February 21 to March 1, 2003

From the Editorial Desk: Prior to the war in Afghanistan, Pakistan offered a temporary home to 3,321,161 Afghan refugees – the second largest refugee population in the world, after the Palestinians. Since the fall of the Taliban regime in Afghanistan, over 1.6 million refugees have returned home, but well over a million still remain. Pakistan would like to see them leave, but as Mary explains in this, the third of her diary excerpts, it is not that simple. Late in February, Mary visited three refugee camps near Peshawar – Jalozai, Manshera and Zanday. She found that three quarters of the refugees are women and children, and that widows in particular prefer the security they know in the camps to the uncertainty of life back in Afghanistan. The fact that they have access to medical services in the camps gives them an added incentive to remain. This is in spite of the fact that medical services are – by any normal standards – extremely basic. In Zanday camp, Mary was able to talk to 40 pregnant women who had just finished a course in reproductive health care. Her conclusion – that they had known depressingly little about their own bodies, and needs, when training began. This is the case for the vast majority of refugees remaining in Pakistan. It is one more reminder that many Afghan women remain desperately vulnerable and in need of support.

Keeping the peace: Hajidost Mohammed, elder at Jalozai camp

Rumors of a forced repatriation at Jalozai Camp piqued my curiosity and I traveled there with two other journalists, both Afghans, to check out the situation. The rumors turned out to be false. The trip to the camp, however, gave me a chance to explore some of the reasons why many of these refugees would prefer stay in the squalid conditions of the camp than to return to Afghanistan.

Jalozai is home to 20,000 refugees who live in mud houses, squeezed together on a 10-square-mile area an hour outside of Peshawar, just off the main road to Islamabad. Most of the refugees are from Afghanistan’s Paktia and Kunar provinces.

When we arrived in Jalozai, we went first to see Jameel Uddin, a representative of the Pakistani government and administrator of the camp. After a careful conversation about the services provided in the camp, I asked him about allegations that Afghan refugees were being forced to leave. He denied the rumors, although he said that approximately 6,000 families left Jalozai for Afghanistan between June and November of last year. “The cold season started and now people are coming back,” said Uddin. “But if they leave, they leave voluntarily.”

Uddin said that most of the refugees who leave the camp do so to collect the money that UNHCR pays in relocation fees, a story I have heard many times. UNHCR pays $10 in relocation fees to families that go to Jalalabad and $30 for those who go to Kabul.

Refugees have been known to go back and forth over the Afghan border to collect as much in fees as they can and, in the past, UNHCR had almost no way of keeping track. A few months ago, however, UNHCR initiated a program to scan the irises of refugees who accept the relocation money. Each refugee is allowed to collect only once.

In spite of this, many of the people who left Jalozai camp have returned since the UNHCR started the iris-scanning program – at least half, Uddin said. And so far, he said, the refugees are staying.

In many ways, the refugees in Jalozai have it better in the camp than they would have in Afghanistan – and they are the first to admit it. They have electricity, access to water wells, and a sewage system that may not be complex but is at least functional. And just down the road there is a commercial district and a busy bazaar where the refugees can buy food and supplies.

Security in Jalozai is good, Uddin said, adding that he and the Pakistani police drive around the camp several times daily to keep a check on the situation. Uddin said he certainly wanted to avoid any security problems at “his” camp, but he acknowledged that an outbreak of unexpected violence always is a possibility. “These are former Afghan soldiers,” said Uddin. “You have to watch them.”

There are four Basic Health Unit facilities in the camp and eight primary schools in Jalozai. The Jihad Hospital has been operating in the camp for 20 years, dealing mainly with diarrhea, dysentery, respiratory infections and tuberculosis, said Dr. Mohammed Amin, who runs the Jihad Hospital.

This month, the Al Khidmat Welfare Trust, a Pakistani NGO, will provide another doctor and provide prescription medicine from its dispensary to children. The NGO Afghan Women’s Resource Center runs a pregnancy and reproductive health program.

