? Lancet 2001; 357: 1431–32. Nutritional surveillance, Afghanistan: preliminary report. Amsterdam: MSF, 2001.
Nathan Ford, Austen Davis Médecins Sans Frontières, 124–32 Clerkenwell Road, London EC1R 5DJ, UK (e-mail: [email protected])
Internally displaced people—refugees in their own country camps in Kunduz province, and n a recent planning document, the 42 000 highly vulnerable stranded UN estimated that 5 million people in Faryab province in the Afghans, including 956 000 internorthwest. nally displaced people, were affected In the short-term, IOM’s priorities by the humanitarian crisis before the remain to manage camps for interSept 11 attacks on the USA. nally displaced people in Herat, According to the UNHCR (United Mazar-I-Sharif, Faryab, and Kunduz. Nations High Commission for The main aim is to deliver critical Refugees), 387 000 such people were located in Afghanistan’s northern regions controlled by the Northern Alliance, 200 000 were residing in the northwestern province of Herat, 200 000 were in southern provinces around Kandahar, 94 000 were in Badakhshan, and 75 000 in Hazarajat region. UNHCR also estimates that before Sept 11, there were 2 million refugees in Pakistan, 1·5 million in Iran, 15 400 in Tajikistan, 8300 in Uzbekistan, and 1500 in Turkmenistan. These figures exclude asylum seekers beyond Central Asia, Building tents in Maslakh Camp, Herat, Afghanistan including about 100 000 in shelter (blankets, tents, construction Russia, 36 000 in Europe, 17 000 in materials), food, and other essentials North America and Australia, and (household fuel, personal hygiene 13 000 in India. and sanitation items such as soap) International Organization for before the onset of winter to the Migration (IOM) has worked in camp-based populations of migrants. Afghanistan for many years supportAs one of about 100 Afghan staff ing voluntary returns of Afghans from still working for IOM inside Iran in close cooperation with Afghanistan, an IOM national medUNHCR. Before Sept 11, IOM ical officer continues to assist in assisted 150 000 people in six camps health-related tasks in two main in and around Herat city who had camps in Herat city: Shaydee and been displaced by conflict and Maslakh. His role involves monitordrought. IOM also assisted 30 000 ing disease morbidity and deaths Afghans displaced by conflict in two
based on information obtained from other agencies delivering health services, assessing new health-related needs, identifying gaps in health services with other partners, training health workers and community leaders in delivering health education messages, monitoring the distribution of food, hygiene, and sanitary rations, supervising the installation and maintenance of sanitary facilities, and providing medical support services to families voluntarily returning to their places of origin. The report compiled from health clinics for the week ending Sept 16, 2001, in Shaydee camp alone, includes over 65 malnourished children admitted to supplementary feeding centres, nine cases of malaria, 275 children receiving oral rehydration therapy, 139 immunisations, and five deaths. Disease morbidity was dominated by diarrhoea and urinary-tract infections, which is typical of the period following the end of the second annual rainy season. It was not possible to obtain more recent health statistics reports after mid-September because of various restrictions imposed by the Taliban on international agency staff. However, most health agencies anticipate a sharp rise in acute respiratory disease in children during the imminent winter months. Based on a survey in the camps on Oct 11, 2001, IOM’s field team in
1544
THE LANCET • Vol 358 • November 3, 2001
Jeff McMurdo/IOM 2001
I
For personal use. Only reproduce with permission from The Lancet Publishing Group.
