Written evidence submitted by EMERGENCY (AFG0037)
EMERGENCY is a humanitarian organisation that provides free, high-quality healthcare to victims of war, poverty, and landmines, alongside building hospitals and training local staff. We pursue a human rights-based medicine. The right to be treated is a fundamental and inalienable right belonging to everyone, and our model is based on equality, quality, and social responsibility.
In Afghanistan: EMERGENCY has been present since 1999. EMERGENCY started its work in Afghanistan by opening a Surgical Centre in the Panjshir Valley. We wanted to offer free treatment to the victims of the war between the Taliban and the Northern Alliance, and of the landmines laid during the Soviet occupation. We later went on to open a Paediatric Centre and Maternity Centre next to the Surgical Centre in Panjshir.
In April 2001, we opened the second Surgical Centre dedicated to war victims, in Kabul, still in the hands of the Taliban, and in 2004, the Lashkar-Gah Surgical Centre, in Helmand province, in the south of the country.
All our hospitals are linked to a network of 44 First Aid Posts and Primary Healthcare Centres in 31 districts to ensure the stabilisation and rapid referral of patients in need of urgent care.
This written evidence will focus on themes referred to within the following questions, as set out by the inquiry:
- What are the humanitarian and human rights implications of the Taliban takeover? How can the UK support those at risk – particularly women and girls – both in the immediate and longer term? What steps is the Government taking to do this?
- What does the withdrawal from Afghanistan mean for future UK foreign policy, including relations with the US, the Indo-Pacific tilt, and the strategic approach to overseas aid?
The impact of the conflict on EMERGENCY’s medical facilities
- Statistics of patient injuries from our medical facilities show that the security situation has been deteriorating in Afghanistan over the last 20 years and particularly in the last few years.
- In 2001, our hospitals treated 686 war victims, in 2020 that number was 5,021, a 632% increase. The worst year was 2018 with 7,106 war victims. 40% of war wounded treated in our hospitals are women and children. In 2018 there were 1,887 war wounded children treated in our hospitals. An average of five every day.
- Over the past 20 years, our three main hospitals had hoped to develop into facilities specialising in treating civilian trauma injuries, but instead have had to continue to work to treat patients with increasingly complex war injuries.
- This is due to increased aerial bombardment, the indiscriminate use of improvised explosive devices and the shifting of frontlines towards urban centres rather than rural areas. As a result, our Afghan specialists, trained to international standards, have had to acquire new skills to deal with multiple devastating injuries.
- Afghan and international troops contributed to the death toll. The 2010 Afghanistan Rights Monitor reported that 12% of civilian deaths were attributable to Afghan forces and 21% to US or NATO forces caused initially by aerial bombardment, and later by drones. According to official US military sources, 2019 saw the highest number of bombs dropped in Afghanistan since records began in 2006: 7,423, eight times those dropped in 2015.
- There has also been a dramatic escalation in the number of attacks against vulnerable and highly visible targets, which aim at capturing media attention. These attacks have also highlighted, since 2015, the entry onto the scene of the Afghan conflict of Daesh, now known as ISIS-K, in open competition with the former Afghan government and Taliban forces.
- It is ISIS-K who claim responsibility for the attack at Kabul airport on 26 August, when EMERGENCY received more than 60 casualties. Sixteen were already dead on arrival due to the severity of their wounds. The total death toll was more than 180.
- At the beginning of 2021, in the capital alone, an average of three attacks by Non-State Armed Opposition Groups were recorded every day. In 2021, our Surgical Centre in Kabul has already recorded 16 mass casualty incidents, with 286 patients treated as a result of these incidents alone.
- The respect for the neutrality of health facilities has decreased over the years. We have experienced violations also in our facilities, manly the most remote and rural ones.
- In a recent report on our activities that provide services for maternal and new-born health in Panjshir, 40% of patients surveyed said that safety was the main barrier to accessing care. This illustrates that the impact of war on civilians goes far beyond the deaths and injuries directly related to the fighting.
