The Fourth Wave of Covid-19 Hits Afghanistan: “According to Sharia keeping yourself healthy is a must”

Another wave of Covid-19 struck Afghanistan early in 2022 with doctors throughout the country reporting a rise in cases from January onwards. The devastation suffered by the Afghan health system since the suspension of most foreign aid following the Taleban takeover left it wholly unprepared to deal with the wave. While cases are now tailing off, AAN’s Rohullah Sorush and Thomas Ruttig (with input from Sayed Asad Sadat and Sayeda Rahimi) examine the impact of Taleban rule on Covid-19 reporting, assess the progress of vaccination campaigns and testing, and look at the many problems facing the Ministry of Public Health (MoPH) as a result of the suspension of aid.
Dr Salma leads a health education session to curb the spread of COVID-19 among women in Afghanistan. Photo: Angela Wells/IOM, 5 March 2021.

A very different MoPH under the Taleban
The fourth wave of Covid “is hitting Afghanistan hard,” the International Federation of the Red Cross and Red Crescent Societies (IFRC) warned in late February. Doctors across the country confirmed the rise in cases to AAN. In Kabul, the 100-bed Afghan-Japan Communicable Disease Hospital was receiving between 85 and 90 patients daily in mid-February. According to several doctors at the hospital, around 80 per cent of patients were testing positive for the virus.[1] While numbers being tested have been extremely low, almost half the samples taken in diagnostic centres are showing positive results, according to the World Health Organisation quoted here. This, the IFRC said, indicated “an alarming spread of the virus.” Doctors at the Afghan-Japan Hospital said they lacked the means to identify the virus’s variety, but were almost certain it was the Omicron variant (see media reporting here). This wave came after the country had been cut off from foreign aid which had been supporting the health sector leading to the closure of many facilities. Meanwhile, just ten per cent of the Afghan population is fully vaccinated.

In spite of the rise in Covid figures, the MoPH under the Taleban has been reluctant to share information with the media and public about the pandemic, and when they do, there is generally a significant discrepancy between their reports and data from other sources. Given that the health sector was the area in which the Taleban retained the former Republic-era minister for longest (keeping Dr Wahid Majruh in place until 21 September while replacing all the other ministers immediately), this inertia has come as a surprise. It was thought that by retaining qualified health staff, the Taleban had understood the gravity of the health crisis (AAN reporting here). Indeed, the US government’s Special Inspector General for Afghanistan’s Reconstruction (SIGAR), in its regular quarterly report released in January 2022, had said that after the takeover, the Taleban authorities had “generally been supportive of COVID-19 vaccination campaigns in the provinces” and “endorsed the implementation of mosque-to-mosque vaccination efforts” in cities such as Kabul, Mazar-e Sharif, Kandahar, Herat and Jalalabad. This was followed, according to SIGAR, by a national Covid-19 vaccination campaign launched by UNICEF and WHO to increase uptake and avoid approximately 1.9 million doses of available vaccines expiring on 16 October 2021. However, it is increasingly apparent that such efforts petered out. Certainly, when it comes to informing the public via the media, the Taleban now only share data via voice messages or video clips to a WhatsApp group for journalists once a week, if that.

The MoPH is led by acting minister Dr Qalandar Ebad,[2] appointed on 21 September 2021 (see AAN reporting here). He has appealed to people to protect themselves from the virus and to get themselves vaccinated: “According to Sharia, keeping yourself safe is a must. So please get Covid-19 vaccination to be safe from the virus,” he said in a televised broadcast on 29 January 2022 (see here). So far, however, other measures have not been forthcoming.[3]

Testing for Covid-19

Despite calls for people to ‘stay safe’, testing for the virus has drastically diminished since the Taleban takeover. Data as of 13 April 2022 indicates that of the almost milliontests carried out throughout the country since the start of the pandemic in the spring of 2020, only 185,690 (almost 20 per cent) of these had been conducted since the Taleban took power in August 2021.[4] This is at a rate of some 23,000 tests per month in the six months under the Taleban, compared to over 43,000 tests per month under the previous administration. The number of confirmed cases throughout the pandemic gives some indication of the severity of each Covid wave that has hit the country, with the third wave (in June 2021) seeing the highest number of recorded daily cases at 2,023 per day.[5] Since the Taleban takeover, the highest number of cases registered has been 992 per day (on 10 February 22). However, given the low number of samples now being analysed, it is likely thatthe realnumber could be much higher. This supposition is supported by WHO data, which indicates that almost half (47.85 per cent) of the samples collected have been positive.

