Afghanistan Analysts Network – English

Economy, Development, Environment

Covid-19 in Afghanistan (9): Into the third wave

Thomas Ruttig Rohullah Sorush 26 min

Afghanistan has entered the third wave of the Coronavirus pandemic amid an unprecedented rise in confirmed cases. Doctors in various provinces detected signs of the impending new wave soon after the start of the Afghan new year (21 March), but the government only imposed contact restrictions on 28 May and enlisted religious scholars to urge people to observe protective measures. It warns now of “difficult coming four weeks“ with no signs of cases declining. The influx of more infectious variants of the virus appears to have exacerbated the situation. Despite growing testing capacities and more facilities to treat Covid-19 patients, the Afghan health system’s remains severely under-equipped. Popular misperceptions of the virus, resulting in complacency, have contributed to the new outbreak. But Afghanistan belongs to the big bloc of countries, particularly those in the Global South, with insufficient access to vaccines. AAN researcher Rohullah Sorush and co-director Thomas Ruttig contacted 20 out of 34 provincial health directors early to get a sense of the evolving situation throughout the country and look at figures and trends.

A bazaar in Kabul, well into the third Covid-19 wave in late May 2021, where most people did not wear masks. Photo: Rohullah Sorush/AAN.

Facts and figures

Afghanistan has entered its third wave of the Covid-19 pandemic, with a dramatic increase in confirmed new cases reported from all provinces. [1]Sources: MoPH’s daily lab result reports and Tolonews’ daily reporting, also based on MoPH figures. With very few exceptions, from the end of the second and less serious wave in November 2020 until March 2021, Afghanistan logged fewer than 30 daily new infections. The number of confirmed cases had even reduced to zero in several provinces by mid-May, as various provincial health officials told AAN.

Since early March, the daily caseload has increased dramatically. It doubled to over 60 by the end of that month and topped 1,000 cases on 30 May. By 2 June, it was 1,509 – with 6,753 cases over the previous seven days, almost double the week before. 

Acting Minister of Public Health, Wahid Majruh, said at a press conference in Kabul on 9 June: “Yesterday 1,724 people tested positive for the Coronavirus. The numbers speak for themselves. Last week we had 10,024 confirmed cases. Compared to the previous week, we have a 180-200 per cent increase in the number of cases.” On 10 June, the number of new cases was further up to 1,824. 

According to Majruh, the third wave “is far more virulent than the first and second waves.” He said the ministry had studied “schools and universities in five provinces over the past two days, and we found that 28 to 32 per cent of the students and teachers we tested using the rapid antigen test were positive. It means the levels of contagion are far higher than [those based on] the PCR test.” He warned that currently “we are not witnessing a downward trend in the virus’ transmission graph;” that for “the coming four weeks we are preparing for the worst situation;” and that “the statistics we announce are certainly not the true number of people who have been infected. These are the people whose symptoms were so severe that they were forced to come take a test.” He named the provinces of Kabul, Baghlan, Kunduz, Kandahar, Uruzgan, Maidan-Wardak, Panjshir, Faryab and Badghis as particularly badly hit. Majruh said: “If things continue in this way, it will break the back of Afghanistan’s health sector.”

The number of new cases remained well below 1,000 per day during the first and second waves, except on two days in June 2020 (see graph in this AAN report). In the first wave (May/June 2020), numbers were around 400 new cases daily. The highest number of new cases per day in the second wave (November 2020) was 290. Since the start of the pandemic in early 2020, Afghanistan reported a total of 75,119 confirmed Covid-19 cases, with 3,034 fatalities. Overall, Afghanistan has recorded nearly 2,000 cases per one million population. Of the 14,122 active cases registered by 2 June, eight per cent (1,124) were serious or critical. Afghanistan currently ranks 62 in the number of active cases but 21 for “serious and critical” ones on the Worldometer website [2]As in our earlier Covid-19 reporting, AAN uses Worldometer figures because it enables us to compare Afghanistan with other countries. (as measured by the number of cases per one million), which seems to indicate that only those with severe symptoms seek medical attention. 

The spokesperson for the Ministry of Public Health (MoPH), Ghulam Dastagir Nazari, told the Kabul-based Pajhwok Afghan News agency on 22 May that “with the rise in positive cases, fatalities have also gone up” to a total of 220 over the past month, a 3.5-fold increase over the previous month. 

When compared to the global picture, Afghanistan’s figures are still relatively modest. For example, Germany (with more than double Afghanistan’s population but a test rate of more than 130 times) had 142,400 active cases in late May. The global experience has shown that due to the virus’s incubation period, the rise in the number of deaths lags behind that of new cases by around two weeks. There were 27 fatalities on 2 June; by 6 June, the number of deaths had almost doubled to 50. However, as observed previously, it can be assumed there is significant underreporting as people infected with the virus keep their illness hidden, and many of the dead are buried in secret at night (see AAN reporting here). 

Importantly, in its “Strategic Situation Report: COVID-19” published on 20 May 2020, the World Health Organization (WHO) pointed out that “confirmed cases of and deaths from COVID-19 are likely to be underreported overall in Afghanistan.” This can be partly attributed to the fact that relatively few people are tested (as AAN also reported in September 2020). MoPH advisor Dr Mohammad Sherzad confirmed to Pajhwok on 22 May that Covid-19 figures collected by the ministry included “only seriously ill patients who visited health [facilities].” He pointed out that the lack of an “active surveillance system in Afghanistan to show where the affected person contracted the virus and who the patient met … [means] exact figures could be ten times higher than reported.” Dr Zahir Shah Nekmal, director of public health in Ghazni, and Dr Ashraf Naderi, a provincial health official in Kandahar, also told AAN that relatively few people take steps to be tested. 

