Vignettes of a South African Township called Mdantsane

Thursday, December 29, 2016

Cottage Landscape

Impasto Acrylic on Canvas - Amitabh Mitra

Thursday, December 8, 2016

Tuesday, December 6, 2016

Assignment Afghanistan - Amitabh Mitra

Fact Figures for Afghanistan April 16 2015
• 2.7 Million Afghan refugees displaced to neighboring countries
• 829,295 Afghans internally displaced by conflict
• 48000 Afghans returned from Pakistan till 2015
• 8827 Afghan households affected by severe weather events from Feb – March 2015. This would be more now because of the recent earthquake
• Humanitarian funding to Afghanistan - $ 69,305, 905

Lorenzo Tugnoli – The Little book of Kabul
‘’Afghanistan has been called the land of 30,000 villages. What is remarkable is that every one of them is unique. The dramatic variations in power, ethnic, tribal, religious, and family dynamics from one village to the next are what make the country both endlessly fascinating and vexing to foreigners attempting to intervene here. It is why no strategy, whether military or political, can be applied uniformly, with success, on a national scale: why the effectiveness of foreign intervention — whether by militaries or civilian aid and development groups — can differ so markedly from one area to the next. Eleven years into the war, NATO’s best and brightest are still struggling to understand the myriad complex forces influencing stability and its collapse on the village level. Why do some communities embrace the Taliban, while other rise against them? Why do some welcome the government, while others eschew it.’’

Why Afghanistan ?

I would like to choose Afghanistan as a Case Study for Complex Humanitarian Emergency. I believe from historical aspects, Afghanistan could never stay as a united nation but a complex conglomeration of tribal entities. Such tribal entities can forge temporary alliances for their benefit but can never unite to elect a leader. Afghanistan from the time of British East India Company’s ambitious plans to bring Kabul to its fold failed miserably to the present times when this country has become a failed state, Afghans are essentially proud people, their hospitality knows no bounds and culture, a profound reflection from the Silk Route is still instilled in every Afghan.

A country which has never been ready for a democracy can never be forced into democracy by developed countries that do not know or are not willing to understand the mind of the Afghan.

Let me quote award winning author/ historian William Dalrymple’s words from his latest book on Afghanistan, Return of a King, and The Battle for Afghanistan. ( Bloomsbury)

The First Anglo- Afghan War ended in Britain’s greatest military humiliation of the nineteenth century: an entire of what was then the most powerful nation in the world ambushed in retreat through high mountain snow drifts, and there utterly utterly routed by Afghan tribesmen.
The west’s first disastrous entanglement in Afghanistan has clear and relevant parallels with the current deepening crisis; there are extraordinary similarities between what NATO faces today in cities likes Kabul and Kandahar, and that faced by the British in the very same cities, fighting the same very tribes, nearly two centuries ago.

In the backdrop of the Soviet invasion, American and NATO’s desperation to come out of Afghanistan without leaving a viable government and infrastructure in place, the country has ripened to a Complex Humanitarian Emergency where the Afghan pride is foremost, more important than Health disaster.

Description of the Response
What is a Complex Humanitarian Emergency
Complex humanitarian emergencies have been a major political, security and public health feature of the post-Cold War world. These man-made disasters account for more morbidity and mortality than all natural and technological disasters combined. In order to deliver effective aid during complex humanitarian emergencies, international relief agencies must have a solid understanding of the political and social climates in which they are operating. In addition, they should base their health interventions on objective epidemiological data, especially standardized rates of morbidity and mortality. Most deaths during complex humanitarian emergencies are due to preventable causes, especially increased rates of infectious diseases malnutrition and violent trauma. The most appropriate health interventions are therefore based on the models of public health and primary health care, emphasizing disease prevention and health promotion. The field of humanitarian assistance has become increasingly professionalized in recent years, with its own professional standards, literature, research agenda and training opportunities. It is an unfortunate reflection on the current state of international affairs that the number of complex humanitarian emergencies and the enormous levels of suffering associated with them are unlikely to decline in the foreseeable
Complicated Humanitarian Disasters and therefore its broad based epidemiology is characterised by
• specific vulnerabilities of refugees
• specific vulnerability of Internally Displaced Person ( IDP)
• Age and Gender studies which varies with different models

