MSF experiences from Afghanistan: Maslakh camp

by Saskia van der Kam

Saskia van der Kam is the headquarters nutritionist in MSF Holland. This article draws on her field trips to Afghanistan and a number of other MSF Field Reports

The ENN would like to point out that the practice of conducting nutritional surveys using Mid Upper Arm Circumference (MUAC) as the only anthropometric measure is not widely endorsed in current emergency nutrition guidelines. However, agencies (and their guidelines where these exist) are not in total agreement. Some agencies advocate its use where rapid assessments are needed while others are of the view that MUAC measurements should only be used for screening.

While there is a certain amount of debate on this issue currently Weight/Height remains the internationally accepted indicator for assessing prevalence of acute malnutrition among under five year olds in emergencies. (Ed).

Maslakh camp is located approximately 20 km from Herat in Western Afghanistan. A period of drought and conflict in the region led to large numbers of IDPs moving into the camp in late 2000. MSF Holland began working in the camp in 2000, implementing a supplementary feeding program for children under five and pregnant and lactating women. Medical screening (including measles vaccination and MUAC measurements) was also carried out by MSF at a reception site with medical cases being referred to MDM clinics for treatment. An MSF Therapeutic Feeding Centre (TFC) was subsequently opened in July 2001 and a second one in December 2001. MSF were also working in the paediatric ward of the regional hospital in Herat, which involved treatment of the severely malnourished cases.

Maslakh camp dramatically reduced in size as people returned home throughout 2002. ENN. O'Reilly 2002

During this period of MSF activity in the camp, it was unclear how many IDPs actually lived there, Estimates ranged from 160,000 to 300,000 people. Up until September 11th, the Taliban had a base nearby and were effectively in control of the camp. They were very reluctant to allow information gathering in the camp. Surveys were therefore not allowed nor was it possible to ask too many questions at the reception site screening.

From what information was available, it appeared that the majority of the IDPs had left their places of origin (mainly Baghdis, Ghor and Faryab provinces) due to hunger and drought, while a smaller proportion had fled due to fighting, insecurity, discrimination and violence or fear of violence. In the absence of accurate population figures, WFP provided rations for 300,000 people up until the reregistration exercise by IOM (International Organisation for Migration) in February 2002. The ration comprised 50 kg of wheat per month per family (equivalent to 800 kcals per person per day for a family of six).

Post-September 11th

Following events of September 11th, MSF expatriate staff were evacuated. Local staff however continued to work in the camp and expatriate staff returned towards mid-November. At this time there were large movements in and around the camp. Prior to September 11th the IDPs mainly comprised of Pashtun, but after September 11th there were increasing numbers of new arrivals of Uzbek and Tajik origin.

With the American bombardment close to the camp, IDPs panicked and fled the camp to hide in safer locations. With increasing pressure on the Taliban, more and more of them mingled with the IDPs in the camp - often concealing weapons. The situation in the camp was unsafe and tensions were ever present. Pashtun men and women were arrested at random and taken into jail in Herat city where their relatives needed to pay money to get them released. Ration cards were sometimes taken from Pashtun people with the offer to return them in exchange for information about the Taliban. Groups of armed men entered the camp in the evening to commit robbery and intimidation.

Throughout this time MSF continued the medical screening at the reception site. In November 2001 approximately 10% of children screened were malnourished (MUAC < 12.5 cm). MSF Holland had opened a second TFC shortly after the return of expatriate staff in November. However, the default rates in the TFCs were extremely high (approximately 30-40%) with the peak in October probably coinciding with an increasing population movement (Pashtun leaving and Tajik and Uzbek entering the camp) as well as increasing tension and insecurity in the camp. Interviews with mothers at the TFCs highlighted a number of pertinent factors.

