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154 INTERNATIONAL JOURNAL of HEALTH SCIENCE
Department of Epidemiology and Tropical Medicine, Gdynia, Poland ABSTRACT
30 millions but these data are only approximate because of Afghanistan is the country located in Central Asia which is regular migrations of Afghans abroad, mainly to Pakistan andIran (during the last three decades approximately 5 million characterized by the worst epidemiological parameters in the Afghan people have emigrated, and 3.1 million of these have region, and also in the world. The illness profile is dominated returned), and also within the country (approximately 2 million by vector-, respiratory-, water- and food-borne diseases. Mal- of internal refugees during the civil war, nowadays the inter- nutrition is common. The situation can even be worse due to nal displacements are estimated at 200.000 people).10,11 catastrophic disasters, mainly droughts and floods. To make Afghanistan is a country of a highest population growth rate, the picture of hazards complete, one has to include mines estimated at 4.77% per year in 2005. The total fertility rate is and unexploded ordnance scattered in hundreds of square 6.75 children per Afghan woman. In 1979, 15.682.000 inhab- kilometers of the Afghan territory. Their number is estimated itants lived in the country, so during the last 25 years the pop- at 7 to 10 million, which makes Afghanistan one of the most ulation has grown by more than 90% in spite of the high mor- mined countries in the world. This is a review article on the tality rate caused by warfare, famine and diseases. According health hazards in Central Asia, based on the Afghanistan to the United Nations calculations, the birth rate the number of Afghans may have reached 97 million by 2050! An average Key words: Afghanistan, Central Asia, health hazards, pub- Afghan is very young. In 2005 as many as 44.7% of the pop- ulation were below 14 years of age, 52.9% in the age range15-64, and only 2.4% were over 65 years old. The mean age of an average Afghan is 17.56 years. The population health Traveling to Afghanistan nowadays is truly health- and life- status parameters place Afghanistan among the poorest threatening.1,2 Destroyed country infrastructure, low sanitary countries in the world. The total mortality rate is estimated at and epidemiologic conditions, low level of medical assistance 2.07% (20.7 deaths/1000 inhabitants per year), infant mortal- (lack of medical personnel, shortage of basic medicines and ity rate (under 1 year old) - 16.3% (163 deaths/1000 live hygienic means) - all contribute to the dissemination of many births), that of children younger than 5 years - 25.7% (257 infectious and non-infectious diseases.3-5 More than 70% of deaths/1000 live births). Life expectancy at birth of an average the health care functioning in Afghanistan is dependent on the Afghan is estimated at 43 years only, and one per four Afghan help of foreign humanitarian organizations.6-8 Afghanistan is a children dies before being 5 years old.10,12,14 region of an extreme danger of terrorist and criminal attacks.
This is a review article based on current reports and fact Bomb attacks, thefts, kidnappings mostly directed against sheets focusing on the health hazards found so far inAfghanistan.
Stabilization Forces soldiers and humanitarian organizationworkers have become the order of the day. Remains of thewartime are visible in the whole territory of the country with mines and unexploded shells posing the highest danger. Just Afghanistan is considered to be a country where the risk of traveling on Afghan roads is extremely dangerous because of infectious diseases occurrence is very high. This situation their catastrophic technical condition and notorious disobedi- results mainly from contamination of water and soil, limited ence of traffic rules by local riders.1,9 access to uncontaminated drinking water, catastrophic status In July 2005 the population of Afghanistan was assessed at of plumbing, water and sewage treatment plants, limitedaccess to health-care institutions, lack of basic medicines andmedical equipment.3,15 Other health hazards come from Corresponding author: Lt. Col. Krzysztof Korzeniewski MD, PhD
numerous asymptomatic carriers of infectious diseases among local population, mass migrations of people (inside and Department of Epidemiology and Tropical Medicine outside the country), overcrowding in refugee camps, large territory of endemic areas, and high number of vectors of 81-103 Gdynia 3, PolandE-mail: [email protected] HEALTH HAZARDS IN CENTRAL ASIA ON AFGHANISTAN EXAMPLE 155
Malaria. Approximately 80% of the disease cases are caused
Diarrheas. The diarrheal diseases morbidity risk in Afgha-
by Plasmodium vivax but in the recent years an increased nistan is high regardless of the season of the year. Seeming- number of cases have been caused by P. falciparum.18,19 The ly, diarrheas can pose no health problem to the local popula- disease occurs seasonally (April through November) and tion, as the number of asymptomatic carriers is rather large.