During the first wave, there were 34 labs throughout the country able to process Covid-19 tests, AAN reported, with an overall capacity for testing 6,565 samples per day, although that level was never reached during the first two waves (the first wave in June 2020 and the second was in November 2020). It was only in spring 2021 during the third wave, that labs were examining more than 6,000 samples a day (AAN reporting here). Following the Taleban capture of power, the most samples examined in any one day has been 2,073. According to WHO, however, there are now 38 functioning Covid-19 labs across the country with a maximum capacity for analysing 10,250 samples per day. Although the number of labs analysing Covid-19 samples has increased, according to WHO, the number of daily cases reported has decreased. This indicates that fewer people are getting tested. Not a single case of Covid was reported throughout January or February 2022 in five provinces: Badakhshan, Jawzjan, Daikundi, Farah and Uruzgan. Other provinces have similarly reported very few cases in these two months.

Given the high positive rate when patients are tested, the low reporting of Covid indicates low levels of testing rather than low prevalence of the disease. In hindsight and according to official figures, the wave’s peak appears to have come in mid-February, when about 900 cases were being reported daily nationwide. By April, confirmed cases were noticeably lower: since 1 April, daily cases reported nationwide have ranged between 24 and 100. We spoke to hospital staff in three different provinces to get some idea of how the wave is tailing off.

From the Covid hospital in Lashkargah in Helmand province, Dr Massud told AAN they were still seeing between 10 to 80 patients every day. He thought numbers would be higher were it not for the opium harvesting season, which means many people are reluctant to leave their land. He said they were hospitalising at least three to four patients every day. On the day we spoke, 13 April, they had hospitalised 11 people, seven women and four men.

From Paktia and the 50-bed Covid hospital there, Dr Khaled said that, compared to the winter, Covid-19 cases had certainly decreased in the province. They were still seeing patients and currently had two in hospital with serious symptoms, but in general, they were advising people to stay home if they had mild symptoms because of their limited facilities – two labs, but a shortage of medicine.

In Kapisa, Abdul Mutaleb Hamed, who is in charge of the province’s Covid-19 hospital also said fewer patients with Covid-19 symptoms were seeking help. He estimated that seven in ten people in the province have been infected with Covid-19, likely the Omicron variant. His current concern is a lack of vaccines: there was still demand in the province, he said, but no vaccinations were available and he had asked MoPH about this.

Suspension of foreign aid means fewer hospitals open and a lack of equipment

The decrease in the number of people getting tested is linked to the breakdown of large parts of the health system since the Taleban took power, due to a halt in development aid. Among the clinics and hospitals that had to shut were around three-quarters of the country’s public Covid health facilities, although the number of Covid clinics closing is unclear, and accounts differ. In late December 2021, Pajhwok reported the MoPH as saying that, of the 38 Covid-19 clinics, 17 remained active and 21 were inactive “due to the financial crisis.” On 26 February, MoPH spokesman Jawed Hazhir confirmed this figure to AAN, saying there was one clinic per province in Kabul, Balkh, Ghazni, Helmand, Herat, Kandahar, Kapisa, Khost, Kunar, Nangrahar, Nuristan, Paktia, Panjshir, Parwan, Samangan, Wardak and Zabul. Those that had closed due to the financial crisis, he said, were in Badakhshan, Badghis, Baghlan, Bamyan, Daikundi, Farah, Faryab, Ghor, Jawzjan, Kunduz, Laghman, Logar, Nimruz, Paktika, Sar-e Pul and Uruzgan.

The IFRC has reported a much lower number, saying fewer than ten Covid-19 hospitals were functional and that they had been unable to keep up with demand. Al-Jazeera reported only five functional clinics in the country, saying that 33 others had been forced to close due to a lack of doctors, medicine and heating (see this Al-Jazeera report). WHO noted that out of the 11 that were active, nine were partially functional. Their January 2022 report confirmed the closure of Covid-19 hospitals in Logar, Bamyan, Daikundi, Badakhshan, Farah and two hospitals in Kabul, the Qasab 100-bed and Muhammad Ali Jinnah.

