WORLD HEALTH ORGANIZATION
Health Talks Afghanistan
September 2001
Emergency response
“unacceptable” levels of severe malnutrition,
given the existence of a general food
distribution. The centre saw a 3% death rate in
July and August.
One factor is the high rates of diarrhoea
prompted by poor water and sanitation services
which have been the subject of a massive effort
in construction over recent months. But the
picture is complicated by the reluctance of
mothers to take children to the therapeutic
feeding centres, possibly because they cannot
be away from the rest of their family all day.
MSF is about to duplicate both the
supplementary and the therapeutic feeding
centre to cope with the numbers.
Agencies race winter to protect IDPs
With winter just six weeks away, and numbers of
displaced from rural areas continuing to grow
particularly in the Northern region of
Afghanistan,
international
and
national
organisations are racing against time to get
protective measures in place.
In Herat the camps set up for the displaced
continue to grow by around 8,000 people a
month and many are still housed in rough
shelters giving little protection.
The International Organisation of Migration
which administers the largest camp in Herat
estimates at least 6,000 new shelters are
needed to house families which have already
arrived and another 6,000 in preparation for
those who may come before winter closes the
roads in mid November. A further 4,000 shelters
in Maslakh camp need repairs. In the Northern
region, many small ad hoc camps are scattered
across a wide area, making it even more difficult
to provide assistance.
Last winter, at least 150 people died from cold
and exposure in Maslakh camp in a week which
saw temperatures unusually plummet to -25ºC.
WHO is particularly concerned that cold,
overcrowding, poor nutrition and the resulting
lowered resistance to conditions such as
respiratory tract infections could have a tragic
consequences particularly among children,
many of whom are under nourished. Like others
the agency is appealing for funds to help
maintain essential drug supplies, improve staff
capacity and support emergency needs in water,
sanitation and fuel supply.
“We need to be able to support the IDP health
clinics in treating patients quickly and well this
winter, and be ready to help with fuel supplies
and other materials to protect against the cold,”
says WHO officer in charge in Herat, Dr
Mohibullah Wahdati.
Distribution in remote Ghor
The International Committee of the Red Cross
has begun a massive distribution of aid in Ghor
province where fighting and drought is severely
affecting the population.
Over the next month, some 11,500 metric
tonnes of food, seeds, blankets, kitchen and
water equipment and other non-food items are
being trucked into the drought and conflictstricken area in an effort to help families avoid
displacement from areas that remain secure.
Médecins sans Frontières has also this month
started a programme to feed children in several
areas of Badghis province identified as most
vulnerable to try and help people stay in their
own homes. But medical co-ordinator Lindel
Cherry says it is crucial that other agencies also
act in these areas if people are to stay. “We can
do our part but if they don’t have a water source,
they are not going to stay.
Promoting safe delivery wherever
Some 100 traditional birth assistants are being
trained in the principles of clean and safe
delivery, danger signs and how and when to
refer in the Herat IDP camps this month.
The work is a combined effort between WHO,
UNICEF, WFP which is providing ‘food for
training’ and implementing NGOs such as
Médecins du Monde and Ibnsina. The group
also hopes to train a further 100 in camps in the
Northern region of Mazar before winter.
WHO maternal and child health officer Dr Annie
Begum who carries out the training with local
physician trainers says training TBAs is valuable
Malnutrition at worrying levels
Two supplementary feeding centres in Maslakh
camp in Herat are providing extra rations for
more than 2,000 children every day, and
Médecins sans Frontières, which runs one of the
centres plus therapeutic feeding centres in the
camp and in the city’s hospital, reports
1
September 2001
This document was researched and written by Hilary Bower, information officer for WHO Emergency and Humanitarian Action
Department, Geneva, The content does not necessarily reflect official WHO views or policies.
WORLD HEALTH ORGANIZATION
even if they are again displaced or return to their
home. “They take the knowledge with them and
in some cases we will be simply refreshing those
who were trained by the international community
many years ago.”
The vast majority of Afghan women give birth
with only the assistance of their family members
and the country has one of the highest maternal
mortality rates in the world. (see page 7)
district earlier this month. While IOM provided
transport, Oxfam is providing seeds and other
basic help in the targeted villages.
For its part, WHO is appealing for $6.5 million
dollars to reactivate health services and facilities
in 27 districts to help prevent displacement and
encourage those in camps to return to their
villages.
The project involves activities from building
capacity at district level to manage and support
health services through to supplying and reequipping facilities and training health staff.
Linking camp clinics to families
WHO and NGO teams running the five clinics in
Maslakh camp are to set up defined catchment
areas for each clinic this month to reduce overcrowding and duplicative use of the clinics,
improve the links between clinics and the
families they serve and the ability of health
educators to reach every family.
From the new grid system being applied in the
camp, WHO and the health teams will identify
coverage areas for each clinic, and will supply
families with a numbered family health book,
detailing the names and ages of the family head
and each family member. This book will be used
to track a family’s health and well being and
provide epidemiological data.
At present, fewer than 20 health educators work
in Maslakh camp, despite large problems with
hygiene, nutrition and missed illness. With the
catchment system, health educators will be
responsible for a certain fixed number of families
who they will visit regularly.
In a linked initiative Médecins du Monde is
dramatically expanding the number of health
educators in the camp, adding an extra 60 who
will be based in 10 ‘container’ health posts in the
areas of the camp covered by the NGO.
The idea, says MDM head of mission Thomas
Durieux, is for the health workers to provide
health education on a shelter to shelter basis, to
encourage the formation of communities around
the containers, and to provide ‘first aid’ to take
some of the load off the clinics while improving
the attendance of the seriously ill.
IDP coordinator appointed
WHO has recruited a dedicated international
IDP co-ordinator and intends to employ two
further national IDP focal points in the North and
the West to reinforce its assistance to internally
displaced populations and the organisations
working with them, and extend its public health
programming.
Dr Yusuf Hersi intends to survey all IDP
settlements, both organised and ad hoc, to get
comprehensive picture of the public health
situation. He is also keen to develop a system of
needs reporting and supply which will allow to
NGO and MoPH health facilities working with
IDPs to receive appropriate drugs directly in a
more coordinated fashion.