endemically in the most part of the country, usually below On the other hand, diarrheal diseases are quite common 2000 meters above sea level, along river valleys, in rice farm- because food and water are contaminated not only with land, near water reservoirs.20-22 A research study conducted by human and animal excrements but also with pesticides and the World Health Organization experts has revealed that toxic industrial chemicals.15,18 Diarrheas are responsible for nowadays malaria occurs in Afghanistan also at higher alti- more than 50% of deaths among children under 5 years of tudes. A high malaria incidence rate was confirmed in the age.6,32 In 2004, in Kabul only, more than 6.000 cases of diar- local population of the Bamian province (2.250-2.400 meters rheal diseases were registered weekly, half of them affected above sea level). Most of the cases had been caused by P. fal- children younger than 5 years of age.32 Only 7.7% of Afghans ciparum.23 Today malaria contributes to 10-20% of all pyretic have access to tap drinking water (2003). Most Afghans use diseases in Afghanistan.24,25 Studies carried out in 2002 water from wells or directly from rivers and canals. Only revealed that 10% of the Afghan population living in areas 32.5% of all used sources contain safe, controlled, and decon- below 1.500 meters above sea level were infected with Plas- taminated water.6 In the whole territory of the country there modium parasites.25 In 2003 Afghan medical services regis- are only 2.8% of toilets meeting basic hygienic standards. In tered more than 591 thousand suspected and confirmed the majority (more than 60%) of cases cesspools function as cases of malaria in the whole country.26 However, the anec-dotal number of all malaria cases in Afghanistan is estimated lavatories.12 The main contagious and parasitic etiologic fac- tors of diarrheal diseases are enterotoxic Escherichia coli, 21 In the Jalalabad region, with its irrigat- ed areas of rice cultivation, the morbidity rate is estimated at Campylobacter, Salmonella, Shigella, adeno- and rotaviruses, 240 cases/1000 people per year.21 Malaria cases are observed and also protozoa (Entamoeba histolytica, Giardia intestinalis).
in villages and in towns, including the capital city of Kabul. In The amebiasis morbidity rate among Afghans is estimated at the early 1980s, the number of malaria cases caused by P. fal- 3% of the population. The giardiasis morbidity in children ciparum did not exceed 1-2%. Nowadays it reaches up to 20%, which mainly results from an increased resistance of Intestinal helminth worm infections. It is estimated that
Plasmodium parasites to the treatment used so far (Chloro- 90% of the Afghan population are infected by at least one quine), and an increased insensitivity of infection vectors helminth worm. Because of ascariasis only, the morbidity (Anopheles mosquito) to pesticides employed. 21,27,28 including an asymptomatic carrier state is estimated at 60% Leishmaniasis. Two clinical forms of the disease occur in
of the country population. Among other helminthic infections, Afghanistan: cutaneous and visceral (kala-azar). Cutaneous the most popular ones are ancylostomiasis, strongyloidiasis, leishmaniasis (CL) in the Afghan territory is caused by L. major (wild rodents are the source of infection, e.g. gerbils) and L.
Viral hepatitis type A & E. These diseases occur endemical-
tropica (human source of infection).3,17 Most CL cases in ly in all Afghanistan.22 There is a high risk of infection regard- Afghanistan are caused by L. tropica.29 The disease is encoun- less of the season of the year. The morbidity is strictly con- tered endemically countrywide, in the west (Herat), south nected with low hygienic standards and the contamination of (Kandahar), north (Mazar-e Szarif), and east (Kabul).20,22 Kabul, food and water with pathogenic microorganisms.30 the capital city of Afghanistan, is currently the biggest focus Cholera. It is not one of the main gastrointestinal tract infec-
of cutaneous leishmaniasis in the world. In 1996 the number tious diseases in Afghanistan, but it is an extremely danger- of cases was estimated at 270 thousand.3,20 In 2001, 2.7% of ous disease because of its severity and epidemicity.34 The last Kabul inhabitants (out of total nearly 3 million) had active skin epidemic took place in Kabul in May and June 2005, when lesions resulting from CL, and 21.9% displayed post inflam- 3.245 people developed an acute diarrheal disease. A bacteri- matory scars.20 The number of CL cases in Kabul in 2003 was ological screening examination of stool specimens revealed estimated at 67.5005,however, given a massive influx of exter- cholera in most cases.35 In the recent years, cholera has been nal refugees from Pakistan and Iran, and internal displace- diagnosed in 14 provinces of the country.27 ments from other regions of the country, who can contribute Respiratory tract diseases. Lower respiratory tract diseases
to an increase of the infection rate, the disease morbidity andincidence rates are bound to become higher.
