Imagine you are an Afghan, living in Afghanistan. You are one of the poorest people on the planet. You have a house full of children, you earn just a few hundred pounds a year, and there is war on your doorstep. The government doesn’t seem to care whether you live or die. And, right now, the only thing you and your family have to look forward to is one of the year’s main religious festivals, Eid ul adha.
You’ve been putting aside the pennies all year so you can buy your kiddies new clothes, and you’re looking forward to some time off to spend with your extended family, eating, laughing, watching variety television. This year, the fun is especially precious as the Taliban are advancing across the land, and if they prevail, the fun will be over for the foreseeable future.
Now imagine you are a public health official in Afghanistan, dealing with a devastating third wave of Covid-19, desperate for vaccines to arrive because you believe you have the capacity to inoculate the entire population in a matter of weeks. You’ve done it before, with polio, measles, tuberculosis (though not for a census, but that’s another story). And the global bodies in charge of these things have promised you millions of doses.
Vaccines arrive, around a million, with many millions more promised over the coming weeks and months. Confident that more are on the way, you start administering first doses. But just as the cupboard is almost bare, when you are down to the last 100,000 doses, and you’re expecting more to arrive so you can maintain the momentum of the national rollout, you get a letter. “Oops, sorry, brother,” it effectively tells you, “because of the situation in India, your vaccine deliveries will be delayed.”
That’s what happened, according to Dastagir Nazari, who is not only the spokesman for Afghanistan’s Ministry of Public Health, he is also the director of the country’s national immunisation program. The letter came from Covax, a global coalition of public health organisations that has, as its core aim, equal access for all the people of the globe to Covid-19 vaccines.
“I always liked the sentence which we heard in Covax meetings – no one is safe until everyone is safe. This is something everyone needs to understand. If we vaccinate 100 per cent of our people in Afghanistan, it doesn’t mean that we are safe. We have to vaccinate 100 per cent of people on the entire globe. Only then will we be able to be safe,” Nazari said.
“I always say that the Covax facility failed for the equal distribution of the Covid-19 vaccine,” he said.
Nazari is a well-educated, erudite, even-tempered man. He sips tea from a mug painted with a beautiful red and blue traditional Persian design, and wears small, frameless glasses. His passion, anger and disappointment about the way his country has been treated by the vaccine coalition nevertheless rise to the surface as he tells the story of Afghanistan’s Covax let-down. And he admits that, with the Eid ul adha holiday just days away, the situation is now close to hopeless.
With the advent of Eid on 21 July, he says, how can Afghans be told to stay at home and stay alone? Afghan people, he says, “have been hit with many things, with fights, poverty, challenges, families with a minimum of six kids, earning less than $500 a year, and it’s their only opportunity to celebrate.
“From a human perspective, I cannot say the right thing to my people, telling them to stay at home. But from a doctor’s perspective, from the job I am holding as spokesman, as immunisation director for the Ministry of Public Heath in Afghanistan, I have to say those words. We at the ministry have to make some sort of intervention to control people from going out.”
Afghanistan is in the grip of a devastating third wave of the pandemic, though with all that is going on in the country right now, it hardly seems fair to expect ordinary people to pay too much heed to yet another blight that might make them ill or kill them. There is, after all, a war on.
The Taliban’s advance is fierce and fearsome. The country is bathed in panic. Yes, there are signs everywhere in the major cities telling people to wash their hands, keep their distance, wear masks. Shops and restaurants have ample hand sanitiser, and mobile telephone services deliver public awareness announcements before calls are connected. Elbow bumps sometimes replace the kisses and embraces of traditional greetings, and people will even say they’ve been double vaccinated before they move in.
Covid-19 is a public health catastrophe in Afghanistan, and few people I know have not lost a relative – or more than one. The hospitals are overwhelmed, the cemeteries are filling up, only now is oxygen being made available to health facilities. Several months ago, rare oxygen supplies were being intercepted on their way to clinics by warlords, powerful men with private armies who usually get what they want. A friend of mine did say it’s not as serious this time as the first wave was – “I saw people fall over in the street last year,” he said. “I’m not seeing that now.” A spike in infections and deaths is expected to follow the Eid holiday.
The official figures, announced daily by the Ministry of Public Health, are not considered accurate, rather than a reflection of the reach of the illness. Many Afghan people falling ill are not presenting at hospitals or clinics, which means many are dying at home. Bodies are usually returned to villages – Kabul, for instance, is home to around six million people, but very few of them are from Kabul. The more people who attend funerals in the old village, the better the send-off for the deceased. And so Covid-19 spreads wider and further.