Reasons for high default rate at the TFC

Mothers had been in the camp for several months before their children became malnourished (3-7 months). The high default rate from the TFC was due to:

• Reluctance to leave their habitation for fear of theft of treasured possessions. Women were also reluctant to be out in late afternoon when it is starting to get dark.
• Reluctance to attend the TFC for fear of missing a re-registration or a food distribution. "My husband looks after my other child when I am not there and he takes him along when he goes looking for firewood. My home is empty during the whole day... I am afraid that if somebody passes by for a survey we will not be registered and therefore not receive any distributions. That's why I decided to come to the TFC every other day instead of every day" (Abida comes from Badghis and is mother of 2 young children).
• Reluctance to leave other children behind. "Now that my mother is gone it is a problem for me to come here every day. My father works and I need to take care of my other brothers and sisters as well. I hope this one will get better soon so I can stay home" Amina is 13 years old and comes from Chakchacan (Ghor). She has been living in Maslakh for 8 months now and comes to the TFC with her baby sister. She has 4 brothers and sisters and her mother had just died after Ramadan.
• Husbands would not allow wives to leave for more than one day. Many men do not want their wives to talk to other men or for men to look at their wives. There were reports of violence against women by their husbands because of their attendance at the TFC.
• Mothers/carers were not seeing immediate improvements in health and nutrition of children.
• Some of the defaulters mentioned the fact that it was winter and they did not want to leave their shelter in the morning due to the cold.

Nutrition survey findings

Because of the high defaulter rate at the TFC and the fact that most children attending the TFC had been in the camps for several months, MSF were concerned that the prevalence of malnutrition in the camp was higher than the one detected at the reception centre. This prompted MSF to conduct a nutritional survey. At the end of January 2002 MSF conducted a MUAC survey with a representative sample of 1,869 children in the camp. This found a global malnutrition rate of 26.4% (MUAC <12.5) and a prevalence of 6.6% severe malnutrition (MUAC<11.0 cm). A MUAC survey was conducted rather than a weight for height survey mainly to allow a rapid survey. The camp was unsafe and it was incredibly cold. The survey only took one day.

Child being encouraged to eat in the Maslakh TFC. ENN, O'Reilly. 2002

Inappropriate food distribution system and registration difficulties

MSF concluded that the high rates of malnutrition in the camp were mainly due to an inappropriate food distribution system, difficulties with the registration system (which was imposed by the Taliban) and insecurity in the camp.

Some of those interviewed in MSF programmes indicated that new arrivals were waiting for one to three weeks before being registered at all in the camp, while widows and orphans without male representatives may not be registered. In addition, some Afghan men had two wives and thus two families. They would often bring their first wife and family to the camp and then once settled in, return home for the second one. When they subsequently tried to register their second family, they may be accused of cheating as their name was already on the registration list. While new arrivals at the camps were waiting to be registered they would not have proper shelter or food supplies. Others were moving into the camp without being registered.

"We left 3 days ago and arrived here the day before yesterday. We lost two children during the journey because they were sick, hungry and cold. When we got here we had many problems at the registration. Originally we were 20 families but they only registered 16 of us. Four women are widows and as they have no male head of family to represent them, they could not be registered. When we get something we will share our distributions with them. For the moment we are all hungry and cold and we sleep out in the open air. We don't have any relatives to help us. Two of my children are very hungry and sick. I think they will probably die" (mother at registration site).

The situation around the registration site was at times disorganised and on occasions quite hostile. The level of fraud and intimidation by those trying to repeat register under different names was such that in mid- December the site had to close for security reasons following a shooting incident. (It remained open as a distribution point for non-food items.) IDP registration was moved to 4 outlying sites on roads leading into Herat, in order to only register genuine cases.

Families were registered in groups (up to 40 families) with one representative (block leader) nominated to receive the registration list and be responsible for all the families. This individual was therefore responsible for the distribution. There were however some problems with this method, e.g. families did not know each other well, making the system subject to disputes.

The new authorities were actively searching for Taliban in the camp and used the food distribution as a means of pursuing this objective. There were many reports of arbitrary arrests of Pashtun people and exclusion of people from the food distribution if they did not provide information on the identities or hiding places of Taliban or weapons. In addition Pashtun people were often prevented from using safe water wells and latrines with adverse consequences for their health.