What the Widows Say

About 20 minutes into the conversation with Uddin, he began to shut down. I am not sure if it was my question about forced repatriation or if he simply got tired of the conversation. For starters, he refused to allow discussions to be recorded on tape.

A request to record was not part of the permit to visit the camp, he said. We read the permit together and, while it did not specifically mention taping, it did make clear that the purpose of our visit was reporting. I did not push the issue.

Then Uddin said that none of the refugees would be available to see reporters on a Friday afternoon. The men “are getting ready for Mosque,” he said, and the women would be uncomfortable with visitors if the man of the house is not present.

So we asked to see Hajidost Mohammed, the camp elder, who we thought might be able to make arrangements for us to visit with some of the refugees. In the end, Uddin agreed and allowed us to travel inside the camp, but only if we were accompanied by an armed Pakistani police officer.

Mohammed lives in a remarkably nice house in the camp which is made of concrete, not mud. His house stood in stark contrast to the rest of the camp, yet it seemed fitting for the man who is the highest-ranking camp elder. He arranged for us to meet with two women, cousins, who are widows and have been living in the camp for about 20 years.

They two couples left Afghanistan when war broke out between Russia and Afghanistan. “We had nothing, no safety,” said Ameena, 30. “We were scared about coming here, but they were telling us that people from Afghanistan were treated well here. Therefore, we came.”

The husband of one of the women, Daljan, died 13 years ago. He served as a commander in the Afghan army, even as he and his family were living in the Jalozai Camp. “We received his dead body,” Daljan said. Ameena’s husband died 14 years ago. He worked on electric production for the camp and was electrocuted on the job.

Until last year, the two women said, refugees were receiving aid packages – sugar and grain, for example. Now, rations to the older camps have been stopped and the women rely on handouts from relatives. Still, they said, Jalozai Camp remains their best option. “If there was aid again, we wouldn’t say no,” said Ameena. “But if there is none, we will pray to God for help.”

In Jalozai Camp, they pointed out, there are schools for their children and health services – and all of it is free. “I hope for my daughter to have even more progress than my son,” said Daljan. “I want her to have good schools, good education. I don’t want the same for her as I had and then her to be illiterate.”

“We wish we could be literate,” said Ameena.

In contrast, the women said, Afghanistan holds no opportunities at all. “It’s like a desert there for us,” said Daljan, 35, referring to Afghanistan. “No home. Nothing. Here, it’s freedom for us. We’d like to go back to our own country. But we have no facilities there. There are no schools and no electricity in the town I’m from.”

They have not been asked by Pakistani officials to leave Jalozai, the women said, and they have no plans to return to Afghanistan. “If you have a home in your country, then you can have a good life,” said Ameena. “If you don’t have a home, what other attractive point is there in any country.”

Asked what they would do if the Pakistani government forced them to leave the camp, the women said they would go, albeit reluctantly. “If they forced us, we would react just like you would if I picked up a stick or gun against you,” said Daljan. “Even you would run.”

The Lure of Security

We left the two women and returned to Mohammed, the camp elder, who invited us to stay for lunch. He also invited the Pakistani police officer. For some reason, the police officer’s presence seemed strange to me. Maybe it was the big gun he had lying beside him. Or maybe it was the fact that he represented the “other.” This refers to the Pakistani government, which would like to see all of the refugees in Jalozai leave as soon as possible.

I asked Mohammed a series of questions as he ate, starting with his perspective on the general feel among the refugees about the services provided in the camp.

“You talked to those women, you see how they live,” he said. “You see what they need. They need everything. But the people in this camp are so happy because of the security and because they receive services. In the early years we had no schools for girls. Now we have them. People here have hospitals and clinics. In Kabul they don’t even have homes. They’ve lost their homes.”