HEALTH AND HUMAN RIGHTS
Herat will attempt to supply wood for cooking and heating, kerosene for lanterns, winter clothes and shoes (especially for women and children), in addition to an increased food ration. During the week ending Oct 12, 27 of 50 latrines were rehabilitated in Shaydee camp and 26 100 laundry soap bars distributed as well as various items of clothing for women and children. In addition, 3500 kg of beans, 3000 kg of cooking oil, and 2500 kg of sugar were distributed to support the 20 000 people in Shaydee camp. Food rations are designed to provide full daily require-
ments of protein, carbohydrates, and fats through a diet consisting of wheat, beans, sugar, and cooking oil. The UN’s Inter-Agency Regional Contingency Planning Framework (Oct 4, 2001) analysed the situation in the aftermath of the Sept 11 attacks on the USA and subsequent military strikes against targets in Afghanistan. The UN estimates that the ongoing strikes will potentially lead to an outflow of 1·5 million refugees to Pakistan, Iran, Tajikistan, and Turkmenistan. Within Afghanistan it is anticipated that the military strikes will result in at least another
100 000 internally displaced people moving to Herat and 200 000 moving towards the camps in the northern region. The UN also expects about 500 000 refugees in neighbouring countries to return to pockets of stability within Afghanistan. Assisting their return and helping them reintegrate and re-establish their lives will pose another challenge to the international community. Akram A Eltom IOM, 17 route des Morillons, CH-1211, Geneva, Switzerland (e-mail: [email protected])
Aid workers in Afghanistan: health consequences he work of bringing food and development aid to Afghans at risk of starvation now depends on the Afghan aid workers of local and international non-governmental organisations (NGOs) and UN agencies. International co-workers were evacuated from Afghanistan in the wake of the Sept 11 attacks in the USA. Afghan aid staff have always been the mainstay of aid efforts in the country. They travel throughout Afghanistan, face the gravest dangers, and take the greatest risks. Recently, Human Rights Watch reported that aid offices and staff have been attacked by the Taliban and other groups. On Oct 14, 2001, an Afghan NGO told The Lancet that “Our staff called from Kandahar and told us that the Taliban have taken over all offices of the aid agencies and put their guns on the roofs.” Afghan aid workers face emotional stress from providing aid and relief. We know little about the psychosocial effects of long-term war on a population, but we have even less information on how war affects caregivers in such circumstances. Aid workers are at risk of stress-related illnesses, including mental health problems. In interviews with Afghan aid workers, most spoke about the trauma they had faced during war and the difficulty in doing their work now because of flashbacks, intrusive thoughts, non-directed anger and depression, and fear of the future. Many of the men have been imprisoned and beaten or tortured and found difficulty in keeping resulting anger and other emotions out of their family life. Female staff have also been harassed and beaten. Afghan aid workers face danger, trauma, and frustration, with profound mental health and psychoso-
T
THE LANCET • Vol 358 • November 3, 2001
cial consequences, and effects on their personal health and relationships with their families and communities. War has amplified the conflicts within their families and joint family systems. Debriefing, a process of helping aid or disaster relief workers cope with the emotional stress of their work, is standard procedure for disaster relief workers in the western world. Such treatment for workers is rare in Afghanistan. An informal survey of NGOs working with refugees in Pakistan and in Afghanistan showed that only a few agencies are addressing staff mental health needs. The
“Our staff called from Kandahar and told us that the Taliban have taken over all offices of the aid agencies and put their guns on the roofs.” UN’s World Food Programme (WFP) has a peer counselling programme for their aid staff in the area. Selected local staff in each office are trained in peer counselling techniques by Dr Kamran Ahmad. Other local and international agencies said they had provided stress reduction workshops for employees. Cooperation for Humanitarian Assistance (CHA) has initiated a mental health programme for its staff. The programme started with a workshop in March, 2001. Follow-up was provided by an American professional counsellor, Nina Lawrence, who spent 8 days with CHA, during 3 months, assisting individuals and helping train the mental health team. As one staff member said: “I used to think I didn’t need any help. Now I can see how much difficulty I was
having all along and I know how to get the help I need.” The counselling method, called focusing, is closely linked to Sufi tradition and can be easily linked to Islamic models. It was chosen because it allows deep work on psychological issues to be done without breaching ethical dilemmas of trust and disclosure. Those being treated can work on their psychological problems or needs alone or with a listener, who merely reflects back what the participant says. The listener may never know the nature of the problem, which means that private issues do not have to be revealed, and breaches of trust are not a risk. Since the programme was initiated, staff have reported that levels of tension and anger at work have decreased because managers are better able to deal with their anger, and are acting on their frustrations less often. CHA’s director noted that the managers’ problem solving abilities have also improved. One manager stated: “Old family issues and old pain about the war were weighing me down, always increasing my tension and anger. Now that is much better. The pressure is less.” CHA staff are reporting a mix of emotions, including fear, frustration and hope, after the bombing started in Afghanistan. They have described how focusing has helped them to cope and feel hopeful for the future despite the worry and uncertainty of their situation. Aid agencies must address the mental health needs of their staff and enable them to feel hope, which is critical to mental health and wellbeing. Patricia Omidian (e-mail: [email protected]) Patricia Omidian is a medical anthropologist and was the technical advisor for the CHA mentalhealth programme.
1545
For personal use. Only reproduce with permission from The Lancet Publishing Group.