The foreign funding that does remain is a lifeline, but also only a drop in the water. The Pajhwok report said the main hospital in Kabul was funded by WHO, while those in Nangrahar, Herat, Helmand and Kandahar were funded by the International Organisation of Migration (IOM). Both eyewitness and media reports from various provinces have confirmed that very few hospitals are still operational.

Zalmai, a resident from Khost, told AAN on 1 March that the Covid-19 section in their provincial hospital (still open in late February, according to the Taleban) was no longer active and there was neither medicine nor oxygen. Similarly, in Nimruz, the Covid-19 hospital closed for a period, as staff had not been paid; however the NGO, Cooperation and Humanitarian Assistance (CHA), had picked up the costs at the 20-bed clinic for two months, enabling the clinic to reopen on 20 March (see Hasht-e Sobh reports here and here). It said that this was a result of the US government allowing certain emergency transactions into Afghanistan again after 25 February when the US treasury introduced new waivers to US sanctions. In Ghor, CHA funding has dried up and while the main hospital is still open, doctors have not been paid since before the Taleban took over, according to the head of the Covid-19 hospital there, Muhammad Sharif Qazizada. There is no more medicine, he said, and two of its four doctors had left because they had not been paid. CHA told AAN in March that UNDP had reissued their contract to fund the Covid-19 hospital in Ghor after the Taleban takeover, but that UNDP had only provided funds for a month. In Laghman, the head of primary healthcare, Dr Muhammad Asef Safi, told AAN on 9 March that after their 20-bed Covid-19 hospital was shut down on 15 January due to a lack of funding, the number of Covid-19 cases started rising in the eastern provinces:

Covid-19 patients come to the central hospital of Mehtarlam because we have a lab there, but after diagnosis, they are sent to [the regional centre] Jalalabad for treatment because the hospital here does not have medicine or equipment. Also, after the [Taleban] takeover, the number of patients coming to public hospitals has increased, but there’s also no medicine or equipment. Staff members at the central hospital in Mehtarlam have not had any salary for the past six months.

Daikundi’s Covid-19 hospital, formerly funded through the multi-donor Sehatmandi programme, has been closed since December 2021. The deputy director of the provincial public health department, Dr Sayed Eshaq Hussaini, told AAN on 10 March:

There was a hospital built by funding from Ayatollah Sayed Ali Sistani in Daikundi [Ayatollah Sistani is a leading Shia cleric in Iraq, with many followers in Afghanistan. The hospital was inaugurated on 23 Saur 1399 / 12 May 2020]. It’s named Amir ul-Mumenin Hospital. During the Covid-19 pandemic, it was allocated for [treating] Covid-19 and then, the [Afghan] NGO, Move Welfare Organisation (MOVE), started supporting it. Then, another hospital was built for Covid-19 patients in Daikundi. WHO provided a PCR machine for testing. However, now that hospital isn’t active. It’s been closed for four months. Staff have not received their salaries for four months either. Patients come to the central hospital in [Daikundi’s provincial centre] Nili. They have signs and symptoms of Covid-19, but the PCR testing and diagnosis [equipment] is not active.

In Badakhshan, the provincial director of public health, Dr Majdud ul-Hakim, told AAN on 8 March that the hospital in Faizabad had shut down:

Covid-19 cases have been on the rise since the weather got cold, but the hospital is not active anymore. It is because all services such as tracking Covid-19 cases and hospitalisation have stopped due to lack of funding. Patients refer to private doctors and get some medicine. There is a PCR lab in the provincial hospital, but very few people refer there. No one exactly knows the number of people infected with Covid-19 recently. Many people do not go to the public hospital because no service is provided to them.

