June 2004

Afghanistan :: Focus on basic health care and emergency preparedness. The Medecins Sans Frontières projects in Northern Afghanistan

Médecins Sans Frontières has been working in Northern Afghanistan since 1992 on projects aimed at bringing emergency aid to the Afghan population. Twenty years of warfare have seen the Afghan health care system suffer heavy blows. In order to meet the enormous needs, Médecins Sans Frontières started to set up a network of clinics in 1996: they provide primary health care with a special focus on mothers and children, and serve as bases for emergency operations in epidemics or natural disasters. A peep behind the curtains.

© Carl De Keyzer/Magnum Photos Thoidad is responsable for the pharmacy in the Charkent clinic.

“It’s even worse in the winter,” smiles Thoidad, a young Afghan who runs the pharmacy at the Médecins Sans Frontières clinic of Charkent. It had taken almost three hours to come from Mazar-i-Sharif in the Land Rover. The steep road winds through the Tangi Shadian mountain pass where workers are hammering at enormous boulders to make building blocks to reconstruct the city after years of war damage. Scattered all over the landscape lie the rusting remains of armoured tanks and anti-aircraft guns, and fluttering white flags on the graves of fallen Mujaheddin.

Hours of driving across dried river beds full of loose cobbles, through ravines, over barren hillsides with snow-covered tops. “It is bitter cold in the winter here when snow can be meters thick. Sometimes the clinic is cut off from the living world for weeks on end, so we stock medical supplies to last four months,” he says.

Charkent is one of the most remote clinics run by Médecins Sans Frontières in Afghanistan. Its sun-baked brick walls blend in perfectly with the Sharshar Bazaar village clinging to the hillside. There is a quiet atmosphere in the separate men/women waiting rooms. A couple of men are sitting on a bench, waiting their turn. They all sport thick beards and moustaches, baggy pants and longai, the Afghan turban, and nod a friendly welcome with their hand on their chest.

“Life is hard,” says Nasim (55), one of the villagers. “There are no roads. The harvest looks bad. During the great drought a few years ago, we had to sell our cows because we could no longer feed them. Some people from surrounding villages went to town and sold their children to make a bit of money. We were mixing flour with water and each villager received five spoonfuls of porridge twice a day. That’s all we had.”

The great famine is over in Afghanistan, but the poor diet of the mountain people lead to chronic malnutrition. There are many medical problems in this desolate district that has a population of some 60,000 people. The small Médecins Sans Frontières clinic is the only medical infrastructure which people of the region can turn to for basic health care. People in need of medical care used to have to go to town on foot or on donkey, which could take them several days in snowy weather.

Twenty clinics for primary health care
Médecins Sans Frontières has been working in Northern Afghanistan since 1992 with projects focusing on bringing aid to the Afghan population and emergency preparedness. The activities were initially aimed at the regions and provinces where there were refugees (Tadjiks from 1992 to 1997) and displaced persons (from 1993 to 1997) and emergencies such as the epidemics of cholera in 1993 and 1995. Twenty years of warfare have seen the Afghan health care system suffer heavy blows. In order to address the enormous needs, Médecins Sans Frontières set up a network of clinics to provide basic health care in the same regions where the organisation was already working.

Charkent is one of 20 clinics run by Médecins Sans Frontières in the northern provinces. “The concept behind this major programme was to keep it as simple as possible,” says Krist Teirlinck, Medical Co-ordinator for Médecins Sans Frontières and based in Mazar-i-Sharif for many years. “Each clinic provides the local population with the same basic medical package. The project is aimed at the most vulnerable population groups, in cities as well as in the countryside. We devote special attention to women and children.

“We provide curative and preventive health care. The Ministry of Health supplies the buildings and pays local staff wages. Médecins Sans Frontières pays extra incentives, provides training and supervision, supplies the medication and epidemiological follow-up.”

By early-2004 there were 18 Ministry of Health clinics and two Médecins Sans Frontières clinics spread over five provinces (Kunduz, Baghlan, Balkh, Sar-e-Pul and Faryab). They provide a global monthly 41,000 curative consultations, 3,600 pre & post-natal consultations and 36,000 vaccinations.

“This network of 20 clinics widely spread over several provinces also forms the base of our emergency preparedness for Northern Afghanistan, ” says Krist Teirlinck. “They perform as local antennas which can provide us with very early signals of potential epidemics. Their logistics and pharmaceutical supplies form an efficient system which can be instantly operational on the outbreak site of a natural disaster. A great asset in a country 20 times the size of Belgium and regularly stricken by earthquakes.”

