Article: V. PAVLIK, J. FAJFROVÁ (CZECH REPUBLIC)
The Hygienic Conditions in Afghanistan
From the department of military hygiene, Faculty of Military Health Sciences University of Defence, Hradec Králové, Czech Republic
The article describes the hygienic and epidemiological situation in Afghanistan, mainly the current hygienic conditions, water supply and waste disposal. The most frequent infectious diseases in this Asian country are mentioned. At the same time it describes standard hygienic condition at the military camp of the Headquarters ISAF in Kabul.
The Islamic Republic of Afghanistan is situated in Southwest Asia. It has the longest border with Iran and Pakistan. As far as the geography is concerned, it is mostly a mountainous country, especially in its central part. The capital city of Kabul lies about 1800 m above sea level. There are large deserts and semi-desert in the north and south of the country. Afghanistan is extremely poor and its economy is disrupted by the war and diseases. The network of medical facilities is very sparse and the quality of medical and health care is low. Moreover, the majority of all the medical care is situated in the capital city of Kabul. This fact together with the above-mentioned low standard of local health care could be responsible especially for the increased incidence of infectious diseases in this country.
The author of this article has served as a Medical Operations Officer at the Headquarters ISAF in Kabul. It was one of the highest medical positions of the ISAF mission in Afghanistan at that time. His main duty was to manage and coordinate the Military Medical Service of the ISAF mission in the country. A military physician in the position of the Medical Operations Officer is directly responsible to the Chief Medical Officer of the ISAF troops in Afghanistan for coordinating all medical evacuations and subsequent treatment in the NATO medical treatment facilities. The integral part of his work is to coordinate and manage the hygienic and epidemiological situation in the country.
The current hygienic situation in the country
There is a very high risk of infectious diseases in Afghanistan, varying in relation to location, individual exposure, elevation above sea-level or the temperature of the environment. The dust, which is present everywhere, is typical for the whole territory of the country. It can be the transmitter of infection in many cases. Afghanistan is a country with one of the worst world statistics of morbidity and mortality. To give you an idea I would like to mention some of the recent data:
The mortality of women in labour is 1600/100.000, the mortality of infants (up to 12 months) is 165/1000 and child´s mortality (up to the age of five years) 257/1000. The life expectancy is only 43 years. Only in a few poorest countries in Africa the life expectancy is even lower. More than 70% of the population suffer from malnutrition. About the same percentage of the population is illiterate. Most of the households are permanently without electricity, running water and available health care. The availability of health care depends largely on the existence of transportation. The country has a poor transportation infrastructure. In addition, the travelling is restricted due to the great danger of attack by anti-government forces.
The problem of the transmission of infectious diseases is multiplied by the low quality and standard of hygienic facilities. In most cases toilets without a built-in “flush system” are used. On several occasions people in rural areas were found to defecate almost everywhere according to convenience. It is important to observe that particularly the rural population does not know or does not use toilet paper. Often, toilet paper is replaced by anything available. This is one of the main reasons why infectious diseases are easily transmitted in the population by feco-oral route. You should consider very carefully shaking hands during the contact with the local population. Local foodstuff and water sources, including the ice, are contaminated with pathogenic organisms against which especially foreigners without vaccination have no immunity. Local food, water or ice cubes for drinks cannot be recommended for consumption.
Underground wells and mountain rivers are used as the sources of drinking and cooking water. However, the water from these sources is definitely not good for drinking. It contains a considerable amount of nitrites and nitrates in most cases. A sewage system is only present in some parts of the capital city. In almost all other areas, septic tanks without solid bottom are used, often situated very close to drinking water sources. The only possible solution is to drink branded bottled water. However you should be aware of a quite well-known practice of filling the plastic bottles with water from contaminated wells and selling this water at the market. Due to the above-mentioned facts, it is possible to state that the consumption of foodstuff and water from own supply or from well checked sources is the only effective prevention of food-borne infectious diseases.5
Malaria and Leishmaniasis are the main infectious diseases in this country transmitted by insects, which are vectors of infection.
Malaria does not normally occur in regions more than 2000 m above sea level. In about 90% of the cases malaria is caused by Plasmodium vivax. But the resistant form caused by Plasmodium falciparum also occurs in Afghanistan. The risk period is from May to November. In 2003 more than 500 000 cases of malaria were reported among the civilian population and in 2006 more than 250 000 cases. Among the participants of the ISAF mission 90 cases of malaria were reported in 2007 and 31 cases in 2008.
Leishmaniasis is caused by Leishmania parasites which are transmitted through the bite of the sand fly which is very small and easily gets through larger meshes of mosquito nets. There are three main forms of this disease - cutaneous, mucocutaneous and visceral. Rodents and pets can be the source of this infection. The preparations with pentavalent antimony are used for the treatment of this disease. This disease can be prevented by exterminating the transmitters of infection in the surrounding of dwelling places, sleeping under the mosquito net and using insect repellents.