The appeal of food: fresh food in the Jalozai market gives refugees another reason to remain in Pakistan

We discussed the rumors about a forced repatriation from Jalozai Camp, which Mohammed said he did not know anything about. But he gave me a clue as to where the rumors might have started.

This year, Mohammed said, the Afghan elders in the camp signed a three-year agreement to keep the camp open. The Pakistani government signed the agreement, too, and then threatened to renege on the deal. Mohammed explained that “someone” came from Kabul – he would not say exactly who – and met with government officials. And now the three-year agreement is back on.

Aside from the people who have been leaving Jalozai to collect the UNHCR money, he said, those who return home are those who have something to do in Afghanistan, and somewhere to go. For example, some of the refugees in the camp were part of the Northern Alliance. They are returning to Kabul for the Karzai government, working for ministers who were among the Northern Alliance leadership.

One of the benefits offered by Jalozai is security, said Mohammed. By this he meant not the security provided by the Pakistani police, which Uddin had referred to, so much as the security system that the Afghans have created.

Jalozai has a Parliament, a judicial system and a policing program. There are 174 elders in the Parliament of Jalozai Camp and Mohammed is the leader of the group. When I asked if he is the president, he laughed and said, “Yes, I’m something like that.” Asked if women are among the elders, he replied: “Women are in the home.”

The elders meet about problems in the camp and come to a group decision. Any problem the Jalozai Parliament cannot resolve, it sends to the camp authorities to handle.

“Afghan people always solve their problems through a jirga – or a gathering,” said Mohammed. “At first there was no security here. There was robbing and stealing. We have don’t have that anymore.”

When lunch was over, Mohammed asked if he could pose just one question to me. “Why are you here?” he asked. I explained that I was reporting the situation facing refugees in the camps in hopes that public attention would improve the conditions.

“That would be a good thing,” he said.

Medical Services – Poor and Expensive, but Better Than Nothing

I went to Menshera, where three old camps are located. Here I found refugees to be similarly resigned to life in the camp as the refugees of Jalozai. They wished for better, but were aware that they had more than they would in Afghanistan. Access to some services, they said, is better than no access at all.

Hanging about the clinic: Nageebullah, 9; Mohamad, 12; and Asadullah, 6. Nageebullah wants to be a doctor.

“In terms of health services, they are better off here than in Afghanistan,” said Dr. Mahd Arif Agub, medical coordinator for Church World Service, a Pakistani Christian organization that runs the health services in the camp. “There are just three or four Basic Health Units providing services for three or four provinces in Afghanistan. There are three clinics for the camps in Manshera.”

Three camps are located in Manshera: Barari, 20,000 refugees; Akhaki, 28,000 refugees, Ichrian, 12,000 refugees. The refugees in the camp are primarily Pashtun, and most of them originated from three Afghan provinces: Paktika, Nangahar, Barlan.

Many of the women in the three camps have husbands who live in the Gulf States and send money back to the family for support. Even if the women accumulated enough savings to leave the camp, they would not go, said Dr. Agub. “Their family is here and they feel safer here,” he said.

During my one afternoon in Menshera, as the rain poured and the temperature turned chilly, I explored the medical services available to women in the Akhaki camp. If services are what make life in the camp better than returning to Afghanistan, I wanted to see the type of health services they are receiving.

Two days a week are set aside for female visits. The other days are designated for post-natal care, male patients, tuberculosis screening and treatment and malaria.

In one day, between 9 a.m. and 2 p.m., the doctor sees upwards of 140 patients. The day I was there, more than one hundred women and men clustered outside the door, sheltered from the rain only slightly by a tin overhang. There was no shelter at all from the chilly wind.

With such a large patient load, it is not surprising that the medical exams are far from thorough. Women sit on a stool next to the doctor, who sits on a chair at a folding table. I watched as a pregnant woman balanced herself on a tall stool, next to the doctor, who sat on a chair at a folding table.

The doctor gave the pregnant woman a few pokes in the stomach and a placed a stethoscope quickly on her chest, over her clothes. The doctor then scribbled some notes in the woman’s health book and sent her on her way.

