IRIN interview with WHO official

As the battle inside Afghanistan intensifies, so too does its impact on the health situation. In a country with one of the highest infant-mortality rates in the world, where half the children are stunted, and one woman dies of pregnancy-related causes every 30 minutes, the effects of war are devastating. In an interview with IRIN on Monday in the Pakistani capital, Islamabad, Dr Rana Graber, programme manager for emergency humanitarian action for the United Nations World Health Organisation (WHO) for Afghanistan, said urgent action was needed. WHO-Afghanistan has predicted, according to previous trends, that - in addition to casualties resulting from the war - respiratory infections, obstetric complications and diarrhoeal diseases would be killers this winter due to the serious depletion of family resources, poor nutrition, exposure during displacement, overcrowding and inadequate health care and referral services. In addition to the provision of food, shelter and security, saving lives would depend on the presence of health workers in the field and sufficient medical supplies in both peripheral and referral centres. QUESTION: How would you describe the situation in terms of health inside Afghanistan? ANSWER: In order to understand the current situation, you have to understand what was happening before. Previously there were very bad health indicators. Some 250 children out of every 1,000 die before they reached the age of five. This is probably one of the worst health indicators in the world. When you look at that - which is an indication of the whole health situation - and then add the other problems of drought, displacement, intense conflict, and additional stresses, undoubtedly a worse health situation will result. The health situation was bad to start with, but now it's worse. There is no question about it. Q: What diseases are you particularly concerned about at the moment? A: The three main problem areas we foresee for the winter that are worsened by malnutrition are respiratory infections, maternal and infant mortality, and diarrhoea. Respiratory infections start out as a common cold, and are worsened by low immunity due to factors such as malnutrition to become pneumonia. This problem of deaths due to respiratory infections is one of the biggest killers in the winter with children, and we are expecting more. The second item is maternal mortality - as well as infant mortality - which occurs due to complications during delivery which cannot be addressed due to a lack of available health services. And lastly is diarrhoea, which occurs particularly in the camps when people are crowded together and don't have adequate and safe water resources, as well as poor sanitation conditions. These are the three things we are expecting to cause more deaths this winter. Q: How bad is the situation going to be? A: We have done some calculations. Already the crude mortality rate in Afghanistan is 28 per 1,000. If we have an excess, of for example only 20 percent due to all these problems and the worst winter in the country's history, we estimate about 42,000 additional deaths this winter. On a yearly basis alone, we have about 250,000 children dying. Now, in addition to those, due to the inadequate health service, war, displacement, and malnutrition, an additional 42,000 may die. Q: Have recent developments inside Afghanistan impacted [on] the patterns of diseases in the country? A: Measles usually peaks in the winter in Afghanistan, in January and February. This year, the health sector partners are conducting some measles campaigns, and we hope that will cut the incidence of measles. This risk of death from measles is much higher in a malnourished child. The other area to address are respiratory infections. They peak usually in January and February. The last two years we have had the highest reported respiratory infections then, with another peak in April. It looks like it will be the same this year. The third area is malaria, which normally has two peaks, in June and in November. In June, it's vivax malaria, which is not as serious as falciparum malaria, which peaks in October/November. We have had an outbreak of falciparum malaria. This type has the potential for causing cerebral malaria and for deaths. It's much more common to have deaths with falciparum than with vivax malaria. During the outbreak in Jalalabad and Mehtar Lam [both in the northeast] last month, some 1,600 had to be hospitalised. This is unusual, because it shows that there was severe or complicated malaria. Some of these of course were cerebral malaria. There were 17 deaths reported from the hospital facilities, but, keep in mind, there are many remote areas of the country that are not served by health facilities. I expect the real figure to be double that amount. In the eastern areas we have better services than we have in some other areas. Due to all the recent displacement, however, this same area saw a doubling of its patients as a result of displacement from Kabul and Jalalabad. Although it's been there before, I think the malaria outbreak in the eastern region was related to the displacement caused by military intervention. The situation was magnified, given the number of people there, the number of people exposed and the number of people that previously had not been exposed. This undoubtedly creates a new group that will have a worse situation. Q: Regarding these reports of malaria in Jalalabad, was this an isolated incident? A: No, this was throughout the whole eastern region. In many districts of the eastern region, including the Nangarhar, Laghman and Konar provinces, we have indications that [the incidence of] malaria is very high. In some districts this ranges from 20 to 50 percent of the population, and they all had this falciparum