Infants, Infection, and Insurgency: Disease Burden in Afghanistan

For a general Western audience, mention of Afghanistan may bring to mind several narratives: domestic implications of endless war, wariness of radical Islam, images of burning poppy fields supplying the international drug trade. While these observations are grounded in some degree of fact, they largely reflect an extraordinarily poor society with significant barriers to development just beginning to rebuild. To put this in perspective: the average Afghan* woman will live to 52 years and will bear six or more children. The average male will support his family on an annual income of $584 USD, and will not see the age 50.

Of course, this sort of extreme poverty extends to health access. Of the different population- and disability-adjusted life year burdens measured by the Institute on Health Metrics and Evaluation, Afghanistan comes dead last – behind all other countries – in 19 of 50 categories.

Image
Relative comparison of the 15 countries with the highest disease burdens. That red ain’t a good thing (source: IHME).

At nearly 120 deaths per 1,000 live births, Afghanistan’s infant mortality rate is higher than that of any other country; in its especially remote regions, such as the Wakhan Corridor, an estimated 50% of children die before reaching the age of five. 34 years of constant war have wreaked havoc on health systems, skepticized a populace, and left mortality and morbidity burdens frozen in time, reflective of another era.

So How Did We Get Here?

At risk of dramatic oversimplification, the current era of conflict in Afghanistan stretches back to 1979, at the beginnings of a bloody war between the Soviet-backed regime and U.S.-backed mujahedeen insurgents. After the Cold War ended in 1989, this proxy war continued as civil war between the factions initially funded by each superpower. The organization we now know as the modern Taliban prevailed, ruling until the U.S.-led invasion in 2001.

While the country may still be considered in a state of war, health systems began to recover after the fall of the Taliban in 2001. The group’s militantly conservative influence on health in the country is far from over – the cultural implications of long-standing religious traditionalism have significantly impeded maternal health, and a spate of shootings have targeted immunization workers over the past two years – but formal structures such as hospitals and schools have once again become centers for community treatment, outreach, and education.

Though conflict-based mortality is what makes international news, purely war-based injury is nowhere near the top contributor to Afghanistan’s burden of disease. As with other LMICs, the dominant offenders are diseases and conditions that have largely been eliminated elsewhere. Birth remains a key area of complication, with maternal and neonatal mortality rates consistently at or near the highest in the world. Infectious diseases and malnutrition plague all Afghans, but pose an especially significant burden on those under the age of five. While still lagging behind in terms of mortality, non-communicable diseases are beginning to gain ground: traditional indoor cooking methods likely contribute to the increasing morbidity of chronic cardiovascular and respiratory diseases, and as Afghanistan continues to recover it is expected that NCDs will come to play a more significant role.

However: the impact of war, and in particular insurgent rule, is dramatically underestimated when it comes to computing actual DALYs lost. IEDs and beheadings are easy to count, but the pregnant woman who can’t leave home for prenatal check-ups fly under the radar. Nobody has really run the numbers on this, because they’re hard. We’ll get to that.

Setting the Stage for Health Barriers: A Formidable Geography

As a landlocked state bridging the Far East and the Near East, Afghanistan evades classification: with a non-Arab population, it lies outside of the Middle East proper (despite being religiously and culturally associated with the region), and may be categorized in West, South, or Central Asia, depending upon the whims of the cartographer. Afghanistan’s disease profile is largely dictated by its daunting terrain: the Hindu Kush range isolates swathes of desert and creates a porous border with Pakistan, with which it is often paired in the military slang of the West.

Glacier melt settles into reservoirs, pooling water in valleys that attracts malarial mosquitos – but very little precipitation falls throughout most of the country, contributing to water insecurity. Extreme temperature swings of up to 63 degrees Fahrenheit per day make growing seasons unpredictable and crop shortages common (this is where I concede that it’s got Texas beat). As a consequence, malnutrition is extremely common: about 60% of children are stunted.

The complexities of mountain terrain and its impact on health are perhaps best exemplified by the Wakhan Corridor in Northeastern Afghanistan. Stretched in an isolated valley of the Hindu Kush between China, Tajikistan, and Pakistan, the area has avoided much of conflict of the past century but has also missed out on many benefits of modern medicine. Other countries will not accept the formerly nomadic population, but they also cannot cross the mountain range into Afghanistan proper. Alex Duncan, a doctor who lived alone in the region for five years, reports that nearly one-third of infants died at birth with another sixth of children succumbing to malaria, tuberculosis, or pneumonia before age five. Grieving and impoverished parents frequently turn to opium.

wakhan map
Like Florida, but with fewer rednecks (thieved from NPR).