The WHO report said “limited public health resources, lack of people coming forward for testing, as well as the absence of a national death register” could mean that Covid-19 cases and related deaths are underreported in Afghanistan. According to the report, as of 20 May, “only 434,506 tests have been conducted for a population of 40.4 million” since the start of the pandemic. This means that Afghanistan ranked 194 of 220 countries and territories on that day. Afghanistan’s test-positivity rate of 15 per cent also indicates “overall undertesting of potential cases,” said the report. Five days later, on 25 May, of the 3,489 tests conducted countrywide, 24.8 per cent were positive, according to Worldometer.

Furthermore, the report hinted at gender-related disparities, saying there was an “over-representation of men in testing,” resulting in men accounting for 66 per cent of confirmed Covid-19 cases and the majority of the fatalities. Interestingly, most confirmed cases were men between 15 and 30 years of age, while most who died were men between 50 and 79. Afghan media outlet AVA Press also reported outbreaks at schools from Mazar-e Sharif where students were not wearing masks and spread the disease to their families. This seems to indicate that, like in other countries, younger people are getting infected in much higher numbers than during the first and second waves.

It can be assumed that the lack of access to health facilities for large parts of the population due to widespread insecurity and prevalent outbreaks of fighting contributes to the under-reporting. Health facilities are mainly located in provincial and district centres under the government’s control. For those living in Taleban-controlled areas, where there are fewer health centres, visiting such facilities means the risky crossing of frontlines into government-controlled areas (see in the AAN series “One Land, Two Rules” – the synthesis report here).

The impact of new Covid-19 variants 

One feature of the third Covid-19 wave in Afghanistan is the growing prevalence of new mutations of the SARS-CoV-2 virus, such as B.1.1.7 and B.1.617.2, formerly called the ‘British’ and ‘Indian’ variants. The WHO now labels them as Alpha and Delta.

On 27 March, minister Majruh inaugurated a new genotype testing centre in Kabul, the country’s first lab with the capacity to diagnose the B.1.1.7 (Alpha) variant. He said this new variant was now widespread in Afghanistan, with “seven out of 11 COVID-19 cases” testing positive for it. The first seven cases of the variant were detected in Nangrahar, the province with a busy border crossing to Pakistan. In Pakistan, the third wave started in February 2021 and was reportedly dominated by the Alpha variant at its onset (see here and here), while in May, the Delta mutation came to the foreground. Between 1 and 31 March, the daily number of new confirmed Covid cases in Pakistan rose from 1,300 and 4,600. Since then, the numbers have declined and were at the 1 March figure again, with 1,303 on 10 June (see here).

On 24 May, Afghanistan’s MoPH sent a file to AAN showing that 332 of 592 Covid-19 samples (56.1 per cent) from 19 provinces had been confirmed as mutant cases, which shows a high positivity rate (positive tests as a percentage of total tests). The majority of those cases were detected in Kabul and Nangrahar, followed by Herat and Kandahar. Dr Nasir Ahmad Durani, director of public health in Nangrahar, told AAN on 21 May that this mutant type was prevalent in Nangrahar, Kunar, Laghman, Kandahar and Khost provinces. All these provinces share a border with Pakistan and feature official and informal crossings. Up to tens of thousands of Afghans travel to and from Pakistan each day through the official land border crossings in Nangrahar and Kandahar (see AAN reporting here). Through Islam Qala, the main Afghan-Iranian border crossing near Herat, the Afghan Ministry of Refugees and Repatriations and the UN-affiliated International Organisation for Migration (IOM) recorded 246,324 deportees and returnees from Iran between 1 January and 9 May 2021.

The usual coping mechanism for Afghans in case of serious illness – sending relatives for medical treatment to Pakistan or India – is not fully available in the current situation. Although borders are not entirely closed, Afghanistan’s ambassador in New Delhi, Farid Mamondzai, warned citizens not to travel to India and said: “There is no place left in [Indian] hospitals for treatment of patients… A number of patients who traveled to India [from Afghanistan] for treatment were also infected with Covid-19.” He also said that weekly flights between the two countries had been reduced to 50 per cent and hinted that flights might cease altogether. AAN has heard reports from Afghans seeking to travel to India for medical treatment that visas have become more difficult to obtain. The Torkham (between Nangrahar province and Pakistan) and the Islam Qala (between Herat province and Iran) border crossings are open for business, as is Spin Boldak (between Kandahar and Quetta/Pakistan). 

President Ashraf Ghani wearing a mask during a meeting with representatives of the International Committee of the Red Cross in Kabul on 10 June 2021. Photo: Presidential website.

