When AAN first tried to map the trends in the spread of the Coronavirus pandemic in Afghanistan in March 2020, almost three months after the first outbreak in China, we found that the country had only been moderately affected. Since then, the number of confirmed infections and deaths have risen, but numbers remain relatively modest, particularly compared to neighbouring countries like Iran and Pakistan. AAN’s Rohullah Sorush (with input from Sayed Asadullah Sadat) takes a closer look at the official figures and their sources, and compares them with other information, including government estimates and anecdotal stories from people closely involved. All agree that the real number of deaths and infections, both symptomatic and asymptomatic, is significantly higher than those officially given – something the authorities readily admit – although nobody knows how much higher. This report aims to give an overview of what is known, or can be extrapolated, about the spread and impact of the disease, and serves as a warning that, given Afghanistan’s low and unevenly spread testing capacity, official figures cannot serve as the sole basis for analysis or decision-making.
A street vendor sells face masks in Kabul. Photo: Wakil Kohsar/AFP, June 2020
Highlights of the report
- Knowledge about the Coronavirus transmission in Afghanistan is based on testing by the Ministry of Public Health (MoPH). Testing capacity has increased over time, but remains very low with labs only located in Kabul and six other provinces. So far, Afghanistan has tested 109,281 samples and reported 39,145 confirmed cases and 1,446 deaths. Most infections have been reported in the provinces where the labs are located (Kabul and six other provinces).
- Officials have released varying estimates as to the actual number of people in Afghanistan who may have been infected by the virus, including Muhammad Yaqub Haidari, the provincial governor for Kabul, who quoted an estimate of roughly two million people in Kabul alone, and an MoPH survey in early August that estimated that around ten million people all over Afghanistan may have been infected. Those directly affected by the virus, such as gravediggers, coffin-makers, patients and relatives also confirm that numbers have been much higher than suggested by the official figures.
- In July, the MoPH announced that the number of Covid-19 infection cases had fallen by 30 to 40 per cent, and that the worst of the pandemic was over. Lockdown measures were eased, although the government still asks people to wear masks and to practice social distancing.
- Based on anecdotal reporting there does appear to have been an actual slowing in the spread of the disease and its resulting deaths. But with winter looming and the threat of a second wave or renewed outbreak, it is unnerving that there is still much we do not and cannot know.
Because most of what we know about the spread of the Coronavirus in Afghanistan is based on the tests done so far, this report first describes the country’s testing capacity and how it has changed over time. Then it gives Afghanistan’s current official data on Covid-19 infections and deaths, which largely reflects the geographical distribution of the conducted tests. Next, it explains how everybody involved seems to agree that these numbers are, at the very least, incomplete. This section quotes public health officials and other authorities, as well as journalists, gravediggers, coffin-makers, patients and relatives. Finally, the report discusses what we can know, or extrapolate, about the spread and impact of the Coronavirus pandemic in Afghanistan.
Afghanistan’s limited Covid-19 testing capacity
Most, if not all, knowledge about the Coronavirus transmission in Afghanistan is based on testing administered by the Ministry of Public Health (MoPH). This testing capacity has changed over time. In the beginning, from 1 March 2020, there was only one lab in Kabul that tested Covid-19 samples. As infections increased, a second Covid-19 lab was established in the western province of Herat on 19 March, followed by a third in Nangrahar, in the east. On 30 March, the then-Minister of Public Health, Ferozuddin Feroz, said that the country’s testing centres now had the capacity to test 600 samples per day – 400 in the capital Kabul, 100 in Herat and 100 in Nangrahar – and that they planned to further increase the number of centres.
On 4 June, the MoPH announced it had expanded its testing capacity to 2,000 samples per day. However, this was by no means enough, as at that time – as the pandemic seemed to be at its peak – the MoPH said it received 10,000-20,000 samples on a daily basis.