In Bamyan, without donor support, the hospital would not be functioning. A doctor at Bamyan’s public hospital, Dr Na’im, told AAN on 5 March thatthe Agha Khan Foundation had been funding doctors and nurses to work with Covid patients. “The Covid-19 section has ventilators and oxygen,” he said, “but people have to buy medicine from pharmacies outside the hospital.”At the same time, said another doctor at the hospital, Azim Besharat, Bamyan’s capacity to take in Covid patients has been reduced. He told AAN in early March that there used to be 20 bedsallocated for Covid patients in Bamyan’s government hospital. This special ward has now been moved to a new wing, but only has ten beds. He said the Agha Khan Foundation had hired three doctors and three nurses. In Herat, MSF (Médecins Sans Frontières) is supporting the Shahid Razi Covid-19 hospital in Guzargah, in Herat city and it is running as normal. In Kabul, the Afghan-Japan Hospital alone remains open for Covid patients, although doctors there said in March they had not been paid in five months (see here).

On 11 April, health officials in Faryab told Salam Watandar News that the 40-bed Covid-19 hospital there had closed. They said they had to close it because their salaries haven’t been paid for the past nine months.

Various organisations – WHO, NGOs and foundations – have stepped in to fill the funding and support gap for some hospitals around the country. Without that, there would be no operational Covid-19 treatment centres in Afghanistan at all. Some hospitals are only able to remain open because local staff are continuing to work despite not being paid in months. Moreover, according to WHO, the Covid-19 hospitals that are still active are facing other difficulties, such as shortages of food, fuel and other supplies. A doctor at the Esteqlal public hospital in Kabul, which had offered treatment for Covid-19 patients during the first, second and third waves, told AAN that the situation with hospitals in the city was “very bad.” Many doctors, especially women, he said, had left the hospital and that Covid patients were not being treated there anymore. An MoPH staff member told AAN: “You go, you work, but there is no food and no heating in this cold weather. Staff are not getting their salaries regularly either.” Raising concerns about the influx of non-professional officials under the Taleban, he said, “not only hospitals, but also the ministry looks like a mosque.”

Vaccinations

Thanks to donations from various countries, the number of vaccinations went up in Afghanistan after the Taleban takeover, but overall, they remain low. On 1 January, India donated half a million doses of Covid-19 vaccines and promised to send another half a million (though the second batch has yet to arrive). In December 2021, China donated 800,000 doses of the Sinopharm vaccine, one of three million doses it said it would deliver to Afghanistan.

There seems to be a discrepancy between the number of people who have been fully vaccinated, according to Taleban and according to the IFRC. On 1 April, MoPH spokesman Hazhir in the video clip sent to journalists and also posted on his Facebook said that at least 8.5 million Afghans had already received the Covid vaccine and that the process was ongoing in 377 Covid-19 vaccination centres throughout the country (of which 16 are in Kabul). He said that since the Taleban came, China, Italy, Austria, India, France as well as the COVAX programme – a partnership between WHO, the Global Alliance for Vaccines and Immunization (GAVI), the Coalition for Epidemic Preparedness Innovations (CEPI) and UNICEF  – have donated 4.5 million doses of Covid-19 vaccines to MoPH. In addition, China, Asian Development Bank (ADB), India and COVAX have promised to donate 6.6 million more doses of Covid-19 vaccines by mid-2022.

Hazhir also said that before the takeover, 1,200 vaccination centres were open and active, but then due to lack of support, they were reduced. In a press release, however, the IFRC said that only ten per cent of the population (circa three million) was fully vaccinated (with either two doses of AstraZeneca or a single dose of Johnson & Johnson vaccine). WHO statistics also show a substantial decrease in the number of Afghans currently being vaccinated. In its January 2022 bulletin, the humanitarian health cluster reported that in December 2021, 420,372 individuals had been fully vaccinated while the figure was at 115,739 in January, almost a quarter of December’s figures.

Despite an announcement at the end of February of a public health campaign being launched to promote nationwide vaccinations and the MoPH’s claim on 1 April that it had 2.8 million doses of Johnson and Johnson vaccines, 600,000 doses of Sinopharm vaccines and 100,000 doses of AstraZeneca, there has been no campaign so far. Vaccinations are, however, ongoing in hospitals and vaccination centres.