No privacy. No discussion. I watched the doctor examine this pregnant woman and at least five other people were in the room at the same time.

The adjoining room was a makeshift surgical unit, where doctors perform minor gynecological procedures. The room was frigid and the only provision for heat was a small gas-tank heater that was not big enough to heat the room. I could only assume that the doctor would be the only one getting any heat during surgery.

The exam table was a simple flat board and had no stirrups. The surgical light was like a desk lamp. The gynecological tools were rudimentary, nothing I recognized. Sterilization options were not extensive: the tools were dipped into a solution and placed on a tray that sat in a dusty, locked filing cabinet.

And none of this comes to the refugee women for free. Church World Service, until recently, was charging 15 rupees per doctor visit. Now the rate is 10 rupees, and church officials are planning to reduce the price to five rupees. Apparently, UNHCR asked for a rate reduction and the church has complied.

Many of the refugees who go to this health clinic walk 4 kilometers to get there – about a half hour walk — or must pay three rupees each way for transportation. That makes a visit to the health clinic both tiring and expensive for these women. Yet, while some of them complained that they had to wait too long at the health clinic, most said they were glad they have a doctor at all.

Urbashar, 5 has a sore throat. Her mother has a sore throat too, but she has only 10 rupees for the doctor – enough for one person

Noorhaga, for one, was there with her daughter Urbashara, 5, and they had been waiting more than an hour in the cold and rain. She had spent a lot less time than most people, but more than enough for them.

The mother and daughter both had swollen glands and sore throats, which upset Noorhaga so much that she kept grabbing the hand of anyone who would touch her neck and feel the bulging gland. “Sometimes we have the money, sometimes we don’t. Today, I have only 10 rupees, so I cannot check myself with the doctor,” she said. “I only have money for Urbashara.”

She looked at the crowd of people still waiting to be seen. “Today it’s raining,” she said. “The line would grow if it was not raining.”

Haz Rabibi, 30, was close to tears. She had a back and headache problem. She had a five-month-old baby at home and her other children, all under the age of 10, were watching their smallest sibling. “I just want to cry at what’s going on,” she said. “Still we are waiting and nothing.”

At 12:20 p.m. – less than two hours before the clinic was scheduled to close – 80 people were still waiting to be seen.

Mastana, 42, was making her visit to the health clinic with her son Nugradin, who is one-and-a-half. His mother was convinced he had jaundice and, indeed, he had a yellow tinge to his skin. She only had been waiting in line 10 minutes – but they were 10 frustrating minutes. Staff at the health clinic told Mastana that she had brought the wrong medical record for Nugradin.

So she had to walk back to her home, another 10-minute walk in the rain, get the correct medial card, and trek back to the health clinic again. “I’m not satisfied,” she said, her words not conveying the frustrated look on her face.

Angoura, 30, was one of the happy ones in the crowd. She went to the clinic complaining of pain in her throat and teeth pain. After waiting an hour, she left the doctor’s office with pain tablets in her hands – not a cure, but at least something that would relieve the pain.

“They’re good with us,” she said. “I’m happy. Asked if she minded the long walk to the clinic, the long wait and standing outside in the cold, Angoura shrugged and said, “We’re a needy people.”

Zhakihila, 20, and Zainaba, one-and-a-half, arrived at the clinic at 8 a.m. They were still waiting four hours later and did not know why. “There are lots of people here and we’re cold,” she said, lifting up the cloth of her dress to show the thinness of the material. “But what should we do?”

Then there was Nageebullah, 9, a grinning boy who seemed to know everyone and who was hanging outside the clinic. Just hanging…

According to clinic workers, Nageebullah shows up just about everyday. Asked why, Nageebullah said he wants to be a doctor. He thinks the services provided by the camp clinic are good, but he thinks he can do as good a job – if not better. “I’ll do my best to study,” he said.