Ahmad Abid Humayun is the executive director of Sanayee Development Organization, an Afghan NGO that works on peace, development and community health – and was involved in the vaccination rollouts earlier this year. Indeed, Sanayee administered my second dose of the AstraZeneca vaccine, in early June. Humayun asked that I invite as many of my friends, neighbours and colleagues as wanted to be vaccinated. Within a couple of weeks, Sanayee had ceased administering first jabs as supply had run out or expired.
Humayun is critical of the government’s approach to the vaccination campaign, questioning why vaccine doses were sent to far-flung and sparsely populated provinces, rather than concentrating first on Kabul, and then on other dense cities, such as Kandahar, Herat, Mazar-I-Sharif and Jalalabad. All the Ministry seems to do, he says, is call meetings, have meetings, meetings about meetings.
To hear Nazarin of the Ministry of Public Health tell it is to hear a tale of optimism that came crashing to earth with one disappointment after another. On discovering in April that Canada had a stockpile of AstraZeneca vaccines that were about to expire, he headed to the Canadian Embassy to say he would do anything to secure them rather than see them destroyed. He never heard back and Canada extended the expiry date.
To be sure, Afghanistan was unprepared for the high-velocity punch of the pandemic. Aid-dependent since the Allied invasion of 2001 – in retaliation for the 9-11 attacks on the United States – many hundreds of millions of dollars were spent by donors on developing a public health system. Pandemic preparation was not part of the planning. Primary health care and reduction of maternal and child mortality were the priorities.
When Covid-19 arrived in Afghanistan, there were only 133 intensive care unit beds for a population of around 36 to 38 million. PCR swabs had to be sent to The Netherlands for analysis. The pandemic became an excuse for building a health infrastructure, finding qualified scientists and doctors who had not, until then, been needed by the national health system, and expanding tertiary health services. Who knew, said one person in the sector, that we had PhDs in microbiology here in Afghanistan? But, even now, there are only 1,500 ICU beds, according to the Ministry. Oxygen, ventilators, medicines and now vaccines are all thin on the ground.
For Humayun and his good friend Ahmad Nabi Maqsoodi, the excuses of unpreparedness and inadequate planning just aren’t good enough. Why, they ask, did Afghanistan’s health authorities acquiesce with global health trends instead of insisting that donor funds were spent creating a comprehensive sector able to treat the ill, no matter what is wrong with them?
Maqsoodi, 31, spent two weeks, from 10-25 June, working around the clock to ensure his mother, Toorpakai, had enough oxygen to keep her alive. She contracted Covid-19 while visiting her ill brother. After he died – possibly of Covid-19 but no one knows for sure – she returned home to Kabul. Within days she needed hospitalisation, but four hospitals rejected her because they had no beds. She ended up in a military hospital built specially for Covid-19 patients, but which lacked the facilities to treat her.
“The hospitals were just like shelters, a roof and a bed and nothing more,” Maqsoodi says. Doctors had no idea how to treat his mother. “Three doctors gave three different versions of treatment. We have no idea if she received the proper treatment.” He had to pay ever-rising prices for medicines at pharmacies outside the hospital, as the government failed to prevent price gouging.
With other family members, Maqsoodi travelled from Kabul to neighbouring provinces in a relay to find oxygen to keep his mother alive. During this time, all the people living in his father’s house but one tested positive for Covid-19. The only one who did not was a brother who had been vaccinated. His mother died on June 25.
Afghans are susceptible to rumour like no place I’ve ever been. Many people believe that just contracting the illness will render them infertile. Some have been encouraged to believe that being devout will protect them. And now it’s getting around that, six months after being jabbed with the Johnson & Johnson vaccine, insanity will set in.
Maqsoodi, who works for the Ministry of Economy, is clearly traumatised by the experience of caring for his mother, and angry with the government for not providing adequate health care. It’s all very well, he says with bitterness, following the guidelines of donors while spending their millions. But the country’s health authorities should have ensured Afghanistan has a comprehensive health care system. “I love my country and I never wanted to leave here, but now, I just don’t know if I can stay.”
He wants to be vaccinated, he says. His brother is proof that vaccination is protection. But how, he asks. Where? “I did not have financial problems, I could purchase the oxygen and medicines my mother needed. But what about the people who cannot? Most people in Afghanistan cannot even get to a hospital.”
Now he fears what the Eid holiday will bring. It is an Afghan tradition that relatives and friends visit the home of a deceased person on the first Eid after their death. After trying to limit the well-wishers who wanted to visit after his mother died, Maqsoodi knows his family is going to have a busy holiday week. He shrugs. “What can we do?”