Growing poverty, overburdened hospitals and limited awareness of Covid

The suspension of so much foreign aid has not only had a devastating impact on the country’s health system, but also on people’s livelihoods generally. Many can no longer afford private health treatment and must rely increasingly on government-run health centres and hospitals, which are both under-equipped and lack capacity. (Read AAN’s latest economic reports herehere and here ). The head of monitoring and evaluation at the Afghanistan Medical Council, Dr Khesraw Yusufzai, told AAN on 12 March:

After the fall of the former government, 90 per cent of the health facilities collapsed. Fortunately, the Sehatmandi project has resumed in all provinces. However, the national hospitals, as well as Covid-19 centres still have a lot of problems. Covid-19 cases, particularly of the Omicron variant, are on the rise, but there is no donor [analysing possible cases of] it. In addition, national [ie government-run] hospitals do not have any budget either. The government pays the salary for the staff, but you even cannot find a syringe at those hospitals. Patients have to buy everything from the drugstores.

Furthermore, many people simply cannot access Covid hospitals, even in the provinces where they exist, given that many live in remote areas and cannot afford transport to provincial centres, as a resident of Jaghatu district of Ghazni, Khatira Hedayat, explained:

A month ago, three members of my family got sick. They had symptoms of Covid-19, like fever, headache, coughing and a sore throat. There is only one clinic in our area, which doesn’t provide enough health services, so how can they take care of patients with critical conditions? We had to take my family members to Ghazni city, but there, also, the hospital doesn’t provide good services. We had to see private doctors and buy some medicine. Many people live in remote villages in districts of Ghazni and when they get sick, particularly if they are infected with Covid-19, financially, it’s difficult for them to go to the city for treatment.

Yet even without people pouring in from remote areas, hospitals are still overwhelmed. In Parwan, between 1,200 to 1,300 people are being referred daily to the only public hospital in the province, Hasht-e Sobh daily reported. According to the hospital’s director, Abdul Qasim Sangin, they only have the capacity to treat 300 to 400 patients per day. Paktia’s Covid-19 clinic is also buckling beneath the burden of so many daily referrals. Dr Khaled, who works there, told AAN on 1 March:

Because the Covid-19 hospital in [the neighbouring province of] Paktika is closed, patients come to Paktia for treatment. We don’t have enough capacity. We’ve asked the MoPH to send us Covid-19 diagnosing kits, but they’ve not sent them yet. We have two Covid-19 labs, but we’re faced with a shortage of kits. We don’t have enough supplies and medicine.

Given the difficult working conditions, patchy salary payments and many other issues (such as the ban on secondary education for girls), it is no surprise that the health system is losing professionals. Dr Yusufzai of the Afghanistan Medical Council pointed to this as a serious problem facing the Afghan health system since the Taleban takeover:

Our specialists and cadres have left the country. There are others leaving these days. If they cannot go to European countries, they can get visas and go to Pakistan and Iran. Every day I see hundreds of people at the gates of Pakistan and Iran embassies in Kabul. They get visas and leave the country.

Pervasive, widespread poverty has limited the public’s awareness of Covid-19 and its readiness to take precautions. Many Afghans have simply been preoccupied with very real daily difficulties, without the extra burden of having to wear a mask or keep their distance from others, as AAN reported in 2021 (see for example here and here). Women’s access to health has been particularly hampered by Taleban restrictions, although for many women, especially those living in rural areas, problems with access have just continued, before and after the fall of the Republic, because of poverty, cultural norms and previously, insecurity (see this 2021 special report).

The public health system under the Republic was already underfunded (see this AAN report). Many provinces only had basic health services. The system was not free as the law stipulated: many personnel charged fees for (scarce) medication, often sending patients to buy it from private pharmacies linked to or directly owned by them. The same was the case with clinics: doctors working in public hospitals that lacked resources used to refer patients to their own (better-equipped) private clinics.

Omicron does appear to be less serious than earlier variants with relatively lower mortality and hospitalisation rates, and while the vaccination rate in Afghanistan is low, the fact that many people have been infected previously will also give some protection.[6] Afghans reported to us that people generally had become less concerned about Covid, treating it as an ‘ordinary disease’ and were therefore taking fewer precautions to limit infections or get treatment. “Even if people have signs and symptoms, they just take medicine such as painkillers, but they don’t go to any clinic or hospital,” Abdullah said. He said people were more concerned about poverty. Muhammad Taqi from Mazar told AAN that people with symptoms did not bother going to hospital to be tested:

They only buy medicine from pharmacies. People don’t take Covid-19 seriously. They don’t maintain social distancing. They don’t wear masks either. They’re not afraid of being infected with Covid-19 and consider it an ordinary disease.

