Covid-19 in Afghanistan (1): No large outbreak yet in the country

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Afghanistan has so far been moderately affected by the coronavirus pandemic, with fewer than 100 people testing positive and four confirmed fatalities. There are strong indications that these cases may have been seeded by the outbreak in neighbouring Iran, via Afghans who returned from that country. AAN’s Thomas Ruttig has compiled an overview of what is known about the situation and the measures taken by authorities so far. He concludes that, given the country’s generally weak infrastructure, variable health coverage – particularly in rural areas – relatively late and patchy preventive measures and a partly reluctant public, fears are that the virus might spread more extensively.

The figures so far

With four new cases in Herat and one in the southwestern province of Nimruz, the number of coronavirus infections in Afghanistan confirmed by the Ministry of Public Health (MoPH) rose to 94 on 26 March 2020. On the same day, Afghanistan registered its second Covid-19 fatality, a 45-year-old woman in Herat; the first was a 40-year-old man in Chimtal district of Balkh province. Two more people were reported dead on 26 March, both in Herat, a 50-year-old woman and a 55-year-old man. 

In two other cases people diagnosed as infected with the virus were released from hospital as cured (one in Herat and one in Daykundi). 

With such low figures, Afghanistan so far seems much less affected than its more populous neighbours Iran (with over 27,000 infections and 2,000 deaths reported) and Pakistan (over 1,000 cases and 19 deaths).

According to data on a twitter feed used to spread official data and messages on the coronavirus in Afghanistan, 84 per cent of the people who tested positive for coronavirus were men and 16 per cent women (as of 23 March). 

The first Afghan case was reported on 24 February in Herat, the province where, at the time of writing, two-thirds of the cases have been registered. (We will report from there separately in the future.) According to one report dated 18 March, three returnees from Iran had reportedly died from a “mysterious cause” in a Taleban-controlled area, in Sherlas village, Pasaband district of Ghor province. The cause of death was possibly the coronavirus, but this has not been confirmed.

The BBC’s Persian service reported the first five Covid-19 cases among Afghan medical staff: four in Herat and one Kandahar on 25 March.

According to the MoPH, at least before 16 March, all people in Afghanistan who had been tested positive for coronavirus had returned from and caught the virus in Iran. After the breakout spread there, tens of thousands of Afghans returned to Afghanistan, fearing getting infected too. In the first week of March, the returnee figure stood at 19,000; in the second week of March it rose to 53,000. 90 per cent of the returnees came back voluntarily; the remainder had been deported by Iranian authorities. According to some media reports (eg, see here), some Iranian hospitals had refused to treat Afghan patients. 

On 26 March, the MoPH stated that 28 of the 80 known coronavirus cases at that point had no history of travel abroad. This seems to indicate that the chain of infection has started to become domestic. On the same day, authorities in Herat stated that one of the coronavirus fatalities in the city was a 38-year-old man who had “come” from Britain; it did not specify whether he was a tourist, returnee or deportee.

Afghanistan initially closed the border with Iran on 23 February but reopened it within 24 hours, forced by returnees stranded in the no-man’s-land between the two countries. An estimated 1.5–2 million Afghans are living in Iran, from long-term refugees to short-term labour migrants. In addition, large numbers of businesspeople, students and pilgrims continuously travel to the Shia holy sites of Mashhad and further on to Iraq.

According to the Afghan Minister for Refugees and Returnees, Sayed Hussain Alemi Balkhi, 16 Afghan refugees have died from the coronavirus so far in Iran. The first coronavirus fatality in Saudi Arabia was also reportedly an Afghan, a 51-year-old male resident.

According to Afghan government sources, the overall infection figure for the country includes four cases of personnel of the US/NATO-led Resolute Support (RS) Mission. Initially, on 15 March, RS denied any infections there, but on 25 March, an Italian news agency confirmed four cases among its country’s military contingent.

At least three embassy staff have fallen ill, the latest one reported on 25 March, but it has not officially been confirmed at which embassies and whether these are local or expat staff members. A 26 March Afghan media report said two were foreign diplomats, one an Afghan staff member. An earlier media report connected the first two cases to the US and Turkish embassies.