The government finally reacts – after earlier warnings

In mid-April, the Kabul-based daily Hasht-e Sobh cited MoPH officials saying that while reported cases were on the rise, the ministry did not believe this to indicate that the country was entering the pandemic’s third wave. The WHO did not explicitly contradict this in its 20 May Strategic Situation Report saying, at that point, the figures were only “potentially signalling a third wave.” In late April, the Afghan government denied it had the plan to impose a 40-day lockdown (or at least severe limitations on movement). On 5 May, the MoPH appealed again to the public to take health guidelines seriously, including refraining from participating in large gatherings, which it said are the leading reason for the rise in infections. However, the ministry said, the infection rate still did not warrant lockdowns in cities.

Finally, on 28 May, the ministry ordered all universities and public and private schools in 16 provinces to close for two weeks. The measures went into effect the following day “to prevent further spread of the virus.” [3]The 16 provinces mentioned by Majruh are: Kabul, Badakhshan, Balkh, Ghazni, Helmand, Kandahar, Kapisa, Kunduz, Laghman, Logar, Maidan Wardak, Nangrahar, Nimruz, Paktia, … Continue reading It issued a statement raising “serious concerns” for the health sector and said it was “sounding a serious alarm in the country.” The statement asked all citizens to observe all measures put in place to combat Covid-19, including “social distancing, washing hands and wearing masks.” 

On 3 June, President Ashraf Ghani went public with a speech, saying the country was now “facing the third wave.” He appealed to the population to take preventive measures and said their “participation” was essential to “manage the crisis and minimise its negative effects.” Ghani announced that the government would try to buy more vaccines, stressed that there were no adverse side effects associated with the vaccine and urged the public to be vaccinated because it is an “important [measure] to protect you and your families.” He added the government would not resort to drastic social distancing measures, as this could harm the country, mentioning the ongoing harvest. Instead, he appealed to citizens to show individual “responsibility.”

On 8 June, the 28 May measures were extended and amended for another two weeks and again for the 16 provinces, starting 12 June. Minister Majruh explained them in detail at his 9 June press conference. He followed up with a strong recommendation that all other provinces voluntarily follow the same rules, saying that the government was preparing to make the “difficult decision for the other 18 provinces.” 

The measures now in force include:

  • all educational institutions remain closed;
  • restaurants can serve up to ten people and are urged to restrict service to takeaways and deliveries and use outdoor areas;
  • are open for takeaway and deliveries only;
  • all gatherings “including political, social and academic” are banned at least until next week;
  • a letter was sent to the Ministry of Haj asking that social distancing be observed in all Friday prayers and other [religious] gatherings and masks should be mandatory there and to request that prayers are held in the open air;
  • government employees under 55 years can go to work nationwide but must wear face masks; those older than 55, with underlying conditions such as diabetes and cancer, and women more than four months pregnant will work from home;
  • wearing a face mask in public spaces is mandatory.

Majruh compared the virus to a suicide bomber and said that people had not observed anti-Covid measures; he held up a mask and said, use this inexpensive weapon to combat the virus and keep yourselves and your families safe. He asked the public not to assault medical staff at the hospitals, referring to what he called a serious case of assault in a Kabul hospital where the family of a woman who died attacked the staff, destroyed medical equipment and damaged vehicles in the parking lot. He called on community leaders and civil society actors to help keep medical staff safe and said we cannot deal with this issue using the military. 

Before these drastic words, there were ample early warnings. Provincial health officials in several provinces told AAN in May that they had seen signs of a new outbreak early. Dr Faridullah Nasrat, the acting director of public health in Nimruz, said: “the third wave came to Nimruz and other provinces in Afghanistan at the beginning of this year” (the solar Afghan year, starting on 21 March). Dr Rasul Gul Samar, director of Public Health in Logar, confirmed this for his province when speaking to AAN on 17 May 2021. Dr Aziz ur-Rahman Safi, director of public health in Kunar, said that positive Covid-19 cases were rising in late April. He said: “We have a ten-bed hospital for Covid-19 patients, but there were 12 or 13 new patients every day.” He said that the numbers went down slightly in the ensuing weeks to “eight to nine patients,” but “this is the third wave.” He also said the number of deaths in Kunar in April was already higher than during the first and second waves. Nangrahar health director Durrani observed the same pattern: an increase first, then a slight decrease, concluding: “The third wave of Covid-19 has hit Nangrahar.” Dr Gul Ahmad Ayubi, acting director of Public Health in Balkh, told AAN on 2 May that the third wave had begun, as did Dr Muhammad Shoaib Danesh in Kapisa, saying it started in mid-April.

As early as February, Afghan health professionals appealed to the government and educational institutions to enforce health guidelines such as social distancing, using masks and washing hands in the new academic year. On 27 May, Kabul municipality made the first move, ahead of the government, and ordered the city’s wedding halls closed, starting 3 June. The end of Ramadan (this year on 13 May) marks the start of the traditional wedding season in Afghanistan. The weddings, which regularly host several hundred guests, can easily turn into super-spreader events. The Kabul administration waited over two weeks to announce the ban, apparently not daring to take this step immediately after the end of Ramadan, as it might have led to protests by those who had booked and paid for weddings.

The government also enlisted the Ministry of Religious Affairs and the ulema (religious scholars) to promote the vaccination campaign to stem the spread of the virus (see here). Dr Gul Ahmad Ayubi, acting director for public health in Balkh province, confirmed to AAN that, at mosques in his province, the mullahs “talked about vaccinations and encouraged people to get vaccinated.” On 30 May, the Shia Ulema Council issued a strongly worded statement asking people to follow the MoPH Covid-19 regulations and avoid holding large gatherings. During earlier Covid outbreaks, the Afghan government had refrained from formally prohibiting large religious gatherings, such as Friday prayer, to avoid provoking religious sentiments.

