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Early Responses to COVID-19 in Afghanistan Commentary EMHJ – Vol. 26 No. 12 – 2020 Early responses to COVID-19 in Afghanistan Shugufa Basij-Rasikh,1 Merette Khalil 2 and Najibullah Safi 1 1World Health Organization Country Office, Kabul, Afghanistan. 2World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt. (Correspondence to: Merette Khalil: [email protected]). Citation: Basij-Rasikh S; Khalil M; Safi N. Early responses to COVID-19 in Afghanistan. East Mediterr Health J. 2020;26(12):1442–1445. https://doi. org/10.26719/emhj.20.137 Received: 09/07/20; accepted: 29/10/20 Copyright © World Health Organization (WHO) 2020. Open Access. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Introduction crowds and upscale hand-hygiene were issued, and Min- istry of Interior Affairs (MoI) banned large gatherings, The World Health Organization (WHO) declared COV- sporting and entertainment events (2,12). Quarantine and ID-19 as a pandemic on 13 March 2020. It has spread to lockdown were implemented throughout the country more than 200 countries, with over 35 million cases and 1 (Figure 1) (2,13,14). Notably, the political changes in gov- million deaths, with no guaranteed treatment but recom- ernment and new minsters of health disrupted the na- mended preventive measures like hand hygiene and so- tional response to COVID-19 and resulted in policy mod- cial distancing (1). As a donor-dependent conflict-affected ifications, fragmentation and delays in implementation. country, Afghanistan faces challenges with health-care delivery and managing its double burden of diseases, giv- In March 2020, the MoPH developed the National en the limited health literacy and preventative measures, Emergency Response Plan for COVID-19, in collaboration shortages of skilled health workers, and fragile health with the World Health Organization (WHO) (13,15). The infrastructure (2,3). Afghanistan has a population of 32 government allocated 8 billion afghanis 1 (Afs) (0.5% of million; 75% live in the rural areas and 80% living below GDP) for emergency pandemic response, of which 1.9 the poverty line (4). Given Afghanistan’s close proximity billion afghanis (0.1% of GDP) for urgent health needs (6). to China, the Afghan Ministry of Public Health (MoPH) The government announced lockdown in three provinces began discussing preparedness measures for COVID-19 bordering the Islamic Republic of Iran due to surge in as early as December 2019 and predicted that 80% of the cases and all flights were suspended from Kabul (14). population could be infected with upward of 125 000 deaths in Kabul alone if preventative measures were not Role of media and communication followed (5–7). Collaboration with media and religious leaders was es- The first case of COVID-19 in Afghanistan was sential in assuaging panic in communities, combatting reported on 22 February 2020, when 150 000 nationals misinformation on the virus’ spread, and growing stig- returned from the Islamic Republic of Iran to Herat ma against the overburdened health system. MoPH and (8). More recently (5 October 2020), there were 39 422 Ministry of Communication and Technology Affairs confirmed cases, 32 879 recovered and 1466 deaths, and jointly developed a mobile application providing updates increasing (9,10). Kabul and Herat are the most affected on COVID-19 (9). The WHO emergency team launched parts of the country (9,11). Despite its fragile health a media campaign, conducted month-long roundtables, system and limited preparedness and surveillance and oriented 55 256 community and religious leaders in capacities, Afghanistan was among the first countries in all 34 provinces (13). Information Education and Commu- the Eastern Mediterranean Region and world to consider nication (IEC) materials were developed from the Islamic multisectoral and proactive preparedness measures in perspective (including a fatwa regarding COVID-19 pre- managing the COVID-19 outbreak. ventive measures), and distributed by Ministry of Reli- gious Affairs and WHO; further materials were prepared National interventions for those illiterate or have no access to internet (9,16,17). Measures to increase preparedness, detection and re- This was particularly important as the first wave of COV- sponse to COVID-19 were issued and implemented at a ID-19 coincided with numerous religious holidays where national scale starting January 2020, prior to the first case large gatherings and close physical contact would have being diagnosed in-country. One of the earliest measures been common and a potential spreader of the infection. included cross-border screenings at points of entry (Fig- Unfortunately, MoPH struggled to control communities’ ure 1); this was due to the surge of returnees from the Is- adherence to these preventive measures, especially giv- lamic Republic of Iran, which at the time was a hot-spot en the shortages of personal protection equipment (PPE) for COVID-19 cases. Presidential decrees to avoid large and the harsh economic conditions facing the country (5). 