Afghan Refugee and Humanitarian Parolee Health Profile

Afghanistan is an ethnically diverse country rich in history and culture. Afghanistan is a land- locked nation, and is bordered by Iran, Pakistan, China, and three former Soviet countries: Uzbekistan, Tajikistan, and Turkmenistan. Its unique location has historically invited foreign interference, ongoing internal conflicts between different tribal groups, and war.

In 1902, Afghanistan formed as an independent nation ruled by a monarch after Britain failed to annex the region. Between 1902-1960s, Afghanistan underwent a period of modernization and growth, which was largely concentrated in Kabul, leaving rural areas behind in terms of development. In rural areas, this lack of development, associated poverty, and ongoing class divisions led to ongoing internal conflicts between different tribal and ethnic groups (M Sayad-Shah, personal communication, October 10, 2021).

In 1953, Afghanistan allied with the Soviet Union for economic and military support. In 1973, a coup overturned the ruling monarchy. The Republic of Afghanistan was established, solidifying ties with the Soviet Union. The U.S., other western countries, and the Soviet Union, recognizing the strategic geopolitical location of Afghanistan, continued to attempt alignment with Afghanistan, by providing ongoing economic and military support.

A second coup in 1978, led by the Afghan Communist Party, resulted in Afghanistan’s rejection of overt Soviet influence and an embracement of policies based on Islamic principles and Afghan nationalism. However, Soviet ties remained. To curb the advancement of communism, the U.S. and other western countries supported religious freedom fighters, known as the Mujahadeen, who revolted against Soviet ties.

In the early 1980s, the Mujahadeen united and revolted against the Soviet-backed Afghan Army causing approximately 6.2 million Afghan refugees to flee to the neighboring countries of Pakistan and Iran in the subsequent decade.¹ In 1988, Osama bin Ladin and other Islamists formed al-Qaida to confront the Soviets and others who opposed Afghanistan as a nation governed by Islam. In 1989, peace accords were signed between the U.S., Pakistan, Afghanistan, and the Soviet Union, ending a decade of Soviet occupation. Following the Soviet Union’s withdrawal, Afghanistan was largely left in turmoil, with a political vacuum. Some Mujahadeen members were joined by other foreign fighters to form the Taliban.

In 1995, the newly formed Taliban rose to power by supporting traditional Islamic values and Sharia law. This led to approximately 1 million Afghans fleeing to refugee camps in Pakistan, and ethnic groups throughout the country continued to fight the Taliban for control of the country. After multiple al-Qaida attacks on American targets, U.S. and British forces launched airstrike attacks in Afghanistan that lead to the subsequent withdrawal of the Taliban in December 2001. However, ongoing internal conflict and unrest continued to contribute to many Afghans being internally displaced or forced to flee the country and required continuous presence of NATO peacekeeping troops. In 2013, the Afghan army took over operations from NATO forces, and in February 2020, the U.S. and Taliban signed an agreement for the complete U.S. withdrawal from Afghanistan by May 2021.

On July 5, 2021, the U.S. officially withdrew all military forces from Afghanistan, with the final contingent of troops rapidly departing from Kabul Airport on August 30, 2021. The Taliban quickly took over the country, leading to chaotic evacuations of Afghan families; this included many Afghans who had worked for the U.S. military, internally displaced people, and those seeking asylum. In the rapid evacuation, some family members were separated, including children, and many Afghans had to leave behind essential medications, glasses, and other health care necessities.

The United Nations High Commissioner for Refugees (UNHCR) reported that there were 2.6 million registered Afghan refugees and asylum seekers and an additional 3.5 million Afghans that were internally displaced at the end 2021.² The Afghan refugee crisis continues to be one the largest refugee crises in the world.

The historical background is based, in part, on PBS's A Historical Timeline of Afghanistan. August 30, 2021. Accessed 9/19/2021.

The Islamic Republic of Afghanistan is a landlocked country located at the crossroads of Central and South Asia and borders the following countries: China, Iran, Pakistan, Tajikistan, Turkmenistan, and Uzbekistan (Figure 1).³ The terrain is mountainous and contains the Hindu Kush and Pamir Mountain ranges. The land is rich in natural resources including natural gas, petroleum, copper, precious and semiprecious stones, zinc, iron ore, sulfur, chromite, talc, lead, salt, and barites.^3,4

Figure 1: Map of Afghanistan, provinces, and surrounding countries

Source: CartoGIS Services, College of Asia and the Pacific, The Australian National University. Afghanistan - Provinces. Accessed 1/10/2022.⁵

As of 2017, Afghanistan had a population of more than 30 million people, with 47.7% under the age of 15 years, 2.7% aged 65 years and older, and a median age of 17 years old. Birth registration and cause of death are neither nationally, nor systematically recorded. Therefore, birth and death statistics are unreliable (in 2013, birth registration covered only 37% of the population and cause of death was neither nationally nor systematically tracked).⁶