Health Minister Ferozuddin Feroz, referring to warnings by the World Health Organisation (WHO), repeatedly highlighted that the virus infection could spread and affect large parts of the population if guidelines offered by the MoPH and WHO were not implemented and heeded. His deputy Feda Muhammad Paikan said on 26 March that there was the possibility of a large number of coronavirus cases in Kabul that have not been recorded so far.

A recent article by medical experts in the British Medical Journal moreover warned of the weaknesses of the health system in South Asia, explicitly including Afghanistan. It pointed to the so-far patchy preventive measures by governments and the problems that will be posed by the limited screening and quarantining capacity. It said that

Given extremely limited diagnostic testing, the region [of South Asia, including Afghanistan] may not have sufficient information to gauge the true extent of the epidemic and is ill prepared for the potential crisis that lies ahead. Although all countries took individual actions, it took the collective political leadership of SAARC almost two months to put aside political differences and meet to discuss the dangers to the region posed by covid-19.…

The only effective intervention implemented is that all countries in the region have drastically reduced or stopped air travel and imposed quarantine protocols on people arriving by road or air from countries with covid-19 transmission. However, facilities for screening and quarantine remain limited and of questionable quality.

According to World Bank data, Afghanistan has an average of only three doctors per 10,000 inhabitants. In comparison, India has eight, Pakistan ten and Germany 42. A March 2020 report by the US Government’s Special Inspector General for Afghanistan Reconstruction (SIGAR) lists “inadequate staffing, poor working conditions, insecurity, unreliable data, and allegations of corruption within the Ministry of Public Health” among the obstacles that challenge Afghanistan’s health sector. The Global Health Security Index, that measures epidemic preparedness, ranks Afghanistan among the least-prepared countries of the world.

The WHO and others have been helping the country get ready for an outbreak of the coronavirus since January, according to this media report but, according to the organisation, “there’s a funding gap of at least 3.5 million” US dollars. 

Various regional countries and organisations have offered support. The United Arab Emirates sent 20,000 test kits in mid-March. China has also offered to send medical supplies and has given advice to the Afghan government. The South Asian regional organisation, SAARC, of which Afghanistan is a member, agreed on joint measures to fight the virus and set up a joint emergency fund to which also Afghanistan pledged to contribute.

Apart from a few limited early steps, the Afghan government has only recently started to impose wider-reaching measures to limit the social contacts of its citizens, and only in certain sectors and areas of the country. So far, these measures have been far less strict than what has been imposed in many other countries, such as, recently, India. 

Measures taken so far to try to stop the spread of the virus

Initial steps to contain the outbreak of the virus were limited, as they had been in many countries. After the outbreak in China’s province of Wuhan became known, the MoPH on 26 January, according to this media report, ordered the formation of teams to screen incoming travellers at airports and border crossings. The WHO at that time offered to help diagnose test samples abroad. President Ashraf Ghani asked the Ministry of Finance to allocate 25 million USD to fight the coronavirus outbreak, while on the same day, Health Minister Feroz, echoing colleagues in other countries, called the virus threat “not very serious.”

On 30 January, with no cases reported in Afghanistan thus far, a 30-bed isolation ward was opened in Kabul and MoPH personnel were sent to check incoming travellers from China and through the Torkham border crossing with Pakistan. (Travellers entering through Kabul airport told AAN they were checked for fever.) On 11 March, the deputy health minister Paikan, said 600 people who arrived from China had been tested.

In terms of ‘social distancing,’ on 5 March, health minister Feroz recommended that people should not participate in the forthcoming Nowruz celebrations, but the call still fell short of a ban and other measures were not announced. 

