Kabul, Kandahar, Jalalabad, Quetta, and Peshawar are the main cities within Pakhtunkhwa.
However, the concentration of population around northern and central KP, and eastern Afghanistan result in Peshawar’s position as a political and economic centre for the entire Pakhtunkhwa.118
A distinguishing feature of Peshawar is its medical infrastructure. There are six principal state owned and operated hospitals in Peshawar with an even larger and growing number of private hospitals, clinics and laboratories.119 Relative to the region, these hospitals provide a high standard of medical care and have led to the development of Peshawar as a destination for medical travel across southern Afghanistan. This medical infrastructure remains one of the principal drivers of cross-border movement, attracting patients from over much of Afghanistan and FATA.
Other than at Peshawar, the Afghan borderland has a minimal medical infrastructure. The agency administrative centres in each of the FATA agencies also house a basic hospital and clinics, albeit with limited capabilities.120 These facilities do attract patients from within each agency as well as from across the Durand Line. However, tribesmen state unequivocally that the facilities and expertise in Peshawar are of a much higher quality than those in FATA resulting in their travelling to Peshawar for medical care.121 Further, Kabul has seen a growth in the number of private hospitals since 2003, the prominent ones being CURE international, DK- German Medical Diagnostic Center, and Imran Clinic. However, each of these is a private facility and far beyond the means of most Afghans.
In contrast, the Khyber Teaching Hospital in Peshawar charges a nominal fee, often not paid.
Affiliated with the University of Peshawar, Khyber Teaching Hospital saw 40% of its beds
118 Interview with Muhammad Nawaz Afridi, at Peshawar 23rd August, 2008. This view was widely held among a number of interviewees and officials.
119 State hospitals include: Mission Hospital, Lady Reading Hospital, Khyber Teaching Hospital, Cromwell Hospital, and Al-Khidmat Hospital. These are supplanted by Rehman Medical Centre and Tehkal Medical Centre a prominent among the private hospitals and clinics in Peshawar. .
120 Interview with Dr. Muhammad Nawaz Khan at the Khyber Teaching Hospital. 8th August, 2008.
121 Interview with Dr. Muhammad Nawaz Khan at the Khyber Teaching Hospital. 8th August, 2008.
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occupied by patients from Afghanistan in August 2008.122 The hospital is immensely overcrowded. Apparatus is basic and electricity is intermittent. The intake of new patients has been reduced to two days per week, excluding cases of trauma. Yet large numbers of tribesmen with their families continue to descend on the hospital and are often seated in the court yards and steps outside the hospital.123 In the case of the Rehman Health Institute, a private hospital highly regarded for its apparatus and doctors, 90% of patients present in August 2008 were from across the Durand Line.124
Medical migration constitutes a significant fraction of all cross-border travel from Afghanistan into Pakistan. In September and November 2008, surveys of individuals at the Torkham and Spin Boldak border crossings revealed that 9.5% were travelling to Pakistan for medical care,125 the overwhelming majority of which were intending to travel on to Peshawar for medical care.
The long-term trend for medical migration at these border-crossings is 11.2%, while 21% of migrants report that travel into Pakistan is for medical and social services.126 This percentage corresponded to approximately 2000 individuals a day crossing the border into Pakistan for medical care alone.127
In addition to medical migrants entering Pakistan through the border-crossings at Torkham and Spin Boldak, an as of yet un-enumerated flow of persons continues across the hundreds of trails that traverse the Durand Line along much of its length. The percentage of these that travel to Pakistan for medical care is yet unknown, but is considered to be of a similar order to that arriving through Torkham and Spin Boldak. 128
The role of Peshawar as the centre of medical infrastructure in the Afghan borderland has been enhanced as a result of the mass internal displacement of individuals through 2008 and 2009 following major military operations in Swat, Bajaur, South Waziristan and Orakzai.
122Interview with Dr. Muhammad Nawaz Khan at the Khyber Teaching Hospital. 8th August, 2008
123 Observed by author at Khyber Teaching Hospital, Peshawar in August 2008.
124 Observed by author at Khyber Teaching Hospital, Peshawar in August 2008.
125 Study on Cross-Border Population Movements Between Afghanistan and Pakistan UNHCR and Altain Consulting, Kabul, June 2009 pp. 22, 32.
126 Ibid.
127 Study on Cross-Border Population Movements Between Afghanistan and Pakistan UNHCR and Altain Consulting, Kabul, June 2009 pp. 22, 32.