On 5 August, MoPH spokesman Akmal Samsur said that the country’s daily testing capacity had increased by another 1,000 tests. In a conversation with AAN, he said, “In June, we had a lot of samples pending, but now, we have the capacity to test almost 3,000 samples from the whole country per 24 hours, and we plan to increase it further.” He said the MoPH was going to open new labs and train lab technicians in Bamyan, Daikundi, Badakhshan, Faryab and other provinces with the aim of being able to test 10,000 samples per day. However, as of 23 September, no more testing labs have opened in those provinces, neither has the MoPH reached its goal of 10,000 tests a day.
Masuma Jafari, deputy spokesperson for the MoPH, told AAN on 13 September that there are now 14 private and 13 government labs in Kabul testing Covid-19 samples. These 27 Kabul-based labs have a combined capacity of 5,150 tests per 24 hours (3,150 tests by the public labs and 2,000 tests by the private ones). In addition, there are six provincial labs, respectively in Herat, Balkh, Kandahar, Nangrahar, Paktia and Kunduz provinces, as well as at the Aqina border crossing in Faryab. These are all government-run labs; the private labs have thus far only been permitted to operate in Kabul. The capacity of these labs varies, not just in terms of their numbers (Kabul far outperforming the others), but also in terms of their territorial coverage and daily testing capacity (see Figure 1 that shows which provinces are serviced by which lab).
Figure 1: Covid-19 testing capacity in Afghanistan. Source: AAN’s compilation of MoPH data as of 13 September 2020.
The limited number of labs, especially in the provinces, means they have to cover very large areas. For instance, the lab in Nangrahar has a maximum capacity of 200 samples per day in a province with an estimated population of over 1.6 million people. This lab also needs to process the samples from three other provinces: Laghman, Kunar and Nuristan, which have a combined estimated population of over one million people, according to the MoPH site.
The MoPH says there are currently no pending samples in the country’s Covid-19 labs. As of 23 September, a total of 109,281 samples have been tested in public labs across the country, according to the data the MoPH shared via its designated WhatsApp group. For the period between 1 and 23 September, the labs tested 6,119 cases: between 95 and 532 samples per day, with an average of only 266 tests per day. These figures are from the public labs for the whole country, which the MoPH publishes on a daily basis.
Overall, the country has conducted 2,793 tests per one million people as of 23 September 2020, according to the real-time statistics website Worldometer. (1) This is one of the lowest rates in the world (compared, for instance, with Nepal that has administered some 31,961 tests per one million people).
It is clear from both the limited testing capacity, and the limited actual testing, that only a fraction of the spread of this disease is being tracked. The International Rescue Committee (IRC) reported on 1 June that, at the time, an estimated 80-90 per cent of potential Covid-19 cases were not being tested. The New York Times also reported that according to a doctor working in a hospital dedicated to Coronavirus treatment, roughly 75 per cent of the patients who died at the hospital had not been tested for the virus.
How the samples are gathered, transported and reported back
In practice, Afghanistan has faced serious challenges in testing people for the Coronavirus infection (2) including frequent interruptions in its labs’ operations. Dr Muhammad Rafiq Sherzai, the spokesman for the public health department in Herat, told AAN in late June 2020 that work in Herat’s lab stopped three times due to a lack of necessary equipment and testing kits. He said twice the lab had stopped working for a duration of three days and a third time for eight days. AAN is also aware of a fourth disruption in the operation of the Herat-based lab in late August.
For Afghans who are able to secure a test, there is often a time lag between the taking of the sample and the reporting of the result. In the beginning this was sometimes by as many as 15 to 20 days, according to spokesman Samsur, especially at first in Kabul – in late February and early March – and for the provinces that lacked labs. For these provinces, it still often takes days to transfer the samples to the related labs and to get the results back.
Samsur explained the process to AAN on 16 September: when someone with signs of Covid-19 goes to a hospital, for example in Ghazni, a doctor examines him or her. If s/he has severe symptoms, samples are taken and s/he is either hospitalised or told to quarantine at home. Then, the surveillance teams, using local transportation, transfer the samples to the lab (for Ghazni this is the lab in Kabul), where the samples are tested on a daily basis.
