Before the war, the health situation in Afghanistan was among the worst inthe world primarily because the health infrastructure was grossly inadequate andmostly limited to urban centers. Protracted conflict since 1978 worsened theinequitable distribution of health manpower and services. The estimated infantmortality rate was 163 per 1000 live births (1993); the under five mortalityrate 257 for every 1000 live births (1994); the maternal mortality rate 1700 per100,000 live births (1993); and life expectancy at birth was 43.7.

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

The tragedy is that 80 to 85 percent of these diseases can be avoided bypreventive measures and by the provision of proper health care, or cured at anaffordable cost. However, currently there is only one health center to care forevery population group of approximately 100,000. Only 12 percent of pregnantwomen have access to maternal and emergency obstetric care; only 38 percent ofchildren under one year are fully immunized. These problems are compounded bythe fact that fully three-quarters of the nations physicians have left thecountry resulting in a physician/patient ratio of over 95,000/1. Because of theinadequacy of the health delivery system, a majority of the population relies onindigenous healers such as traditional midwives, herbalists, bone setters andbarbers who circumcise, let blood, pull teeth, and perform other curativeprocedures. Mullahs, sayyids and other specialists prepare curative andprotective amulets.

The war and deteriorating economic, social, and physical conditions in bothrural and most urban areas, have impaired housing and environmental sanitationfacilities in general and added sinister dimensions. By the end of 1996, it wasestimated that 1.5 million men women and children were physically disabled bywar injuries, including amputation, blindness and paralysis, as well asdebilitating infectious diseases, such as poliomyelitis and leprosy. Birthcomplications causing disabilities such as cerebral palsy and mental retardationalso increased. Another 10 percent of the total population representing familiesand associates of the disabled are directly affected by these disabilities. Theyrequire information and instruction not only regarding physical care, but alsoin ways to integrate disabled persons into communities as respected andproductive members.

Sadly, the number of disabled increases daily because of an estimated 10million landmines and unexploded ordnance (UXO) that contaminate the landscape,the largest concentration in the world. A 1993 national survey revealed therewere over 465 square kilometers of minefield, of which 113 square kilometerswere high priority areas directly affecting residential areas, farm lands,grazing pastures and canals; subsequently further high priority areas totallingmore than ninety square kilometers were identified; and, as refugees return, newminefields 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 minesdestroyed. The UN Mine Clearance Programme in cooperation with eight NGOs,includes 50 demining teams and 10 mine dog groups, as well as male and femalemine awareness teams, staffed by some 3,000 Afghans. Due to continuinghostilities, however, several de-mined areas have been re-mined. It will be manyyears before Afghanistan will be free of this menace.

Assistance to enhance the capacity and increase the accessibility of healthservices, emphasizes basic preventive and curative primary health services, withspecial attention to strengthening Mother Child Health and health man powerdevelopment at all levels, including Traditional Birth Attendants and communityhealth workers. Providing safe potable water sources and sanitation facilitiesis also a high priority since contaminated water sources are major causes ofhigh morbidity and mortality. Upwards of 60 NGOs, in addition to theInternational Red Cross Committee and the International Federation of Red Crossand Red Crescent Societies, WHO and UNICEF have been active in the health sectorover the years, assisting everything from regional, provincial and districthospitals to basic health clinics, as well as specialized services inphysiotherapy, drug detoxification, TB and malaria control.

The Mass Immunization Campaigns launched by WHO and UNICEF, in partnershipwith the Ministry of Public Health, utilizing a cadre of more than 15,000vaccinators, health workers and volunteers throughout the country, are singularsuccesses accomplished with the active cooperation of all parties to theconflict. In 1995, 2.6 million were vaccinated against DPT and measles; in 19962.3 million children under five received oral polio vaccine; during 1997, thenation-wide goal is to reach approximately four million children under five, inaddition to 60 percent of women of child bearing age. The ultimate aim is tototally eradicate the polio virus in Afghanistan.

As in the case with the education sector, however, the overall results aregenerally spotty. New and refurbished buildings intended to dispense medicalcare stand empty because of lack of personnel or equipment; some have beencommandeered by political groups for offices. Of the thousands trained invarious medical fields, few find employment. Databases list increasing numbersof "discontinued" projects and facilities. This is particularlydisheartening because the lack of medical facilities is a major deterrent torefugee repatriation.

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