This is the question Nazarin also asks as he faces up to the reality of the past 18 months. And the reality yet to come.
By September 2020, Afghanistan was one of the early joiners of Covax, and by late December had developed its national vaccine deployment plan ready to receive vaccines when they became available the following month. Amongst many in the public health sector, hope was high that Afghanistan had caught up and was ready to roll out the life-saving vaccines.
At the end of January, 500,000 doses of the AstraZenica vaccine arrived from India. Soon after, another 468,000 does arrived from Covax. The Ministry’s vaccination drive began in earnest, with officials believing they could vaccinate almost a million people with their first jab, because more would be arriving shortly.
The armed forces and police, officially numbering more than 300,000, were among the first to be vaccinated, prioritised as essential to the survival of the state and as vulnerable because they live at close quarters on bases and so cannot socially distance. People over the age of 50, those with co-morbidities, and teachers were also near the top of the list.
“In the back of our minds we had a written letter from Covax that… no worries, you are going to receive three million doses of vaccine in the next three months, so just get the first shot administered, you will receive backup,” the MoPH’s Nazari said.
And then India happened. Vaccines slated for Afghanistan were diverted. First dose administration halted. Afghanistan’s health authorities began begging their friends in the international community for whatever they could get. Flights from India were not stopped, and thousands of Afghans flooded home to escape the unfolding calamity there – with apocryphal stories of people dying on the planes. Pakistani workers heading for their jobs in the Gulf began arriving in Kabul to avoid flight bans from Islamabad, bringing the disease with them. Negative PCR tests could be purchased in Kabul for $45.
The Afghan government has once again tried a lockdown, though such measures were seen by many during the first wave last year as an excuse to entertain at home. Schools and universities closed as students and teachers went online – and they closed again last month. During Ramadan, from mid-April to mid-May, the MoPH co-opted religious leaders to reassure the public that being vaccinated did not constitute a breaking of the traditional daylight fast.
Those initial 968,000 vaccines were administered in three weeks, Nazari said, sent to all provinces and quickly used, with wastage of 3.5 per cent, compared to 10 per cent in countries such as Pakistan, Bangladesh, Nepal, Nigeria. The Johns Hopkins University’s Coronavirus Resource Centre said that by 14 July Afghanistan had administered 962,093 doses, with 219,159 people fully vaccinated, or 0.58 per cent of the population.
Humayun, of Sanayee, says these figures have also been spun to put the government in a good light. He said allocations to NGOs administering vaccines, like his, were counted as having been administered. He believes the waste was much higher in Afghanistan than the Ministry would have us believe. “Often, a ten-dose vial would be used only for two vaccinations, the rest would be thrown away, but the ten doses were counted as having been administered,” he says. The counting methodology is wrong, the figures are wrong, the vaccination numbers are much lower than reported, he says.
The United States has allocated 3.3 million Johnson & Johnson doses to Afghanistan. The first tranche of 1.46 million arrived on 9 July, and the roll-out began the following morning; the rest are due by the end of this week. For a country at war, where hundreds of thousands of people are being forced from their homes by fighting, a one-jab vaccine would seem the perfect option.
A nationwide survey after the first wave found that ten million people had been infected with the coronavirus. Another survey, conducted by the Ministry, Johns Hopkins University and WHO, is underway to find how many Afghans have antigens.
And then there is Eid. A spike in infections and deaths after the holiday is only to be expected. I asked Nazarin what he would wish for if his fairy godmother suddenly appeared with a magic wand. “I would need a minimum of 21 million doses of AstraZeneca and I would require a campaign-based modality to vaccinate an entire nation in 15 days,” he said. “We have this capacity. We have proven that many times in the past many years,” he says, and tells me about a measles vaccination campaign that was completed in two rounds, in December 2018 and January 2019, when 14 million children aged under ten years old were inoculated, in the midst of the conflict, in just 15 days.
So Afghanistan is no stranger to vaccination campaigns. But the country has been under-served in many ways, not just public health, by the many donor countries and organisations that decided that things would be done their way. And by a government mired in corruption and which seems so remote from the Afghan people as to not care. Health facilities are still under-staffed and under-resourced. And still, after a year and half of pandemic, the population remains at risk.
“Three million vaccines we have received, one million have been administered. So with 21 million doses of vaccine, we would be able to vaccinate the entire country in 15 days,” says Nazarin. And with a short burst to release his suppressed anger about vaccine nationalism, hoarding and selfishness, he rushes off to another meeting.
Photographs by Paula Bronstein