In remote provinces, there is still a time lag of at least four days between samples being taken and the results being reported back. Dr Juma Gul Yaqubi, director of the Public Health Department in Ghor told AAN on 16 September: “We have contracts with the local transportation companies to take the samples to Herat. It takes two days now to bring samples from Ghor to Herat and then two more days to report back the result.” He said that earlier, during June and July, it had taken 10 to 20 days to transfer the samples and get the results.
Dr Ishaq Ali Darman, the director of the Public Health Department in Daikundi, told AAN on 17 September, “During the peak of the virus, it took 11 days to send the samples [to Kabul] and receive the results back. Now it takes four to seven days.” He said there was a surveillance team in the hospital in Daikundi that collects the samples, sends them to Kabul by local transport and then the surveillance team in the MoPH reports back the results via email.
How the figures on deaths are gathered
The MoPH explained to AAN that all patients who die at a hospital and who have shown Covid-19 signs and symptoms are registered as possible Covid-19 deaths by the surveillance team, but they are not counted as such unless they have been confirmed with a test. The surveillance team also registers patients who have tested positive and who have later died at home, provided that their relatives inform the MoPH.
Sherzai, the spokesman for the Public Health Directorate in Herat, told AAN that there were two categories of deaths that were counted as confirmed Covid-19 deaths: those who had been tested positive before their death, and those who were suspected of having contracted the disease and who were tested after their death. Sherzai told AAN that there were 65 death cases in Herat who were suspected of having been infected with Covid-19, but who had not yet been registered in the system since their results were still pending. He thought that about half of those cases might be positive.
The MoPH takes the samples in the first six hours after a patient has died. If the result is positive, the death is registered and announced as such. If more than six hours have passed, they will not take a sample (and will thus not know whether this was a Covid-19-related death).
Current official figures
The data on infections, deaths and recoveries are collected by the surveillance teams of the MoPH, to whom the Covid-19 hospitals report on a daily basis. These numbers depend on the limited capacity of Afghanistan’s labs, which have to confirm whether a patient has indeed contracted Covid-19. It is then no surprise that Afghanistan’s official data on Covid-19 infections and deaths largely matches the geographical distribution of the tests administered so far, as is shown in Figure 2.
Figure 2: The provinces that reported the most tests and infections are also those where Covid-19 testing labs were based. Source: AAN’s illustration of MoPH data, 23 September 2020 (see also footnote 2).
Although, according to the MoPH, the disease has spread to all 34 provinces since the first case was reported in Herat on 24 February (read previous AAN reports here and here), the provinces that are reported as the most infected are also those with large cities where testing labs are situated (as listed in Figure 1). The one exception is Kunduz. (3) One thus wonders what the geographical distribution of the disease would be, if the testing capacity had been more equally spread across the country.
Overall, Afghanistan has reported 39,145 infections and 1,446 deaths due to Covid-19 between 24 February and 23 September 2020, according to the World Health Organisation’s Coronavirus Disease (Covid-19) Dashboard’s Afghanistan page, which relies on MoPH data.
Figure 3 Confirmed Covid-19 infections and deaths in Afghanistan, 3 January-23 September 2020 (12:21 pm CEST). Source: WHO Coronavirus Disease (Covid-19) Dashboard.
Figure 3 shows the daily reporting on confirmed Coronavirus infections and deaths, and is marked by rises and falls, which are partly due to interruptions and delays not just in administering the tests, but also in reporting test results across the country. For instance, when a lab stopped working due to the lack of testing kits, people often had to wait for days to get their results, causing a fall in the reported number of cases. This was then followed by a rise, after the piled up cases were processed. In other words, the ups and downs are partly an indication of Afghanistan’s inconsistent testing capacity.
What is notable in Figure 3 is the fact that the number of reported cases declined, whereas the number of reported deaths has stayed relatively high for much longer (although it is currently tapering off).
