J Ayub Med Coll Abbottabad 2003;15(1)
CHILD HEALTH IN AFGHANISTAN: A GLIMPSE ON THE FUTURE OF A WAR STRICKEN COUNTRY
Mohammed Ibrahim Khan, Samreen Khan, Ulrich Laaser, Rashid Chotani*
Section of International Public Health, University of Bielefeld, Germany, * Centre for International Emergency, Desaster and Refugee Studies, The John Hopkins School of Medicine & Public Health, Baltimore, USA
Afghanistan has one of the world’s poorest human development indicators1-3. Among the population of 24 million roughly 10.7 million are children under the age of 181,2. Figure-1 shows under five population in Afghanistan. Precise data showing country’s recent demographic and epidemiological profile is scarce as series of wars and political conflicts barely permitted such research intentions and health care interventions. The crisis of more than 23 years has left devastating effects on the health and well being of millions of children. It has killed over 1.5 million people, including more than 300,000 children2. An extensive review of contemporary literature is presented here to provide an account of social, physical, and mental health of Afghan children with an aim to depict the severity and complexity of the situation induced by war of more than a decade. Data on child vulnerability indicators were retrieved from MEDILINE, reports of WHO, and United Nations Agencies.
Child Vulnerability Indicators in Afghanistan
Series of wars and drought for more than three years have threatened the survival and existence of tens and thousands of children. According to a survey 60 % of Afghan children have lost their family member, and 39 percent have lost their home1-9. The burden of poverty falls heaviest on the children, who frequently abandon education in order to contribute to family income. They work on farms, collect water and firewood and scavenge the garbage cans for food scraps. In Kabul alone, more than 50,000 children work as shoe polisher, selling fruits or newspaper or begging on the streets8-9. More than five million people with a huge proportion of children are internally displaced1,2. More than 6 million displaced Afghans represent the largest single group of refugees world-wide10-12. Alone in Pakistan approximately three million Afghans have taken refuge in the last few years. Children comprise 20 % of the total number1. Poverty prevails, with 80% of people living below the poverty level14-20. Adult life expectancy is 45 years for men and 47 for women1-3. According to the UNICEF's estimations more than 5 million people-70 percent of them women and children rely on humanitarian aid to survive. 75% of the population living in rural areas have no access to any kind of health facilities7,11. According to the UNICEF, 2001 the total number of under five population in Afghanistan is 728049. War induced displacement and famine have forced large populations to move towards big cities in search of food and shelter. Among the internally displaced populations majority is under five, approximately 429567 in Kabul, 80930 in Logar, 126000 in Wardak, 49700 in South Parwan and 41852 are in Kapisa9,10. Displaced populations are exposed to an unprecedented scale of disease, deaths and disabilities. Reports show that one in every four children dies before his or her fifth birthday and one in five children is born in a refugee camp6,7. Infant mortality is 165 (per 1000 live births), under five child mortality 257 (per 1000 live births) and prospects for improving child health are still dimmer. Maternal morality is one of the highest in the world, i.e., 1700 per 100,0003,10,11,28. Poor obstetric care and illiteracy have been proved to have a direct relation to the infant mortality1-11,21. The deteriorating child health has been out of focus for decades. Repeated wars, political turmoil and disasters have left grave effects on the physical and mental health of children. Post traumatic disorders, widespread infectious diseases, malnutrition have increased the sufferings of Afghan children to an unacceptably higher level. The situation of internally as well as externally displaced Afghan children is grim. The trend of childhood mortality in Afghanistan (see Figure-2) from 1955 to 1990 has remained almost static and has shown very little improvement change so far. Neighbouring countries like China and Iran, both have achieved considerable decline in the under five mortality ranging from 225 to 38 and 239 to 45 respectively while infant mortality in Afghanistan is still 165 (per 1000 live births) and childhood mortality 257 (under five per 1000 births)11.