- Since the Taliban takeover in August 2021, EMERGENCY’s Surgical Centre for war victims in Lashkar-Gah has opened its admission criteria to civilian trauma, while patients, particularly women, have resumed referring to EMERGENCY’s Surgical, Paediatric and Maternity Centre in Panjshir. Security conditions are still strained in Kabul, where the Surgical Centre for War Victims continues to treat war victims, manage mass casualties and receive patients from afar due to the collapse of the health system.
- We believe the data we have collected shows a clear trend of deteriorating security over the last few years. Understanding the nature of injuries and kind of violence that is being experienced offers irrefutable facts about the security context of a country. We recommend that the UK and other international actors support the gathering and analysis of data such as this (anonymised and aggregated) and help facilitate their sharing widely in order to better understand the security context in complex environments such as Afghanistan. This information should be shared also among decision makers when considering military intervention or evaluating the impact of military interventions.
Humanitarian impact in general
- In these 20 years, despite twelve-figure bilateral and multilateral investments in the conflict, terrorism has not been beaten, but has adapted, in the country and around the world. There are almost four times as many Islamist militants today as there were on September 11, 2001, and nearly 100 Islamist extremist groups remain active. The presence of ISIS Khorasan, which is openly opposed to the Taliban, is particularly concerning.
- Insecurity and corruption have progressively increased in the country. The corruption perception rate monitored by Transparency International ranks Afghanistan 165th out of 179. At the same time, dependence on international aid has increased, as has crime, sex work and drug trafficking. It is precisely the fight against this "social degradation" that has enabled the Taliban to maintain the support of rural communities, especially the Pashtun population, in a large part of the country.
- The situation in the country is uncertain and close to economic collapse. Cuts in donor support to the country’s largest health project, Sehatmandi, has left thousands of health facilities without funding for medical supplies and salaries for health staff. The Sehatmandi project has been the main source of health care in Afghanistan, through more than 20,000 health workers at 2,309 health facilities in 30 out of 34 provinces. In 2020, more than 30 million people benefited from it. Only 17% of all Sehatmandi health facilities have been fully functional since the Taliban seized power. This had a rippling effect on the availability of basic and essential health care, as well as on emergency response, polio eradication, and COVID-19 vaccination. Efforts are underway to restore the Sehatmandi project; the Global Fund has provided $15 million for three months, of which nearly $8 million was used for salaries for health workers, while much of the rest was spent on providing basic medical equipment, essential drugs and supplies. However, more efforts are urgently needed to meet the health needs of Afghans.
- Afghanistan’s reserves are frozen, the banking sector is paralysed and the liquidity crisis is worsening. EMERGENCY’s employees have been working for weeks without receiving a salary due to the impossibility of making unrestricted withdrawals and transfers from Afghan banks. These difficulties have been also affecting the payment of local suppliers who play a crucial role in supplying our hospitals; the most critical supplies are fuel for generators and ambulances, food for staff and patients, medicines, and oxygen.
- Humanitarian flights by the UN have been partially reactivated over the capital. The UN provides five flights a week to Islamabad, where obtaining the necessary visa has been difficult for many nationalities. Commercial flights have been suspended. Land borders are open and shipments of materials essential for the maintenance of humanitarian aid are slowly resuming by container and cargo.
- It is essential to urgently provide protection and humanitarian assistance to the 39 million Afghans remaining in the country. We recommend the UK Government show their support by contributing to the Urgent Appeal launched by the United Nations (UN) to reach USD 1.2 billion in humanitarian aid and development cooperation.
- We recommend that the UK Government uses their leverage in Afghanistan and with its international partners to quickly deliver humanitarian aid to the population in need. Key to this will be to help restore full functionality in banks, allowing unrestricted withdrawals and transfers. This will provide practical support to the humanitarian operators who remain in Afghanistan.