Similar sentiments came from residents of Kabul, Khost, Gardez and from Badakhshan, where Matiullah from Baharak district said:

I think a lot of people have already had Covid-19. Many people here have had a cough, a sore throat and fever, but they see private doctors and take some medicine. They don’t take Covid-19 seriously. They don’t wear masks. The Covid-19 hospital is not active anymore to test people if they have Covid-19 and provide them treatment.

The particular risk from the Omicron variant of ‘Long Covid’, when symptoms last longer than three months, is not yet clear, given its relatively recent emergence.

Conclusion

With Afghans struggling with a whole host of problems, given how the breakdown of the economy has exacerbated the already widespread poverty, it is not surprising that there has been less public attention to the still ongoing Covid pandemic. The lower risk to patients of the Omicron variant may also be playing a part in this. However, the Taleban administration’s response to the most recent wave has been unsystematic, at times even seemingly playing down its scope, with the slow provision of up-to-date, detailed information especially glaring. They are also lagging in reacting to a countrywide measles outbreak (more about this in a forthcoming AAN report).

The was a glimmer of hope in the qualified praise by UN special envoy for Afghanistan, Deborah Lyons, in her 2 March 2022 briefing to the Security Council in New York for “progress that we have been making with the de facto authorities on expanding the polio programme.” Cooperation on anti-Covid vaccination also indicates that the Taleban are capable of reacting to public health needs, but in other areas, there is still much that needs to be better.

The weak response to the fourth wave of Covid is also symptomatic of a much wider health crisis in Afghanistan, with women, in particular, facing particular problems since the Taleban cracked down on their ability to move freely including to health facilities. The suspension of foreign aid has had a devastating impact on the country’s already ailing health system, leaving fewer hospitals and clinics open. Those still running often lack the necessary medical supplies or equipment to deal with the pandemic or money to pay staff. With qualified medics fleeing the country, the outlook for the health sector is bleak. Despite efforts by NGOs and international agencies to provide stopgap help to a handful of hospitals around the country, Afghanistan’s healthcare needs are vast and immediate and will not end with the waning of this latest wave of Covid-19.

Edited by Emilie Jelinek and Kate Clark


[1] A doctor at the Bamyan hospital told AAN, “Every day around 20 people are tested. If we were to test everyone, 70 per cent would probably be positive on Covid-19.” He said all 23 patients who had tested positive since 5 February, including 15 women had had to be hospitalised. At a Covid-19 centre in Paktia, a doctor told AAN, “We had 20 patients today, ten of whom were hospitalized in our emergency ward. This means Covid-19 cases are on the rise and we are already experiencing the new wave.” In Mazar-e Sharif, resident Muhammad Taqi said that at the beginning of March, “around two weeks ago, many people got sick. Everyone I saw told me that all his family members were sick. They had sore throat and cold. It is not clear if they were infected with corona.”

[2] According to his official bio on the MoPH website, Dr Ebad reportedly holds degrees from medical faculties in Jalalabad and Islamabad.

[3] The ministry has not responded to AAN’s queries, either via phone or messenger.

[4] Data received by AAN via the MoPH’s Whatsapp group under the Islamic Republic just a few days before the Taleban takeover shows that a total of 738,599 samples had been tested since the start of the pandemic.

[5] Figures were higher in the initial phase of the virus ( see this AAN report), with around 400 per day; the figure was at 290 per day during the second wave at its highest (on 24 November 2020) and during the third wave 2,203cases per day (on 17 June 2021,as per AAN’s previous reports on Covid-19 here and here).

[6] See research from Imperial College London, published on 17 March 2022, here: “After adjusting for a number of factors, the risk of hospital admission for Omicron cases was found to be less than half (59% lower) compared to the risk for Delta cases. The risk of dying was 69% lower for those with Omicron compared to those with Delta infections.” Vaccination, the research found, lowered the risk greatly, as did having previously been infected: “Having had COVID-19 previously also offered some protection, likely due to the immunity from a past infection: the risk of hospital admission was 45% lower for unvaccinated cases who had had a known past infection, compared to unvaccinated cases for whom the infection was their first.”

 

The Fourth Wave of Covid-19 Hits Afghanistan: “According to Sharia keeping yourself healthy is a must”