Undertesting and underreporting

According to the WHO’s latest report, the country’s “laboratories are testing 7,500 samples” per day, with a slightly higher total daily capacity of “up to 8,500 samples.” While this is extremely low compared to global figures, it is a notable increase compared to the 6,565 tests per day conducted in 2020 (see AAN report here). Speaking to AAN on 30 May, MoPH spokesperson Nazari claimed the total capacity had risen to 24,000 samples per day and could be doubled by introducing a second shift if demand increased. He said there were 28 government and private Covid-19 labs in Kabul, Herat, Kandahar, Balkh, Kunduz, Nangrahar, Paktia and Faryab provinces, as well as the border crossing to Turkmenistan, Aqina port. According to Dr Khosrow Yosufzai, head of the Monitoring and Evaluation department of Afghanistan’s Medical Council, [4]The Medical Council of Afghanistan (Shura-ye Tebbi-ye Afghanistan) is an independent government office that reports to the Office for Administrative Affairs (Edara-ye Umur) of the president. Its … Continue reading there is also testing at Kabul airport. [5]According to media reports and Wolesi Jirga statements, there is controversy over the acceptance of test results and vaccination certificates from local laboratories at Kabul airport. According to … Continue reading The MoPH has repeatedly told AAN they are trying to have a testing lab in every province (see also this WHO report).

Yosufzai said that despite increased testing capacity, demand continued to outstrip available supplies. He also told AAN the quality of testing at private clinics was “bad and concerning” as they were mainly interested in “making money” and were “pulling the wool over people’s eyes.” 

Health officials from various provinces told AAN there is more openness for testing and vaccination in the general population in recent weeks, which they attributed to the visible increase in the number of seriously ill people. For example, Dr Ashraf Naderi, director of public health in Kandahar, told AAN on 18 May 2021, when people “saw many people were infected, they started coming to be vaccinated.” He said the public awareness campaign to promote vaccinations was “effective.” Dr Nekmal in Ghazni also told AAN: “As awareness has increased and [people] see confirmed cases are rising, they are coming to us to be vaccinated.” Dr Durani in Nangrahar told AAN that “the number of people coming for vaccination has been higher than our expectation.” However, Dr Abdul Maruf Jalili, director of public health in Laghman, said: “People come to the centre [for vaccination], but not at the level we expected.”

The state of vaccinations

On 26 May, the MoPH said it had “successfully completed the first phase of the vaccination campaign” (See ToloNews here). On 31 May, Dr Mirwais Alizai, deputy MoPH spokesman, told AAN that 608,020 people had been vaccinated so far, some with two doses, others only one. This includes 118,085 health workers, 79,217 teachers and 5,551 media workers. The vaccine is administered in health facilities mainly based in provincial and district centres and mobile teams travelling to rural areas. A Kabul-based journalist reported in Undark, a non-profit digital magazine, that a number of vaccine doses had remained unused and expired (the article included photos of such doses), an allegation the MoPH vehemently denied.

According to a Pajhwok news agency report on 14 March, “based on the president directions to the Ministry of Public Health (MoPH), the vaccine against [the] coronavirus must be administered first to security forces, health officials and journalists.” Earlier, Pajhwok cited the MoPH as reporting “over 90 health workers have died from coronavirus in Afghanistan.”

So far, Afghanistan has entirely been able to use the Astra-Zeneca Covishield vaccine only, which requires two doses 8-12 weeks apart. The first batch of half a million doses donated by India arrived in February before India ceased international shipments of the vaccine to respond to its own significant outbreak. Afghanistan also received 468,000 doses under the UN’s COVAX initiative in March. 

But what looked like a successful start was quickly undone by the – at least short-term – reality on the ground; the country has run out of vaccines. In mid-May, the MoPH officially asked the provincial health officials to stop administering first doses to new people. This was confirmed to AAN by provincial health officials in 20 provinces. Currently, the country is waiting for a consignment of 400,000, later increased to 700,000 doses, donated by China. However, there is no indication of when the vaccines will be delivered. On 7 June, Javid Ahmad Qaem, Afghan ambassador to China, tweeted that 252 boxes of vaccines “produced by Beijing Institute of Biological Products” and syringes had been handed over and will reach Kabul on 10 June. On that day, official Chinese media reported that “a batch” of the consignment had arrived.

As al-Jazeera reported on 5 June, the Afghan government was told by the WHO that the three million doses the country expected to receive by April would not be delivered until August. MoPH spokesperson Nazari was quoted as saying that he had knocked on the door of several embassies and so far had only “gotten diplomatic answers” but no vaccine doses.

The donation from China, when it arrives, will not answer Afghanistan’s needs; with no further deliveries in sight, the MoPH vaccination plans seem unrealistic. The ministry told AAN they plan to vaccinate 20 per cent of people over 18 years of age by the end of 2021 and 60 per cent by the end of 2022. The first target is in line with the UN-led COVAX initiative, which pledged 112 million USD for vaccines to cover 20 per cent of the population.