Communicable disease
Donations target tuberculosis
Donations of $850,000 from Italy and $350,000
from Norway have brought back into sight the
possibility of tackling the country-wide TB control
and treatment in Afghanistan.
More than 16,000 people die of TB every year in
Afghanistan and the situation has been
worsening as more and more people find
themselves displaced, poorly nourished and
crowded into poorly ventilated tents and houses.
Herat Hospital estimates it has seen its
tuberculosis patients more than double in the
past two years.
Other than in the main cities, TB clinics are few
and far between, drug supplies are erratic and
expensive for patients, and health worker
knowledge of how to effectively cure TB is poor.
Indeed poor and irregular pay makes for low
motivation among staff which is especially
damaging for a disease which requires a high
level of supervision.
Ironically, though massive displacement is
exacerbating spread of tuberculosis in
Afghanistan, the same movement of population,
plus the timely donation of monies, may also
provide crucial opportunity for cure since
thousands are pouring into urban centres from
Returnees will need major support
The International Organisation for Migration
says more than 20,000 people in Herat have
registered to return to the original homes if
conditions are right, including a large number of
ethnic minority people.
“In Faryab, for example, we believe it would be
possible to get a significant number of people
back to the place of origin by dealing with the
provision of drinking water and food,” says a
spokesperson.
Two ‘pilot’ returns have already taken place.
Thirty one families in one group and 91 in a
second returned to their villages in Gormach
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September 2001
WORLD HEALTH ORGANIZATION
rural areas where there has been no access to
TB programmes for years.
“People often say there’s no point in treating
people in camps because of the instability, but
for many of these people there is no place to be
treated where they come from,” says WHO
representative to Afghanistan, Dr Said Salah
Youssouf.
In other countries of complex emergency, such
as Somalia, TB programmes bring patients to
specific camps for the length of their treatment
to allow good supervision and supply of correct
drugs. In some ways, displacement may have
inadvertently started this process in Afghanistan.
The Italian and Norwegian donations will be
channelled through WHO to a wide partnership
of international and national players (see below)
and allow the launch of intensive efforts to cure
existing sufferers.
This includes providing supplies to treat some
13,000 patients a year – more than three times
the current rate – re-establishing laboratory
diagnosis facilities, and training staff to work with
the gold standard DOTS or directly observed
treatment short course strategy. It is hoped that
the new money will also allow some staff
incentives to be paid.
ensure logistic and administrative support to the
demonstration sites, and for expert NGOs to
help expand activities into areas without
treatment facilities.
Donations from the Italian and Norwegian
governments totalling over $1.2 million will make
moves to follow these recommendations possible.
Drugs plus food raise cure rate
In Kabul, the German Medical Service’s 30-yearold tuberculosis treatment centre has a cure rate
of almost 85%, with less than 10% defaulting on
the six-month long treatment.
“Let me tell you the miracle,” says programme
manager Reto Steiner. “We are able give people
an incentive. We give them food – wheat, rice,
vegetables and oil – and it has the dual benefit
of reducing defaulters and making sure the
patients eat better.”
In Kabul GMS treats some 800 new cases a
year. A second specialist NGO, Medair,
supports Ministry of Public Health TB clinics and
treats more than 1300. A Medair survey last
year estimated that some 10,000 people in
Kabul contract TB every year.
Very few NGOs are presently involved in TB
care outside of Kabul. However, one model site
is NGO Lepco’s centre at Chak e Wardak, some
2.5 hours drive on rough roads from Kabul. Here
Dr Mahd Arif tends patients and a profusion of
flower gardens with equal care and DOTS is
implemented strictly with high cure and low
default rates.
Dr Paulo Mantellini is WHO’s new Stop TB coordinator for Afghanistan. He can be contacted at the
WHO Afghanistan office, ph:+92 51 2211224 or via
any WHO in-country field offices.
Demonstrate DOTS, says conference
DOTS (directly observed treatment short course)
‘demonstration’ sites should be developed in
each region to gradually introduce strictly
controlled therapy for TB nationwide, according
to participants at the first National Tuberculosis
Coordination Meeting held in Kabul in August.
Conference participants, which included over 40
ministry and NGO representatives, were
adamant that DOTS should be the main form of
treatment, but equally insistent that it should
only be introduced in a step-wise fashion to
avoid further development of drug-resistant TB.
DOTS should only be expanded when these
demonstration sites, which will receive free
drugs and food support, are producing high cure
rates said delegates, who advised against too
rapid expansion. The use of the most important
weapon against TB, rifampacin, especially
should be limited to DOTS sites with good
supervision.
Where
DOTS
cannot
be
guaranteed conference participants said patients
must only be given regimens which do not
include rifampacin.
Delegates also called for recruitment and
training of TB coordinators and deputies for
each region who would train, supervise and
Outbreak in North but Kabul cases down
A serious cholera outbreak is continuing in
Afghanistan, particularly hitting regions where
there are major IDP populations. But in Kabul,
preparedness activities seem to be paying off.
So far this year there have been some 5000
cases and 100 deaths from cholera outbreaks,
many of which have been in the Northern and
Western region where large numbers of IDPs
have gathered. On top of crowding and poor
hygiene conditions, drying up of shallow wells
has forced large populations back onto river
water which is easily contaminated.
NGOs such as Médecins sans Frontières, the
Danish Afghan Committee, the Danish
Committee for Aid to Afghan Refugees and local
NGO Coordination of Humanitarian Activity,
have set up cholera camps in several areas to
provide life-saving oral rehydration therapy.
They also continue to carry out chlorination of
wells and health education while WHO provides
cholera kits and technical guidance when
needed.
In Kabul, however, several years of
preparedness and prevention work appears to
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September 2001
WORLD HEALTH ORGANIZATION
have been able to limited cases in the capital, of
which it was once said that health workers could
predict everything about the annual cholera
epidemic except the names of the people who
would die.