Bridging humanitarian response and development
- In 22 years of work in Afghanistan, EMERGENCY has spent approximately 133 million euros raised from private and institutional donors and from the Afghan government, which has contributed first $1.5 million and then $2.5 million to the running of EMERGENCY's activities in the Panjshir Valley since 2012. With this sum, in addition to treating millions of people, we have trained new specialist doctors and health personnel, and currently employ around 1,500 Afghans. These funds, spent over two decades, are comparable with the amount needed to keep a small contingent of soldiers in the country for a year.
- In 2012, our hospitals were recognised by the Ministry of Health as specialised post-graduate training centres in surgery and gynaecology. In 2015, recognition was added for specialisation in paediatrics. In eight years, we have trained over 60 residents. The specialisation programme in gynaecology is exclusively for women. Practising gender equality in Afghanistan, even in areas not under Taliban control, has never been easy. Our Maternity Centre in Panjshir was the first free facility dedicated to women in the entire province, but already a few years after the start of clinical activities, it has become a reference for the neighbouring provinces as well.
- The report ‘A Quiet Revolution’, published by EMERGENCY in 2019, highlights that 58% of the all-female staff at our Panjshir Maternity Centre are women who were the first to work in their families, and 53% said they were the highest earner in their families. The women workers said they had acquired a more respected social status in their community and a decisive role in decision-making processes within the home, and often outside. Their presence also contributed to raising awareness of maternal health among other women in their village or neighbouring areas, as well as their husbands and male relatives.
- Today, these women continue to work with us and provide life-saving care to Afghan mothers. This has not changed and we are determined that it will not change in the future. Health is in fact one of the few sectors for which the new de-facto government has expressly allowed the participation of female staff.
- As well as fostering the provision of healthcare, providing jobs and vocational training is a key element to rebuild a country devastated by conflict. It means creating development, restoring dignity and hope, improving services, and laying the foundations for a healthier social fabric.
- We recommend that the UK government commits to supporting the development of Afghanistan’s healthcare system. Investing in health must also be a priority in order to give the Afghan population a future, rebuilding essential services and offering jobs, including to women. It will be crucial to preserve this sector, to protect the rights of everyone to be treated and of people of all genders to have access to training to build their independence and professional dignity.
- The credibility that we have built up through our work over the past 22 years has allowed us to keep the channel of dialogue open with all the actors on the ground, while respecting the different cultural sensitivities. We have met with the new Taliban authorities, and with the Ministry of Health in particular. We have shared our approach with them and reiterated the importance that our staff, patients, facilities and ambulances do not become a military target, while respecting the principles of neutrality, impartiality, independence, and humanity. To date, there has been no attempt to break this commitment.
- Neutrality, independence, and impartiality is what allows EMERGENCY and other humanitarian organisations to do our job in conflict zones. Respecting and supporting these principles, which underpin humanitarian work, and allowing organisations such as EMERGENCY continue to do our work uncompromised by political agendas, is the most important action that all governments, including the UK Government, can take.
 ARM Annual Report Civilian Casualties of War January-December 2010 https://reliefweb.int/sites/reliefweb.int/files/resources/4F00E4279B04731A4925782A00212588-Full_Report.pdf
 US dropped record number of bombs on Afghanistan last year, The Guardian, https://www.theguardian.com/us-news/2020/jan/28/us-afghanistan-war-bombs-2019
 Special Focus: 11 September 2001-2021: The World 20 Years Later, Institute for International Policy Studies, https://www.ispionline.it/it/pubblicazione/11-settembre-il-mondo-20-anni-dopo-31597
 Corruption Perception Index 2020, Transparency International Index, https://www.transparency.org/en/cpi/2020/index/nzl
 Acute health needs in Afghanistan must be urgently addressed and health gains protected, WHO https://www.who.int/news/item/22-09-2021-acute-health-needs-in-afghanistan-must-be-urgently-addressed-and-health-gains-protected
In test, U.N. skirts Taliban to pay Afghan health workers, Reuters, https://www.reuters.com/world/asia-pacific/test-un-skirts-taliban-pay-afghan-health-workers-2021-11-10/