Populations are known to flee the violence of their countries. The fleeing population has a different morbidity and mortality rates which is understandably higher than the ones who are in the safety of refugee camps. Therefore the internally displaced persons (IDP) and who are exposed to violence show the highest death rate especially minors experiencing death rates 800 times higher than the baseline

Its importance lies on the fact that humanity has always learned from their past mistakes, documentations of CHE in detail are kept to use them in the future for deployment. But as I understand that CHEs of 1994 would never be the same as possible CHEs in the future and might even involve developed countries and therefore with newer emerging diseases, changing patterns of diseases known, change in the behavioral pattern due to rapid globalization and the rush for a grab of outer space by developed countries, the epidemiological models that I have discussed in length might not agree to futuristic patterns of life and living.

Sphere in Afghanistan

Although still in infancy, every humanitarian and medical team response must try to adhere to the Sphere principles of universal minimum standards. The minimum standards cover four primary life saving areas of humanitarian aid, water supply, sanitation and hygiene promotion, food security and nutrition, shelter, settlement and non food items and health actions.
ACBAR, The Agency Coordinating body for Afghan Relief, functioning since August 1988, responding to demands from Afghan and International Non Government Organizations involved in assistance work in Afghanistan and refugee work in Pakistan
ACBAR has taken up the implementation of minimum standards of Sphere Project and assists every other humanitarian and medical team to adhere to these standards
My Medical Response Team headed towards Afghanistan must collaborate with ACBAR for interpreters and local assistance.
So how do we go and where do we go into Afghanistan
Even before we think of going into Afghanistan, I would like to show you the map where we plan to set up our Medical Camp.

Where shall we put our camp
Spin Boldak in Kandhar Province in Afghanistan

Why should we put our camp there

Because its right at the border of Baluchistan, the closest town being Chaman. Chaman is also on the silk route. The distance between Spin Boldak and Quetta which has many tertiary hospitals is 136.6 kms via N25. The distance between Spin Boldak and Chaman is 11 Kms and takes 13 mins to reach there. 30.000 people move in and out of these porous borders everyday for business and labor.

Afghan refugees and internally displaced Afghan nationals have the biggest camp in Chaman and Spin Boldak
Chaman and Spin Boldak are part of the Pashtu speaking Baluchistan
Chaman is used by NATO forces as a major supply route and remains under NATO administration and security
The Baluch nationals are also close to India and fighting for their own independence

How do we go ahead in establishing our camp
Its most important to get permission from Government of Afghanistan, Government of Pakistan, NATO and USAID to start a Level 1 and 2 Medical Assistance Camp
Chief Minister Dr. Abdul Malik Baloch of Baluchistan must be consulted. He is a liberal, Centre Left politician belonging to National Party at Baluchistan. He can allow us to use the Quetta Airport and Quetta highway to bring our relief materials
Its important to point out that although our camp is in Spin Boldak, Kandahar, we shall be also be treating local Baloch nationals from Quetta and Chaman
Quetta and Chaman has the largest refugee camps from Afghanistan
Kandhar was the strategic trading centre on the Silk Route, disputed control by Mughal and Persian Empires. The best of miniature art once came from this place.
Toryalai Wesa is the Governor of Kandahar province. Highly educated, his wife is a gynecologist. I am sure he would provide the permission to establish and allow his security forces to defend the camp
MOUs signed
Services providing clearly stated

Medical Intelligence
Even before we plan to establish a medical and humanitarian aid camp, we would need extensive intelligence reports from this area
Political intelligence is combined with Medical intelligence to understand the depth of the Complex Humanitarian Emergency ( CHE)

NGOs working in Afghanistan are
UNHAS United Nations Humanitarian Air Service
Save the Children
International Federation of Red Cross and Red Crescent Societies