After a number of Covid-19 cases were registered in several provinces, the government closed all state-run and private schools and universities, including madrassas, on 14 March. The measure will at least be in force up to 18 April (see here and here). On 25 March, the Ministry of Education said it was working on an “alternative education plan” for the emergency, that would involve teaching students via the media, indicating that the school closure is likely to last for a while longer. On 14 March, the government also banned large sport events and weddings with more than 1,000 attendees, while the National Olympic Committee (NOC) and the General Directorate of Physical Training cancelled all sport events. (1) 

Most of the strictest measures, such as cancelling large public events and imposing day-time curfews, came from provincial authorities. The provincial administration of Samangan, for instance, ordered the closure of all government and private schools, as well as other learning centres, after the detection of the first two coronavirus cases in the province on 11 March, three days before the central government did so. The Samangan administration also postponed all exams. On 14 March, Balkh’s provincial governor cancelled the massive Nowruz celebrations that are traditionally held at the Rowza-ye Ali in Mazar-e Sharif and that bring together large crowds of people from all over Afghanistan. The government followed four days later, cancelling large Nowruz festivities elsewhere in the country, such as at the Karte-ye Sakhi shrine in Kabul. The Ministry of Interior closed its passport/tazkera office on 18 March and the National Statistics and Information Authority (NISA) stopped the separate distribution of e-tazkeras under its auspices. (It also stopped its online service.) 

On 22 March, Abdul Hakim Munib, Minister of Hajj and Religious Affairs, told a gathering that people with coronavirus symptoms should avoid attending mass prayers in mosques and should quarantine themselves, again falling short of announcing a complete ban on gatherings, a move similar to what was happening in many other countries. Herat’s authorities had already completely called off all Friday prayers at that point. On 23 March, Herati officials quoted president Ghani as saying that families of health workers who would die of the virus would be given the same compensation as martyrs.

On the same day, the Independent Civil Services and Administrative Reforms Commission (ICSARC) decided to reduce government office hours to five hours per day, in a two-shift mode (here and here). President Ashraf Ghani and his close advisors were shown wearing facemasks in some meetings (and not using them in others, for example when meeting US Secretary of State Mike Pompeo on 23 March, or only sloppily, see here). Both houses of parliament decided to reduce their plenary sessions to one per week, but to continue working in the committees.

Daykundi province imposed a day-time curfew on 22 March. The authorities of Baghlan’s provincial centre, Pul-e Khumri, on the Herat-Mazar-Kabul stretch of the national ring road, announced the closure of hotels and public baths on 24 March. The government followed suit by announcing day-time curfews for the capitals of Herat, Farah and Nimruz provinces, along the Iranian border, on 25 March. (According to one Afghan media report, Chinese experts had already recommended the closure of public places to the government in mid-March.) The authorities of Nangrahar took the same measure on that day, additionally announcing that all shops except those selling food and essential goods would remain closed. Kandahar and Kunar followed on 26 March, for their respective provincial capitals. On 26 March, AAN staff in Kabul picked up rumour that similar measures would be imposed in the capital, starting coming weekend, on Friday 27 March (see also here).

Photos on social media showed deserted streets and closed shops in Herat on 25 March. A video on the same day, however, purportedly showed passengers from Herat arriving in Kabul by plane, a scenario reminiscent of the virus’ spread from northern to southern Italy, the country currently with the highest ratio of deaths worldwide. The strict government measures in the western provinces of Afghanistan have reportedly been announced only for the next three days, but might be extended. 

On 24 March, Ghani issued a presidential decree covering the prison population. This included a de facto blanket amnesty for several groups of prisoners, including women, children, the elderly and the incurably ill. (2) Excluded are prisoners accused of murder, kidnapping, drugs offences, corruption, sexual assault, armed robbery and looting, as well as prisoners accused of crimes against internal and external security, which includes imprisoned Taleban. For the latter category, another decree is already in place (see AAN analysis here). The MoPH was also tasked to take all preventive and curative measures for those prisoners who would remain in jail.

In various provinces, such as Herat, Nangrahar, Kabul and Samangan, additional clinics are under construction or have already been established. The construction of a 100-bed hospital in Nangarhar was announced on 11 March and that of a mobile hospital at Torkham, including Covid-19  test kits and an isolation ward, on 14 March. In Samangan’s Aibak town, the building of the local Teacher Training Institute has been temporarily turned into a hospital with 50 beds, and construction of another 50-bed hospital was announced on 23 March. (In January, it had been reported that a hospital in Aibak which was scheduled to open in November 2018 had been further delayed to the coming Afghan year, starting in March 2020. It was not clear whether this is the ‘new’ hospital announced on 23 March.)