128 The number of migrants that cross the border at points other than Torkham and Spin Boldak is higher than at those points, but tends to be from localities in the immediate vicinity of the border. Such crossings are made by individuals a number of times a day in many cases. Based on the number of villages in the immediate vicinity of the border, an estimation can be made of the number of cross-border migrants. This number is of a similar order to that at the major crossing points, which makes for a total cross-border migration from Afghanistan into Pakistan on any given day of around 65,000 individuals.
Estimates place the number of internally displaced at over 1 million,129 many of whom have arrived in Peshawar in pursuit of medical care. In response to this influx, the medical facilities in Peshawar are greatly overwhelmed, leading to the movement of internally displaced individuals and cross-border migrants beyond Peshawar, a trend reflected in statistics charting the destination within Pakistan of cross-border migrants which show that 6.6% of cross-border migrants now travel beyond KP to other destinations in Pakistan.130
There is currently no method of verifying whether patients are from KP, FATA or Afghanistan.
Patients report that there is no impediment to them in crossing the Durand Line into Pakistan for medical treatment.131 This absence of control, both at the border and in hospitals, has served to reinforce the position of Peshawar as the medical infrastructure for the entire Afghan borderland. This position, in turn, attracts increasing numbers of patients from further afield in Afghanistan, beyond the areas in proximity of the border.132 In November 2008, all 34 provinces Afghanistan were represented at Torkham and Spin Boldak on a given day.133 67.5%
of cross-border migrants, however, were from the Pashtun dominated provinces contiguous with the Durand Line. Hence Peshawar is integrated into both sides of the Afghan borderland across the Durand Line on account of, in addition to many other facets, its medical infrastructure.134
4.8 Conclusion
Borderlands in Asia are a form of reaction of the substructures that underlie the postcolonial state to the imposition of an international border across them. The incongruity between the contours of the postcolonial state and the primary substructures that underlie it results in the socio-political contusion that characterises borderlands in Asia.
As part of the larger substructure of Pakhtunkhwa that underlies Pakistan and Afghanistan, the Afghan borderland has existed on a geo-physical level and psycho-social scale for over a
129 The Internal Displacement Monitoring Centre maintains a data base on Pakistan‟s internally
displaced population. See: http://www.internal-displacement.org/countries/pakistan . Accessed Janaury 2011.
130 Study on Cross-Border Population Movements Between Afghanistan and Pakistan UNHCR and Altain Consulting, Kabul, June 2009 p.28.
131 Ibid, p.5.
132 Interview with Dr. Muhammad Nawaz Khan at Khyber Teaching Hospital, Peshawar on 8th August 2008.
133 Study on Cross-Border Population Movements Between Afghanistan and Pakistan UNHCR and Altain Consulting, Kabul, June 2009 p.25.
134 Observed by the author at Khyber Teaching Hospital, Peshawar in August 2008.
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millennium. Despite the current absence of a conventional political manifestation, this larger substructure retains primacy as a psycho-social driving factor among the tribal Pashtuns, challenging the tenuous grip of the Pakistani and Afghan states over it.
This study confirms that the Durand Line does not constitute an effective barrier between the tribal populations on either side of it. Further, its validity as an international boundary is continuously challenged by sub-state, tribal centres of power, authority and legitimacy that constitute a specific borderland identity within the larger Pashtun identity.
These borderlanders are characterised by the frequency and scale of their inter-tribal cross-border movements. Such patterns of movement manifest in the structure of cross-cross-border economic flows, trends of cross-border marriage and social interaction and the jirga process, which is an inter-tribal political process disregarding of the border and part of the larger dynamic of inter-tribal politics and militancy which proceeds largely unimpeded by the Durand Line. These cross-border inter-tribal dynamics are a manifestation of the competition between the tribe as an enduring sub-state form of polity, and the state. The replication of this cross-border dynamic across the cross-borderland between a number of prominent tribes, establishes a collective disregard for the authority and legitimacy of the state in the borderland, enhanced by the mass cross-border movement on daily basis by individuals around the wider domain of Pakhtunkhwa in pursuit of objectives as varied as trade, medical care and education.
The combination of this tribally driven disregard for the contours of the state, and mass cross-border movement of individuals from across Pakhtunkhwa, creates interdependency between populations across the border, assimilating KP, FATA and southern Afghanistan on a practical level, as the cases of medical infrastructure and the structure of cross-borderland economic flows establish. This assimilation, evidenced by the prominence of Peshawar across the entire borderland and much of Pakhtunkhwa as a principal economic and infrastructural node, is driven by the re-emergence of the underlying substructure of Pakhtunkhwa as a primary ethno-linguistic, cultural and geographic identity. The near-obfuscation of the role of the Durand Line as an international border enhances the degree of autonomy of the tribes in the vicinity of the border, eliminating the barrier to a tribally driven re-territorialisation of pre-state identity and polity.