NEWS FOCUS: Nightly bombing raids have made Afghanistan a perilous place - but the country's inability to feed its people and care for the sick means a cruel fate awaits even those who survive the onslaught.Tash Shifrin reports

Their country already pummelled by nightly bombing raids, Afghans must, since last week withstand an escalation of the West's reponse to the horrific attacks on the World Trade Center.

As carpet-bombing by US B-52s becomes a regular occurrence, pictures of civilian casualties are beginning to come through. But Afghanistan is already a hard place to stay alive.

In a landscape largely made up of mountains and desert, with limited clean water and food, one in four children die before they are five years old. There may be life after 40 - but not much of it in Afghanistan, where average life expectancy is 46.

Infant mortality is 165 per 1,000 live births. Mothers do not do much better: maternal mortality is the world's second highest - one woman dies every half hour from birth-related problems.

The World Health Organisation says getting information out of Afghanistan about the current situation or the effects of the bombing is 'extremely difficult', but the pre-existing conditions were grim enough. 'A lot of it is linked. It is hard not to say It is linked to 23 years of war, ' says Loretta HieberGirardet, WHO's Afghan crisis information officer. She points out that 50 per cent of children are malnourished. 'It makes them much more susceptible to diseases like measles, acute respiratory diseases or malaria.'

About 30 per cent of outpatients have 'unidentified pain' says Dr Khalid Shibib, WHO's Afghanistan desk officer. Diagnosis is problematic. There is no electricity in many of the communities.

WHO issued a communicable diseases warning this week, as mass migration to the borders adds to already poor conditions.

Only about 25-30 per cent of the population has access to portable drinking water, up to 20 per cent to sanitation.

'Already the country was very, very vulnerable before this crisis, ' Dr Shibib says. 'There are injuries from landmines, accidents and non-communicable diseases like in any other country in the world.'

But hunger is the biggest threat.

'Mortality is almost always accompanied by malnutrition, because if you are well fed you do not die.'

Dr Shibib paints a grim picture of health services in a country where 50 out of 330 districts have no medical facilities whatsoever.

'We have a very weak health system - almost totally dependent on external aid before this crisis and, you can imagine, now more aid is needed.'

'Any notion of a health structure in the way we understand it is absolutely irrelevant in Afghanistan, ' says Bev Collin, a nurse by training, and the medical co-ordinator of the Medecins Sans Frontieres operation in Afghanistan. She spent 18 months there before returning to Britain in September.

There are faculties of medicine and acute hospitals in the cities, built by outside powers such as China, she says. 'Herat, Kandahar and Kabul are examples. It is one hospital covering a huge area.

They have hardly any medicines or facilities at the hospitals.'

Instead, patients buy their drugs in the bazaar.

Ms Collin says: 'Talking about the ministry of health is strange because they're a totalitarian regime. They are trying to repair the system, but quite often you're dealing with a mullah who doesn't understand.'Hospital directors are non-medical, she adds. 'They are Talibs.'But the doctors are impressive, 'struggling against the odds'.

'The de facto healthcare system is private. Clinics are concentrated in urban areas. Hundreds of doctors set up their own clinics and develop their own profiles and reputations. It is business.'

Few doctors want to work in the rural areas where the social environment is starkly different. They are primarily male and from elite backgrounds. 'The country's not homogenised; It is made up of different groups of people in terms of background, education, approach to living, ' says Ms Collin.

Around 80 per cent of the population lives in rural areas - they are peasants, largely nomads: 'Their understanding of healthcare is quite limited. There are traditional methods, through mullahs and traditional healers, ' she says.

Ms Collin says drought and shortage of food have already caused 'ruptures' in the social fabric of Afghanistan. 'They've exhausted their coping mechanisms, which are quite impressive.

With this assault, I wouldn't be surprised if we move to humanitarian disaster there very quickly.'

WHO's Ms Hieber-Girardet says that now there is an exodus of the urban population from cities such as Jalalabad and Kandahar.

'It is heavily overburdening rural facilities. In the case of Jalalabad, rural facilities are reporting a 60 per cent increase in the number of people seeking medical attention.'

WHO has a key role in propping up health services in Afghanistan and is getting 60 emergency health kits into the country, each with material and medicines for 10,000 people for three months. But Dr Shibib adds that there is a health advocacy role too. 'These people have no ambassador in Britain to talk about their health. I consider myself their health ambassador.'

So he urges people in Britain 'not only to help through appeals, but where they have contact with Afghan people'. Dr Shibib is not Afghan himself.He is 'much luckier', he says.He is Palestinian.

Afghan people themselves are the reason that the Red Cross is still able to maintain its work inside Afghanistan. Its 1,000 local staff have been crucial since expatriate aid workers were forced to leave. Spokesman Will Slater says:

'Their activities concentrate on running 47 primary healthcare clinics across the country, but also supporting 16 hospitals and six orthopaedic centres.'

The centres treat landmine victims and people having limbs amputated after bullet wounds as well as those with spinal tuberculosis and congenital disorders.

Mr Slater says: 'The clinics are able to function.We are able to get supplies through to restock them but we have to negotiate [deliveries] one by one with local militias to get to Kabul.

'The staff have been doing a magnificent job, ' he says. But he adds: 'The effects of the bombing have been very demoralising on their continuing operations.'

The Red Cross operation has suffered directly with four warehouses hit. 'We had five warehouses in total. Three were struck on Friday, and one a week earlier.'

Mr Slater says the buildings were clearly marked.

Dr Craig Burgess is at the sharp end. He works for medical emergency charity Merlin, and spoke to HSJ from Tajikistan, just over the Afghan border, and very near the frontline between the Taliban and the Northern Alliance.

Getting through on the phone includes the bizarre experience of being put on hold, while a tinny rendition of Love Me Tender plays down the line. It is an odd tune for a war zone.

He says: 'We aim to help eight primary care projects in Takhar province, hopefully in the next few weeks.'

But access difficulties mean that for now, his project is helping thousands of refugees from Northern Kunduz who are 'pretty dependent on external assistance', living on two islands in the river between Tajikistan and Afghanistan. Anaemia, scurvy, diarrhoea and malaria have been the main problems, he says.

Come winter, it will be acute respiratory tract infections.

'The international agencies can't access Taliban-controlled areas, which makes it difficult to provide humanitarian aid. In Northern Alliance areas there is potentially better access to healthcare.'

The bombing campaign has 'made things worse because you can't get near the front line', Dr Burgess says. 'The main crossing point was bombed on Sunday.We can't cross to provide assistance.'

Merlin was not part of the joint call by several aid agencies for a pause in the bombing to allow aid to get through, but from his base near the front Dr Burgess says: 'I would certainly advocate that.

That would be a good idea. A full stop would be better.'

Oxfam urged a suspension of the bombing, pointing particularly to the threat of starvation. It warned that around 400,000 people are already believed to be surviving on wild vegetation and essential livestock, while 2 million people do not have enough food aid to last the winter.

Barbara Stocking, Oxfam director and former head of the NHS Modernisation Agency, says: 'We just do not know how many people may die if the bombing is not suspended and the aid effort assured.

We do know the Afghans are an extremely resilient people who will do all that it takes to survive.

But if nothing changes, there will be huge loss of life and unspeakable suffering this winter.'

At the time of writing, the bombing continues. l