How Afghanistan Was Forced to Use Herd Immunity to Fight COVID-19

Yousuf Khan Aryobe was a doctor at Child Health Hospital in the Afghan capital of Kabul. He received a woman who coughed in front of him and went away in late March 2020.  As she showed symptoms of COVID-19, Dr. Aryobe feared she might have had contracted the infectious virus.

“I did not like her cough,” Dr. Aryobe told his brother when he returned home in the night. Two days later, Aryobe fell ill and went to test his blood at a private laboratory in Kabul, as the testing for the coronavirus was limited. Aryobe was diagnosed with typhoid fever, and he wrote a prescription for himself for drugs to treat typhoid.

Dr. Aryobe’s Worsening Condition

The health condition of Aryobe did not improve and he visited a designated health facility for COVID-19 to test for the virus. The initial screening showed Aryobe had a normal temperature and healthcare workers denied him a test. But Aryobe showed his identity card proving he was a physician and insisted on a test.

The healthcare workers took his blood sample and said that the result would come back within 24 to 48 hours. They promised him that they would send an ambulance for Aryobe if he tested positive. Neither the test result came, nor the ambulance. After nine days of waiting, Aryobe’s health deteriorated and he went again to follow up.

The healthcare workers had issued the results in a paper sheet and had dropped it in front of the hospital. “If he had received his test result on time, he would have quarantined himself and would eat a lot of fruits to boost his immune system,” said Aryobe’s brother Bahtarian Paktiyawal Aryobe. “All the nine days, he [Dr. Aryobe] was thinking of being infected by typhoid fever.”

Mass Infection

During those days of waiting, Dr. Aryobe did not quarantine himself, and the virus infected his entire extended family members of 33. Three of them did not survive: Aryobe himself as well as one sister, and one brother died of the virus. The family was left on its own to battle with the virus, said Mr. Paktiawal.

Even as the virus hit Afghanistan slowly, the country’s past failures took their toll: a raging war, dysfunctional institutions, and a majority-uneducated population. For 18 years, the country enjoyed international money and international assistance to build functional institutions that could have save lives of Afghans like Aryobe from the virus.

“The government of Afghanistan is a weak government that crumbles with corruption. In the meantime, the war created additional troubles for the government,” said Mohammad Naser Timory, head of Advocacy at Integrity Watch Afghanistan. “But the healthcare system has problems that it should have addressed them before this virus. The corruption and incompetence should have been too addressed in the past.”

Afghanistan’s Institutional Weakness

Although the government attracted international aid, Afghanistan lacks national wide effective institutions to handle the pandemic that is increasingly becoming a catastrophe. The pandemic reveals the government’s inability to prioritize, manage the catastrophe, and coordinate an effective response. On the other hand, the Taliban’s refusal for a ceasefire also sucked resources.

“From day one, there was no effective preparation” to fight COVID-19, said Dr. Baz Mohammad Shirzad, former advisor to Afghan Public Healthy Ministry. “Each institution was given a goal [of fighting COVID-19] without a plan. Budgets were allocated for each province, but this budget was without a plan. Two or three governors spent the money effective, while others just spent them however they liked.”

Default Policy: Herd Immunity

The embattled Afghanistan unofficially adopted herd immunity policy, leaving people to get infected and develop immunity to the virus. The government imposed lockdown in several provinces and began testing, but lack of widespread testing, trust in the government, and remors and economic hardship drove people to defy the orders. The battled government was reluctant to force the lockdown.

As of May 26, Afghanistan recorded 11,831 positive cases, 220 deads, 1,128 recovered from the virus. The country–home to 35 million people–tested a total of 32,870 samples for the virus. 35.99 percent of the samples were positve in the country, while that rate is 12 percent in the world. The fatetly rate is 1.86 percent. The real figures could be higher than the offcials records, according to experts.

“When the coronavirus was announced a global emergency [on 31 January 2020], it meant that the virus was coming to every country [including Afghanistan],” said Dr. Shirzad. “The public health ministry had three months to take basic preparation like designating quarantine places, purchase of protective gears, hiring of additional healthcare workers” and to prepare for testing.

Afghan Politicians Still Fighting Over 2019 Election

Instead of massive preparation for the pandemic, Afghanistan’s political leadership was fighting over the results of the 2019 presidential election. As the country recorded its first positive case of the coronavirus in late February, President Ashraf Ghani and Abdullah Abdullah took the oath of presidency just a thin wall away from each other.