Regionally, in terms of official figures on deaths and infections, Afghanistan is placed roughly between, on one hand, Iran and Pakistan, which have reported many more infections and deaths, and on the other hand its ‘other’ neighbours, Tajikistan and Uzbekistan, which have reported far fewer infections (Tajikistan) and deaths (both Uzbekistan and Tajikistan) than Afghanistan (see Figure 4, below). Having reported no cases, the other Central Asian neighbour, Turkmenistan, claims to be like Antarctica – the world’s only continent that still seems to be free of the Coronavirus (see these reports here and here).
Figure 4: Reported coronavirus infections and deaths as well as deaths and tests per one million population in Afghanistan and its five neighbouring countries, disregarding China, its sixth and largest neighbour. Source: for reported infections and deaths, WHO Coronavirus Disease (Covid-19) Dashboard, 23 September 2020 (12:21 pm CEST); for deaths and tests per one million population, Worldometer, 23 September 2020.
The MoPH comments on its own figures
The official data on the transmission of the Coronavirus in Afghanistan has been treated with considerable scepticism, including within the MoPH, particularly since July when the MoPH data showed a dramatic decrease in infections compared to the two previous months (see Figure 3). In fact, on 9 July, the government started to project that Afghanistan had hit the virus’ peak and that the worst of the pandemic was now over (see here also here), with the number of Covid-19 infection cases having fallen by 30-40 per cent, compared to June and May.
As a result, Afghanistan has gradually eased its patchy and poorly-enforced lockdowns and in early August allowed schools to partially reopen. (4) Since then the number of reported cases has remained remarkably low. This matches the very low testing numbers mentioned above, so it is hard to know to what extent the low number represents an actual decline in the disease.
What is clear, is that there is a broad consensus within Afghanistan’s pubic health community that the official figures represent only a fraction of the actual numbers.
On 19 July, Muhammad Yaqub Haidari, the provincial governor for Kabul, said that based on a survey conducted by the Emergency Committee for the Prevention of Covid-19, with the help of clerics, local elders and people in charge of cemeteries, he estimated that as many as two million people may have been infected in Kabul alone, by 9 July. (AAN has not seen the survey and therefore does not know about its methodology or credibility.)
On 2 August, MoPH spokesman Samsur said that the ministry “guessed” that the number of people infected with Coronavirus in Kabul might be “five to 50 times higher” than officially reported (which, at the time, was a little under 37,000 cases), since patients with mild symptoms were only advised to stay home and were not registered in the MoPH data collection system. He also noted that the MoPH was worried about a possible second wave of Covid-19 infections, particularly when the weather gets cold again.
On 5 August, the MoPH shared with the media details of a survey conducted by the MoPH, with the help of World Health Organisation (WHO) and Johns Hopkins University, that estimated that 31.5 per cent of Afghanistan’s population (about ten million people) may have been infected with the Coronavirus all over the country. Ahmad Jawad Osmani, the acting Minister of Public Health, further said, based on this survey, that an estimated 46.4 per cent of children in Kabul had been infected, that these infections had been asymptomatic and that they had likely spread the disease to those in their environment, the elderly in particular.
There are also suspected patients of Covid-19, which have not been announced. For example, according to MoPH officials in Herat, there are 57,282 suspected cases in Herat that have symptoms and were registered by case finding teams (MSF, IOM, ADA, WVA, UNDP and OPD sections of private hospitals), from which the MoPH asked for help during the peak of the virus. Because they were not tested, they have not been included in the daily updates by the MoPH.
Anecdotally, a relative of the author was recently infected, along with his wife and three children. The wife and children had mild symptoms and quarantined themselves at home. The relative went to a private hospital as his situation was somewhat worse than the rest of the family, where he was tested as positive. He was put under treatment and in quarantine for three weeks, but since he did not refer to a government hospital, he was not counted among the MoPH cases.
Anecdotal data suggests that some people who were symptomatic did not go to public hospitals because of concerns over the lack of adequate facilities (including oxygen, hygiene, staff, beds and ventilators), as well as fears of contracting the disease at the hospital. Others who did refer to public hospitals faced problems. For example, family members of patients in Muhammad Ali Jinnah and Afghan-Japan Hospitals, both of which are allocated for treatment of Covid-19 patients in Kabul, complained about the lack of oxygen for patients in need.