Parasitic diseases are very common among the Afghan population. It is estimated that about 90% of the population are infected by a parasitic disease. The prevalence of Ascaris lumbricoides and echinococcosis is the most frequent.
Respiratory infections such as diphtheria, tuberculosis, meningitis or influenza rank among other severe infectious diseases in Afghanistan. Zoonoses such as leptospirosis or anthrax also occur in this country. Afghanistan is the only country in Asia besides Pakistan and India where poliomyelitis occurs in an endemic form.
It is a national responsibility to vaccinate all the participants of the mission in a specified way before their departure to Afghanistan. The members of the Czech Army are vaccinated against poliomyelitis, typhus, hepatitis A and B and meningitis. In certain parts of Afghanistan an anti-malarial prophylaxis is compulsory. The Czech Army soldiers were administered anti-malarial drugs, for example, in Logar Province. The Czech Army soldiers in Kabul did not have to take these drugs. In contrast to this policy, all US soldiers have to take anti-malarial drugs in the whole territory of Afghanistan.
The hygienic conditions at the Headquarters ISAF in Kabul
Without exaggeration, it is possible to state that the ISAF military camps and diplomatic quarters are the only places in Afghanistan with a high standard of hygiene. The military camp of the Headquarters ISAF in Afghanistan is situated in the centre of the capital city near diplomatic quarters. Soldiers are accommodated in one-bed, two-bed, three-bed and four-bed containers. All the buildings of the military camp which serve as accommodation of soldiers consist of container systems, generally with two floors above each other. Common toilets and showers are situated in the hallways. Each container has its own air-conditioning and one or two internet connections.3
There are a few dozens of sanitary facilities in the camp which are also situated in containers. Altogether, these facilities contain 200 toilets, about the same number of showers and wash-basins. Urinals are with or without water flushing. The cleaning teams which consist of the locally hired personnel provide the cleaning of these facilities. Washing water is taken from the local wells. It is chlorinated and regularly checked. Deep wells (18-45 m) situated in the military camp are used as primary water source. From these wells the water is pumped into water reservoirs from where it is distributed through the plastic pipelines all over the camp. Water chlorination is provided daily by means of chlorine tablets. Chlorination level is tested twice a week.
Most of the waste comes from the kitchen, offices and a warehouse. Solid waste is removed daily based on the contract with a local company and taken outside the town to a dumping place. The containers for sorted waste placed at the military camp are dumped daily. The daily amount of waste is estimated to be a few tons. Sewage water is collected in a pipeline system and discharged into an underground concrete tank. Then it is pumped and taken to a specified place outside the town a few times a week based on the contract with a local company.
The American catering company provides the catering services to all American and allied troops in whole country. About 20% of the foodstuff and ready-to-eat food is transported by air from Dubai, where the company has a large food warehouse, to Kabul. This foodstuff normally contains items which can go bad easily, as for example cheese or dairy products. Everything else is being transported by sea to Karachi sea-port and from thereover land through Pakistan and half of Afghanistan to Kabul. This transportation is not without problems. Long delays and the lack of certain types of foodstuff are quite common. It is no exception that basic products are not available for weeks becausesome trucks are held up at the troubled border between Pakistan and Southwest Afghanistan.
Prior to entering any of the dining rooms, diners are to wash their hands by using running warm water and anti-bacterial soap, drying them using the disposable paper towels. A sufficient amount of disposable paper towels is provided. During my stay at the military camp no disease or an epidemic situation connected with food intake in the close catering system of the camp was reported. Rare alimentary diseases were always epidemiologically connected with the consumption of foodstuff outside the military camp, in the capital city itself. Thus it is possible to state that the standard of the hygiene is good at the military camp of the Headquarters ISAF. It complies with all the NATO hygienic standards according to the STANAG (Standardization Agreement).
Afghanistan is a poor, mountainous country with a low standard of medical support and hygiene. A large number of infectious diseases and a high degree of prevalence of these diseases among the local population are connected with these facts. The participants of the ISAF mission must be vaccinated in a specified way and must keep primary and preventive measures during their whole participation in the mission.6
Lieutenant Colonel MD, PhD Vladimír Pavlík, CZE Army Faculty of Military Health Sciences
University of Defence Hradec Králové,
Třebešská 1575, 50001, Czech Republic.
Specialization in General Medicine, Hygiene and Preventive Medicine, Internal Medicine. NATO language proficiency 3 in French and English. Supervisor and lecturer of preventive medicine, nutrition and food, combat rations, metabolism diseases, obesity in the Czech Army.
Source: Medical Corps International Forum 1/2013