Ending the cycle-turning crisis into opportunity in Afghanistan: humanitarian aid efforts can help create community self-reliance.

Afghanistan teetered on the edge of the abyss even before the bombs began to drop. While watching war coverage on TV, one is barraged by a numbing litany of appalling health statistics: one of four children does not survive to the age of 5, only one in five Afghans has access to clean water, maternal mortality rates are the highest in the world, life expectancy is in the low 40s—it goes on and on.1,2 Last summer, the harvest failed again, and between the threats of starvation and bombing, countless Afghans left their homes to join a swarm of internal refugees looking for a haven that didn't exist. The crisis, though, has presented an opportunity. Although the situation remains volatile and unpredictable, a massive aid effort has been mobilized. Many Afghans are still at risk of hunger, exposure, and disease, but their numbers are far less than the 7.5 million estimated by the United Nations in late September.3 The magnitude of resources and proposed effort is unprecedented, and now the flickering prospect of peace creates the possibility that this aid can lead to lasting change. Where to begin is a hard question for health professionals. We are not prepared to deal with chaos and starvation, and our best efforts disappear into a gaping maw of endless need. If we step back and take a triage approach, Afghanistan's most critical health needs are food, stability, and the rebuilding of civil society. In recent years, war and drought have created a disastrous synergy: the drought multiplies the effects of 22 years of war, and ongoing political chaos disrupts the famine relief efforts. In the absence of the institutions and infrastructure that make up civil society, little can be done to create lasting change. Stability, the availability of food, and the rebuilding of civil society are intertwined goals. To create the stability needed to break the cycle of crisis, food must be delivered in a way that keeps people in their homes and that starts the long process of rebuilding. In the fall of 2000, I traveled far into the remote central plateau of Afghanistan to visit a project that was taking an integrated and proactive approach to crisis by using famine relief as a way to jump-start the rebuilding of civil society. UN wheat trucked over the high mountain passes from Kabul served as a catalyst for mobilization around community projects and the revival of decision-making councils. Assured that they could survive in their villages, people began to invest in their future again. With something productive to do, Kalashnikov-toting young men left their gangs and joined other men to rebuild their community infrastructure. Experience in China, India, and Peru shows that similar processes of building self-reliance through community mobilization can grow rapidly when they are part of a well-designed strategy that is supported by leaders and outside experts.4 This sort of integrated grassroots approach is what is needed to tackle Afghanistan's ongoing health crisis. Afghanistan's most important resource is its capable, resilient people. There are no effective central institutions to provide a framework for rebuilding, and only local institutions and groups have continued to function through years of chaos.5 In the end, a process that gets the community organized and mobilized may be the only way to address major health needs in a lasting way. Groups of mothers can learn to treat the two leading killers of young children, diarrhea and pneumonia, without health professionals. They can be taught simple but state-of-the art methods like cerealbased oral rehydration therapy and pneumonia algorithms based on counting respiratory rates (Carl Taylor, Dept of International Health, Johns Hopkins University, oral communication, March 2001). Effective vaccination campaigns and lasting solutions to water and sanitation problems must be based in community organization. To maximize food production while avoiding ecosystem collapse requires organization and decision-making skills. In the far-flung villages of Afghanistan, no one is available to provide services, and the mobilization around urgent health needs is an ideal way to build self-reliant local infrastructure. As health professionals, our challenge is to understand the root causes of Afghanistan's health crisis, the limitations of our own training and approach, and the nature of the efforts needed to bring lasting health to Afghanistan. Organizing, mobilizing, and teaching may be the skills that leverage resources into change. There is a window of opportunity to influence planners and policymakers; health professionals and citizens need to advocate for aid that is done well enough and long enough. If we take advantage of this historic opportunity, the people of Afghanistan may be looking at a brighter day than they've seen in a long time.