Nutritional Crisis and War injuries among children
According to UN agency around 120,000 Afghan children currently face famine. Iodine and vitamin A deficiency is largely noticed8,9,15,19-22. Report from Terre Des Hommes determined that chronic malnutrition remained high, with 53.7% of children between 6–59 months stunted, including 27.3% severely stunted making children more vulnerable to disease20,22. An estimated 7.5 million children and adults are currently at risk of hunger and malnutrition. Rights of children were seriously and widely violated. Girls’ right to education and sports is still overtly denied7-10. Socio-cultural norms put additional restrictions on women and girls. Because of the current crisis it is predicted that about 20–40 000 children could die and around 10 million people will be forced to live on US$1 a day9. It certainly impacts access to health services, health allocations by the governments, access to drugs against HIV/AIDS, TB and malaria, and child health17,30,31. There are currently estimated 5.3 million vulnerable people inside Afghanistan1-3,13. Country’s health system performance is paralyzed and extensively damaged during the war on terrorism23. None of the children growing up today in Afghanistan has ever known peace8,9. It is estimated that over 2 million Afghans suffered from mental health problems1-3,7. UNICEF-supported study in 1997 found that the majority of children under 16 years in Kabul suffer from psychosocial war trauma. Ninety-seven per cent had witnessed violence and 65 per cent had experienced the death of a close family relative. Experts say that approximately 30%–50% of a population undergoing violent conflict develops some level of mental distress. There are estimated 10 million land mines, the equivalent of roughly one for every child. Reported by Save the Children survey, 85% of all unexploded ordnance (UXO) victims were children in Kabul, during the years 1990-94. Alone 3,000 injuries from landmines and UXO in 1999 have been reported. More than 130,000 Afghans under the age of 18 have been killed by land mines so far7.
Measles, cholera, tuberculosis, malaria, meningitis, hepatitis, typhoid, childhood respiratory infections, and diarrhoea are the major killer diseases. Diarrhoea alone causes the death of 85,000 under five children per year1-3,14-18,22-31. Two to three million malaria cases with 6% P. falciparum were notified to the health authorities in the last few years25. Similarly leishmania affects seriously women and children in Afghanistan24. Immunization coverage is profoundly low. Lastly noticed overall mortality due to measles and related complications was 10.8% in Kabul26,30. In South Asia, over 40 percent of the total confirmed cases of polio occurred in Pakistan and Afghanistan in 200010. The mass migration of Afghans to Pakistan and to other neighbouring countries has posed serious threat to the global polio eradication program10,17,30,31. Moreover a tuberculin survey in Pakistan revealed that the prevalence of tuberculous infection was 13.8% (May 1985) in a sample of 4108 Afghan children (average age of 8 years). Thirty-three percent had not received their BCG vaccination29. A survey during the 1990–94 on cancer reported 22 % prevalence of 1655 children. 69% were males, 31% females Afghan refugees referred to the cancer hospital in Northern Pakistan27.
The impact of previous conflicts and recent war on children’s social, physical and mental health is enormous and needs a great deal of attention and commitment from the Government. While the debate of reconstructing Afghanistan is currently in progress, saving the future of nation and child health development must be a top priority. Joining these efforts, international assistance is direly needed to handle the deteriorating child health situation. Improving child health in Afghanistan is certainly a daunting task and will require committed and holistic efforts over period of years. Every aspect of child health needs to be dealt with an appropriate strategy. As evident from the facts that infectious diseases and war induced injuries contribute heavily to the current burden of disease, deaths and disabilities in Afghanistan. Therefore WHO’s strategies need to be universally adopted in the country. The strategy of integrated management of childhood illness (IMCI) addresses five major killer diseases with a simple and cost effective manner. War has left tens and thousands of orphans. Under five children currently make a large proportion of Afghan’s population and immediate attention (See Figure-1).
In the prolonged period of war tuberculosis control program was severely disrupted. Tuberculosis control network need to be immediately restored, drugs provided with the Directly Observed treatment; short course (DOTS) strategy among internally displaced and non-adhered patients. All interventions need to focus equally on providing rehabilitation and treatment for mental illnesses, robustly expand and include program for massive immunization in their essential package of services. All legal measures need to be taken to protect children’s rights and specially that of girls to education, health and social choices at all fronts.
Health in Afghanistan. Situation Analysis-WHO Reports (http://www.who.int/disasters/country.cfm?countryID=1&DocType=2); Crisis in Central Asia, 2000-1.
WHO special report on the situation in Afghanistan. Health situation updates 2002. (http://www.who.int/disasters/country.cfm)
WHO special report. on the situation in Afghanistan & Health in Afghanistan 2001-. (http://www.who.int/disasters/country.cfm)
Afghanistan Health facility and manpower information. (http://www.who.int/disasters/country.cfm) WHO report on Afghanistan, 2001.