While UNICEF has provided chlorine and WFP
food for work for well chlorination, WHO and
NGO
partners
have
intensively trained
community and health workers in prevention
techniques and hygiene education, as well as in
quick identification of cases – all of which seems
to have paid off this year with no outbreaks
reported so far compared to 6,400 cases in 1999.
Social stigma attached to leishmaniasis is high
particularly for women who may be thrown out of
their home, and both sexes are frequently
barred from sharing food and ostracised.
A guide to treating cutaneous leishmaniasis in
Afghanistan and Pakistan has been developed by and
is available from HealthNet International and WHO.
Haemorrhagic fever strikes again
WHO is investigating three reported deaths from
haemorrhagic fever in the Western region of
Afghanistan. Diagnosis of Crimean Congo
haemorraghic fever was made in Iran in one
case, who travelled there for treatment. Another
is thought to have travelled by car to Pakistan,
while the third died in Farah province.
Last summer an outbreak of CCHF in the Herat
region took 15 lives before being brought under
control. A WHO headquarters outbreak team
trained healthcare staff, who are particularly at
risk since the highly infectious disease is
transmitted through often minimal exposure to
contaminated blood. The WHO office in Herat
maintains a store of Ribavirin which is crucial to
protecting contacts.
The Organisation urges anyone who encounters
deaths involving bleeding to contact a WHO
sub-office or the support office in Islamabad
immediately.
Leishmaniasis epidemic spreads
The
extended
epidemic
of
cutaneous
leishmaniasis in Kabul city has now reached
50,000 new cases a year. And there are fears
that a new outbreak may erupt as internally
displaced people move into the newlyconstructed Sakhi camp in Mazar-e-Sharif.
The camp is sited in an area well populated by
giant gerbils, the rodent carrier of the animalborne form of leishmaniasis, says Dr Kamal
Mustafa, WHO’s officer following the disease.
“We have sent bed nets especially to target
women who suffer the greatest social stigma
from leishmaniasis, and we have prepositioned
3000 vials of pentostam, the treatment drug, in
Mazar in case of outbreak,” he says.
The epidemic in Kabul is mainly due to
population displacement and environmental
damage from the war which has provided the
ideal environment for the sandfly which is the
vector for the human-to-human form prevalent in
the capital. But the disease has also appeared
for the first time this year in Faizabad and
unusual numbers of cases are turning up in the
northern and southern regions, all most likely as
a result of displacement, says Dr Kamal.
Treatment is the first line of control because if
the sand-fly cannot feed on the lesion, it cannot
transmit. In 2000, collaboration between
HealthNet International, Japanese NGO TODAI,
IMPD and WHO, enabled the treatment of
almost 36,000 cases Kabul and 17,000 cases in
other regions. One element was WHO’s
discovery of a new source of reliable drugs in
India which cut the cost of a 100cc from $100 to
$10.
The organisations also ran training in diagnosis
and treatment for male and female doctors,
nurses and laboratory technicians in five regions
to encourage the prompt therapy that can
greatly limit the effect of the disease.
Left alone leishmaniasis will eventually cure
itself, but often only after the victim has suffered
multiple ulcers which are not only susceptible to
other infections, but leave disfiguring scars.
Drought brings back Gulran disease
An unusual and rapidly fatal liver disease, last
seen in the drought of the 1970s, has reemerged in the Gulran district west of Herat.
Named after the district, Gulran disease is linked
to a common weed called charmac and causes
rapid liver damage, anorexia and fatigue. In
advanced stages, patients develop hugely
extended bellies, wasting and bruising, which
can be confused with kwashiorkor.
So far in this outbreak there have been 400
reported cases and over 100 deaths since mid1999. In 1975, after two years of severe drought,
almost 25% of the region’s then 7200-strong
population developed liver problems and over
1600 cases were reported.
The condition appears to be linked to drought
conditions and WHO is currently conducting
studies to find out what is the most important risk
factor. “Some of our theories are that consuming
charmac seeds mixed with wheat or drinking milk
from goats which graze on charmac may be the
cause of the disease,” says WHO communicable
disease officer, Dr Rana Graber.
Salty well water and poor nutrition appear to
exacerbates the effects and lack of knowledge
among health professionals means response is
often late or incorrect, all leading to a very high
death rate from the condition. Improving
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September 2001
WORLD HEALTH ORGANIZATION
nutrition, separating the weed from diet, and
good hospital care can reverse the illness, but
action has to be taken quickly once the toxicity
becomes evident. A WHO plant biologist will
arrive this month to investigate the phenomenon.
A collaboration between WHO and specialist
NGO HealthNet International, the project has
doubled its original stock of 200,000 nets
through cost recovery, while also distributing
more than 260,000 nets over the past two years.
The programme focuses on pregnant women
and children under five who are the most
vulnerable to bad outcomes with malaria. Areas
where more then 30% of the malaria is caused
by the more dangerous falciparum parasite are
also targeted. Nets are sold for between $1.50
and $3 each.
Other key components of the project are training
in
re-impregnation
methods,
community
awareness-raising,
health
education
for
prevention and health worker training in
appropriate treatment and prompt diagnosis.
HealthNet International also runs a similar
programme in the refugee camps of Peshawar
where programme manager Dr Abdul Rab
reports there has been an over 50% reduction in
falciparum malaria.
Funds for malaria currently come from the
European Union via HealthNet and WHO’s
Eastern Mediterranean regional office which
also supplies about a third of the countries
needs for choloroquine and sulphadoxinepyrimethamine or Fansidar. NGOs make up the
vast majority of the remainder.
Roll Back Malaria
Poor immunity puts displaced at risk
People displaced from the Central Highlands
into the endemic lowlands are now among the
most vulnerable to malaria.
“These people are the real victims of malaria.
They are the ones who are dying because they
have very little immunity,” says WHO Roll Back
Malaria officer Dr Kamal Mustafa, who is
currently organising a series of four situation
analyses to underpin the implementation of the
Roll Back Malaria programme in Afghanistan.
The first survey took place in August in the
opposition territory of Badakhshan and
surveyors are now visiting the remainder of the
North East (Kunduz, Baghlan and Taloqan)
which is the most highly endemic area and due
to the frontline passing directly through it, the
most difficult to access.