are leading causes of the Afghan population morbidity and the maniasis (VL) in Afghanistan is caused by L. donovani. The mortality among children under 5 years of age.36 The main eti- source of infection is of animal origin (dogs, foxes, jackals).
ologic factors responsible for lower respiratory tract diseases This form of the disease occurs much less frequently than CL.
are Streptococcus pneumoniae, Mycoplasma pneumoniae The endemic areas are located in the western part of the country.20 The transmission of cutaneous and visceral leishma- Tuberculosis. It is an endemic disease observed in all Central
niasis occurs in Afghanistan seasonally, from April to Octo- Asia, and poses a serious epidemiologic problem also in Afghanistan.22 In 1997 the morbidity rate in Afghanistan was Crimean-Congo Hemorrhagic Fever. In 2000, 27 cases of
estimated at 753 cases/100 thousand inhabitants (among the disease (including 16 deaths) were registered in the Herat them 35% were infected but asymptomatic).33 In 2003 this province.20,31 Another 47 cases in the region of the Afghan- rate decreased to the level of 321 cases/100 thousand peo- Pakistani border were recorded in 2001.3,17 In March 2002 ple, which still located Afghanistan as one of the first places unknown hemorrhagic fever (Crimean-Congo is suspected) in the world in tuberculosis prevalence. Such a high morbidity killed 28 people in eastern Afghanistan.3,17 In the Afghan terri- rate results from two factors. The first one is a small percent- tory the transmission of the disease occurs from May to Octo- age of vaccinated infants (according to WHO, 49% were BCG vaccinated in 2002, and 59% - in 2003). The second factor is 156 INTERNATIONAL JOURNAL of HEALTH SCIENCE
coexistent diseases impairing immunity. It is estimated that in nance, remainders of bombs, grenades, shells, which were Afghanistan 5% of tuberculosis patients are HIV-positive.27,35 not exploded. It is estimated that mines and unexploded ord- Since 1996, the World Health Organization have started pro- nance still cover more than 700 million square meters of the moting a new tuberculosis treatment and control strategy Afghan territory.43 Probably only two provinces are free of (DOTS - directly observed treatment short-course). Although these lethal traps. The most mined provinces of Afghanistan the new strategy has been introduced in 85% in the world, are Herat and Kandahar, however any amount of mines and Afghanistan has succeeded to implement it in 15%, and Pak- unexploded shells are practically met everywhere, especially istan in 6% only, which results in the tuberculosis morbidity near the borders with Pakistan and Iran. Also in the capital city just in these two countries contributing to the majority of of Kabul, there are a lot of places not cleared of mines.44 It is cases in the Middle East and Central Asia.37 estimated that most mines and unexploded ordnance are still Sexually transmitted diseases. In Afghanistan such sexual-
in pastures (61%), arable fields (26%), near roads (7%), ly transmitted diseases as gonorrhea, chlamydiasis and tri- places of residence (4%) and irrigation systems (1%).44 In the chomoniasis are quite widespread.15,38 Cases of syphilis and Afghan land there are approximately 50 various types of chancroid are also diagnosed. One has to remember that hep- mines made in the USSR, China, Yugoslavia, Czechoslovakia atitis B virus is also transmitted by sexual contacts, and cases and many other countries.44 Out of all the countries in the of hepatitis B infection are often diagnosed in the Afghan pop- world, Afghanistan has the highest casualty toll from explo- ulation (the prevalence varies from 10% of population in Kabul sions of mines and other shells.45,46 Every month in 1993, to 15-20% in Ghazni in 2002).39 Surveys conducted in 5 Afghans injured and killed by explosions reached the stagger- Afghan provinces showed a considerable percentage of ill- ing number of 600 people.47 In 1997-2002, UNMACA (United nesses caused by the genitourinary tract inflammations.