Ghani and Abdullah negotiated a power-sharing deal for months and finally signed a deal in May after three months of bitters. The coronavirus, however, was not negotiable and the virus spread slowly in every coroner of the country. The Afghan big cities turned into hotspots of the coronavirus after arrival of thousands of returnees from Iran, the epicenter of the virus in the Middle East.

The Advantage of Rural Living for Slowing Down COVID-19

With 75 percent of the Afghan population live in rural areas and 46 percent of them are younger than 15, the community transmission of the virus was slow. The villages are distant from each other, provinces are less connected and cities lack modern transportation systems that could help to spread the virus fast like in the developed world.

“In developed world, everything is interconnected, and the virus spread fast,” said Norullah Navayee, a researcher at National Centre of Public Research in Kabul. “Here in Afghanistan, the virus can spread only within a small community” there was little chance the virus spread fast, as social structure are not interconnected nationally, but only locally.

The spread of the virus was further slowed down by lockdown. The community transmission of the virus was recorded in late March and the Afghan government imposed lockdown in early April in different provinces of the country. But lack of widespread testing and isolating the patients of COVID-19 missed the opportunity of the slow spread of the virus.

One Lab for an Entire Nation

For the first months, there was only one laboratory for testing. The Public Health Ministry set up new testing centers for the coronavirus in different provinces of the country. The ministry opened up a testing center for Herat province, the initial hotspot, after opening up a testing center in Nangahar, a province with less COVID-19 patients than Herat. Elsewhere in Balkh province, one testing center was opened to serve the northern region of the country. A total of 10 testing centers were ultimately opened.

The new testing centers did not lead to a widespread testing. With the country relied on international aid packages that included testing kites, many Afghans were unable to test for the coronavirus. At most, each testing center was able only 100 to 200 samples in the early stages. At least twice, the testing center in Herat province stopped testing due to shortage of equipment.

“We needed to have 10,000 testing at least every day,” said Dr. Shirzad.  Even the limited testing centers were marred with irregularities and people had to wait even as long as two weeks to have results. In some province, that limited testing was not available at all.

In central Daikundi province, where thousands Afghans returned from Iran and were suspected of coronavirus, people had to wait for at least two weeks to have test results, said Ali Akbar Jamshidi who represents Daikundi at the Afghan parliament. When patients received the test results, they would often have recovered or died of the coronavirus, Jamshidi added.

In northern Faryab province, where as many as 23,000 Afghans had returned from Iran, there was not testing available in early April. Mohammad Naim Musamam, director of Faryab Health Department, was told that the testing center in Balkh province did not have testing kites and that should not take blood samples for testing.

With 25 suspected cases in Faryab hospital, “If they are positive and we release them then one person can infect an entire district and village. If we keep them, two positive cases can infect the 23 others,” said Musamam in early April.

Turned Down for Tests

In northern Kunduz province, healthcare workers of the provincial hospital wrote an open-letter to Ghani and complained over the process of testing. 40 to 50 patients have come for testing, but they are denied of testing, just because they do not a written order from a powerful official in the province, read the letter.

In Kabul, the Health Ministry randomly selected 500 people who did not show symptoms of the coronavirus. The Ministry tested them for the coronavirus. Out of them, 156 people tested positive for the virus. The random study suggested that a high percentage of Kabul population — six million people — were infected by the virus.

“We have increased the testing capacity from 200 to 2,000 every day,” said Wahidullah Majruh, deputy for Afghan Health Ministry. “But we may receive 10 to 20 thousands samples every day.  Do not call me. Our collageus 24 hours per day, but delay in release of test results are inviable.”

With lack of widespread testing, the mainly uneducated Afghans — burden by the economic pressure — were unable to see the virus in themselves and in their community. In 2017, 64 percent of the people over the age of 15 were unable to read and write. The uneducated people could not understand the pandemic, said experts.

Conspiracies Abound

The rumors spread faster than the virus. One rumor said that the virus was not real, but only an excuse for the Afghan government to attract international aid.  Hasht e Subh Daily, an independent national newspaper, conducted a poll in Herat, the initial epicenter of the virus in Afghanistan. The newspaper randomly questioned 100 people, including educated and government employees, about whether they have heard of the rumor.

94 percent of them said they had heard of the rumor. 20 percent of the surveyed people believed that many healthy people were quarantined in return of cash to fake the real positive cases of the coronavirus, so the government would receive additional international aid. 20 percent of them said that the government showed the positive cases of COVID-19 higher than actual cases.