They will also survey the Eastern region which is
highly endemic and an area to which refugees
are
likely
to
start
returning
and
Kandahar/Helmand in the South which has a low
prevalence of malaria but is the most prone to
epidemics of malaria, due to the presence of
large numbers of displaced from the central
highlands and its position on the transit route
through to Iran.
The situation analyses are the first step towards
creating strategies for Afghanistan under the
Roll Back Malaria programme which aims to
control the disease through access to prompt
diagnosis,
appropriate
treatment,
raised
awareness and preventative measures such bed
nets and environmental control.
Collaboration across sectors and with all
possible players is also a fundamental tenet of
the programme. So far 38 of the 54 NGOs
working in health have agreed to participate in
the programme. Seed funding of $25,000 has
been provided by WHO and $10,000 by cosponsor, UNICEF. But far more will be needed if
the strategies that result are to reach the 13
million people at risk.
Mental Health
Spotlight on psychological health
WHO is about to begin an Afghanistan-wide
assessment of the mental health situation and
activities in the field.
An Afghan doctor trained in mental health and
psychology in India, Dr Said Azimi, hopes to
complete the field work before winter and use
the results as the foundation for a national level
workshop on mental health for potential partners
including the Ministry of Public and NGOs.
Dr Azimi also carried out a three-week awareness
raising course for male physicians in Kabul this
year covering both pathological and psychological
disease. WHO hopes to repeat the training for
female physicians if funds can be found to
support a female trainer from overseas since no
Afghan female doctors have adequate skills in the
area.
Currently there is little mental health training in
the Afghan medical curriculum nor, outside of
Kabul any psychiatric hospitals. Some
organisations do have mental health activities,
such UNICEF’s grief and trauma counselling
courses in Kabul, and it’s hoped the assessment
will both support the development of knowledge
and
awareness
nationally
and
enable
WHO has translated management guidelines,
teaching manuals and health information materials
into both Dari and Pashto. Please contact Dr Kamal
Mustafa for copies.
Bednets prove self funding
Afghanistan’s largest bed net programme is
proving to be almost self funding.
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September 2001
WORLD HEALTH ORGANIZATION
organisations and funders to identify appropriate
activities.
Targeting micronutrients in Kabul
Micronutrient deficiency is prevalent in many
parts of Afghanistan particularly among women,
girls and children. In Kabul, WFP and WHO are
working together to ensure that bread consumed
by some 500,000 people from the food agency’s
assisted bakeries projects is boosted with
essential micronutrients.
While WFP co-ordinates and supplies the
bakeries, WHO has added funds for the
micronutrients and trained WFP staff in
awareness of the problems and solutions.
Micronutrient deficiency is a major cause of birth
defects as well as poor health.
WHO has also trained 22 health professionals
from across Afghanistan as trainers in
community nutrition focusing on how to integrate
the promotion of nutrition into health care
services, assess community needs, develop
growth monitoring activities and
nutritional
counselling, and promote breastfeeding and
proper weaning. Some 200 health staff have
now been trained in community nutrition.
Nutrition
Vulnerable pinpointed in new surveys
Nutritional surveys are taking place in four
regions of Afghanistan in an effort to quantify the
risk of increasing malnutrition in the run-up to
winter. Supported by the funds from the US
Government’s Disaster Assistance Response
team UNICEF, Médecins sans Frontières, Action
Contra la Faim, and Save the Children Fund (US)
are carrying surveys in the North East, North,
West and Southern districts. The aim is to get
nutritional indicators in three key communities:
IDPs, populations living in areas worst affected
by the drought, and those living in less affected
areas.
Levels of acute malnutrition have, until this year,
rarely been reported above 7-8%, partly
because even when coping mechanisms are
extremely stretched, Afghan families prioritise
children. But chronic malnutrition appears to be
high, affecting growth rates and vulnerability to
infection.
UNICEF is also working to try and streamline the
collection of nutritional data so as to make it
comparable across the country. However, one
problem to be overcome is how to maintain the
comparability with figures collected in the past in
a particular region if the approach is changed.
Child Health
Immunisation needs outreach boost
WHO and UNICEF hope to introduce the
concept of ‘sustainable outreach’ immunisation
services later this year to try and boost
persistently low level of childhood vaccination.
Although there has been a tenfold increase in
the number of fixed immunisation points – from
50 in 1992 to 556 in 2001 – and over 1200
vaccinators incentivised by UNICEF are sited in
266 of the country’s 332 districts, the number of
children protected by essential vaccines still
struggles to make it over 40%.
Two key problems persist according to
according to UNICEF senior programme officer,
Dr Solofo Ramaroson: the ability to reach deep
into the remote and difficult terrain and to
correctly supervise and monitor immunization
throughout the country.
Sustainable outreach takes the principles of the
polio national immunisation days with their high
level of social mobilisation and community
participation and applies them to routine
vaccination using teams which visit remote and
under-served areas two or three times a year,
actively seeking out children, says WHO’s Dr
Mojtaba Haghgou.
Poor economy hits children
Over 15% of severely malnourished children
admitted to the therapeutic feeding centre in
Indira Gandhi Children’s Hospital in Kabul in
July died despite efforts to save them, says
clinic supporters Action Contra La Faim.
Most of the children come from Kabul city or
nearby districts, says clinic co-ordinator Dr Asef.
“But they often come very late and in very bad
condition because they usually go to a private
doctor first.”
Over 120 children were admitted in July 2001,
compared to 80 last July. “The most important
causes of malnutrition are economic problems
and low education level, “ says Dr Asef.
“Families are eating very poor quality food. They
can only afford low quality rice and tea – they
can’t buy milk or meal. Then if the children get
diarrhoea or respiratory infection, they lose
weight very quickly.”
The clinic’s 35 beds are overflowing with
wizened marasmic children, while up in the
nursery, senior nurse Nooria says the average
weight of newborns is between 2 and 2.5kgs.
“We expect it when mothers are so small and
malnourished,” she says.