There have also been voluntary measures, often initiated by communities or professional associations. Religious scholars, for instance, passed a declaration on 22 March to reduce prayers in mosques, called on the government and the Taleban to create a joint commission to prevent the spread of the coronavirus, and called on Afghan traders to not increase food prices. The Money Changers Association announced a one-week shutdown of Kabul’s main money changing bazaar, Sarai-ye Shahzada, starting on 28 March. Civil society organisations distributed protective gear to police and street vendors. AAN saw shops and whole markets closed down by their owners in various parts of Kabul, despite there being no instruction to do so. Others were still open. On 25 March, religious scholars in Paktia province appealed to the local population to avoid gatherings and fully cooperate with government efforts to check the virus spread.

Parts of the public have shown considerable reluctance to comply with the authorities’ protective measures. Photos on social media showed a large Buzkashi match allegedly taking place in Baghlan around Nowruz, as well as masses of people flocking to Kabul’s popular weekend resort at Kargha Lake for the Afghan New Year on 20 March. On 24 March, Afghan media reported from Nangrahar province that some madrassas were still operating, while in Kabul, some wedding halls were still open around the same time. 

Moreover, those showing symptoms or even having tested positive have often displayed irresponsible behaviour. Kabul residents told AAN how they feared the bad hygienic conditions and a lack of medical equipment and food, even in key hospitals. This situation, coupled with the fear of being quarantined and suffering the related income losses and, as one Afghan author put it, the widespread “fatalism”, have apparently contributed to various incidents of patients breaking out of hospitals and even isolation wards (one report here). Others with possible symptoms are trying to avoid testing and possible detection, all the while exposing the people around them to the spreading disease. 

Border closures and refugee issues

The Afghan-Pakistani border crossing at Torkham that was closed and briefly reopened on 16 March, was closed again on the same day for “all kind of movements.” The closure is supposed to last for – at least – two weeks . Before that, Pakistan had deported six Afghan citizens with symptoms of Covid-19 through Torkham. According to residents in Kandahar, the second key border crossing, at Spin Boldak, is now also closed for travel but not for goods.

Uzbekistan closed its border with Afghanistan on 23 March for people travelling across. That far, it had allowed food stuff to pass and it was not immediately clear whether this was also stopped. According to Mir Habibullah Guzar, police chief for the Hairatan port in Balkh province, Afghans, who were currently in Uzbekistan will be allowed to return home, but no one will be allowed to enter Uzbekistan from Afghanistan. On 24 March, the Chamber of Commerce in Balkh province reported that Kazakhstan had stopped its flour exports to Afghanistan. 

Kabul’s airport was still open for some domestic and international flights on 26 March. However, UAE’s Emirates company has suspended flights, starting 26 March until end of June. Its subsidiary FlyDubai only said it has suspended its flights until 9 April (but has already cancelled flights on 25 and 26 March). There were no incoming flights from Delhi starting on 19 March, as India has suspended air links with Afghanistan. Turkish Airlines still had a flight from Istanbul on 25 March. Among Afghan companies, Ariana had an incoming flight from Ankara and KAM Air from Istanbul. The latter company also had incoming domestic flights from Mazar-e Sharif, Kandahar, Farah and Herat. (3)

The UNHCR reportedly suspended the assisted return of Afghan refugees from Pakistan on 18 March. Afghan deputy refugees minister, Dr Alema, has also urged European governments to suspend the deportation of rejected Afghan asylum seekers for the duration of the crisis.

What is happening in Taleban-controlled areas?