Also: with a total population of roughly 30 million, Afghanistan is tremendously rural. Even Kabul barely exceeds one million residents. Obviously, this further complicates distribution of health services.

An External Assessment of Priorities

As the U.S. drawdown begins, the Department of Defense needs to take stock of its humanitarian initiatives. Obviously I don’t know how this is going but I suspect Not Well, based upon a few separate and distant anecdotes (perhaps most notably, a program to take stock of how or whether DoD development projects were transferred to local control was cancelled due to funding constraints). Since we’re not doing that, someone else probably should. The MoH’s site is a bit scant, so I’ve made a go of it:

Burden 1: Maternal and Neonatal Health

Let’s get the numbers out of the way: 71% of women self-reported a decline in physical and mental health status under Taliban rule, during which they were forbidden from working outside the home, attending school, or leaving the home without accompaniment by a male family member. As such, it is not surprising that these structural impediments to women’s health access had an extraordinarily regressive effect on prenatal, neonatal, and maternal health. Of women surveyed in 1996, 49% reported chronic musculoskeletal pain, 19% reported chronic headaches, and 23% reported gynecological issues. During this time, 70% reported poor access and 20% reported no access to health care in Kabul during pregnancy.

It’s important to quantify these indirect deaths and complications in order to take proper stock of the situation for future policy decisions and budgetary allocations – that is to say, to figure out what exactly was prompted by an external agent and what can be recovered over time without substantial changes in prior policy.

Today, 460 women still die during every 100,000 childbirths: by some accounts, the highest maternal mortality rate in the world. Women marry young and bear over six children each, providing an opportunity for something to go wrong with each pregnancy. Chronic malnutrition has led complications from prematurity to total more than five percent of Afghanistan’s lost DALYs, with birth trauma and asphyxiation, neonatal sepsis, and other neonatal complications contributing another 10%. All of this leads to an extraordinary neonatal mortality rate of 119.4 deaths per 1,000 births.

On the upside, this is where Afghanistan has made the most progress over the past decade. There are also neat local solutions to health barriers sneaking out of the woodwork (I’m partial to the inflatable donkey saddle…and to the fact that there’s a website that’s actually named “Donkey Technologies”).

Burden 2: Warzone Maladies: Injuries, Accidents, and Structural Violence

When tabulated as a portion of total disease burden, war, violence, and self-harm (including suicide bombings) constitute a scant 3.32% of all DALYs lost. But the health burden of war in Afghanistan should not be limited to these particular maladies: depression, anxiety, and post-traumatic stress disorder have reached epidemic proportions in the country after three decades of conflict. Further, the cultural and political climate propagated by both forces in power and violent nongovernmental threats have had a direct impact on Afghanistan’s disease incidence and health infrastructure. Under Taliban threat and rule, medical professionals have been killed or driven out of the country, rural immunization workers have been targeted and murdered, and women have been prevented from seeking antenatal care. This system of structural violence is not captured in raw numbers, but the resulting impact on health access and disease burden is enough to warrant their consideration.

One unfortunate constant throughout the past decade of war in Afghanistan has been creeping remnants of previous two: the landscape is still littered with landmines and pressure-plate IEDs, which caused 913 civilian casualties in 2012. Left over from Soviet occupation, both landmines and weapons still impose a significant burden in terms of both mortality and morbidity. While the number of annual fatalities may be small, it is important to note that non-fatal casualties from the types of weapons employed here may impose significant burdens in injured individuals, including lifelong amputation and blinding, that impede them from obtaining self-sufficiency and stable work.

In 2012, the United Nations Assistance Mission in Afghanistan “documented 1,507 civilian casualties from 73 incidents of suicide and complex attacks”, 328 of which were fatal. This number refers specifically to non-specific civilian casualties, excluding targeted attacks on individuals; such attacks are generally random, designed to propagate mass casualties, and conducted with either body-born improvised explosive devices, remote-controlled IEDs, or mortar fire. 71% of causalities were committed by non-governmental forces using such tactics; the remainder were killed by Afghan police, Afghan soldiers, and international troops. In the same year, 1,077 additional casualties (including 698 deaths) resulted from targeted killings using similar methods, which typically exhibit a higher “success” rate on behalf of the attackers. A 2010 report from the Afghanistan Independent Human Rights Commission identified 16.5% of victims as children, and given the country’s high birth rate, it is logical to assume that this statistic has remained consistent.