“The public trust could help a lot at this time,” said Naser Timory of Integrity Watch Afghanistan. “Many countries faced challenges, but people trusted the political leadership and the institutions. We did not have such a trust. The people did not trust the government so the president or the minister would instruct them and the people would have followed [the public health advice],” Timory added.

When the novel coronavirus hit Kabul in late March, a rumor spread: A new-born baby told his parents that the cure for the virus was drinking two cups of black tea at the midnight. Friends were calling each other to spread the cure. Another rumor spread: COVID-19 does not infect true Muslims.

In Herat, Mullah Insari held Friday prays despite the government imposed lock down. Mr. Insari preached to his followers that the coronavirus was a means for the infield world to close down mosques. He said that true Muslims were immune to the coronavirus, while the positive cases were rising and the testing centers were facing shortage of equipment to show the positive cases.

The social and religious hardcore lifestyle of Afghans turned the coronavirus into a stigma. Even when a person was infected, he feared rejection by society in case of acknowledgment. The director of Kabul Health Department Khushal Nabizada said that the people did not report deaths suspected of the coronavirus.

Afghanistan’s Poor and Food Insecure Suffer

The rumors coupled with the economic pressure of lockdown in cities weighted heavy on the shoulders of people to stay at their homes. Even if they wanted to stay in their homes, many were unable to afford the lockdown in a bid to save themselves from the coronavirus. Fifty-four percent the population lives under the poverty line and 12.5 million Afghans were severely food insecure, according to World Food Program.

“People are at risk of losing their livelihoods,” said Elisabeth Koek, Protection Specialist of NRC in Afghanistan. “Our biggest concern is that government and other actors enforced measures to protect people might actually cause them further economic hardship. That is a primary concern across the country.”

Starvation Risk Rises

With lockdown, thousands of people lost their jobs, went down the line of poverty and more people become food insecure. Save the Children reported that seven million children were at risk of starvation. The UN included Afghanistan among countries in the world that were at risk of famine. Meanwhile, the price of food items, such wheat flour and cooking oil has risen up to 23%.

“If I stay at home, we got into fight with the family members who are asking food,” said a 45-year old father of six children, who was a day-laborer in Kabul. “If I stay at home, I die [of starvation], If I come out to work, I die of [the coronavirus.] Either way, there is dying.”

In Daikundi province of Afghanistan, the market faced shortage of food supply, given the lockdown of big cities and surge of prices, said Mr. Jamshidi from the province. The people were largely unable to buy food items. “This crisis [hunger] is more severe,” said MP Jamshidi.

Volunteers Rally Together to Help

In response, many volunteer groups organized online fundraising to collect money for distribution food packages among poor families. Landlords waive rents for households and shops, helping them to survive the pandemic. Tailors made facemasks for needy people and hospitals. The government did its own response.

The Afghan government negotiated with neighboring countries to keep borders open for the flow of goods to avoid a food crisis. “Keeping borders open and partially controlling the food price” is a good sign of the government works, said Timory of Integrity Watch Afghanistan.

The government once distributed wheat for poor people, and then set up a new response: distribution of breads for people to avoid mass starvation crisis. Through local representatives, the government issued cards for poor people who could receive breads free from their local bakery. But the measure had their critics and problems.

In Ghor province, dozens of people gathered in front of local government compound in early May to protest over the unfair distribution and shortage of distribution of breads for people. The protestors threw stones to the compound, and in return the police opened fire on them and killed five people and one local reporter.

“Can you feed poor people with bread?” asked Dr. Shirzad, former advisor to the health ministry. “There should be food aid packages and distribute them for people so they could survive the pandemic. For their own corruption, they ignored health of people, as people make crowds in front of bakers to receive their free breads” possibly further spreading the coronavirus.

Government Mulls Food Aid

One government official said that that they were mulling over making food packages for people that could help them to survive the lockdown and avoid starvation.  But as the two-month long initial lockdown dragged on marred with irregulations and with lack of widespread testing, people began breaking the lockdown and social distance measures.

In Balkh and in Nangarhar provinces, local officials opened their capitals and people rushed to markets looking for jobs and shopping to celebrate Eid al-Fitr. In Kabul shopping malls were packed with buyers and the city was crowded again. Streets had traffic jams.

Mayor of Kabul Mohammad Yougub Haidary officially scheduled reopening of private business and city within different timeline of a day. For example, barbershops are allowed to work from 2 P.M. to 8 P.M., while many barbershops were opened all days before this announcement. Haidary appealed to the public to avoid the usual Eid celebration.