Curative medical care
Pul-i-Kumrhi is the most important city in the eastern province of Baghlan. Drab apartment blocks with the washing drying outside the windows and cement factories with their adjacent workers dwellings are clear reminders of the Russian times when the city was called “Little Moscow”.

Twelve kilometres outside of the city lies the Médecins Sans Frontières-run Bagh-i-Shamal clinic, a white low-rise concrete building which opened its doors in September 2002. The separate wings for men and women are only partitioned by a curtain and the staff moves freely from one area to the other. A cordial atmosphere, unthinkable only a few years ago under the Taliban regime.

The premises are representative of the curative care provided by Médecins Sans Frontières in the Northern provinces. The normal set-up in all 20 clinics features a registration room, a consulting room, a nursing room and a pharmacy which is completely stocked by Médecins Sans Frontières. In each clinic there are approximately three doctors, one pharmacist and one nurse who also performs malaria tests. All patients are registered on arrival, when a medical file is started. Doctors write a monthly epidemiological report.

Doctor Najia Fazli is the enthusiastic doctor of 31-years-old at the helm of this clinic. “We now provide care to 9872 families, which amounts to almost 70.000 people,” she proudly says. “In the early days the number of patients was significantly lower but our growing reputation is keeping the figures on the increase. People now come to this clinic from as far as 25 km away, and we only have a slowdown during the harvesting season because people are too busy working in their fields. Priorities follow the seasons: in the winter we mostly see people with pneumonia and respiratory infections. In the summer we see more patients with diarrhoea and malaria.”

The fact that many diseases are season-related is a well-known phenomenon in Médecins Sans Frontières clinics. Mainly, patients report acute inflammation of higher and lower airways, asthma and breathing disorders, acute bloody or watery diarrhoea. Diarrhoea is particularly widespread during summer because of the dire shortage of clear drinking water, especially in the countryside. Other frequent medical problems are scabies and skin diseases, digestive disorders, inflammation of urinary tracts, anaemia, hypertension and malaria.

Apart from the preventive health care and the pre & post-natal consultations, the Médecins Sans Frontières network of clinics handles 41,000 curative consultations a month. Crowded waiting rooms are evidence of the extent of health care needed by a population living in a country where life expectancy is as low as 41.9 years. Only 29% of Afghans have access to health care and 81% of the population living in the countryside have no clear drinking water. People are dying from simple, avoidable illnesses like diarrhoea and often come to consult when the disease is in an advanced stage. That is why the continued provision of a quality curative care is a priority.

Ali Chopan clinic, Mazar-i-Sharif region. In the period March May, 2004, MSF Belgium handed over its current activities to the Ministry of Health and to organisations charged with reconstruction of health care. The hand-over happened in the context of political, military and economic developments that raise questions about the remaining possibilities for independent humanitarian action in Afghanistan. Photo © Carl De Keyzer/Magnum Photos

Pilot Project against leishmaniasis
Médecins Sans Frontières is running a pilot project to fight leishmaniasis in Mazar-i-Sharif and in Dawlatabad. This is an old yet still extant disease transmitted by contaminated sandflies. The form found in Afghanistan is called cutaneous leishmaniasis and often causes large skin ulcers than can lead to disabilities and permanent scarring.

In the waiting room of the Karte Armani clinic in Mazar-i-Sharif, 80-year-old Haji Aziz is sitting with festering ulcers on his jaw, elbows and armpits. He has been ill for four months. He swivels to his right when he sees us and shows us his wounds. He laments: “I have had eight shots, but it’s not healing so I stopped. What shall I do now? ”

“The pilot project we have started consists of 14 intramuscular injections”, says Krist Teirlinck. “Normally it should help, but the problem is that many patients interrupt the treatment prematurely.” Haji Aziz has to resume his therapy. He is not the only one. The pilot project has, in the meantime, shown that a large number of leishmania patients in Northern Afghanistan are in serious need of medical treatment. Médecins Sans Frontières is therefore likely to widen the project and has already ordered the medication for 10,000 treatments.

See a doctor for a token fee
In order to guarantee access to the population, Médecins Sans Frontières provides health care and medication completely free of charge. There is a fee of two Afghani (about three euro cents)
for a consultation, the price of a bun, which almost every Afghan can afford.