Medical Intelligence regarding causalities, trauma, maternal mortality, infant mortality, psychiatric influence, tropical disease pattern, HIV and AIDS related diseases, sanitation, hygiene, clean water supply, infrastructure for hospital, can be gathered from these agencies
The military, NATO and US Army has its own Medical intelligence Wing
2.5 million deaths have occurred till this day, only 11 percent resulted from trauma due to war. The remainder occurred from diarrheal diseases, malnutrition and malaria

Disease Non Battle Injuries ( DNBI)
Water and Food Borne Diseases ( Cholera, Dysentery, Salmonella)
Infectious Diseases ( Influenza, Tuberculosis, Syphilis, Typhoid, Wound Infections)
Insect transmitted diseases ( Malaria, Dengue, Yellow Fever, Encephalitis)
Occupation and Environmental Health threats ( OEH ) Contaminated Soil, toxic industrial, chemicals and materials, chemical, biological, radiological, toxic industrial chemicals and materials, chemical, biological, radiological and nuclear agents ( CBRN)
The Armed Forces Medical Intelligence Centre brings medical intelligence gathering more efficiently

Burden of disease 2010 in Afghanistan
• Lower Respiratory Tract Infection
• Diarrheal Diseases
• Preterm birth Complications
Risk Factors
• Household air pollution from solid fuels
• Childhood underweight
• Dietary risk

How do we go in and come out – Entry and Emergency Exit

A detailed preparation is necessary
Kandhar International Airport to Spin Buldak 93.5 kms 1 hour 17 mins
Quetta International airport to Spin Buldak 126.5 kms 1 hour 41 mins
Any of these two airports can be used; Quetta is widely used by NATO forces
In situations of eminent danger and insurgency, the best escape route would be via Chaman to Quetta

Preparedness to Response- What to expect, What we can do
1 Insecurity, Displacement and Humanitarian Access
2 Natural Disaster Preparedness and response
3 Food Security and Emergency Food assistance
4 Health and Nutrition

Type of Response

Humanitarian Medical Relief
• Short Term
• Long Term
• Short term is time bound extending from weeks to a month or two
• Long term is extending to years where public health becomes the background and a permanent infrastructure is built like the Emergency Trauma Hospital in Kunduz which was bombed recently by NATO forces, reason?

Services Providing


• Primary Prevention – Stopping the violence/ Neutral stand
• Secondary Prevention
• Early detection
• Contingency Planning – Inadequate resources in Afghanistan
• Personnel Training – Indigenous Health Workers in Conflict zones
• Tertiary Prevention – Prevention of excess Mortality and Morbidity after disaster
• Relief Measures
• Adequate Food Rations- 2000 kilocalories of energy per person per day
• Epidemic Preparedness/ Vaccines/ measles/polio/neonatal tetanus
• Maternal and Child health care

• Triage services
• Trauma – Adult and Pediatric
• Minor Wound Repair
• First and Second Degree Burn treatment
• Plaster cast and non surgical fracture treatment
• Circumcisions
• Resuscitations and Advance Life Care stabilisations
• Observation care
• Transfer by road/air ambulance to tertiary care centre as per contract
• Non Trauma
• Pediatric/Adult
• Tropical Diseases
• Pulmonary TB
• Acute and Chronic Respiratory Tract Infection
• Diarroheal diseases
• Meningitis
• Chicken Pox
• Diabetes
• Hypertension
• Osteoarthritis
• Malaria
• Dengue


• Blood Counts/ Culture
• Malaria Smear
• Sputum for TB
• Urine Dipstix
• Creatinine, Urea, Sodium, Potassium, Glucose

• Mobile
• Chest
• Abdomen
• Skull
• Limbs

Risk and Challenges

Violence Prevention and Neutral Stand in Afghanistan – Biggest Challenge

It has always been widely discussed and published about neutral stand being taken by Humanitarian relief agencies especially in Afghanistan but it’s nearly impossible to take such a stand when violence incites violence, tribal honor is at stake. Peace loving Balochs are targeted by NATO forces and Pakistani army. Nawab Akbar Bugti, a Baloch nationalist leader was killed on 26 August 2006 by Pakistani commandos.

Since then, the entire Balochistan which involves parts of Afghanistan remains as a conflict zone.

