Following the Soviet invasion of Afghanistan in 1979, an estimated 4 million Afghans fled across the border into Pakistan to escape the conflict. Some returned after the Soviet forces withdrew in 1989, but many remained, and in early 2001 the United Nations High Commission for Refugees (UNHCR) estimated that there were approximately 2 million Afghan refugees in Pakistan. In the months immediately following the September 11 terrorist attacks in 2001, at least 200 000 more crossed the border1 fearing American retaliatory military action and fighting between the Northern Alliance and Taliban Forces.2 Around 1.5 million of these refugees are receiving assistance from UNHCR in refugee camps located outside major urban centres; 60% are children under 18 years of age.2 The problems of these refugees are compounded by an unsympathetic Pakistani government, tired after decades of taking responsibility for the influx and faced with many competing priorities including fighting the insurgents in the north of the country.3 International humanitarian aid has been forthcoming, but it has been inadequate given the magnitude of the problem, and official development assistance concentrates only on those inhabiting the UN camps.

The conflict and the ensuing refugee problem has contributed to Pakistan's persistently poor health indicators: the worst progress in life expectancy in the region (62 years at birth in 2003 and 63 years at birth in 2009) and an under-five mortality of 101 per 1000 compared with Bangladesh (77), India (85), Nepal (76) and Sri Lanka (14).4 The proportion of malnourished children (underweight for age) remains stagnant at a very high 38%, there are concerns about outbreaks of vaccine-preventable disease as many Afghan refugee children are unable to access vaccination services before and after migration, and the incidence of tuberculosis (TB) has increased from 140 per 100 000 in 1995 …