People who have talked to AAN said that private hospitals were not much better. Many of the private hospitals were afraid of treating patients with obvious symptoms of Covid-19 and referred those patients to government-run hospitals. Besides, a lot of people could not afford the costs in private hospitals. When the MoPH allowed some private hospitals to test Covid-19 samples, people complained about the high cost of tests.
MoPH deputy spokeswoman, Jafari, further told AAN that their Covid-19 surveillance efforts had found patients who had no symptoms, but when their samples were tested, the results had been positive. She said it was not clear how many people, or what percentage of actual patients, had been asymptomatic.
There is thus a broad understanding that the official figures represent only a fraction of the actual spread of the disease, and a general sense that many of those who have been infected have been either asymptomatic or only showing mild symptoms (see also here).
An update on Covid-19 in Afghanistan by WHO/OCHA (World Health Organisation and the United Nations’ Office for the Coordination of Humanitarian Affairs) also noted that, in addition to the limited public health resources and testing capacity, the absence of a national death register contributed to the likely underreporting of corona-related deaths. A national death register could have helped estimate the country’s ‘excess mortality,’ which could then be attributed to the Covid-19 disease.
What the public says about the spread of the virus
The official figures do not match the information and experiences from the wider public. According to the MoPH figures, at the peak of the virus’ spread in May and June, 20-40 people died on average per day, but officials, journalists, commentators, residents and gravediggers have talked to AAN about how there were many more infections and deaths than reported.
A local journalist in the eastern province of Kunar, whose entire family had suffered and recovered from Covid-19-like symptoms, told AAN in late July about not just the widespread infections, but also the deaths from the Coronavirus in the province that he was aware of, in particular in his local community. “Every day the main mosque announces five or six deaths,” he said. “This is due to Corona, because before the arrival of Corona in Afghanistan, we did not hear about five or six deaths through mosque loudspeakers every day, but now we do.”
Muhammad Zia, a resident of the Dar ul-Aman area in Kabul city said, “Roughly more than 2,000 friends, relatives and family members have been infected. None of them went to any hospital, because they don’t trust those hospitals that treat Covid-19 patients.” Muhammad Musa, a resident of the Qala-ye Shahda area of Kabul city told AAN: “In our area many families have been infected and many people have died. There are families that have lost three or four members due to Covid-19.”
AAN also talked to gravediggers in different parts of Kabul city, who said they had noticed a significant increase in the number of deaths, in comparison to pre-Covid-19 times. For example, on 1 July, Hassan, a gravedigger in a cemetery in the Shahrak-e Omid-e Sabz area of Kabul city, said, “During this disease, particularly in the month of Jawza (21 May-20 June), 25 dead bodies were buried here on a daily basis […] During the last two weeks, the number of dead bodies brought here has decreased to some extent, but if we compare it to the time before corona, it is still a lot.” He also spoke about the demand for more gravediggers. The number of gravediggers in his cemetery, he said, more than doubled, from six or seven to 15 during the Coronavirus outbreak.
Yusuf Khan and Jawid, gravediggers in, respectively, the Siya Sang and Shohada-ye Salehin cemeteries, talked about their increased workload, saying they were now digging between 10 to 20 graves a day, even sometimes at night, which both said was much higher than the normal demand for their work. Ajmal, a maker and seller of tombstones near the Siya Sang cemetery, similarly talked about the increased demand for his work. “During the Corona and quarantine period, the number of deaths increased so much that it was difficult for me to provide headstones for my customers.”
The Afghan media also carried several stories quoting coffin-makers. For example, Jalaluddin Nuri, who runs a woodworking business in Herat city, told Hasht-e Sobh newspaper that during the peak of Covid-19 in June, the demand in his shop rose to more than 30 coffins per day, on average. Nuri said he and his ten workers had produced 220 coffins for the public health department in Herat, and were going to sign a contract for 500 more. In Nangrahar province, Zabihullah Zmarai, a provincial council member, said he knew a carpenter who had six coffin stores in the city and who was working longer and harder than usual to meet the increased demand. “That carpenter now sells more than 100 coffins every day,” he said.