1 afghani = US$ 0.013 (29 October 2020) 1442 Commentary EMHJ – Vol. 26 No. 12 – 2020 Figure 1 Afghanistan's challenges and responses during the COVID-19 pandemic Afghanistan's Challenges and Responses amid COVID-19 No of Confirmed Cases Number of Confirmed deaths Number of Recovered Cases National Events Global Events 13000 12000 11000 10000 9000 8000 7000 6000 5000 4000 3000 2000 1000 0 All land Ministry of Returnees from Airport First borders Interior Affairs Pakistan announced Iran and screening Movement restriction confirmed with banned all large in Jalalabad, 16 doctors and Chaman and Torkham Pandemic nurses in Herat and Pakistan COVID-19 Pakistan gatherings Pakistan Nangarhar Province borders will open Screening of declared by were closed two further cases in Case was announced between 6 and 9 April points of entrees WHO reopened its the capital, Kabul Ministry of First case in border with Lock down of were announced for stranded Afghans at (borders) - First recovered Education launched China Afghanistan Kabul from 28 the request of the WHO confirmed that - COVID-19 three COVID-19 patient March for three an online website for Afghan Government novel Coronavirus as suspected cases were - Restricted most weeks school students international flights identified - The first possible in Dari and Pashto a cause of respiratory - Temporality closed its - President Ashraf Ghani, fatality of COVID19 was The World Bank approved The lockdown illness border with Iran told the public to avoid large also announced $100.4 million of aid to measures in Kabul public gatherings - Lockdown of the city help Afghanistan and EU Province were - International Aid-Beijing of Herat was announced would provide technical made stricter announced Aid to Afghanistan - All educational support and €117 million institutes closed 1443 Commentary EMHJ – Vol. 26 No. 12 – 2020 Health systems interventions There are total of 8996 medical doctors, 12 588 nurses and 26 696 midwives, resulting in a shortage In February 2020, the MoPH designated the Afghan Japan of skilled health workers nationally, and the issue of hospital in Kabul as an immediate COVID-19 treatment maldistribution since the majority are concentrated in facility (9). In Afghanistan, 1541 beds are designated for urban areas and some 60% work in public-health facilities COVID-19 patients, 700 beds in Herat, 200 beds in Kabul, (3). To respond to the COVID-19 pandemic, MoPH issued a and the remainder are spread around the country (9,11). call to recruit fresh graduates, volunteers, and registered In Kabul, Darulaman Palace and Kabul and Polytechnic medical professionals to work in designated hospitals. universities’ dormitories were converted into isolation In May 2020, 763 medical staff were trained on IPC and facilities. Isolation wards were identified for treatment case management (9,20). However, despite some financial of patient with COVID-19 in all provinces (9,11). By March incentives (hardship payments), it was difficult to retain 2020, there were 300 ICU beds available for quarantine many of these staff due to the challenging working throughout the country (11). conditions, high risk of infection, limited PPE, and Regarding service delivery, under the isolation ward inadequate training and experience in managing critical protocol, mild and moderate cases were to be quarantined cases (especially for new graduates). at home to allow severe cases to be monitored at the hospital (18). The role of private hospitals was neither Recommendations to improve the compulsory nor voluntary in COVID-19 response. Given COVID-19 response Afghanistan’s vertical and contracted-out health systems infrastructure, the provision of non-COVID-19 and The impact of COVID-19 on health, education and the essential health services was continued through NGOs, economy, especially in fragile contexts such as Afghani- utilizing additional triage and infection prevention and stan, is difficult to ignore. An evaluation of Afghanistan’s control (IPC) measures (19). experiences in combatting COVID-19 and the lessons learned from responses and interventions in the early Despite the increasing cases, Afghanistan had one months would benefit policy-makers at the national lev- of the lowest national testing capacities in the Region el as well as public health researchers and humanitarian for COVID-19; this challenge was exacerbated by the actors in similar settings. While Afghanistan has taken
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