“But even these small amounts go back to the savings account held by every clinic,” says Krist Teirlinck. “A health committee of three clinic workers, someone from Médecins Sans Frontières and three people from the local community manage the money to pay for small repairs in the clinic, to buy firewood for the stoves to keep the rooms warm. This system boosts the sense of involvement and responsibility of the Afghan population in the running of ‘their’ clinic.”

Free health care is an important factor for the ever-growing number of patients. The people of Afghanistan are so poor that even a token amount can be too high for them, but two Afghani draws most people in.

In the waiting room of the Bagh-i-Shamal clinic we meet Gul Jan, a woman from Gharaw Shakh, a neighbouring hamlet. Gul thinks she must be in her 70s and nibbles at a crust of bread while waiting for her turn to see the doctor. She says her nine grandchildren have all come to the clinic but today she comes for herself. A luxury unheard of. She remembers how she used to stay at home with typhus and malaria, hoping things would get better by themselves. Since Bagh-i-Shamal was opened, her whole family are regular visitors. A typical case, according to doctor Fazli. She recently heard of an old woman who was in bed with malaria. When she went to visit her and the woman stated her own diagnosis herself, she added, “I know this decease well because three of my children died of it”.

Women and children first
“The curative work is very important, but prevention is our key priority,” says Krist Teirlinck. “This is an area in which Médecins Sans Frontières pay particular attention to mothers and young children. Each clinic has a midwife in charge of the specific health care needs of mothers and children, mother and child health (MCH). The midwife handles the pre-natal consultations, supplies health care advice and informs women of the possibilities of family planning. Her workload is so heavy that she has an assistant to provide health care advice. Vaccination is also of vital importance and therefore each clinic has a team of vaccinators.

The particular care given by Médecins Sans Frontières to mothers and children is anything but normal. Twenty years of warfare and drought have taken an enormous toll. The health statistics for Afghanistan make depressing reading. UNICEF states that the infant mortality rate reaches 165 per 1000 births. For every 1000 child born, 257 die before they are five years old.

The condition of women is very disturbing. Under the Taliban they had almost no access to health care. A recent study shows that the country still has one of the highest pregnancy death rates in the world: for every 100,000 births, 1,600 women die during delivery or as a consequence of pregnancy. Women are exceptionally hard hit in this country. The doors of health care centres and schools were closed to women for a long time, and a great many of them are now war widows in charge of a family, whom they have to feed and care for. These doors are now opening and there is some improvement in sight.

Fighting deadly childhood diseases
Weak and starving children are easy prey for the most common childhood diseases which in a country like Afghanistan often lead to fatal outcome. Measles alone kills 35,000 children here every year, the highest mortality figure in the world for this decease.

This is why vaccination is a top priority for Médecins Sans Frontières in health care. The organisation reached an agreement with UNICEF and acts as a partner to implement the UN Immunisation Programme in all their clinics (Expanded Programme of Immunisation).

Inoculation against the major childhood diseases took a dive during the nineties. The figures are now improving again which means that a larger number of children can make a better start in life. According to UN reports for the year 2002 alone, 11 million children between six months and 12 years old were vaccinated against measles, and more than five million in 2003. Coverage stands at 96%. And more than six million children got their shot against polio in 2003, a coverage of 95%.

Médecins Sans Frontières vaccinates children against six major diseases: measles, polio, tuberculosis, diphtheria, whooping-cough and tetanus. Women of child-bearing age (15-45) receive the Tetanus Toxoid vaccine to avoid transmission to new-born babies. Tetanus is the most critical deadly disease in new-born babies who were born in unhygienic conditions.

Tetanus vaccination gives women significant protection after three injections (second shot after one month, third shot after six months) but they will enjoy lifelong protection after the fifth injection. “The majority of pregnant women come to get their first and second shot, and even the third ”, says Médecins Sans Frontières-representative Tanja Ducomble, “ but many don’t turn up for the fourth and fifth injection. They are often too busy or find the distance or transport facilities a hindrance. But at least the first three shots give sufficient antibodies to their baby via the placenta. A new-born baby will therefore enjoy enough protection until he can receive his own injections.

An active role for mosques
In Western Afghanistan lies Qaysar, a dusty provincial town hidden at the feet of the snow-topped Terband-Turkistan mountain range. Between white-flowered almond trees lies a small Médecins Sans Frontières clinic providing medical care to the local population. In Sofi Gala, a hamlet just outside Qaysar, a team of Médecins Sans Frontières vaccinators is at work this afternoon. In a large room with open doors looking onto the village square are Amanullah and Mohammed Naim, two young men sitting on a carpet with all their vaccines and paraphernalia.