The New Humanitarian reported that the MoPH was “planning for 2,200 facilities across the country to administer vaccines, and it’s partnering with aid agencies that work in Taliban areas” – an indirect offer to the insurgents to be vaccinated. The report added: “Humanitarian agencies are targeting some 8.6 million people considered among the most vulnerable … include[ing] people between 30 and 50 years old in displacement sites, some of the hundreds of thousands of yearly returnees from neighbouring Iran and Pakistan, people in urban slums, and people older than 50 living in the hard-to-reach districts.” According to MoPH spokesperson Nazari, “It’s the same strategy we are using for all vaccination campaigns,” for example, the polio immunisations (find AAN’s latest reports here and here).

On 24 May 2021, WHO Director-General Dr Tedros Adhanom Ghebreyesus told the World Health Assembly: “More than 75% of all vaccines have been administered in just 10 countries.” He said: “There is no diplomatic way to say it: a small group of countries that make and buy the majority of the world’s vaccines control the fate of the rest of the world.”

Afghanistan is a striking example, particularly given that the US and leading EU countries – who are currently withdrawing their troops – have sent no bilateral assistance and remain reluctant to even temporarily waive patent rights to allow the production of generic coronavirus vaccines in countries of the Global South. (The EU parliament has voted in favour of a temporary waiver of patent rights.) 

Reports of some serious side effects associated with the Astra-Zeneca vaccine, which temporarily halted the use of this vaccine in several European countries, also hampered Afghanistan’s immunisation campaign, as the BBC’s Persian service reported. In late April, for example, the government cancelled plans to vaccinate students for vaccination; while it did not give a reason for this decision, it could have linked to the reported side effects. 

Taleban reactions to vaccination

The Taleban are reportedly interested in participating in the vaccination campaign. Their spokesperson, Zabihullah Mujahed, told The New Humanitarian: “If the corona vaccine is implemented in coordination with our health commission and in accordance with our principles, we agree to it.” However, as of this writing, there is no official mention of this on their website, apart from a reference in their 9 May Eid message to “the corona pandemic serving as another tragedy exacerbating the situation” in the country. 

AAN has heard different accounts from various provinces concerning the Taleban’s acceptance of vaccinations. It has been reported that Taleban are preventing vaccinations in Logar, Paktia, Ghazni, Maidan Wardak, Takhar and Laghman, where fighting around the provincial centre of Mehterlam is ongoing. Dr Nekmal in Ghazni said that mobile vaccination teams could not reach several districts in the province due to general insecurity and fresh outbreaks of fighting, such as in the Jaghatu district, where local clinics were temporarily closed. 

Dr Muhammad Shoaib Danish, in Kapisa, said: “In the beginning, we faced restriction by the Taleban in some areas, but we established a commission of the ulema and influential people and adopted a policy of impartiality, keeping the vaccination process out of politics. Fortunately, it worked and now we don’t have any restriction. People from insecure areas of the province come to the [provincial] centre to be vaccinated.” In Maidan Wardak, such an approach did not succeed. Provincial director Dr Muhammad Salem Asgharkhel told AAN: “Vaccinations are ongoing in the province, but it is applied only in three districts, ie the centre of Maidan Wardak and the two districts of Behsud (Markaz-e Behsud and Hessa-ye Awwal-e Behsud). In other districts, the Taleban have prevented vaccinations. We have asked the ulema and influential figures to convince them to allow vaccinations to proceed, but the Taleban did not agree.” 

Baghlan provincial health director, Dr Mohebullah Habib, told AAN on 16 May that the Taleban prevented the hiring of vaccinators. He said when the authorities then contacted them through local councils to negotiate access for vaccination teams, the Taleban said they needed to consult on the issue.

Laghman provincial health director, Dr Abdul Maruf Jalili, told AAN on 16 May that the Taleban did not allow vaccinators in the districts; as a result, both vaccination sites and vaccinators had to be relocated to the centre of the province.

This was also the case in some districts of Takhar and Logar province. Dr Hamidullah Omid, the provincial health director for Takhar and Dr Rasul Gul Samar, provincial health director for Logar, told AAN on 16 May that Taleban prevented vaccinations in some districts under their control.

In contrast, Dr Safiullah, Dr Harun and Dr Ashraf Naderi, directors of public health in Parwan, Jawzjan and Kandahar, claimed there were no restrictions on vaccinations in their provinces, despite a substantial Taleban presence in various districts of the three provinces. In Khost, Dr Habib Shah said he had received a message from the Taleban telling him not to offer vaccinations to the local people. Shah told AAN that he replied, saying that a WhatsApp message was not acceptable and asked for an official letter that never came. “So, we vaccinated in all districts in Khost,” he said. In neighbouring Paktia, according to provincial health director Dr Welayat Khan, the Taleban did not allow vaccinations in the districts, “so people came to [the provincial centre] Gardez for to be vaccinated.” 

Dr Aziz ur-Rahman Safi, director of Kunar’s public health directorate, told AAN: “We have not faced any problems or prevention of vaccinations. We have vaccination sites in district centres as well as the centre of the province. Armed opposition fighters have also been vaccinated in Kunar.”

Oxygen bottles in a Kabul hospital. Photo: Tolonews.

Weak health system

Afghanistan’s public health system is straining under the demands of increasing cases. Acting minister Majruh said at his 9 June press conference that there were “capacity problems” and “we have increased bed capacity by 100 to 200 per cent in the provinces and 600 per cent in Kabul – not only beds but equipment as well.”