Afghanistan gets first GAVI grant
Afghanistan has just been awarded its first
funding from the Global Alliance for Vaccine and
Immunisation (GAVI). The target is to vaccinate
50,000 more children with the DPT 3
(Diphtheria, Pertussis, Tetanus) vaccine by
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September 2001
WORLD HEALTH ORGANIZATION
adding 25 new fixed centres in remote and
under-served regions, working right down to
household level to ensure full take-up of
vaccines and training health workers and
managers in follow-up of children.
The fund will, unusually, be managed by WHO
and UNICEF rather than going directly to the
country government.
skills in emergency obstetric care among female
health workers in clinics and hospitals in
Afghanistan.
While WHO is targeting its initial round of the
Safe Motherhood Initiative on Kabul, Herat, and
districts in the south eastern region and the
north eastern region, working through health
NGOs such as the Swedish Committee for
Afghanistan, Ibnsina and local health NGO
AHDS, UNICEF is focusing on the south eastern
provinces of Laghman and Lowgar, plus Farah
province in the West and Balkh in the North
East. The children’s agency hopes next month
to start teaching a new curriculum developed
with WHO with the help of an WHO consultant in
the field.
“We want to work on the supply side – there’s no
point in creating demand if when women are
referred there’s no good services. Nurses and
female physicians in clinics have to know what
to do in obstetric emergencies, says UNICEF’s
Dr Solofo Ramasoron.
Afghanistan has one of the highest rates of
maternal mortality in the world – some 16,000
women (1700 per 100,000 live births) die every
year of causes related to pregnancy. Among the
causes are: poor availability of reproductive
health care and motivated, skilled health
workers, lack of access to female doctors, very
few midwives, poor referral possibilities, lack of
supervision, low education and literacy levels
among women, and lack of resources – all
added to the problems of a remote mountainous
country and ongoing conflict.
To tackle these problems, the Safe Motherhood
Initiative aims to introduce the skills needed to
provide essential obstetric care at different
levels of the health service and train health staff
in components ranging from antenatal care
through to hospital level emergency obstetric
response. However, says WHO maternal and
child health officer, Dr Annie Begum, important
though it is to improve secondary care, it is
essential to continue training traditional birth
attendants since 90% of Afghan women give
birth at home.
“People say that TBAs cannot manage women
who suffer obstetric complications, but in rural
areas where there is nothing, women rely on
them so we have to train them in how to conduct
a clean and safe delivery, how to recognise the
danger signs, when and where to refer to and
how to provide first aid before referring.”
Dr Begum says the targeted districts are those
where there is the potential to form referral links
from the TBAs through a health clinic and to a
district hospital.
Since 2000, WHO has trained 50 female
physicians in essential obstetric care, 36 TBA
Polio eradication
Strong national teams will do NIDs
At the time of writing WHO and UNICEF hope to
see the first round of the 2001 national
immunisation days (NIDs) go ahead as planned
on 23-25 September, despite the temporary
evacuation of international UN staff from field
offices in Afghanistan earlier this month.
Expanded programme for immunisation team
leader Dr Naveed Ahmed Sadozai says that if
international staff cannot be present, the strong
national staff team is fully capable of
implementing the NIDs.
The NIDs this year are synchronized with those
in neighboring Pakistan and are the most recent
efforts in a campaign that is beating back the
polio virus despite enormous odds. So far in
2001, there have been only 9 confirmed cases
compared to 27 cases in 2000, and 63 in 1999.
Surveillance for acute flaccid paralysis, the
marker used to spot polio, has also improved
dramatically as has investigation of each
individual case, largely due to a network of 237
sentinel sites and focal points across the country.
“We believe we now get to know about almost
every case of AFP,” says surveillance officer Dr
Mojtaba Haghgou. “Many patients go first to a
mullah or community leader, so we have trained
them to report cases also.”
Surveillance data show four remaining hotspots
for wild polio transmission in Afghanistan. Two
border Pakistan’s North West Frontier Province
and Balochistan in the south. The other two are
Herat in the west and Kunduz province in the
north east. Co-ordination and synchronisation of
activities in border areas will be crucial to ensure
eradication, says Dr Naveed.
Routine vaccination has also benefited from the
investment of the polio campaign, increasing
from 7% before NIDs started to 36% in 2000 as
a result of improvements in cold chain and
staffing dedicated to vaccination.
Maternal Health
Targeting essential obstetric care
In the fight against atrocious rates of maternal
mortality, both WHO and UNICEF have this year
shifted their focus to concentrate on developing
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September 2001
WORLD HEALTH ORGANIZATION
“They are very motivated, they can teach very
easily and it gives hope to the patients that there
is a life after disability. It’s not easy to lose a part
of the body but we work to help them find a way.”
Services and staff are mirrored exactly for men
and for women, and the centre recently added a
job centre, vocational training and a micro-credit
operation to its activities.
ICRC, which opened its sixth centre last month
in Faizabad, has helped over 45,000 people
since 1988, almost half at the Kabul centre.
Sadly there is little sign that their activities will be
any less needed in the near future.
trainers and 580 TBAs who now work in 400
villages across five regions.
WHO has translated various Safe Motherhood texts
adapted by the maternal health taskforce into Dari.
Please contact Dr Begum at WHO for copies.
Tracking the gaps that lead to death
WHO and the Ministry of Public Health hope to
pilot a maternal death reporting system in seven
hospitals in Afghanistan. The aim is to track
causes of maternal death and identify the gaps
in service that have the most fatal effect.
Community effort for safe delivery kits
Only 12% of women deliver in the care of a
person trained to help her. This leaves the vast
majority of women giving birth aided only by
family members. To help them, WHO and
UNICEF plan to train traditional birth attendants
and women in communities on how to assemble
a disposable safe delivery kit using locally
available materials and the importance of
utilising all the elements. “We hope increasing
availability of the kit will help reduce neonatal
tetanus. And making the kits could also become
income generating for some families,” says
WHO’s Dr Annie Begum.
Water and sanitation
Turning on the tap in Faizabad
For the first time in their lives, all the residents of
Faizabad city have access this year to piped
water, thanks to UN agency collaboration.