The perception of the west of Taliban again is a bit deceptive. Sunni Islamic ideology which has been radicalized can be roughly termed as the Taliban. But again there are mild and moderates within the Taliban who acknowledge to such an ideology and they can be highly educated intellectuals from all professions. The movement in its milder form is global and not restricted to Pakistan or Afghanistan. Its sympathizers, funded by Middle East countries also do humanitarian aid work in Afghanistan. An example is Jamaat –ud- Dawa, the charitable wing of the banned terrorist organization Lashkar –e - Taiba , it does humanitarian aid work in Afghanistan.

Such radicalized Islamic charitable groups will prevent any incursions to give medical aid even though one has the right permissions

One needs to have armed security to protect such medical missions.

An example being MSF being routed out from Afghanistan and Eastern Congo where in spite of taking neutral stand and doing good work, violence made them to discontinue

Mitigation strategy
Understanding the Afghan culture in detail and implementing while dispensing medical aid is a relevant solution. Women should only be seen by female doctors and strict purdah, hijab should be considered for all female medical professionals in the camp. Pashtu, Dari and Urdu interpreters should be used to bridge communication gap between patients and doctors
Negotiations and special cease fire zones
Use of indigenous staff
Right to health as an urgent intervention strategy as per UN Security Council decision against rogue governments and war lords

Acute Respiratory Infections
Due to bacteria and virus, its widely reported. Pneumonia is leading cause of death in children
Lack of food and shelter is an important cofactor. This must be given priority
Overcrowding in refugee camps also leads to droplet infection
Winter months in Afghanistan are acutely cold and freezing and adults and children suffer from such infections, warm clothes should be distributed
Measles vaccine should be given and screening procedures encouraged

Diarroheal diseases and infections
An average of 85000 Afghan children die from Diarroheal disease every month. This is a major cause of morbidity and mortality. Rota virus, Shigella and E Coli are the main causative agents. Outbreaks of cholera are quite common.
We need to take a serious look into sanitation, drinking water supplies, and access to clean bacteria free water
Health education and use of sugar salt solutions to counter dehydration
Checking into informal settlements and the movement of refugee population
Severe water shortages during summer months also needs to be taken into account
Strategies in chlorination of water supplies and use of of Sodium Hypochlorite should be encouraged

This is a leading cause of morbidity in children less than 5 years of age and recent epidemics are reported in war zones. There is no immunization programme in Afghanistan. Complications- Pneumonia, Meningoencephalitis in malnourished children with Vitamin A deficiency
Overcrowding must be checked
Two doses of trivalent vaccine
Human Normal Immunoglobulin to pregnant women and immunocompromised group

Is endemic in Afghanistan. 300,000 cases in a year Its also a danger to health workers. Chloroqine resistant malaria and cerebral malaria has been reported the cause of death in aid workers. Cham and Quetta is rife with malaria. Plasmodium Vivax and Plasmodium Falciparum from mosquitoes are the agents causing malaria

Concides with refugee concentration, proliferation of vectors,malnutrition and destruction of vegetation around camps
Chloroquine resistence – Pyrimethamine, Sulfadoxine, Mefloquine, Artemesinin
Mosquito nets with insecticides
Mefloqine is shown to produce sllep deprivation, hallucination and anxiety. An US soldier in Afghanistan was affected by this drug
DDT spraying in all houses regularly and health education is important

Undernutrition and Malnutrition

Chronic food shortages has resulted in the spread of scurvy, Vitamin C deficiency results in 6.5 percent of all deaths. Liver Failure has also been been reported. Iron deficiency and anemia is reported among pregnant women and children

Food insecurity due to political insecurity is the main factor. Food Packets, Health delivery and health education is important
Feeding and caring practice must be introduced. Breast feeding counseling and nutrition intervention must be planned.

Physical Trauma
1994 - 33 – 43 percent of death in Kabul War related weapon injuries and unexploded IEDS Occurs in young adults and causes permanent disabilities Polytrauma

Search/deployment of unexploded devices. Peace efforts to continue. Cease fire
GPS coordinates of the medical mission to be given to NATO HQs, Afghan and Pakistan governments