Teaching Refugee Women About Their Bodies

Nowhere is the need for good doctors, more services and basic health education for women more apparent than among those who are pregnant.

Dr. Malalai teaches reproductive health to pregnant women in the Zanday refugee camp

Refugee women lack knowledge about their own bodies, as I discoverd when I visited Zanday Camp. 40 women had just graduated from a six-week reproductive health training program. They were the first class to graduate, and the program has started training a second group of women. It is being run by the Women’s Commission and the Afghan Women Welfare Department (which is a member of the Afhghan Women’s Network). The two NGOs call this is the first program of its kind in Peshawar.

The young refugee women who went through the training learned the basics of reproduction, male and female anatomy, conception, pregnancy, sexually transmitted diseases, infertility, child spacing, birth control — topics that women in the United States and other Western countries take for granted.

When they started the class, the women knew nothing about reproduction and sexuality, yet each of them have seven or eight children. They knew nothing about their bodies. They knew nothing about their husband’s bodies. AIDS was not in their vocabulary.

“Keeping women that innocent, it’s like abuse,” said Dr. Ouahiba Afzal, Reproductive Health Consultant for the Women’s Commission. “It’s their body.”

But by the time they had graduated, the women talked easily about sexually transmitted diseases. And male infertility. And clean breast feeding habits. These were topics they had been too embarrassed to discuss six weeks earlier.

Dr. Malalai, one of the doctors who led the training sessions, told me the story of one young woman who said she did not know she was pregnant until her sixth month. “She knew her periods had stopped, but she didn’t know why,” Malalai said. “When the baby moved, she thought something was wrong with her intestines.”

I sat with a group of the women on their graduation day and asked them to tell me what they had learned. “Sexually transmitted diseases, AIDs, breast examinations,” they replied. They now understood that men should go to the hospital and have their blood and sperm checked for infertility. That pregnancy and child birth carry risks and dangers.

One woman said she was 35-years-old and already she had lost six children — either in the womb or after child birth. Never again, she vowed. Another woman, Faarida Mjan, was alone when she gave birth to her last baby and she did not want to do it again. Similarly, Rahila Noorhan, who was 26 and eight months pregnant, said she would never give birth without someone being with her.

“I learned that a delivery should be in a hospital. And I know doctor visits are important,” she said. Clearly Noorhan had been listening during the child spacing and family planning lectures. “In three years I want to have my next baby,” she said.

Noorhan said she has taught her husband some of the things she has learned. “Now my husband says that having a lot of children is dangerous,” she said, adding that he had agreed to have just three or four children. “If there is no spacing, each time the woman is pregnant, she is using her own resources,” said Afzal, of the Women’s Commission. “She’s at risk of anemia. Even in the Koran it says it is good to space a year and a half and to breast feed.”

Gulbibi Nasir, 30, has seven children. Holding her one-week-old daughter, Farishta, she explained that three others had died during childhood from convulsions. “Now I bring the children to the doctor. I’ll also get vaccines for them.”

One of the most surprising moments during the six week training came for Dr. Malalai when she learned that the Afghan women in the program considered their first milk after birthing to be “dirty.” They would dispose of it rather than feed it to their newborns. “The first milk is so important,” Malalai said. “They didn’t realize this.”

The most difficult topic to teach, Malalai said, was family planning. “Their husbands want children and they don’t want to use protection,” she said.

Habib Ullah, 2, with mother and friends at the end of a 40-day course in reproductive health at the Zanday camp

Husbands are not part of this training program, but Malalai and the other doctors who are coordinating the curriculum see a growing need to educate men in reproductive health issues. Without a buy-in from their husbands, the women who go through the training will have a harder time putting into practice the reproductive health lessons they have learned.

“The problem is – are they (the wives) willing to learn?” said Ouihaba Afzal. “They ask why they need to be involved. If we could just teach them about sexually transmitted diseases and protection, that would be helpful.”