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Measles outbreak strains Afghanistan’s weak health system

‘The devastating thing here is that Afghan children don’t have six months to wait until media attention dies down on Ukraine and turns back to Afghanistan.’

An Afghan child receives a jab during an anti-polio campaign in August 2014. Historically low vaccination coverage in Afghanistan has been further derailed by the pandemic and the Taliban takeover. Parwiz/REUTERS
An Afghan child receives a jab during an anti-polio campaign in August 2014. Historically low vaccination coverage in Afghanistan has been further derailed by the pandemic and the Taliban takeover.

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A massive measles outbreak in Afghanistan threatens to bring what’s left of the country’s health system to its knees while putting an unsustainable burden on humanitarian agencies to fill the gaps, according to aid workers.

“One of our mobile health teams that’s been running for three or four years in Kandahar told us they’d had [an] almost 200% or 300% increase in the number of patients in the last eight months,” Athena Rayburn, director of advocacy, communications, campaigns, and media at Save the Children, told The New Humanitarian.

Save the Children has had to double its mobile health teams from almost 40 to 80 in order to reach those in more remote areas, while Dr. Hamayoun Hemat, deputy medical coordinator in Afghanistan for Médecins Sans Frontières, said MSF facilities are overwhelmed with patients suffering from measles and malnutrition.

Measles cases have been rising sharply since July 2021. From the beginning of January until 14 May this year, 46,632 cases were reported, including 270 deaths – compared with 156 confirmed deaths in all of 2021.

“Measles is on the rise here,” 25-year-old Khojista*, told Save the Children in March after three of her own children experienced the highly contagious disease. “My sister-in-law’s children and all of our relatives and neighbours’ children have measles.” 

Thanks to a mobile health clinic – which visits her village in Balkh Province each week – Khojista’s children were able to receive treatment and recover. But many of her neighbours have not been so lucky. 

MSF reported that one of its projects in Herat province was seeing two children dying from measles each day.

Initially presenting as a rash alongside cold-like symptoms, measles can escalate to blindness, brain swelling, and respiratory infections. A vaccine exists, but coverage in Afghanistan has historically sat at 66 percent rather than the recommended 95 percent.

The causes of the crisis

Poor vaccine coverage coupled with widespread economic hardship in the wake of the Taliban takeover have created the perfect conditions for the virus to thrive. “The poor economical situation, the drought, the [lower] income of families faced with hunger, and fund cutting, job loss… all this is deteriorating the situation,” Hemat said.

Last August, the Taliban seized control of the country, triggering what the World Bank calls “a complex economic crisis”. Foreign governments and multilateral development banks paused billions of dollars in international aid and froze billions more in overseas assets. At the same time, hundreds of thousands sought refuge in foreign countries. Of those left behind, 24 million are now in need of humanitarian assistance and 95 percent of Afghans don’t have enough to eat.

“We live hand to mouth,” Khojista said, adding that her husband works as a labourer, earning 300 afghanis ($3) a day.

A lack of food can lead to malnutrition. Research shows that malnourished children are more likely to suffer a severe form of measles, perhaps more frequently, because their immune system is too weak to fight off infection. 

“The rate of malnutrition and hunger is so high at the moment in Afghanistan [that] children are much more vulnerable, not just to measles but [also to] developing long-term, negative side-effects that can be lifelong,” Rayburn said. Subacute sclerosing panencephalitis is a deadly neurological disease that can develop 7 to 10 years after a measles infection.

“I’ve spoken to families… pretty much across the country, who are eating one loaf of bread for 4 or 5 days,” she said. The higher cost of heating fuel – following the Ukraine crisis – also made spread more likely, with parents unable to isolate sick children during the winter. “[W]hen you only have one room that has fuel to keep warm, you can’t separate your kids, because they’ll freeze,” Rayburn said.

The political upheaval, alongside the effects of the pandemic, has also impacted access to healthcare, Hemat explained. “Some facilities have decreased the number of care staff, and COVID-19 helped [people] to somehow forget about routine vaccinations,” he said, adding that economic hardship also makes it difficult for patients to afford the transport cost to visit a facility for a vaccine even when they are available.

The WHO estimated that 23 million more babies worldwide missed routine vaccinations – including the two recommended measles doses – in 2020 than in 2019.

Even if parents are able to bring their child to be immunised, Rayburn explained that between power outages, transport issues, and supply chain delays, vaccine efficacy could be low. The measles vaccine* must be stored at between -20°C to 8°C, depending on location.

Given such a “major structural upheaval”, Matthew Stearns, International Medical Corps’ country director in Afghanistan, said there were certain to be challenges across all sectors, including healthcare. He said he hoped the current outbreak would be “a one-off, relatively contained, and under control”.

Case numbers are beginning to decline, said Nur Hayati Ahmad, Afghanistan programme coordinator at the International Federation of Red Cross and Red Crescent Societies. However, that doesn’t mean there isn’t still grave concern over what another peak could mean for the fragile health system. “It’s endemic in the country,” Ahmad said. “So it could happen at any time.”

Hemat is also concerned that it’s a signifier of more illness to come. “If measles cases increase, other preventable diseases can pop up too,” he said.

A lack of medical care drives up deaths

There is no specific treatment for measles, but complications – such as meningitis and pneumonia – often require antibiotics and hospitalisation. In Afghanistan, access to both can be a struggle to find following the regime change.

The freezing of foreign aid from big donors such as the World Bank has forced many hospitals to close. “People are getting sick and there is nowhere for them to receive treatment,” Rayburn said.

If there is a hospital, it’s often far away. In the province of Jawzjan for example, Rayburn said it would cost 5,000 afghanis ($56) for transport to reach the nearest hospital. “That’s something that’s completely out of reach,” she said, explaining that families often have to choose between paying rent or paying for a bus to go to hospital.

Khojista said she hadn’t taken her children to the city for treatment because their entire income goes towards buying food. 

What needs to be done?

Rayburn called for foreign governments to consider unfreezing international assets. “Anything we can do to address the liquidity crisis and get the economy moving again; that’s the only thing that’s going to make a difference to families,” she said, adding that the international community must also look at how to constructively engage with the de facto authorities to address this before it’s too late.

Right now, she said it’s “a crisis competition” with the war in Ukraine that stands in the way of getting Afghanistan the attention it needs for solutions to come to the fore. “The devastating thing here is that Afghan children don’t have six months to wait until media attention dies down on Ukraine and turns back to Afghanistan,” she added.

In the meantime, the World Health Organization has been running a vaccination campaign since March to reach 1.2 million children as part of a national response. Faster and wider has been the approach as humanitarian organisations and the current authorities strive to reach the unvaccinated under two, Ahmad said, adding that it’s making a difference already.

“We are of course still concerned about it because the current health system in Afghanistan is broken to a certain extent,” she said, explaining that vaccination efforts should be bolstered by health and hygiene promotion activities. “We need to keep informing people on how this disease spreads.”

*Name changed for security and privacy reasons.

(*In an earlier version we incorrectly gave the storage temperature for the MMR vaccine, rather than that of the measles vaccine commonly used in Afghanistan. Updated on 26 July 2022.

Edited by Abby Seiff.

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