The $550,000 project in the capital of the
opposition territory not only involved extending a
completely new water distribution network into
the new city, but also two large water reservoirs
in the hills above the city, and even a flood
protection system “to protect lives, and our water
project,” says WHO’s water and sanitation
engineer, Dr Riyad Musa Ahmad. Together with
an earlier project which brought water to the old
town, the network now benefits all the city’s
50,000 inhabitants.
While WHO implemented the project and
employed the engineers who designed and
supervised the construction of the network,
UNICEF brought the piping, and the World Food
Programme provided food for work to the
labourers.
Hygiene education is also a key part of the
project, says Dr Musa, and trained health
educators have been working within the
communities to promote healthy and hygienic
practices with water.
“WHO usually focuses on quality of water but
when there is very little quantity this affects
sanitation which inevitably affects water quality.
This is why we, and the other agencies, believe
this project is so important,” says Dr Musa.
 Rehabilitation
Disease is also war damage
One in five people given back their mobility at
ICRC’s orthopaedic centre in Kabul have been
disabled not by rockets or landmines, but by the
lack of access to good medical care.
The centre sees about 200 new patients a
month, 80 per cent of which suffer from minerelated amputations. But around 20% of them
are disabled by other causes such as polio and
cerebral palsy. “In a way they are war victims
too,“ says centre manager Mr Najmuddin. “They
are disabled because they didn’t get the vaccine
or the health services they needed or because
there were difficulties with their birth. We have
many many children with polio contracted before
the polio campaigns began.”
Whatever the cause, the centre – the largest of
its kind in the world – not only makes and fits
prosthesis and supplies ICRC’s five other
centres in Afghanistan, but also ensures through
physiotherapy and careful fitting and practice
that the patient is “100% able to use it.”
They know what they are teaching - over 75% of
the 150 staff have been through the process
themselves. “In the past people thought disabled
people couldn’t do anything, but we have many
disabled people working very hard here, ” says
Najmuddin who lost both legs at 19 in a mine
blast and has managed the centre for 13 years.
Japanese support Northern IDPs
People displaced by drought into some of the
many camps scattered across the Mazar-eSharif and Kunduz provinces will benefit from a
$160,000 donation from the Japanese
Government which is to be used to construct
latrines and make water quality improvements.
The funds are being channelled through WHO’s
water and sanitation programme for Afghanistan
which is now targeting the Northern region since
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September 2001
WORLD HEALTH ORGANIZATION
many other agencies involved in the water
sector technical group have responded to the
needs of the IDP camps of the Western Region.
The money will be used to improve quality of
water and sanitation in the camps and
surrounding areas, says WHO engineer Dr
Riyad Musa Ahmad, by providing micro sand
filters.
Around 20 district hospitals in the area will be
fitted with the technology which has been
especially adapted for conditions in Afghanistan.
Filters, which produce good clean water at
relatively low cost and with little maintenance,
will also be supplied for communities and
families in the IDP camps.
backed the project with $230,000 with a further
$100,000 donated by the Italian Government.
Weekly watch spots outbreaks better
MSF Holland has set up a weekly ‘alarm call’
system for six epidemic-prone diseases that has
significantly
improved
response
to
communicable disease in Kandahar.
The project, which started in September 2000,
involves 18 sentinel sites which collect and
analyse data on cases of malaria, meningitis,
measles, typhoid, watery and bloody diarrhoea
on a weekly basis.
“Last summer we felt we were always running
after diseases. With the alarm call system we
have been able to manage diseases that could
potentially have got out of control, such as the
meningitis outbreak in June this year, in a much
more proactive and coordinated way,” says
MSF-H medical coordinator Beverley Colin.
A key element in the programme, which was
adapted from a ‘weekly watch’ piloted by WHO
in Kabul last year, is the teaching health workers
and community leaders to recognise the early
signs of an outbreak, and to act on the
information. Too often, the beginnings of an
outbreak are only picked up weeks after, either
because available data is not analysed locally or
because there is no data collection.
“This makes a big difference to the speed of
response,“ says Ms Colin. For example, health
workers in Badghis recently started seeing a
50% increase in fever cases and were
immediately alert to the possibility of malaria
outbreak which in turn allowed the emergency
taskforce to plan a response.
MSF has integrated the alarm call system into
the new nation-wide health information system
by using the same case definitions and
incorporating the data into monthly reporting.
WHO is seeking funds to build on and spread on
the experience of these two models particularly
into areas where accumulations of IDPs are
creating ideal conditions for outbreaks.
“The key is to have people watching for early
signs of a problem, knowing who to call and
seeing a response.” says Dr Rana Graber,
WHO’s officer for health information.
Health information
Disease data starts to flow
A country-wide health information system
launched in May should soon start producing
long-needed data on disease burden.
Since January this year over 900 people someone from almost every health facility in
Afghanistan – have been trained in both the use
and principles of health information by the
Health Information System Taskforce, a team
which involves the Ministry of Public Health,
WHO, UNICEF and major NGOs such as
Swedish Committee For Afghanistan, Ibnsina,
Médecins sans Frontières and Aide Medicale
International.
The system has been designed by the taskforce
over the past two years and will provide detailed
information on 36 conditions plus infant and
maternal deaths and causes, and referrals in a
country for which accurate statistics are like gold
dust. The arduously-developed standard case
definitions should also allow comparisons to be
made across the country as well as helping
refresh and focus diagnostic skills.
Though it will take some time to gain
momentum, when all health facilities are
reporting regularly, more than 10,000 forms will
flow initially into WHO offices and eventually, it
is hoped, into national health information units.
Funds allowing, WHO plans to base a computer
expert in Kabul next year to train Ministry of
Public Health staff in input and analysis of data,
as well as basic computer skills.
Collecting health information is crucial to
tracking trends, identifying priorities and
monitoring impact over time. While it needs to
be analysed centrally training has focused on
enabling each health facility to use their own
data for decision-making before sending the
data to a higher level, says Dr Rana Graber,
WHO health information officer. WHO has
Primary health care
Modelling ‘sustainable’ health care
WHO wants to launch model ‘sustainable’
primary health care centres in 22 districts this
year, in collaboration with the Ministry of Public
Health and various NGOs.