It all begins good-heartedly with a cup of tea. Mohammed regularly walks through the village with a megaphone and invites people to come along. This morning there are eight women and 11 children, and another mother just comes in. While Mohammed prepares the injections, Amanullah gives everyone pictures illustrating the usefulness and benefits derived from vaccination. The name of the patient and the treatment are written in the patient list systematically established by vaccination zone so that vaccinators know who has received what and which shot he or she still requires. Patients who, according to the list, still require a vaccine but didn’t turn up are visited at their home after the vaccination session.

The system is simplicity itself and it works, especially when the mullah from the local mosque co-operates. Although it is not always the case, almost all mullahs do so in this district. From the 140 villages in this region, according to Tanja Ducomble, a nurse working here for Médecins Sans Frontières, only one single mullah refuses vaccination in his village due to the shortage of female vaccinators. Médecins Sans Frontières also provides many of them with a short training course on the symptoms of contagious diseases such as cholera so that in case of danger they can immediately send the people to hospital and inform Médecins Sans Frontières in time. It makes them sensitive to the advantages of prevention.

Abdul Satar (34), wearing a radiant white turban over jet black hair, is the young mullah in charge of this village and heartily welcomes the vaccination team. “This work protects our women and children. Who would not appreciate it?” he says friendly. “Médecins Sans Frontières informs me that they are coming so that I can inform the villagers with the loudspeakers at the top of the minaret and encourage them to co-operate.”

There are indeed many mullahs like Abdul Satar, which does not mean that it’s always plain sailing. The shortage of female vaccinators and trained medical staff is generally the most serious hindrance in our work. But even women who have studied how to do this work don’t always get permission from their families to actually work. They must often agree to be attended by a muharram, a male relative who accompanies them everywhere, which makes some activities virtually impossible. In a country where women don’t even ride bicycles, it is at best difficult to find female vaccinators prepared to do the job unaccompanied and on foot. On the other hand our male staff are not always allowed to take care of female patients. The male relatives of the mullah’s wife might prevent it or the woman herself might be afraid to let it happen. Although things are a little easier in cities, these deeply-rooted cultural traditions and customs explain why many women in the isolated countryside are still deprived of basic health care.

Photo © Carl De Keyzer/Magnum Photos Waiting room for female patients in the Baghlan Fabric clinic, Pul-i-Khumri region. Photo © Carl De Keyzer/Magnum Photos Sediga is doing health education in the Qaysar clinic. She's adressing a group of women.

Pulse-campaigns, a new vaccination concept
With a view to working systematically, Médecins Sans Frontières has recently drawn their vaccination zones in three concentric circles. The inner circle is a five-kilometre radius around the clinic itself and patients can walk to the clinic to get their injections.

The middle circle covers the area from 5 to 10 km around the clinic which is visited all year round by mobile vaccination teams on bicycles. Each team consists of two vaccinators and a health adviser. They make sure to visit the same places regularly to ensure adequate follow-up. “Vaccinations usually take place around the mosque,” says Tanja Ducomble. “This is the central place of public life and the mullahs can use their influence to encourage the population to have their injections.”

Finally the outer circle, starting 10 km away from the clinic, is the territory of the pulse campaigns. The principle is simple and ingenious. This vaccination zone is divided into four sub-zones, each with around 20 mosques and surrounding territory. With adequately manned vaccination teams, a complete sub-zone can be covered in one week, then the teams move to the next sub-zone. This rotation means that every sub-zone is visited every other month for the following vaccination. The outer circle is thus completely dealt with after three months.

“When diseases broke out in the past, UN vaccination campaigns were sometimes too limited when vaccinating people against that one disease without further foresight,” says medical co-ordinator Krist Teirlinck. “The result was that illiterate people believed they were immune to all possible diseases with that single shot. People then stopped turning up for vaccination campaigns against other diseases which then had free rein again. The pulse campaigns have a wider scope and vaccinate against all the most important diseases in one go. The rotation system of visits coupled with a systematic public information ensures the necessary follow-up of the population.”

Health guidance and education for mother and child
Mother and child health (MCH) is more than vaccination alone. Education is of vital importance in bringing the basic principles of good health to the female population. In every Médecins Sans Frontières clinic patients have to go through the waiting room or the MCH-worker’s office before seeing the doctor. The waiting time is used to organise group sessions.

Illiteracy is the greatest hurdle to overcome in improving women’s situation in Afghanistan. When the Taliban regime was overthrown in 2002, 79% of women and girls were unable to read. Médecins Sans Frontières information sessions, therefore, use simple drawings and photos.