Nations Mine Action Center for Afghanistan) basing on Among them the venereal etiology was most frequent.38 reports from Afghan hospitals registered 6114 cases of blast According to the World Health Organization the number of injuries among civilians.48 Nowadays, the number of victims is HIV/AIDS cases in the Central Asia region, including estimated at over 100 injured or killed every month. However, Afghanistan, has increased recently.15 The incidence increase these are only estimated data because a lot of trauma cases is noticed among drug addicts who repeatedly use needles are registered nowhere. In 1999 the percentage of handi- and syringes which are not sterile. The Afghan Ministry of capped Afghans was estimated at 3-4% of the country popu- Health so far has confirmed 31 cases of HIV/AIDS and one lation. Most of them have had a limited access to the health case of death caused by AIDS, but unofficially they say about service.49 Nowadays the situation looks even worse. There are 600-700 cases of HIV infections and AIDS in the country.4 new casualties of the civil war from the time of the Taliban Enzootic diseases. The highest risk results from rabies,
regime.50 Adults are mainly injured by antipersonnel mines' which occurs endemically in Afghanistan.22 Affected dogs are explosions during travel, moving on terrains which has not the main source of infection, but so can be wolves, foxes and been cleared of mines.51 Children are mainly affected by blast jackals. It is estimated that a few hundred people die in injuries which occur during play and pasturage of farm ani- Afghanistan every year because they have been bitten by mals.50 Most mines in Afghanistan were planted in the time of rabid dogs.33 In 2001 the World Health Organization estimated the Russian occupation in the 1980s.52 Many areas were cov- that in Kabul only there were noticed as many as 4 cases of ered by mines and unexploded shells during fights between rabies daily among bitten people. Nowadays the highest risk the mujahideen and the Taliban in the 1990s.46 Mines are of contact with rabid animals is observed in rural areas.3,17 often planted near objects of economical importance (facto- Another enzootic disease diagnosed in Afghanistan is brucel- ries, roads, water sources). Unexploded shells often lie on the losis, mainly because of consumption of unpasteurized diary ground surface and are easily discernible. They are very inter- products processed from sick animals.3,17 In the early 1990s esting mainly for children, which usually ends fatally.44 Explo- anthrax was of high epidemiologic importance (49 cases in sions of mines and unexploded ordnance cause deaths or 1991).27,33 The disease was caused mainly by contact with sick injuries, such as limb amputations and multiorgan trauma.53-56 animals, consumption of contaminated meat, aspiration of air A study carried out in Afghanistan revealed that the mortality containing pathogenic microorganisms. Mass preventive vac- rate due to explosions of mines and unexploded ordnance cinations of farm animals (the main sources of infection in Afghanistan are sheep and goats) reduced the risk. In spite of To sum up, the situation of Afghanistan after nearly three this, isolated cases of the disease among people can be still decades of war is dramatically bad. A prevailing part of the Afghan population live in extreme poverty. Food supply is Injuries. Traffic accidents are the most frequent cause of
scarce, access to uncontaminated drinking water is limited, death affecting travelers to Afghanistan. Afghans, just like and there are hardly any sanitary facilities enabling basic representatives of other Muslim countries, do not obey nor hygienic standards. Malnutrition is common. To make the sit- care to know traffic regulations. Another problem is the terri- uation even more catastrophic there are frequent disasters, ble condition of all roads destroyed during wars, and the very mainly droughts and floods. Most of the country is all the time poor technical state of most Afghan motor vehicles. All this controlled by drug barons who, having at their disposal their makes traveling by local means of transport (there are no rail- private armies, decide about the existence of local communi- roads in Afghanistan) an unforgettable experience on one ties. Those about to leave for Afghanistan are recommended hand, on the other a serious health threat.1,22 But the biggest to get vaccinated against viral hepatitis A and B, poliomyelitis, hazard to the health and life of Afghans and that of foreigners typhoid fever, tetanus and rabies. Antimalarial chemoprophy- visiting the country is trauma inflicted by mine explosion and laxis is also recommended (atovaquone/proguanil, meflo- unexploded ordnance. In Afghanistan, one of the most mined quine, doxycycline) and so is the usage of repellents against countries in the world, there are still planted approximately 7 insects (numerous vectors of arthropod-borne diseases).57,58 million antipersonnel (95%) and antitank (5%) mines.40-42 Yellow fever does not exist in the territory of Afghanistan, Except for mines there is a huge number of unexploded ord- however people coming from the zones of the endemic HEALTH HAZARDS IN CENTRAL ASIA ON AFGHANISTAN EXAMPLE 157
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