One example of new hospitals or wards in several provinces is the so-called 100-bed Corona hospital, which opened on 1 June in Paktia (see media report here). This facility, however, was not intended as a Covid hospital. Dr Mohammad Rafi Hamim, a professor at Paktia University’s medical faculty, told AAN that it was built to house the provincial hospital’s infectious diseases ward. While there is no debate about its current use as a Covid ward, there is fierce competition between the local MoPH and the university over who would own the hospital after the end of the pandemic.

In contrast, the head of the Monitoring and Evaluation of the Medical Council of Afghanistan, Dr Khesraw Yosufzai, told AAN as early as in May that in most of the country’s 34 provinces there were no more than three to five hospital beds for Covid-19 patients. He added that these often did not meet international standards for ICU beds. He also said Khost, Nuristan, Badghis, Nimruz, Zabul and Ghazni lacked “proper hospitals for Covid-19 patients,” making the situation in these provinces particularly bleak.  Khost’s health director Habib Shah disputed this statement for his province and claimed on 9 May the situation there was “under control” and that they did not have “a lot of patients.” 

Fawzia, a provincial council member in Zabul, confirmed to AAN that her province did not have a specific hospital to treat Covid-19 cases. She said ten beds at the provincial hospital had been allocated for this purpose, and oxygen and ventilators were available. However, she said, the hospital did not have medicine, leaving patients with little choice but to buy the medication from pharmacies. Dr Yosufzai said only the provincial hospitals in Kabul, Kandahar and Herat had the antiviral medication to treat Covid-19. 

The MoPH spokesperson, Dastagir Nazari, told the German news agency DPA on 3 June that patients already occupied 72 per cent of the country’s 1,500 intensive care beds. In Kabul’s Afghan Japan Hospital, one of the country’s main Covid-19 treatment centres and the only one exclusively dealing with the virus in the capital, beds allocated for Covid-19 patients were fully occupied as early as mid-May. According to witnesses, the hospital was still at full capacity in early June. In Logar, eight of the ten available beds in the provincial hospital were occupied in May.

On 30 May, Dr Yusofzai told AAN that all Covid-19 hospitals in Afghanistan had ventilators, but he did not know how many. He also said that in 20 provinces, the medical staff did not know how to use them. He said that he had alerted the acting health minister, and the government was now training medical staff to use ventilators. According to him, during a recent visit to some provinces, he observed that service delivery had somewhat improved. However, he stressed: “They still don’t know how to use ventilators in Nuristan, and the Covid-19 hospital in Kunduz doesn’t have a lab technician.” He said there were 20 patients in Kunduz but only three beds. These problems, he said, stem from a reduction in the number of staff at Covid-19 hospitals. He said he had discussed staffing shortages with the acting health minister and had received assurances that this issue would be resolved soon. The humanitarian healthcare professional said oxygen was “key for Covid-19 patients, but not ventilators.”

Majruh admitted on 9 June there was “only a shortage of oxygen” and a surge the price of oxygen cylinders, due to increase in demand. He accused oxygen producers of price fixing and said there is wastage of oxygen in private hospital because wealthy patients demand to have more oxygen than they need. He offered training to private hospitals and said that the government would be willing to loan equipment such as oxygen concentrators to private hospitals in an effort to stop wastage of critically needed oxygen. He also said that with the help of UNICEF, the Asian Development Bank and Turkey, the government was building its own oxygen manufacturing plants in several province and that Ghazni and Daikundi hospitals are making their own oxygen. He also insisted that despite the problems “no patient has been without oxygen. But we are up to here. We are at our full capacity. Every new patient strains the health system further.” 

On 4 June, Afghanistan’s Foreign Minister, Mohammad Hanif Atmar, tweeted that he had instructed 15 ambassadors to start sourcing oxygen and other necessary medical provisions as a matter of urgency.

Not all shortcomings are technical or a result of insufficient infrastructure and economic weakness after four decades of war. The healthcare professional quoted above told AAN there were doubts “about the real capacity of the MoPH to coordinate and drive the response” to the pandemic as “most things in the ministry are about politics, not health which made “the system fragile.” S/he added that outsourcing provincial health services to NGOs was problematic because multiple donors with different agendas were “defining the ministry’s priorities” and “undermining the capacity of the government to respond.” The healthcare professional also highlighted an apparent lack of continuity in leadership in the country’s health sector, including “three acting ministers in one year,” and attempts by the president’s office to “bring everything under their control.” 

Public mistrust, complacency and systemic shortcomings

Before Covid-19 cases shot up again, and apparently due to the relatively modest numbers during the second wave, many Afghans became complacent about following health protocols and taking preventive measures. Complacency seems to have also been a factor in the government’s decision to delay announcing that the country was entering the third wave until after numbers had increased dramatically. The WHO also used the term ‘complacency’ in their most recent report without making specific reference to either the public or the administration.

AAN observed that in markets, restaurants and gatherings in most parts of Kabul, people did not socially distance, busses were crowded and very few people wore masks. In government offices, wearing a mask is a requirement for staff members and clients. People observed this rule for a while, and then they became complacent and less careful. For example, banks positioned security personnel at their entrances to ask customers to put on masks before entering. If they did not have a mask, they were told to go and buy one. But later, the banks became lax in enforcing this measure. MP Massuda Karokhel, from Herat, told AAN that people in her constituency do not follow any of the health measures. Some staff in government offices, around 20 per cent, still wear masks. A Ministry of Defence employee told AAN the staff there did not wear masks.

