As the novel coronavirus sweeps across Iran, the Afghanistan-Iran border remains open without considering the health risk that the virus could pose to the population of Afghanistan. The Ministry of Public Health (MoPH), as the leading organization for ensuring the health and well-being of Afghans, has received severe criticism from the public for not taking adequate measures to thoroughly monitor movement on the border with Iran. With over 20,000 cases, Iran is among the hardest-hit countries in the world. The chances of importing coronavirus from will increase by allowing unmonitored movements from Iran to Afghanistan.
On February 24, 2020, the Ministry of Public Health of Afghanistan confirmed its first case of COVID-19, the disease caused by the coronavirus, in a person with a travel history to Iran in Herat province along the border. Currently there are 24 cases of COVID-19 in Afghanistan; almost all of the positive cases are returnees from Iran. Inadequate screening procedures and the lack of a quarantine zone for returnees place doubt on government’s measures to prevent the spread of the virus in the country.
The national government, particularly the president of Afghanistan, had expressed a commitment to battle the COVID-19 outbreak, allocating $20 million dollars to that end and starting construction on a 100-bed hospital for COVID-19 patients in Herat province. However, unless something extraordinary happens Afghanistan is at high risk for a devastating outbreak for several reasons.
First, Afghanistan decided to leave the border with Iran open despite anticipating the severity of the outbreak in Iran. This decision allowed thousands of Afghans to cross the border amid inadequate screening procedures. In addition, the failure of the MoPH to establish a proper and well-equipped quarantine zone at the Iran-Afghanistan border for individuals crossing the border further increases the risk of coronavirus transmission in Afghanistan. Recent studies report that even asymptomatic individuals might have the potential to transmit the disease to others. Experiences from Taiwan, Singapore, and Hong Kong have shown that imposed quarantine procedures and border closures or restrictions were effective in keeping the coronavirus in control.
Second, malnutrition, poor hygiene and sanitation, and poverty could also exacerbate the spread of infectious disease, including COVID-19. Unfortunately, Afghanistan is a country that suffer from all of these problems. Due to these factors, premature deaths and morbidity from various diseases are already higher in the country, and the health system remains incapable of addressing such health-related issues due to technical and financial limitations. The presence of all these factors make Afghanistan more susceptible to the rapid transmission of the coronavirus
Furthermore, the majority of the Afghan population is not ready to follow the recommendations for coronavirus prevention from Ministry of Public Health. Fatalistic beliefs among the people remain a grave challenge for public health professionals trying to convince the public to maintain appropriate prevention methods. Most Afghans are ignoring recommendations due to their inability to comprehend the complexity of the problem and instead are relying on pseudo-religious reasoning such as the rumor that Muslims are immune to COVID-19. Alternatively, the gap in health communications and lack of context-specific solutions for the masses also complicates the situation. For instance, many advertisements encourage citizens to focus on hand-washing practices and using soaps or hand sanitizers. However, even the major cities of Afghanistan lack public toilets, and utilizing hand sanitizer is a rare practice among the public. In such cases, it is important to provide context-specific solutions to the masses and use creative ways to pass along the message. For example, the involvement of imams and other religious leaders could play a great role in raising public health awareness, but that requires policymakers to reach out to religious leaders and mosques to push the message. Traditionally religious leaders have shown apathy toward engaging in health awareness programs, but the serious nature of this crisis has a strong possibility of changing that behavior and inspiring them to play a positive role in this crisis.
The ineffectiveness of the health system is not just limited to prevention. Afghanistan also lacks the ability to contain the virus now that it has arrived. The inability of the public health system to quarantine suspected individuals for the prescribed period could further worsen the situation, allowing the virus to spread to other provinces of Afghanistan. On March 16, all suspected and positive coronavirus cases managed to escape from the quarantine facility in Herat city. The situation highlights that neither the patients nor the healthcare professionals were serious about the epidemic. Health professionals do not feel comfortable confronting those patients because they lack proper training on how to deal with quarantined individuals, and how to support patients in critical condition following complications from COVID-19. On the other hand, delays in receiving coronavirus test results, a lack of trust in hospitals, and a lack of sufficient facilities caused frustration among those who were in quarantine and motivated them to flee the facility. That highlights deficiencies in the leadership and management of health authorities and calls into question their ability to respond to critical situations during outbreaks.
Moreover, transparent reporting and mass testing for the early detection and control of COVID-19 proved to be an effective strategy in some countries. However, Afghanistan has not yet initiated a comprehensive screening and mass testing strategy. Pakistan, which received almost 1 million returnees from Iran, has confirmed 326 cases of COVID-19 infections recently. Most of the cases in Pakistan are related to Iran. Afghanistan, on the other hand, has reported 24 confirmed cases. Given that the border with Iran remains open, many cases might have gone undetected, meaning the number of COVID-19 cases in Afghanistan could be underestimated. The MoPH’s delayed response could turn Afghanistan into an epidemic center of the coronavirus.
Afghanistan remains an endemic country for several infectious diseases, including poliomyelitis. Diarrhea and pneumonia contribute to the majority of deaths in Afghanistan. The outbreak of coronavirus could pose a serious challenge to the country’s already overwhelmed and weak health system. Responding to COVID-19 in a proactive way requires aggressive and comprehensive quarantine and isolation procedures, contact tracing, an active surveillance system, preserving transparency in reporting, and raising public health awareness. It is also vital for the health ministry of Afghanistan to form a technical advisory committee on the national and provincial levels and encourage epidemiologists, infectious disease experts, psychologists, public health experts, and communication specialists to provide suggestions for preventive measures.
Mohammad Azeem Zmarial Kakar is an academic member and head of the public health department at Kandahar University, Faculty of Medicine, Afghanistan. Dr. Zmarial Kakar is a Fulbright & BGF Alumnus. He has served as an acting provincial public health director of Kandahar Province, Afghanistan.