Since 2010, nonspecific attacks have decreased while targeted attacks have become more frequent. It is expected that non-civilian deaths will increase further as international support is withdrawn in 2014.

Burden 3: Mental Health and Addiction

Thirty-four years of occupation, suppression, and displacement have understandably left Afghans shell-shocked and grieving, and the mental health consequences are poorly understood. As Maley (1997) reports: “I would warn against underestimating the psychosocial damage which Taliban rule is inflicting on the people of Kabul, especially among professional women…Afghan languages are not rich in vocabulary which might signal the onset of psychic depression and because of the pressure on individuals to hide the pain they may be experiencing.”

Though cultural context for mental distress in Afghanistan is complicated and subject to misinterpretation by Western observers, it’s clear that the problem is serious. Afghanistan hosts the third highest suicide rate in the world. However, widespread use of suicide bombing tactics by insurgent populations leaves this statistic particularly unreliable: it is unclear whether these deaths are (or should be) counted alongside the more traditional definition of suicide.

In a comprehensive survey, Schlote (2004) found indications of depression in 38.5% of respondents, with over half expressing symptoms of anxiety and 20.4% reporting symptoms of post-traumatic stress disorder. 44% of Afghans report experiencing between 8 and 10 traumatic events within the past 10 years, with 14% reporting 11 or more traumatic events.

Burden 4: Communicable Disease

Communicable diseases are particularly burdensome for children under the age of 5, where resultant failure to thrive may compound morbidity. Despite indigenous malaria (see below; 77,554 cases were reported in 2011) there was virtually no coverage of insecticide treated nets until 2006. Distribution of malaria in Afghanistan aligns with harsh terrain and poor health access in mountain valleys. As such, only about 60% of suspected cases are treated. 93% of cases are P.vivax, of which fewer than 5% are potentially treated with any antimalarial.

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Malaria distribution, courtesy of WHO.

Vaccine-preventable diseases are also common: 3,013 cases of measles were reported in 2013, and only 19% of children receive a full set of immunizations. There are constant concerns, of course, of polio jumping the border. 80% of sanitation facilities are rudimentary, and diarrheal disease contributes to 6.25% of the country’s total DALYs. Finally, while tuberculosis is less burdensome than in other countries due in part to near-zero incidence of HIV, TB did result in 13,000 deaths in 2011 (of 61,000 new cases).

Data Limitations

Afghanistan desperately needs to scale up health surveillance – I almost think this should be the immediate focus as international involvement scales down. Due to collection restraints imposed by conflict, data on maternal and neonatal health obtained from 1979 through 2004 (yes, that long) were calculated using population estimates from the 1979 census. Many development-related metrics are simply missing during the period of Taliban rule (those that are not missing are quite dismal: for example, 19-freaking-percent of school-age children attended school in 2000). No national information on obesity, blood pressure, or tobacco use is available, hampering the reliability of NCD risk reporting. Finally, numbers vary widely source to source; see below for a small sample of discrepancies I found in about 5 minutes.

Measure

Source 1

Value 1

Source 2

Value 2

GNI per capita (2011)

World Bank Indicators

$584 USD

WHO GHO

$1140 USD

Life Expectancy at Birth

CIA World Factbook

50.1 years

World Bank Indicators

60 years

Insights and Progress

At present, the Afghan government spends $8.70 USD per capita on healthcare annually. Total annual expenses are estimated at $50.5 per capita – nearly one-tenth of average per-capita income. While this sort of spending is clearly unsustainable for an impoverished population in a place many aid organizations are reluctant to work, there are several reasons to be hopeful for the future.

The reopening of the University of Kabul has increased the number of physicians from less than one to about two physicians per 100,000 patients in the past decade. Simultaneously, improved security in Kabul has increased the number of health-oriented NGOs working in the country. This has led to new nurse training programs and rural midwifery programs determined to tackle high maternal and neonatal mortality rates. Health researchers are also returning to Afghanistan, providing more reliable health metrics with which a more stable Ministry of Health has been able to make better-informed early gains. Finally, increased agency on behalf of citizens themselves – since both the expulsion of the Taliban and the draw-down of international troops – has led to a renewed sense of ownership over health complications in the country. Within the past year, health innovations such as mHealth surveillance programs and a donkey saddle designed for pregnant women constrained by clothing have been lauded at local events, including TEDxKabul. Afghanistan is opening up to the world once again – and soon, its health burden may catch up.

*As is often the case, there’s debate over the demonym. I’ve gone with “Afghan” for consistency but do realize that people are not nice blankets.

Infants, Infection, and Insurgency: Disease Burden in Afghanistan

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