In some areas, this is gradually changing. The first people to sport masks again were those living in Kabul’s relatively affluent Microrayon development and Wazir Akbar Khan neighbourhood, where residents are generally better educated and more sympathetic to the government. Since the MoPH closed the schools, AAN has observed about four out of ten people wearing masks in these neighbourhoods. Other areas of Kabul city are still far behind. 

Balkh’s acting Public Health director, Dr Gul Ahmad Ayubi, told AAN better-educated people are more “interested in receiving the vaccination, while others are not.” Similarly, the health directors of Jawzjan, Takhar and Kunar said people in their provinces were generally eager to get vaccinated. But their colleague, Dr Lal Muhammad Tukhi from Zabul, said that most people there did not “welcome the [vaccination] process” as they feared the reported side effects like body pain and fever. (There are also rumours that the vaccine impacts a person’s fertility or sexual performance.) 

At the same time, several private education centres in Kabul initially refused to comply with the government’s order to close all educational institutions. At least in the first days, lessons continued. People in charge of one English language centre with several branches in Kabul announced on social media that instead of closing, they would ask students to follow health protocols. AAN contacts described similar scenes in Gardez where except for public schools and universities, all other private training courses, mosques, weddings and charitable events continue without interruption. Students said they felt singled out, complaining that the government closed schools and universities but allowed crowded religious ceremonies and other gatherings. Many students are concerned that these measures could disrupt their education for the duration of the pandemic. 

There is also considerable reluctance among significant parts of the population to accept that Covid-19 is more than an ordinary virus and a widespread stigma associated with being infected. These attitudes are reinforced by an array of rumours and conspiracy myths. Some of these are featured in the Undark article quoted above. There are online videos, some locally produced, that say the virus and the vaccine are part of a conspiracy to reduce the global population or a CIA project to track and target Afghans – an echo of the real story of fake vaccinators trying to get into Osama ben Laden’s house when he was hiding in Pakistan (see also this story in the UK daily the Guardian). Others believe that the virus will not affect Muslims or that the vaccine, produced by non-Muslims, could negatively impact a believer’s faith. There are rumours that the vaccine is made with ingredients that violate Islamic law, such as pork products. (This because certain foodstuff, including some chocolates, contain pork-based gelatine.) Many people mistakenly believe the Covid-19 threat is already over or that it has been greatly exaggerated, pointing to the low figures in government statistics.

Dr Velayat Khan, Paktia’s public health director, told AAN of a report aired on Afghan National Radio and TV (RTA) covering some of the rumours. They are also abundant on social media and in sermons in some mosques. For example, in Paktia, rumours circulated that doctors were deliberately spreading the disease to make money. Sayed Masum Shah, a resident of Gardez, told AAN that many people stay away from the provincial government hospital because they have experienced poor-quality care there, including what they called “neglect” by doctors, in the past. He also said that most people keep their illness hidden and that “no one is talking about what corona is until it knocks a person over.”

The World Bank has highlighted an “avalanche of misconceptions and unfounded evidence”leading to “fear of going into quarantine.” Afghan author Abdullah Ahmadzai wrote of a “combination of stigma and lack of awareness” in an article for The Asia Foundation. One doctor from Kandahar told the BBC that “years of conflict and tragedy had desensitised some of the city’s residents to the deaths, which they described as ‘the will of God.’” (See also this Human Rights Watch report). [6]The WHO uses a population figure of 40.4 million. The WHO said, “stigma” was another “major factor in people choosing not to get tests,” as confirmed by various other sources. [7]See this article on the Frontiers in Psychiatry website that generally reviews stigma related to infectious diseases. In May 2020, AP reported that, in some parts of the country, Covid-19 patients had been “shunned by their neighbours and [at] local markets.”

Carelessness adds to the equation. A doctor in Gardez told AAN that social customs contributed to the spread of the disease: “Unfortunately, the patients brought to the hospital are accompanied by two or three people each time. A person with this disease should be left alone, but it is the people’s customs that someone who is sick should be accompanied. Those people stay with the patient in the hospital and even change each night.”

Finally, there are systemic factors. Senior MoPH advisor Dr Muhammad Sherzad told Pajhwok that the mounting coronavirus death toll was linked to “the lack of public trust in the [health] system, absence of cooperation from the public, non-payment of salaries to [health] workers, unavailability of medicine at health centres [and] negligence of officials.” Dr Yosufzai told AAN that during the first wave of Covid-19, the doctors were afraid of the patients, and the patients were afraid of the doctors. However, now the situation has changed. He said that there were still problems because when clinics were crowded, doctors had difficulty treating everyone. There is also no systematic government-driven immunisation campaign, apart from provincial roving teams that cannot reach all areas, leaving people who want to be tested or vaccinated to their own devices.

In Paktia, doctors told AAN that no corona tests were performed from 7 March to 10 April because an insurgent attack damaged the power grid and disrupted electricity in the province. 