The director of Kabul Health Department Khushal Nabizada said that a usual Eid celebration could lead to “mass suicide.” The usual Eid celebration involves mass gathering in Mosques as well as visiting each house of relatives. “We do not have the time to count the suspected deaths,” said Nabizada after people celebrate Eid in Kabul without considering public health advice.

The people generally broke the lockdown and health officials appealed to them to observe public health advisories such as wearing a facemask and social distance as well as washing hands. With the widespread poverty, Afghans were unable to afford to buy facemask and soups in a bid to protect themselves. Such failures could become a catastrophe, warned the Health Ministry.

Deputy of Afghan Health Minister Wahidullah Majruh said in a press conference that breaking the lockdown failed their strategy to buy more time for the healthcare system to handle the pandemic. “The situation was under control and the spread of the virus was delayed, but people broke the quarantine,” said Dr. Majruh in a personal memo on a Facebook post. “For the sake of your own health, please observe public health advice. Otherwise, the streets will be filled with dead bodies.”

But the Afghan security forces, including the police, were largely seen reluctant to enforce lockdown, as the Afghan forces are already battled across the country by the Taliban group. Refusal of the Taliban to announce a ceasefire hold back Afghan forces from enforcing lockdowns that could save lives from the virus.

COVID-19 Ceasefire a No-Go

UN Secretary General Antonio Gutierres called for global humanitarian ceasefire to combat COVID-19, including in Afghanistan. Secretary General of the Organization of Islamic Cooperation Yousef A. Al-Othaimeen appealed to Afghan leaders to unite for beating COVID-19. Despite the calls for a humanitarian ceasefire, the Taliban mostly have continued to wage war on Afghanistan.

Nonetheless, the Taliban announced a brief three day pause in attacking Afghan forces on the occasion of Eid-Fitre. In response, the Afghan government welcomed the move and announced to hold fire during the Eid celebration. But largely, the war dragged on and the pause of violence was a short-lived dream of peace, which has been delayed for years.

With the US-Taliban deal, under which the Taliban orally had promised 80 per cent reduction in violence, the Taliban focused on Afghan villages and remote areas. The next steps of the peace process moved slowly, as the Taliban demanded release of 5,000 prisoners and the government refused to release them at once but within a timetable.

‘The War is the Mother of All Miseries’

“The war is the mother of all miseries,” said Dr. Shirzad. “Due to the war, Afghanistan still record polio cases, people don’t have access to healthcare services. People were deprived of social welfare. The country still lack asphalt roads” so people could drive fast to access health facilities in the rural areas of the country.

Among many ruthless attacks, one attack took the war to a new level. On May 12, three militants attacked 100-bed hospital in Dasht-e-Barchi neighborhood of Kabul and opened fire on maternity ward of Doctors without Borders. The militants killed 24 people, including two newborn babies, six women with their unborn babies and several other new mothers.

“The attack deeply concerned the Health Ministry and white suit wearers [doctors] and the people,” said Wahidullah Majruh, a deputy for Afghan Health Minister in a press conference the day after the attack in Kabul. “Such incidents threaten health facilities, suck our resources, and kill trust and motivation.”

Following the attack, Mr. Ghani announced offensives against the Taliban, blaming the group for the attack. The United States, however, blamed the Islamic State for the attack. No group claimed responsibility for the attack. The violence further surged across the country and one clinic was bombed in Northern Kunduz province.

The Interior Ministry of Afghanistan claimed that the Taliban were in their spring offensive—the usual offensive attacks of the Taliban after winter rest. Against the expectation of many Afghans that the US-Taliban deal brings less causalities,  The United Nations Mission to Afghanistan documented that the civilian casualties of the war in April 2020 was higher than in  April 2019.

Violence and Instability Makes Population More Exposed to Coronavirus

The surge of violence leaves a mass population in rural areas vulnerable to the coronavirus. The raging war makes it harder for healthcare services provider to reach people who live in conflict areas and put Afghan forces and Taliban fighters at risk of infection by the virus, said experts. The war sucks the major resources, financially and human resources, though the government allocated its non-military resources to fight the virus.

“The government of Afghanistan mobilized all resources and partial army resources to fight the coronavirus,” said Timory of Integrity Watch of Afghanistan. “The government provided budget for each province and offered each governor special authority that can help small procurement in each province.”

When the coronavirus hit Afghanistan, the government allocated nearly eighty million USD—the national budget—for containing the virus. The government distributed different amount of money to each province for purchase new equipment, promoting public health advices and designating new hospitals as well as hiring staff for the hospitals.

