Afghanistan is currently battling its worst humanitarian crisis after the Taliban takeover on Aug 15, 2021, compounded by several public health challenges, including the COVID-19 pandemic which, as of Dec 10, 2021, has been associated with 7321 deaths.
With the freezing of foreign financial reserves and suspension of support from overseas organisations, the national health system is now on the verge of collapse. Political instability led to suspension of financial support from Da Afghanistan Bank, the International Monetary Fund, and the World Bank, contributing to an acute shortage of medical equipment in the context of divided donorship. However, timely intervention from the United Nations Development Programme and the Global Fund now supports health-care workers' remunerations and helps resource health supplies. However, the Taliban has yet to announce a plan for sustaining Afghanistan's health-care system, and hence the future of health care hangs in the balance.
The country's largest health project, Sehatmandi, is a 3-year multidonor-funded project with a total cost of US$600 million. The project was initiated by the World Bank and implemented by the Afghanistan Ministry of Public Health in 2018, with the objective to strategise as well as increase the quality and utilisation of health resources, nutritional needs, and family planning services in Afghanistan. Sehatmandi is currently stalled with only 17% of all health facilities fully functional, and nine of 37 COVID-19-dedicated hospitals have shut down due to cuts in donor support.
The collapse of health services has led to burnout among health-care workers with chronically uncompensated salaries, resulting in a severe shortage of skilled professionals. Moreover, the emergency response has been incapacitated, with a lack of oxygen supply and ventilators, shortage of available beds, and stock-outs of medical supplies; all of which adversely impact critical care management of patients with COVID-19 and other life-threatening ailments. The health-care needs of Afghanistan are dependent on international support and importation of medical equipment, drugs, and consumables. However, even the main access routes, which are routinely used to receive life-saving medical aid, such as coagulation factors and other blood products for transfusions in children with haematological disorders, have been restricted or blocked.
The impact of this crisis on the prevention, treatment, and management of respiratory illnesses should not be underestimated. Lower respiratory tract infections have the highest burden of mortality in children younger than 5 years, and respiratory illness is the second leading cause of death in girls aged 5–14 years. Tuberculosis poses its own set of challenges for the Afghan population, as it is the second most common cause of death among women aged 15–49 years, with a clinical prognosis that is even worse with its drug-resistant forms. Without full access to treatment, the respiratory disease burden will continue to be a serious cause for disquietude.
Air pollution is one of the main environmental risk factors for increased mortality in Afghanistan, according to WHO estimates. Household air pollution causes approximately 27 000 deaths per year, whereas ambient or outdoor air pollution causes over 11 000 deaths annually. Although most of the population are unaware of the risks of air pollution, the increasing levels of PM2.5 have contributed to an increase in disease burden of asthma, chronic obstructive pulmonary disease, pneumonia, and lung cancer. During winter seasons, the prevalence of respiratory diseases further worsens as most inhabitants from low-income strata rely on non-sustainable practices to generate heat due to recurrent electricity shortages. Long standing military conflict might also have led to increased exposure to particulate matter from military armaments and practices.
Prevalence of smoking tobacco in Afghanistan is high (21·9% of men and 3·4% of women), and is greater than in other sociopolitically volatile countries, such as Yemen and Somalia.
Access to health care has been a long-standing challenge in Afghanistan. People living in remote areas are devoid of accessible health services. This gap is further widened due to ongoing conflict and inoperable health clinics, resulting in a frail support system to address the critical care needs of regionally isolated populations. Trauma and injuries due to war and conflicts are an increasing public health challenge with the health system dependent on a limited number of available trauma centres in the country. In addition, emergency transport services are inadequate to aid in the transfer of critical cases to existing medical and trauma facilities. This challenge is apparent with just 29 ambulances providing support to the 4·6 million residents in Kabul.
© 2022 Image from Pixabay
The abysmal situation in Afghanistan has inevitably shed light on the regions' worst food crisis. According to the Integrated Phase Classification, it is projected that 14 million people in the country are experiencing food insecurities. The ramifications of which have deeply affected adolescents and young children. Over 3·2 million children are suffering from acute malnutrition, while more than a million children are at risk of death by starvation. The health care, political, and regional adversities are further impoverished by Afghanistan's deteriorating climate in recent years. In a country where the agricultural sector accounts for about 25% of the gross domestic product, famine and drought will most likely have had a devastating impact on the country's economy and the population's nutrition status. If immediate interventions are not effectively deployed, the imminent food scarcity is bound to worsen critical care demands resulting in escalating mortality rates.
Moreover, the maternal mortality rate in Afghanistan is considered to be one of the highest in the world. Unsafe abortions, sepsis, and peripartum haemorrhage are major causes of maternal mortality in the region. Awareness of contraceptive measures and family planning practices is another considerable barrier in promoting and safeguarding female health.
Another perturbing matter is that COVID-19 vaccination rates have been poor, despite 1·8 million vaccine doses remaining unused in the country. Additionally, routine vaccination programmes deployed in Afghanistan have been largely underwhelming because of long-standing sociopolitical turmoil. A 2018 national health survey reported that merely 51·4% of the Afghan children were fully vaccinated. The Taliban takeover has further hampered routine vaccination efforts, increasing the risk of contracting vaccine-preventable infectious diseases. However, in a recent turn of events, the Taliban-led government recently re-instated nationwide house-to-house polio vaccination efforts, which were previously halted for 3 years. A positive move, most welcomed by WHO and UNICEF. A report from the 2018–19 influenza season highlights influenza poses a significant health burden in Afghanistan, with cases the highest they have been in January, 2021; however, no influenza vaccination programme currently exists in Afghanistan, even for the high-risk population. Given the emergence of new SARS-CoV-2 variants of concern during the flu season, the latest of which is Omicron, we caution clinicians in Afghanistan not to dismiss Omicron as the common cold, despite some similarities in symptoms. Further new longitudinal studies are necessary to better understand and help accurately quantify the potential long-term health consequences associated with the recent developments in Afghanistan.
Poor respiratory hygiene in addition to crowded living conditions, partially the result of a largely displaced population, are serious matters for concern, especially in the context of a primarily unvaccinated population, while the pressure on critical care services intensifies. The demands on health care are substantial and stretch the already limited resources of a collapsing system, leading to delayed patient treatments and higher mortality rates. Critical care in Afghanistan lacks integration within the larger health-care system, including emergency care, so critically ill patients around the country often have to travel long and unsafe distances to receive necessary life-saving interventions. Telemedicine in Afghanistan might help ameliorate current gaps in clinical care. TelemedAF is the first free telemedicine service in Afghanistan. Just launched last year, the team of volunteer physicians at TelemedAF have served more than 14 000 patients and aim to ensure all Afghans receive continuous medical care.
Blighted by regular discord, political and administrative instability in the background of an overwhelmed health-care system and the COVID-19 pandemic, there is an urgent need for collective action to help alleviate the ongoing humanitarian crises in Afghanistan. Steps must be taken by all relevant stakeholders, the international community, and non-governmental organisations to mitigate the systemic challenges at hand by increasing funding, collaborations, and research on the needs across the Afghan's health-care landscape.
Epidemiological research investigations that aim to characterise burden of disease and disparities in health services must be integrated into the national health-care plan, along with both short-term and comprehensive respiratory and critical care education programmes. International and local health policy makers must adopt a shared vision for equitable and high-quality respiratory and critical care in Afghanistan to prioritise the Sustainable Development Goals and improve both national and global health security.
Acknowledgments
We declare no competing interests.