Allegations of corruption in the use of funds for a Covid-19-related bread distribution programme emerged when in July 2020, when the Kabul-based daily Hasht-e Sobh reported “more than 800 million Afs (about 10 million USD) of the funds allocated for the distribution of dry bread in Kabul have been embezzled by municipal officials, the Kabul Bakers’ Union and bakeries,” further undermining the public’s trust in the government and its measures. The resignation, on 23 May, of Ghizaal Hares, the head of the Afghan government’s Office of the Ombudsperson, whose office had been tasked by President Ghani to investigate these allegations, was apparently linked to findings of corruption. In a short statement on Twitter, Hares hinted at this issue, saying her resignation had to do with the lack of a “unified vision for fighting corruption” in the government. [8]The Office of the Ombudsperson (Edara-ye Bazras) was created in August 2019 by presidential decree as part of the office of the president. Its head reports directly to the president, … Continue reading Also, parliament’s attempts to investigate have led to nothing so far.

Finally, and most importantly, in a country where 60 (World Bank) to 80 per cent (UN) live in poverty, many Afghans cannot afford to socially distance or buy masks. AAN has repeatedly heard people say, “if the virus does not kill us, hunger surely will” (see also these AAN reports from Herat on daily labourers here and on the effect of the pandemic on women’s lives here and here.)

Closed shop with Covid-19 awareness material in Herat during the first wave of the corona crisis in spring 2020. Photo: Reza Kazemi/AAN.

Conclusion

A relatively mild second Covid-19 wave in November 2020 seems to have led to complacency in both the population and the government. While people became increasingly lax in sticking to preventive hygiene measures and reluctant to be tested and vaccinated (capacity for both was also low), the government shied away from imposing early restrictions and enforcing hygiene measures in public places. It was also likely occupied with the ongoing war and a stagnating peace process. As a result, it seems Afghanistan has moved into the pandemic’s third wave relatively unprepared.

The rising but – in comparison with many other countries – still low numbers of confirmed cases and fatalities will very likely continue to mask a more stark reality (read an earlier AAN analysis of official Covid-19 statistics in Afghanistan here). Despite (slightly) improved testing and increased hospital capacity, often still below international standards, measures remained inconsistent and came two months after the upswing in the number of cases started in late March – when it could no longer be ignored.

The third wave has turned out to be more severe than the two waves before. With cases drastically up, shortage of hospital beds, the lack of oxygen and few medical personnel trained to operate ventilators point to an acute crisis. 

Not all shortcomings in Afghanistan are homemade. Four decades of war have left the country without adequate infrastructure, economic strength and robust safety nets that allow other countries to impose a lockdown or other strict measures and stem the pandemic. But there are also doubts about the capacity of the responsible ministry and a presidential office intent on dominating decision-making, resulting in political interference into the work of ministries that should be in charge. Also, even a hint of corruption undermines efforts to stem the pandemics and not only the government’s ability to do so but also its credibility.

Like most other countries in the Global South with no production capacities of their own, Afghanistan suffers from the lack of vaccines, the main instrument to break the wave, as well as oxygen. In a time of decreasing attention accompanying the final withdrawal of foreign troops after 20 years, Afghanistan needs urgent international support. Otherwise, it might have to watch helplessly as even more people fall victim to the virus.

Edited by Roxanna Shapour

Our “Covid-19 in Afghanistan” dossier is out now, summarising our reporting on the coronavirus pandemic so far – find it here.

References

References
1 Sources: MoPH’s daily lab result reports and Tolonews’ daily reporting, also based on MoPH figures.
2 As in our earlier Covid-19 reporting, AAN uses Worldometer figures because it enables us to compare Afghanistan with other countries.
3 The 16 provinces mentioned by Majruh are: Kabul, Badakhshan, Balkh, Ghazni, Helmand, Kandahar, Kapisa, Kunduz, Laghman, Logar, Maidan Wardak, Nangrahar, Nimruz, Paktia, Panjshir, Parwan. It was not explained why the measures do not cover four of the nine provinces Majruh called particularly badly hit: Badghis, Baghlan, Faryab and Uruzgan.
4 The Medical Council of Afghanistan (Shura-ye Tebbi-ye Afghanistan) is an independent government office that reports to the Office for Administrative Affairs (Edara-ye Umur) of the president. Its website and structure can be found here.
5 According to media reports and Wolesi Jirga statements, there is controversy over the acceptance of test results and vaccination certificates from local laboratories at Kabul airport. According to Yosufzai, not even test results from Kabul’s Afghan-Japan hospital, a Covid reference facility, are not accepted. Malalai Eshaqzai, an MP from Kandahar, said on 24 May in the plenary of the Wolesi Jirga that staff at the airport had forced passengers with valid records to have another paid vaccination at the airport. She said that tests cost 50 USD at the VIP terminal and 100 USD at the terminal for regular passengers. There were also accusations of nepotism around the lab providing the vaccination at the airport (Afghan media reports here: and here).
6 The WHO uses a population figure of 40.4 million.
7 See this article on the Frontiers in Psychiatry website that generally reviews stigma related to infectious diseases.
8 The Office of the Ombudsperson (Edara-ye Bazras) was created in August 2019 by presidential decree as part of the office of the president. Its head reports directly to the president, ie it is not an independent entity.

Tags:

Ulema vaccination Covid-19 Coronacrisis Ministry of Public Health MoPH oxygen Wahid Majruh Shia Ulema Council Medical Council of Afghanistan WHO stigma hospital capacity COVAX ombudsperson

Authors:

Rohullah Sorush

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