While the government claimed that the distribution was made based on need and urgency in each province, a local newspaper found that distribution was not based on urgency. Farah and Nimruz provinces, two neighboring provinces to Iran from where many Afghans returned, received around 400,000 USD but Badghshan province in the north—far from Iran—received three times more than Nimruz.

“The problem is in the root of the government,” said MP Jamshidi from Daikundi province. “Distribution of resources is based on ethnicity and language in the country. If a province has a good lobbying team inside the government, it will receive aid. If a province does not have a lobbying team, the province will remain deprived of resources.”

Budget Debate

Distribution of the budget was marred with concerns of corruption. The endemic corruption within the government undermined the US efforts to build national institutions and weakened good governance in the country. Many feared that the corruption also undermines the efforts to contain the pandemic that threatens a full crisis.

Timory said that the National Procurement Agency published a report on big contracts related to the efforts for containing the virus. “A big issue is transparency,” said Timory, adding “they have not released details of each purchase, such as the how many items were purchased and how much the items cost.”

One item with its cost was leaked to the social media pages. A government letter showed that one thermos was purchased at $65.26 USD, while its price in public market is around $10 USD. In Daikundi province, MP Jamishidi said that the government allocated nearly $400,000 USD for fighting the virus, but there was no clue where and how the budget was spent.

The budget aimed to strengthen the fragile healthcare system. But in Kunduz, Herat and Takhar provinces, healthcare workers protested over unpaid salaries. Fifty staff of provincial designated hospital for the virus in Herat stopped working after three months of work without payment and demanded their salaries.

The missteps put the country’s healthcare system at the brink of disaster. According to the WHO, in 2018, only a total of 3,135 health facilities were functional for nearly 35 million Afghans and 20 percent of Afghans have no access to medical services at all. The country has seen increasing rates of preventable diseases such as diarrhea and respiratory infections.

“The Afghan healthcare system is not ready to manage this crisis and it was not even prepared to battle such a crisis,” said Timory, adding that “even before the corona crisis, the healthcare system was facing problems to provide health services for people.”

Afghan Doctors are Dying

Within Afghan hospitals, the virus is spreading, killing doctors. Lack of medical protocols on how doctors treat patients and lack of equipment for doctors potentially has led to infection and even dead of doctors and nurses in Kabul and elsewhere. The unprepared hospitals turned into hotspots. One doctor of a private hospital in Kabul died of the virus and the hospital was closed down.

According to official records, as much as 10 percent of healthcare workers in early May made the total of positive cases of the virus in the country. In Kunduz, 60 percent of healthcare workers of the provincial were infected by the coronavirus and continue working and living in the community, said a letter signed by a group of the healthcare workers in the province.

Many healthcare workers of Kabul hospitals show symptoms of the coronavirus and went to quarantine, Khushal Nabizada, head of Health Department in Kabul, wrote in a Facebook post. “As of now [mid May], there are not enough healthcare workers to treat patients.”

The fragile healthcare system provide only passive health services for COVID-19 patients, as major of positive cases of the virus were those who visited the hospital, said Shirzad, former advisor to Afghan Health Ministry. For 80 percent of visitors to state-hospitals, the healthcare workers test them and instruct them to quarantine themselves in homes. “The services are not provided properly,” said Shirzad.

How Long Will it Take Afghanistan to Contain COVID-19?

Shirzad explained that it will take 18 months to two years for Afghanistan to contain the virus. One way is that the world develop a vaccine and distribute to Afghans; another way is that 60 to 70 Afghans will be infected, leaving people to develop immunity to the virus and those who have existence health conditions may not survive the pandemic, Dr. Shirzad said.

The failures of the people and the institutions led to adapting a herd immunity policy that hit families such as the Aryobes, the doctor in Kabul who died of contracting the virus in early April. The entire extended family members of Aryobe had symptoms of the virus, but the testing remained unavailable. One of them was Bahtarian Paktiyawal Aryobe.

After Afghan-Japan Hospital, a designated facility for the virus, denied him testing, Paktiyawal recorded a video in front of the hospital and posted it on the social media pages, appealing to the government. The video went viral on social media pages, but still he was not quarantined in the hospital. Paktiyawal again recorded a video and posted it online.

The leadership of the health ministry came across the video and reached out to Paktiyawal. The family was quarantined for four days in a different designated area for COVID-19 patients. Paktiyawal was hardly breathing and his fever was extremely high by that point. He and his family eventually recovered, but they did not ever receive their test results.

“I came back from death,” said Paktiyawal. “if they spent the budget properly, our fellow citizens would not have so much trouble.”