The Taleban’s first official reaction on their website to the threat posed by the coronavirus concerned the estimated 5,000–12,000 Taleban prisoners in Afghan government jails. In a statement dated 15 March, they urged “international health organisations” to look into their health situation, accused the Afghan government of not taking sufficient measures to ensure their wellbeing, and offered “all” organisations, including the WHO, “cooperation and coordination” for the implementation of anti-coronavirus measures in the areas controlled by them. On 24 March, the MoPH said the Taleban had given the “green light” for “health care teams” to test suspected coronavirus cases in the areas controlled by them. Provincial health programmes that also cover Taleban-controlled areas are carried out by non-governmental organisations. Afghan media reported the first anti-Corona “health team” from a Taleban-controlled area of Kunduz on 26 March.

In another statement published on 18 March, the Taleban called the virus “a decree of Allah … perhaps sent … because of the disobedience and sins of mankind.” They urged Afghans to “deal with it in accordance with the teachings of the Holy Prophet,” to increase their prayers “and reading of the Holy Quran, give alms and charity” but also that “the safety guidelines issued by health organizations, doctors and other health experts must be observed.” Furthermore, the Taleban have distributed messages in audio format through WhatsApp groups and other social media platforms to inform people about the dangers emanating from the spreading virus and to urge them to take precautionary steps. 

In another message issued a day later, the Taleban sent condolences to Iran for the many deaths and urged Afghans living there “to strictly follow the rules and guidelines issued by the said country to combat the spread of coronavirus.”

Some conclusions

Afghanistan’s known Covid-19 caseload so far is comparatively low, but it is unclear what the real figures are. The number of reported positive cases has jumped over the past few days – for example by 33 on 24 March, mostly in Herat – but it is not clear whether this is due to a real spread of new cases or to better reporting and testing. It is also not clear how large the contingent of unreported cases may be. The reported cases might represent only the tip of an iceberg. However, so far, media reports have given no indications of mass outbreaks or large numbers of unexplained illnesses and deaths in the country. 

The spread of the cases – starting from Herat, spreading first to neighbouring provinces in the west and then along the northern stretch of the national ring road to Samangan – seems to indicate that the virus was indeed seeded through returnees from Iran. It is not clear, however, whether Herat has remained the sole source of the spread, or whether returnees from China or elsewhere (possibly Europe) also brought in the virus. It is also not clear whether independent secondary sources are spreading in other parts of the country.

Like the countries in South Asia, according to experts in the field, Afghanistan  is not well prepared for an extended crisis. Its economy – already one of the weakest worldwide and far from self-sufficiency – will badly suffer. With 55 per cent of Afghans living under the poverty line, large parts of the population will have little resilience and coping mechanisms to survive longer term without paid labour. Additional returnees from Iran will increase the burden on Afghanistan’s economy which will not be able to absorb them.

In the middle of an on-going (perhaps somewhat slowed down) war, it will be difficult to implement the same strict social lockdown measures that have been implemented in many other countries. Widespread distrust in the authorities and in the quality of the health services will exacerbate the problem. Military bases and prisons where there is no chance of physical distancing might also enable the virus to spread, particularly if soldiers are allowed to travel home and prisoners are released without proper screening. 

Edited by Martine van Bijlert

(1) Other preparedness measures included the formation on 19 March of a Public Awareness Committee – with the ministers of health, information, hajj, interior, defence, refugees, women‘s affairs and education; the heads of national Radio and Television Afghanistan and the Independent Directorate for Local Governance – and the announcement on 20 March by President Ghani that further adjustments would be made to the national budget, if necessary.

(2) All women prisoners and all children living in jail, as well as all male prisoners above 60 years of age who have been sentenced to terms up to five years are to be released regardless of how much of their terms remain. Prisoners with incurable diseases should also be pardoned and released after a review by the prisons’ health commissions. Those with terms of over five years who have spent at least half of their term should have their terms cut by 75 per cent and are to be pardoned and released when this time has been covered.

(3) Sources: Information received by AAN from various airlines; carrier and airport websites.

Endnotes:

Revisions:

This article was last updated on 22 Jul 2020

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Taleban Kabul Herat Iran coronavirus Covid-19 pandemic

Authors:

Thomas Ruttig

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