Sediga is an older Afghan woman in charge of education in the Qaysar clinic. Like all educators she receives on-going training from Médecins Sans Frontières. Today she explains how injections work, by showing simple sketches and samples of vaccines, and a few basic rules of hygiene. She goes over the most common childhood diseases. Six women with children on their laps listen carefully in the small room. Questions and opinions are mostly voiced by the older women. “And next time don’t forget to bring the women of your village who didn’t come today,” she finishes with a smile, after about 20 minutes. On their way out they each get a little cross marked on their hand to show they have attended the educational session and the doctor won’t send them again.

“There is some progress,” says Sediga. “The most important questions naturally keep coming back. Women want to know how to breastfeed properly or why they don’t yield enough milk, they want information on contraception, pregnancy, balanced diet. I think that women are slowly but surely reaching a better level of education. They also talk to other women. It obviously takes time to change mentalities and family habits. Children often have a poor diet because mothers fed them only breast milk until they were two years old. I need to explain when to start with solid baby food and how they should diversify their ways of cooking and prepare different mixes of vegetable to enrich the diet. Or then I talk about the dangers of the old customs. Some women continue to mix finely chopped dried poppies in their baby’s milk so that they would sleep all day and not disturb their work of carpet weaving. That kind of thing. We have a long way to go, but we have already achieved a lot of good work.”

Lailuma (37) agrees. She has been an educator for 15 months and works at the Bagh-i-Shamal clinic in the Baghlan province. She also believes awareness is on the increase. “Some women come from kilometres away in the countryside to visit the clinic,” she says proudly. “I begin every session by canvassing for the most worrying topic of the day and I build my educating around that.” Many women come with their children. Lailuma also does MUAC tests during her work (Middle Upper Arm Circumference). These measure the circumference of a young child’s upper arm and is used for early detection of malnutrition, as outlined in the Médecins Sans Frontières emergency operation plan.

Those who followed the educational session can then consult the midwife or the doctor. Pregnant women come every two months for pre- and post-natal check-ups. There are still quite a few women suffering from anaemia due to their bad diet and we improve matters with distribution of extra iron and multivitamin pills. Hypertension is also frequently diagnosed. The midwives try their best to prevent premature births. Complex cases and complications are identified so that the patients can be sent to the district hospital in time.

“Just as we do during the educational sessions, a lot of attention is given to family planning and contraception means during consultations. Some women have had up to 14 children
but contraceptive measures do not fit in well with their conservative society,” says Dr Marzia. She supervises mother and child care in the four Médecins Sans Frontières clinics around the city of Pul-i-Kumrhi. “Many mullahs are also against it. The social pressure of bearing children remains very high.”

Working in the villages
Rozia is sitting in the waiting room of the Bagh-i-Shamal clinic. She believes she’s in her mid-30s but she’s not sure, she says with a blush. She has three children, the last one was born in this clinic. They have all received their vaccinations here. She’s beaming as she says that and she has reason to. In Afghanistan, one woman out of nine dies before the age of 45 during delivery or as a consequence of giving birth. The infant mortality rate is 165 per 1000 births, an alarmingly high figure.

“One of the most common reasons for this high infant mortality rate is the appalling conditions in which babies are born,” says Dr Marzia, a 34-year-old Afghan who works for Médecins Sans Frontières in Pul-i-Kumrhi. “Some women give birth with the midwife in the clinic but the majority do it traditionally at home. During their eighth month of pregnancy those who come to consult receive a childbirth kit with some soap and a sheet of fabric, a clean, unused, razor to cut the umbilical cord, compresses and eye-lotion for the baby. Alas, in the countryside women still very often give birth in the stables between the cows and their droppings on the floor. The umbilical cord is often severed with a rusty pair of scissors or a sharp stone which inevitably cause infections.”

Médecins Sans Frontières is trying to improve access to health care and, in order to have more impact has been working for a few years with local midwives known as traditional birth assistants or TBAs. In Afghanistan they are called daias.

The daia tradition
“Daias are mostly somewhat older women who traditionally help with births in villages and are therefore rather well-considered, ” says Dr Marzia. “They have no formal training and they hone their skills as they practise. They used to help midwives when they were young girls and eventually became daia themselves.” Médecins Sans Frontières intends to build on this tradition and started training these midwives.