The concept rests on developing community
participation to manage and financially support
re-invigorated curative and preventive services.
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September 2001
WORLD HEALTH ORGANIZATION
“If assistance stops tomorrow, what will happen?”
asks Dr Abdi Momin Ahmed, WHO officer for
primary health care. “The vast majority of
functioning health clinics in Afghanistan only
exist because of external funds. We want to
sensitise the community to support their health
workers, to assume responsibility for their own
health care systems so that if assistance leaves,
the system does not collapse.”
The programme has several key elements. One
is an intensive programme of orientation and
skill building in community management and
financing of health services (see below).
Health workers also need to be updated in
essential disciplines, says Dr Momin, and
concrete practicalities put in place, including
providing basic equipment and essential drugs
to some 75 basic health centres, and carrying
out some physical rehabilitation on at least 16
units.
So far five district health teams have been
trained in the concepts of sustainable health
care and introductory work has been done with
regional health authorities to gain their support.
However substantial funding is needed to move
into the implementation phase
both the larger towns in Afghanistan and over
the border in Pakistan can tip the balance
between staying and going.”
Although the number of districts providing
essential primary care has risen from 12% in
1990 to 48% in the year 2000, the situation is
still dire in many parts of the country since
geography, insecurity, quality of service and
availability of supplies prevent many from
accessing the care they need.
Cost recovery on drugs helps usage
Cost recovery projects run by NGOs have met
with
surprising
success.
HealthNet
International’s primary care project in Eastern
Afghanistan is achieving over 70% cost recovery
on drugs, for example. Focused on the Shinwar
district, HNI has fostered a complete health care
system from community through primary care to
the district referral hospital and underpins this
system with supplies, equipment, incentives and
managerial support.
The Swedish Committee for Afghanistan, which
supports over 160 health facilities in remote
regions of Afghanistan also uses cost recovery,
charging patients 40% of the market price for
drugs and 1000 Afghanis (US$0.01) for
consultation. Male and a female health
committees identify the roughly 10% of patients
too poor to pay even this meagre amount.
“If we give drugs for free, patients don’t trust the
drug and throw it away. We have also been
working for a long time to teach people in our
communities about rational drug use and now
they are beginning to believe us when we say a
drug is not needed,” says Dr Shafi Saadat,
SCA’s head of the health programme.
Goal is to avert displacement
WHO is carrying out a survey in four provinces
in September and October to get information on
primary health care support and the level of
operation of facilities with a view to targeting
investment in clinics in communities vulnerable
to displacement.
The first survey will take place in Nangarhar and
Laghman, says primary health care officer Dr
Abdi Momin Ahmad, because of their easy
accessibility and the presence of large numbers
of farmers previously involved in opium poppy
production. Herat and Mazar-e-Sharif will be
covered next because of the drought situation
there.
In the Western District, the survey will be the
first step in a displacement prevention package,
designed to run alongside other similar
programmes involving food and seed distribution
and well improvement. Under this ‘survival’
package, WHO is appealing for some $3.5
million to get 27 basic health centres back to an
appropriate operation level and supply and
supervise them for nine months.
“Though a functioning health centre alone will
not keep people in a village or be the main
reason why they return, it is an essential part of
the jigsaw of social and economic support
needed to avert displacement and encourage
return,” says Dr Said Salah Youssouf, WHO
representative to Afghanistan. “If a family
member is sick, the pull of health services in
Evaluation of basic needs project
WHO is to evaluate its long-standing basic
development needs programme this year.
The programme involves giving loans for
projects ranging from health education to literacy
classes and income generation activities with
the aim of improving health through improving
basic living conditions. It is now present in 14
villages in four regions. A 15th village in the
central region has just carried out the baseline
survey that underpins the initiative and which
aims to identify action areas across all sectors.
The aim is for the community to use the baseline
survey which they carry out themselves, to
develop an overall development plan and to
identify priority activities which will improve their
quality of life and health. From this, a committee
develops small projects for funding by UN and
other organisations, either directly through
money or via approaches such as food for work.
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September 2001
WORLD HEALTH ORGANIZATION
One village has targeted literacy programmes
for women, for example, while others prioritise
income generation, or health-related issues such
as improving vaccination rates, educating
traditional birth attendants or clearing mosquito
breeding grounds.
health and higher education, and the Liverpool
School of Public Health, has a mixed intake of
20 males and females as is allowed in the
Northern Alliance sector. It covers management
of health services at district level and practice in
major clinical areas such as mother and child
health, epidemic diseases, vaccination and
nutrition. Two similar courses were held for men
last year in Kabul, and for women in 1997 and
1998 in Kabul and Herat respectively.
Because of the scarcity of Afghan female
lecturers, female courses are more difficult to
organise, says WHO education and training
officer Ms Alexandra Taha. But it can be done
by supplementing Afghan teachers with
international NGO and WHO lecturers. Ms Taha
is also hoping to hold follow-up courses for the
male directors to promote an environment in
which female participants might be more able to
put into practice what they have learnt.
Indeed, a step in this direction was the first oneweek course for provincial directors of health
who are usually non-technical religious leaders
supported by a medically trained deputy director.
The programme ran through essential primary
care areas including communicable disease
control, water and sanitation, essential drugs,
immunisation and mother and child health. But it
also focused on key elements of service such as
teamwork and community organisation, and
included a visit to Healthnet’s primary health
care community participation pilot project which
is achieving 70% recovery of costs on drugs.
“This astonished the directors who hadn’t
believed the community would be willing to pay
for drugs and better services,“ says Ms Taha.
Diagnostics
Tackling training and supplies
Sixteen laboratory technicians from across
Afghanistan gathered in Kabul in early
September for a two week refresher course in
laboratory techniques and diagnosis. The course
is part of a series of training sessions over the
past two years which WHO has carried out both
centrally and at regional and district level to
upgrade laboratory and diagnostic capacity.
WHO provides the majority of available
laboratory supplies since the Ministry of Public
Health does not direct any resources to the area
and NGO support is general restricted to small
clinic laboratories.