"The food distribution is a big problem. The last time we received a bag of wheat was 3 months ago. We have a problem with our representative. He took our card but we have not heard from him since two months. I went to see him five times but he said he is not responsible. My card is in the office" (quote from a mother at the TFC).

The average time since the last food distribution for mothers interviewed at the TFC was 2-3 months. Women often reported that their name did not come up at the distribution site.

IOM were increasingly aware of registration problems and were planning a re-registration of the population in the camp by the end of the year. When the re-registration eventually took place in February 2002, it transpired that WFP had been providing food for more than twice as many people as necessary, that is 300.000 people compared to a registered population of 115,000. The general conditions and security situation improved slightly in the camps in January but deteriorated again (especially for the Pashtun) once the re-registration exercise was over.

Conclusions and lessons learnt

MSF Holland identified a number of key lessons and issues arising out of this experience.

1. The nutritional deterioration of the camp population over a period of months, in spite of large amounts of food going into the camp, demonstrates the importance of establishing adequate food aid distribution systems and monitoring their effectiveness. The registration system imposed by the Taliban to maximise numbers and hence potential aid to the camp, did not ensure fair distribution. Consequently some families suffered.
2. The high default rate from the camp TFC seems to be an experience repeated in other TFCs in Afghanistan. This partly reflects cultural factors and may indicate a need to establish a more home based care, i.e. phase one being implemented at specialised centres with subsequent care at home.
3. Security was inadequate in the camp. There was no police presence nor any reporting system installed for IDPs to report security incidents. A protection role in the camp should have been established much earlier. In January 2002 UNHCR assumed a protection mandate and subsequently chaired a weekly security meeting attended by all agencies.
4. The need to investigate population specific cutoff points for MUAC measurements that correlate with 80% weight for height, if MUAC is to be used to estimate prevalence of malnutrition in nutritional surveys.

The food distribution in the camp changed completely (but not immediately) after the February 2002 registration. Wheat distribution through block leaders was replaced with bakeries and daily bread distribution directly to registered families.

For further information contact: Saskia van der Kam at: saskia_vd_kam@amsterdam.msf.org

A number of staff from other agencies working in the camp were asked to comment on this article. A summary of their main comments follows.

As a follow-up to the survey conducted by MSFH in January, UNICEF conducted a nutrition survey in April 2002 using weight for height. The results indicated an acute malnutrition prevalence of 2.9%. (<-2 SD Weight/Height).

The majority of the nutrition specialists working in Afghanistan have agreed that MUAC surveys are not the most appropriate methodology for estimating prevalence of acute malnutrition.

It is not clear on what basis the high rates of malnutrition found in the survey could be attributed to "poor registration and food distribution systems and insecurity in the camp". Although these could have been contributing factors, more analysis would have been needed before arriving at a definitive conclusion. Furthermore, there is no mention in the article of other potential underlying causes, such as morbidity and inadequate water and sanitation provision. The April UNICEF survey found an under-five mortality rate of 6/10,000 per day. High levels of pneumonia and diarrhoea morbidity as a result of poor hygienic and shelter conditions in the camp were significant contributing factors. Although there were 3 months between the MSFH and UNICEF surveys and a number of important changes had occurred including many people leaving the camp to return to areas of origin as well as a change in the distribution system, the influence of the health environment on the deterioration in nutritional status of under fives was not examined in the MSF survey.

It was extremely difficult to organise a re-registration in the camp as everyone was worried about the insecurity. Some agencies did not want to participate in such an exercise because of the high level of insecurity.

The constraints and obstacles to assessments and interventions in this environment cannot be overestimated. There were reports from the distribution agency about abuses of the system including numerous accounts of attempts to cheat the system and physical threats and beatings of staff when false distribution cards were withdrawn. The UNICEF survey team had to abandon the last few households to be surveyed as " an angry mob consisting of 200-300 people (males and children) surrounded the team and threw stones after them but the team managed to escape". Obstacles to appropriate assessment and investigation were even greater under Taliban rules.