Médecins Sans Frontières launched a regular training programme for TBAs in September 1997. They already work with 250 daias in the Faryab province alone. The vast majority are illiterate and their tuition needs to be practical, with demonstrations, discussions and role plays. During their three-week course they learn about menstruation and conception, characteristics of pregnancy and diet, diseases and hygiene, and pre & post-natal health care.

“Special attention is naturally given to childbirth itself ”, says representative Tanja Ducomble. “The midwives learn how to perform safe deliveries and how to foresee problem situations so they can be prevented in due time. They are briefed on how to bind the umbilical cord hygienically, and learn about placenta and how to stop haemorrhages. We also provide information on the most common diseases and the principles of vaccination. After six months they are invited to take a refresher course.”

Each TBA receives a childbirth kit with standard supplies to perform her duties. Its contents are kept as simple as possible. For example they don’t use expensive imported special thread to bind the umbilical cord but plain cotton thread available from any local bazaar. Médecins Sans Frontières teaches them how to sterilise and use them. They can thus re-supply their kit themselves even if Médecins Sans Frontières should leave the country.

Midwives visit pregnant women at home and direct them and their children to the nearest clinic for controls and vaccinations (childhood diseases, tetanus). After birth, they follow the mother and infant for as long as necessary. These traditional midwives are often the only people to have access to Afghan families and households and their status allows them to talk to young and old alike, so they fulfil a very important role in dispensing general health care information on common diseases like airways infections, bouts of fever or prevention and treatment of diarrhoea.

Sarvnaz, a 42-year-old daia with a smiling dark wrinkled face, performed her last child delivery seven days ago in a remote village. “A baby boy! I was quite alone with the woman, but everything went fine,” she says with satisfaction. She lives in Arzolig Payan, a neighbouring village, and she’s a well-known face in the area. Women send for her when they feel the time has come to give birth. “I used to do deliveries on the bare ground and used to pile up some earth under the mother’s pelvis to soak up the blood, but now I know better”, she says. The most common problems she has to face are post-natal bleeding for which she uses cold compresses on the abdomen. Only once did she anticipate a problematic delivery and call for a doctor.

Shajan (41) is a daia from Pul-i-Kumrhi, and she learned the ropes from her mother who also was a midwife. She remembers the old daias scattering charcoal under the mother when she was ready to deliver. She received her Médecins Sans Frontières training five months ago, an asset she keeps coming back to. “I use the social events in villages to spread health care information,” she confides. “In spring there is the samonak – a typical spring dish prepared by the whole village and shared during the celebrations. Or wedding ceremonies. There always comes a time during these festivities where women will talk about children and pregnancies, and that’s the perfect time to hand out tips and information!”

Photo © Carl De Keyzer/Magnum Photos Two MSF teams crossing each other in the desert between Mazar-i-Sharif and Maymaneh. Photo © Carl De Keyzer/Magnum Photos Bagh I Shamal clinic, Pul-i-Khumri, Baghlan province.

Daias, mullahs and jinns
Islam attaches great importance to a healthy lifestyle and the mullahs often play an important part in the traditional health care system. They have special prayers and charms (tawiz) to prevent diseases, and these are often of very important emotional assistance to community members.

“I know of mullahs who blame the jinns for epileptic fits and tetanus infections. Jinns are supernatural invisible creatures mentioned in the Koran. Jinns can inflict illnesses on people or animals. Hard-line mullahs try to cure patients by isolating them for 10 days reciting the Koran in a dark room. It goes without saying that the lack of proper treatment can lead to fatal complications,” says Dr Marzia. “On the other side, some mothers come to us for vaccination because ‘they protect against attacks from the jinns’ ”.

Lack of information can have an evil effect on health care. However progressive some mullahs can be, others are still convinced that eating fish can induce miscarriages, or that young children who eat too many eggs will become stammerers. Just a sample of the enormity of the task that lies ahead for Médecins Sans Frontières.

Midwives regularly share their experiences. “It is not simple to follow every midwife closely,” says Dr Marzia. “Many of them work in very isolated places. Nevertheless, supervision and constant management is indispensable. We therefore ask them to come and see us once a month at the clinic for evaluation and updating. It is also important to see that they don’t exceed their role or substitute for doctors.”

Twenty years of warfare have annihilated health care in this country and there is a dire shortage of properly trained Afghan staff. “With the lack of formally-trained midwives, working with the daias is a good temporary solution,” says Krist Teirlinck. “They raise the level of mother and child care higher than it previously was, and they play an important role in identifying the problems. Since we started working with them, women are sent to our clinics sooner.”

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