Lancet
Headline: Stop TB partnership to focus on Afghanistan and Pakistan
Date: 26 October 2001
Khabir Ahmad
Efforts to control tuberculosis in Afghanistan have been seriously disrupted by the current population displacements, warned the Stop TB Partnership Forum in Washington, DC, USA, last week.
The coalition of more than 120 organisations including WHO and the World Bank, launched the Global Plan to Stop TB, which recommends expansion of the directly observed treatment strategy (DOTS); prevention of multidrug-resistant TB (MDR-TB); development of new drugs; and strategies to better treat people with TB and HIV. The US$9·3 billion plan will "pay special attention to the alarmingly high incidence of TB in Afghanistan and Pakistan", J W Lee, director of the WHO department to Stop TB told The Lancet.
Since Sept 11, and especially since the US attacks started on Oct 7, hundreds of thousands of Afghans, many of whom are infected with TB, have rushed to the border with Pakistan where they are living in cramped conditions. "TB among Afghans is already a big problem and the present situation is definitely going to worsen it. We can't provide them anti-TB medication in the present situation, although we want to", says Lee.
Even before the most recent population displacements, TB was responsible for 70-80 000 new infections and 16 000 deaths a year in Afghanistan. Most of the people killed or debilitated by the disease are in the economically most productive age group. "TB has been one of the major sources of poverty in the country and destroys families and communities", notes Chris Lovelace of the World Bank.
In 1997, Afghanistan adopted DOTS nationally. Presently there are only 30 health centres that provide TB treatment services. Most of the TB services are in the large cities, from which people are fleeing. The "present control efforts are addressing just a small fraction of the country's TB burden, and this conclusion is reinforced by the few statistics that we have from Afghanistan", according to WHO's Global TB Control Report 2001. Drug supplies to these centres remain "erratic", and health workers' knowledge of TB management is poor. And "poor and irregular pay makes for low motivation among staff which is especially damaging for a disease which requires a high level of supervision", says WHO. Thus the country has failed to achieve the global targets of detecting of 70% infectious cases and curing 85% of those detected. 70% of TB patients have no access to DOTS.
To expand DOTS in Afghanistan, WHO and its partners say they need $11·25 million during the next 5 years. But funds alone are unlikely to guarantee achievements of the targets set because success of the TB control programme will depend on the way in which overall health and food services are provided. According to the United Nations Development Programme (UNDP) about 70% of country's population is undernourished.
"In most aspects, Afghanistan is worse off than almost any country in the world", noted Sakiko Fukuda-Parr, spokesperson for UNDP.
Afghanistan's health system ranks 173 out of 191 countries, according to last year's World Health Report.
Last week's withdrawal of Médecins Sans Frontières (MSF) from Mazar-I-Sharif and Kandahar after its offices in the two cities were looted by armed men has further complicated an already precarious situation. The two cities, MSF says, remained "crucial bases for the provision of medical and nutritional aid to the Afghan population.
Afghans in six provinces have been cut off from vital assistance." "It would be a big blow to the country's health system including the TB control programme. WHO certainly values MSF's work. Large vulnerable populations would be without access to health care if MSF pulls out", a spokesperson for WHO Afghanistan warned.
Several aid agencies including Oxfam International, Islamic Relief, and Christian Aid, have been calling for the bombing of Afghanistan to be paused to allow food, medicines, and other relief to be delivered. The agencies said they cannot find truckers to take food in because they are afraid.
WHO, UNICEF, and other UN agencies say their ability to keep operating in Afghanistan is diminishing day by day as the situation deteriorates.
Reports that UN and aid offices being taken over, relief items seized or looted, and staff beaten by armed men are becoming more common. The number of local aid workers is decreasing since many of them have also fled.
Despite such gloom, Lovelace says he is hopeful that the partnership will reverse the TB crisis in Afghanistan as was done in other countries, such as Somalia and Sudan, that have endured complex emergencies.
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