WHO hopes to improve the supplies to
laboratories next year by employing a national
officer who will travel through out the country to
help strengthen and monitor the supply chain, as
well as provide technical support to the regional
and provincial laboratories. Some facilities have,
for example, been found to have good stockpiles
of some chemicals which cannot be used
because they are missing a single element.
“The aim is to have fully functioning laboratory in
each region working together with the national
level,” says Dr Said Salah Youssouf, WHO
representative to Afghanistan.
WHO is also re-equipping radiology units and
retraining radiology technicians in good practice
and in maintenance. Three new x-ray machines
have been installed in 2001 – two in Kabul and
one in Faizabad – and three more on order are
destined for provincial hospitals.
Study grants but in countries nearby
Seven doctors from different parts of
Afghanistan have been awarded fellowships in
2001 to study in neighbouring countries via a
longstanding WHO programme.
The doctors, who work for and are nominated by
the Ministry of Public Health, travel to countries
such as Pakistan, Iran, Egypt, Bangladesh and
Thailand to participate in post graduate studies
in public health, epidemiology and nutrition.
Several more are to take up places funded via
programmes such as tuberculosis and malaria.
Previously fellowships were given to European
and American schools of medicine, but since
very few of these doctors returned to
Afghanistan after completing their studies, WHO
now focuses on universities in countries closer
by unless there are compelling circumstances.
Currently all fellowships have only been
awarded to men, but WHO education officer
Alexandra Taha says efforts are under way to
find acceptable ways of allowing female doctors
Training and education
All sorts learn about public health
Increasingly diverse groups of people are
participating in public health training in
Afghanistan. While a two month certificate
course in district health practice – the sixth such
workshop to take place in Afghanistan since
1996 – started in Faizabad this month, earlier
this year 18 mullahs from across the country
gathered in Jalalabad to attend a week-long
training in the principles and planning of basic
primary health care.
The Faizabad certificate course, originally
developed by WHO, the ministries of public
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September 2001
WORLD HEALTH ORGANIZATION
to participate, including the possibility of distance
learning linked to internationally-connected
universities in neighbouring countries. “We’re
hoping to pilot distance learning next year. If
materials are on the Internet, we at WHO could
download and get them to the students who could
perhaps sit exams either in Pakistan or perhaps
via an embassy,” says Ms Taha.
region if health authorities agree to set up a
facility that is maintained by a librarian and
accessible to both men and women. Herat
regional health authority was the first to fulfil
both these conditions.
Health promotion
Network of educators needed
Handful of female schools reopen
WHO has recommended that the MoPH set up a
central department for health promotion and a
network of regional taskforces to train paramedics
and community workers and produce health
promotion materials and activities.
Last month WHO expert Dr Muzamil Abdelgadar
held a 4-day training for 24 doctors to create district
focal points for health promotion and a 2-day
workshop for the 16 members of a new National
Health Promotion core group which it is hoped will
be the forerunner of a central department. While
receptive to the recommendations, the Ministry of
Public Health says they will require external funding
to carry them out.
WHO and partner agencies including Save the
Children UK and CARE are also exploring the
possibility of developing a training of trainers
package in the methods and principles of health
education. Many NGOs and technical health
programmes such as the polio campaign and
Roll Back Malaria already carry out health
education activities in communities, says WHO
officer for health education Alexandra Taha, so
this group intends to focus on encouraging the
development of training, strategic and policy
expertise. WHO has also raised the idea of
incorporating health education into the school
curriculum with the Ministry of Education.
Three female schools of nursing are now open
in Kandahar, Herat and Helmand, while in Kabul
some 65 female student are now re-attending
medical school under the supervision of an
highly respected female doctor.
The nursing schools are enrolling new students
as well as those who were unable to complete
their studies, but most of the students in Kabul
are third year undergraduates who are finishing
studies they began before the ban on female
studying. New students have not been admitted,
due to space constraints, say authorities. But
observers say it will be difficult to find new
female entrants to take up medicine since none
can currently attend high school.
WHO is providing books, anatomical models and
teaching aids such as photocopiers and
overhead and slide projectors to both female
and male nursing schools, says Dr Normal,
national officer for medical education in Kabul.
The three nursing schools are also being
supported by the World Food Programme which
is providing ‘food for training’ to both tutors who
receive very limited and irregular state salaries,
and to the students to encourage families to
allow their daughters to study.
WHO also has funds available to support two
Afghan female health trainers for the regional
health offices in the two cities. But though
regional Ministries of Health have agreed to give
the trainers offices in the provincial hospital, so
far no suitable applicants have responded to
advertisements.
Sounds of health
About 50% of Afghan population are thought to
listen in daily to BBC Afghan service’s radio
soap opera “New Home, New Life”. On air since
1994, the programme is, among other things, a
vital vehicle for health information and WHO and
other UN agencies supports it with story lines,
technical advice and funds. In recent episodes,
characters have explained many basic and notso-basic health issues including breast feeding,
hygiene practices, vaccination and diagnosis of
leishmaniasis. It also follows up with a series of
books that retell the stories and messages for
children and which are distributed free
throughout Afghanistan and the refugee camps.
WHO donates $50,000 a year, but continued
funding is not certain and dedicated extrabudgetary
monies
are
being
sought.
Pulling in the same direction
New nurses, assistant doctors and dentists and
pharmacists across Afghanistan now follow the
same curriculum for their respective studies.
After revision and discussion with WHO, the
MoPH and its regional directors last year agreed
to implement a newly revised curriculum across
all paramedical schools. Now WHO hopes to
foster the same idea for trainee doctors in the
country’s five medical faculties.
The Organisation has also imported medical
books and computers to equip a library in each
For further information, please contact: Dr Said Salah Youssouf, WHO Afghanistan Representative,
Support Office, Islamabad, Ph: +9251 2211224 or 2297931, email: WR@whoafg.org, or Dr Khalid
12
September 2001
WORLD HEALTH ORGANIZATION
Shibib, Desk Officer Afghanistan, WHO Emergency and Humanitarian Action Department, WHO
Geneva. Ph: +41 22 791 2988, email shibibk@who.int.
13
September 2001