malaria, which is this very severe form. For sure, it is an epidemic, but this is not the first time they have had an epidemic. A similar situation occurred in Konar three years ago, and two years ago in Nangarhar. As I said, it seems to be magnified by the fact that so many people in the city have gone into the rural areas, which is where we have had this problem. Q: What's the situation now? The situation is under control now. We are still sending teams, as well as more drugs, to the area to treat falciparum malaria, as this malaria is sometimes resistant to the first line of treatment. With those two difficult things about this form of malaria - that it can cause deaths and that it is sometimes resistant - it really is an important outbreak, and it is important that we control it as soon as possible. Q: What do these patterns mean? A: The patterns are something we pick up from the situation inside the country over the years, and it seems to be the same patterns as previous years. However, as I said with malaria, it was probably a magnified pattern due to the influx of displaced persons into the area. The other patterns we are expecting basically mean that in order to prevent excess deaths we need to have more medical supplies and more manpower on the ground so that we can improve the chances that these people will be treated and not succumb to their illness. Q: How has malnutrition impacted [on] the prevalence of disease over the past few months? A: We don't have any real figures, but we know that if someone gets the measles and is malnourished, the risk of death is higher. We know if a woman is malnourished when she is pregnant, the chances for the baby being born premature and underweight are greater, and hence there is less chance for survival. Additionally, we know if the mother herself is anaemic, there is a greater risk of death during delivery. These are very important factors. If the acute malnutrition for children is considered to be 10 percent and chronic malnutrition 50 percent, these are major reasons why we think this winter will be worse in terms of the number of deaths of children and mothers, as well as the ill, elderly, and other vulnerable members of the population. Q: Are there some areas of the country more affected than others? A: As I mentioned in the beginning, malaria is worst in the eastern region, and we don't have any other outbreaks now. We expected one in [the northern province of] Konduz, but we haven't had any reliable information there to substantiate the situation. Generally, due to the problem of inadequate health resources, we have problems everywhere, but usually less, say, in the eastern region as it has a much better number of health facilities for the population. The same can be said about Kabul and Kabul Province. As a rule, Afghanistan is very poor in terms of health resources. In short, whatever problems there are worsen, because there is no treatment for them. Q: Is there a difference between rural and urban areas? A: Traditionally in Afghanistan, there have always been more health resources available in the urban areas. Many of the NGOs who have been around for a long time point out [that] because of the emphasis on primary health care that has been the focus of the UN agencies like WHO and UNICEF [United Nations Children's Fund] and accepted by the Afghan authorities, there are more health centres in the rural areas than before 1978 when everything was quite centralised. Nonetheless, while there are some rural areas with health care, many do not have it. Q: What are the main priorities right now? A: The main priorities for the winter are to get enough essential drugs and medical supplies to all the areas, while the second is to make the best use of health manpower that is on the ground so as to provide services to areas that are under-served. Q: Can you update us on your national immunisation day (NIDS) campaigns inside the country? A: In the previous years, sometimes the warring parties would agree to a cease-fire and then wouldn't uphold that agreement. At other times, they would refuse a cease-fire because the opposite side refused, and then let things proceed. I think we have a situation here where there wasn't any agreement here, but somehow the NIDS went ahead and we had a surprisingly good polio campaign effort. The results are still coming in, but we reached over five million children in this house-to-house effort. We had a lot of WHO staff in the field, as well as the usual 30,000 volunteers. In our view, it was considered a modest success, all things considered. Q: Given recent events, do you expect WHO to increase its presence in Afghanistan? A: Yes, of course. We had to evacuate international staff along with everyone else, but now we had our head of office in Kabul on the first flight in. On Tuesday, we are going to send more people in, though I don't know exactly how many. We usually have one international staff member in each of the regions, in addition to our national staff, who have been there throughout the crisis, and they will returning as soon as UN security regulations permit. Q: Given what you have seen in the past few weeks in terms of recent developments, how do you view the health situation? Do you view it optimistically? A: Anytime peace comes to a country, it's more optimistic. We have had a very difficult past two years because of the drought and because of the ongoing conflict. There has been an active front line for the past few years. We hope that if there is peace in Afghanistan, that things will look better, and we plan return with a larger rehabilitation and reconstruction programme. We hope that health services will eventually be available to all Afghans. This is our goal. At the moment we don't see the peace quite yet, but we are looking forward to the day when there is.