On 14 June, Sayed Abdul Wahid Qatali, the provincial governor for Herat, also told a news conference that about 280 patients with signs and symptoms of Coronavirus had died the week before without visiting a hospital, while the MoPH reported a total of only 89 death cases for the whole of Herat up to that day.
Covid-19 health impacts on Afghanistan
The impact of Covid-19 on the health situation in Afghanistan has been dire. According to this UNDP report, Afghanistan has been especially vulnerable because of its limited health care system and lack of medical personnel, its weak infrastructure and poor social cohesion after 40 years of war, and the large influx of refugees returning from Iran and Pakistan – without proper quarantine and containment measures in place. The government also lacks the revenue and resources to mitigate the pandemic. Due to the limited health care system, many Afghan patients with severe heart, kidney and other diseases used to travel abroad – in particular to Pakistan, India and Iran – for treatment, but due to the Covid-19 outbreak, borders with Iran and Pakistan have been closed and flights to Pakistan, India and Iran have stopped. Therefore, an unknown number of patients with other severe diseases may have died due to a lack of proper medical care during the Coronavirus outbreak.
Looking ahead
Despite a slightly increased testing capacity, testing numbers remain very low. As a result, the official MoPH figures continue to show only a fraction of the actual spread and impact of the virus. According to the MoPH, the decrease in the number of official cases indicates that the first wave of the virus is in its last stages in Afghanistan. Based on anecdotal reporting there does, indeed, appear to have been an actual slowing in the spread of the disease and its resulting deaths, but this could be reversed or followed by a second wave or outbreak. Factors that could exacerbate this are the winter’s cold weather, which makes social distancing more difficult, the spread of respiratory infections or the flu (which may make people believe they do not have Covid-19 when in fact they do), and the threat that, with the relaxed restrictions, current carriers of Covid-19 might easily transfer the disease to others.
The MoPH has asked people to wear masks in an effort to bring the number of cases to ‘zero’ and to prevent a second wave or outbreak of the virus. But with the decrease in cases, people’s behaviour toward Covid-19 has also changed. Most of them do not practice social distancing and do not wear masks. The MoPH has, moreover, not yet reached its testing capacity of 10,000 cases per day, which it will need in the case of a renewed outbreak. Neither do they include the cases from private labs and hospitals in the official figures.
With winter looming, and the threat of a second wave or renewed outbreak, it is unnerving that there is still much we do not and cannot know.
Edited by Thomas Ruttig, Reza Kazemi and Martine van Bijlert
(1) The dashboard from the Ministry of Public Health uses a higher figure per 1 million people – 349 per 100,000; or 3,490 per one million – which is probably due to the use of a different population figure. It still leaves Afghanistan among the countries with the lowest testing rates worldwide. AAN uses the Worldometer figure here, because it enables us to compare Afghanistan with other countries.
(2) There have also been allegations of corruption in the procurement and management of the testing equipment, including reports that medical equipment, such as ventilators meant for Afghanistan, were smuggled to Pakistan (see for instance here). There was also alleged corruption in the distribution of food aid (bread) in Kabul during the quarantine period (see here). Four current and former governors have been referred to the Attorney-General’s Office to face charges of corruption in the management of Covid-19 funds (see here).
(3) Kunduz is reported as being the tenth most infected province – after the other six provinces with labs, followed by Takhar, Bamyan and Baghlan provinces. Find figures on the number of tests, infections, deaths and other Covid-19-related data per province in the public dashboard launched by Afghanistan’s Ministry of Public Health (username: public, password: Covid@19, https://moph-dw.gov.af/dhis-web-dashboard/#/.
(4) In August, the Afghan cabinet approved a partial reopening of schools. According to that plan, grades 11 and 12 at public schools and grades 1-12 at private schools resumed their lessons.
Revisions:
This article was last updated on 24 Sep 2020
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