Ahmad K. Fears that Afghan exodus threatens polio eradication. Lancet 2001;358(9288):1161.
Nutritional Survey Report 2001, Kohistan District, Faryab Province, Northern Afghanistan. Save the Children Federation, Inc. April 4Ð10.
Crisis in Afghanistan. 1995-2002, Save the children (SC). USA Country report.
Liza B, UNICEF, children crisis in Afghanistan. 21 Dec 2001, New York.
Afghanistan Emergency Update. UNICEF Report, 24 September 2001.
State of World’s children. UNICEF. (http://www.unicef.org/sowc01) 2001.
Some Basic Facts on Afghanistan. UNDP Report, 2001
Miller LC, Timouri M, Wijnker J, Schaller JG. Afghan refugee children and mothers. Arch Pediatr Adolesc Med 1994 ;48(7):704-8.
Jama MA. THE WORLD BANK GROUP. Health Services Delivery in Afghanistan. 2001
Singh M, Qureshi MA, Aram GN. Morbidity and mortality in childhood in Afghanistan: a study of 40 492, consecutive admissions to the Institute of Child Health, Kabul. Ann Trop Paediatr 1983;3(1):25-30.
Singh M. Health status of children in Afghanistan. Indian Pediatr 1983;20(5):317-23.
Singh M, Saidali A, Bakhtiar A, Arya LS. Diphtheria in Afghanistan--review of 155 cases. J Trop Med Hyg 1985;88(6):373-6.
Ahmad K. War and gerbils compound Afghan leishmaniasis epidemic. Lancet Infect Dis 2002 ;2(5):268.
Singh M. Health care for children in Afghanistan. Pediatrics 2000;105(1 Pt 1):160.
Report on Famine in afghan children. United Nations Publications on Social and economic Policy (http://www.globalpolicy.org/socecon/un/2001/ 1004stunt.htm). October, 2001.
Terre Des Hommes (TDH). 2001-Letters from Afghanistan (www.tdhafghanistan.org).
Yusuf F. Size and sociodemographic characteristics of the Afghan refugee population in Pakistan. J Biosoc Sci. 1990 ;22(3):269-79.
Jenkins B. Maternal and child health home visiting program, Kabul, Afghanistan. 1996–2001-(TDH) Terre des hommes, (http://www.tdhafghanistan.org/reports.htm).
Southall D, Shepherd C. Humanitarian issues. Paediatrician needed in Kabul. BMJ 1998;316(7124):76.
Rowland M, Munir A, Durrani N, Noyes H. An outbreak of cutaneous leishmaniasis in an Afghan refugee settlement in north-west Pakistan. Trans R Soc Trop Med Hyg. 1999;93(2):133-6.
Suleman M. Malaria in Afghan refugees in Pakistan. Trans R Soc Trop Med Hyg 1988;82(1):44-7.
Arya LS, Taana I, Tahiri C, Saidali A. Spectrum of complications of measles in Afghanistan: a study of 784 cases. J Trop Med Hyg 1987;90(3):117-22.
Khan SM, Gillani J, Nasreen S, Zai S. Pediatric tumors in north west Pakistan and Afghan refugees. Pediatr Hematol Oncol 1997;14(3):267-72.
Rutstein SO. Factors associated with trends in infant and child mortality in developing countries during the 1990s. Bull World Health Organ. 2000;78(10):1256-70.
Spinaci S, De Virgilio G, Bugiani M. Tuberculin survey among Afghan refugee children. Tuberculosis control programme among Afghan refugees in North West Frontier Province (NWFP) Pakistan. Tubercle 1989;70(2):83-92.
Khan IM, Laaser U. Burden of Tuberculosis in Afghanistan: Update on a War-stricken Country. Croatian Medical Journal 2002;43(2): 245-247.
Khan MI, Laaser U. Resistance and refugees in Pakistan: challenges ahead in tuberculosis control. The Lancet Infectious Diseases 2002; 2(5 ):270-27
Address for Communication:
Mohammed Ibrahim Khan, Section of International Public Health (S-IPH), Bielefeld School of Public Health (IBS), University of Bielefeld, Pf 100131, D-33501 Bielefeld, Germany. Tel: 0049 521 106 5166, Fax: 0049 521 106 6009. Email: firstname.lastname@example.org URL: http://www.ibs.uni-bielefeld.de/s-iph/