Polio vaccinators approach a truck to vaccinate children at the Torkham border. Photo: WHO/S.RamoKabul 20 November 2016 - As the number of Afghan refugees returning from Pakistan increases, health services are struggling to meet demand. Over 600 000 Afghans have returned from Pakistan this year - in October alone, more than 170 000 Afghan refugees and undocumented returnees crossed the border to Afghanistan.
The large influx has led to health services being overstretched, especially for reproductive, maternal and newborn health services as well as for treatment of mental health issues and communicable and non-communicable diseases. Outbreaks of vaccine-preventable diseases such as polio, measles and pertussis as well as zoonotic diseases such as the Crimean-Congo haemorrhagic fever (CCHF) pose major threats.
Most Afghans are returning to a country they barely know. Many have lived in Pakistan for years, even decades. As winter is fast approaching and few returnees have existing coping mechanisms and networks in Afghanistan, many are facing an uncertain future in bleak conditions.
“I lived in Pakistan for the past 40 years and I have nothing in Afghanistan,” says 52-year-old Zarbasa, sitting with her eight children in a tent near the emergency health centre at the Torkham border in Nangarhar, eastern Afghanistan. “I have bad back pains but luckily my children are healthy. They just received vaccines and vitamins from health workers here. I am never returning to Pakistan but I worry about our life in Afghanistan.”
Vaccinating every child
In October alone, over 31 000 returnee children were given the oral polio vaccine (OPV) and over 12 000 received injectable inactivated polio vaccines (IPV) and measles vaccines with WHO support.
Polio teams vaccinate returnee children at the Torkham border in Nangarhar in November 2016. Photo: WHO/S.RamoMeasles remains a constant health risk in the country and Afghanistan remains one of the three polio-endemic countries together with Pakistan and Nigeria. This year there have been 12 confirmed polio cases from the eastern, southern and southeastern regions.
There is a risk that even more children may contract polio and become paralyzed if caregivers overlook getting their children vaccinated against the disease.
“We vaccinate hundreds of children every day by giving them two drops of the oral polio vaccine. We often climb into the trucks as they cross the border if the children don’t come down. This way we know we reach all children,” said Sardar, one of the vaccinators immunizing children at the Torkham border crossing. “I want to help our children. Our country needs to finish polio for good.”
In addition to stepping up vaccination activities in border areas to make sure all children are immunized, WHO has provided medical and non-medical equipment, supplies and medicines to health facilities in provinces receiving many returnees.
Overburdened health services
A rapid assessment carried out recently by the Afghanistan Health Cluster in 19 health facilities in six returnee-concentrated districts in Nangarhar found that many health facilities are struggling to cope with the increasing number of consultations. In October, returnees made up 10% of total outpatient and inpatient visits in 13 out of 19 districts in Nangarhar, and the Nangarhar Regional Hospital is particularly overburdened. Acute respiratory infections, pneumonia, diarrhoeal diseases, tuberculosis, malaria, hypertension and mental health issues were commonly reported, along with an increased demand for reproductive, maternal and newborn health services.
As health services are stretched thin, additional human resources and medicine supplies are required at health facilities in areas where many returnees and refugees settle.
Wali Mohammad holds his daughter Amina who is waiting to get a measles vaccination at an IOM transit centre near the Torkham border. Wali broke his arm while rushing to pack his family's possessions to his truck. Photo: WHO/S.Ramo“We get between 100 to 300 patients a day with different health problems such as early deliveries, children with respiratory infections and diarrhoea, tuberculosis and also many trauma cases and injuries as a result of people travelling back in crammed trucks,” says Dr Mustafa Kazim, director of the emergency health centre operated by AADA NGO at the Torkham border in Nangarhar. “There is a lack of supplies and medicines and we are also under-staffed. We desperately need a female doctor.”
The Health Cluster, coordinated by WHO, is working to improve overall health service delivery and enhance disease surveillance and vaccinations. “We are adding tuberculosis screening services to the border points and are working to add the number of vaccination teams and enhance reproductive and maternal health services while also stepping up public awareness campaigns focusing on common diseases,” said Health Cluster Coordinator Dr. Mohammad Dauod Altaf.
The Health Cluster needs an additional US$ 7 million to address growing health needs.
Returning to an uncertain future
The situation in Afghanistan remains volatile with an increasing number of conflict-induced casualties and displacements – over half a million Afghans have been internally displaced this year. As fighting continues to escalate in many parts of the country, many more are expected to flee their homes. This means that over a million Afghans are “on the move” at the end of this year.
Wali Mohammad has lived in Pakistan for 25 years and is now returning because the police were harassing and threatening his family, pushing them to leave.
“I broke my arm as I was rushing to pack all of our belongings to the truck,” he says, pointing to his white cast on his left arm while holding his 3-year-old-daughter Amina in the other at the IOM transit centre near the border. “My goal now is to find work and money to live,” Mohammad says, while vaccinators give Amina measles and polio vaccines.
Jamil Rahman stands in front of his truck carrying all of his family's possessions at the Torkham border. Photo: WHO/S.RamoJamil Rahman leans on his colorful truck at the Torkham border crossing as he watches as his children get vaccinated by polio teams.
“We have lived in Pakistan for 40 years – here we don’t have a house or anything else. I was a mathematics teacher in Pakistan but now I hope to find some work in the agricultural sector. I have two sons and my biggest hope is that they grow to be healthy and get to go to school,” he said.
From the Torkham border point, Jamil and his family will continue to an IOM transit centre 2 kilometres away where they will receive some cash, food items, hygiene kits, medical checks and vaccinations provided by WHO and other humanitarian partners.
As winter sets in, a growing number of returnees and displaced Afghans rely on external aid to survive. The sudden increase in returnees far surpasses planning figures for the 2016 Humanitarian Response Plan and has the potential to lead to a deepening humanitarian crisis in an already fragile environment.