Over 25% of the population lived in urban areas. Gross national income per capita was $2,000. As of 2019, Afghanistan’s total population had reached over 38 million, with life expectancy at birth of 65 years. In the most recent 2018 Afghan Health Survey, of 19,684 households representing 34 provinces, mean household size was approximately 7 persons in both urban and rural areas; only 4% of households were headed by women.⁶

Islam is the official religion of Afghanistan with a total of 80% identifying as Sunni Muslims, 19% as Shi’a Muslims, and 1% practicing other religions (i.e., Hinduism, Bahaism, Sikhism, and Christianity).⁴ The majority of Shi’a practicing Muslims are Hazara and have historically been persecuted for their ethnicity and beliefs.^7,8

People from Afghanistan are referred to as Afghan; Afghani is the currency used in Afghanistan.⁹

Afghanistan’s government recognizes 14 ethnic groups: Pashtuns, Tajiks, Hazaras, Uzbeks, Balochis, Turkens, Nooristanis, Pamiris, Arabs, Gujars, Brahuis, Qizilbash, Aimaq and Pashai.¹⁰ The two largest ethnic groups are Pashtuns (approximately 42%) and Tajiks (approximately 27%).¹¹ Throughout Afghanistan’s history, there has been conflict among the different ethnic groups—particularly among the Pashtun and non-Pashtuns (i.e., Tajik, Uzbeks, and Hazaras).¹² The Hazaras, the third most predominant ethnic group in Afghanistan, has endured significant persecution due to ethnic and religious beliefs; the Hazaras belong to the Shi’a sect of Islam, whereas 80% of the Afghan population identify as Sunni Muslims. During the Taliban’s first rule in the 1990s, the Taliban systematically massacred Hazaras.¹³

While Dari (the Afghan dialect of Persian or Farsi) and Pashto (an Eastern Iranian language) are the official languages of Afghanistan, there are more than 30 languages spoken in the country.¹⁴ Most of the Afghan population is conversant in either Dari or Pashto, but not all are literate in either language. More than 40% of the population speaks Pashto while half speaks some dialect of Persian. Other languages include, but are not limited to, Western Daric, Balochi, Uzbek, Turkmen, Nuristani, Hazaragi, Pamiri, and Pashai. Due to this linguistic diversity, many Afghans are multilingual.¹⁵ Being multilingual in Afghanistan is manifested in different ways—for example, one’s mother tongue may be Uzbek, but they feel comfortable reading a newspaper in Dari.¹⁶

Prior to the fall of Afghanistan, the country’s education system included primary education (grades 1-6, ages 7-12) and secondary education (grades 7-12, ages 13-18). Additionally, the education system included higher education (≥18 years), vocational study (ages 13-20), teacher training (above grade 13), and religious education.^17,18 The Afghan government required nine years of schooling, in theory, but in practice, most children did not have access to formal education. Free schooling also was available through a bachelor’s degree for all Afghans.^18,19 However, due to ongoing war and conflict, the educational system in Afghanistan remains in disarray. The United Nations International Children’s Emergency Fund and the Ministry of Education of Afghanistan estimated that in 2016, there were over 4.5 million children out of school, of whom approximately 3.5 million had never attended school.²⁰ Additionally, there is a gender gap in educational access and attainment. It is significantly more difficult for girls to attend and continue in school.²⁰

In the most recent 2018 Afghan Health Survey, 70% of women had never attended school compared to less than 50% of men. Having a history of any school attendance was higher in urban areas (60%) compared to rural areas (36%), regardless of gender. History of school attendance was also higher among children, with 67% of children ages 10-14 years reporting history of school attendance. Computer access with internet is limited with only 7% and 0.4% of urban and rural household, respectively, having any access.⁶

In 2018, 43% of Afghans (55% of men and 29.8% of women) were considered literate.²¹ Much of this gap has been attributed to sociocultural beliefs (i.e., girls should engage in domestic activities), transportation barriers in rural areas, and lack of infrastructure outside of cities.²² Ongoing sociopolitical and humanitarian crises continue to negatively affect Afghanistan’s educational system.

Family is an integral part of Afghan culture. Afghan households are often large and multigenerational, with the focus being on the collective family rather than on individuals. Family honor is very important.²³ Problems are often dealt with privately and not shared with outsiders to avoid bringing shame to the family.

Afghan families have a patriarchal and hierarchal structure. Afghan males are often seen as the “protectors” of family honor.²⁴ Men usually support the family’s financial needs, while women and girls are usually in charge of domestic duties. Respect for elders is another key component of Afghan culture. Elders will be consulted before a major decision is made in the family. Young children are expected to always show respect and deference to their elders.²²

Afghan adolescent females and women are generally expected to maintain a significant degree of culturally-enforced beliefs around modesty and behavior to protect the family’s honor; this includes wearing modest clothing and abstaining from dating, spending time with the opposite sex, sexual intercourse before marriage, and going out after dark.²³

Arranged marriages are a common practice in Afghanistan. Once married, adolescent and adult females will often move into their husbands’ households.²³ Divorce is rare and stigmatized in Afghanistan, and accurate divorce rate information is not available.²³

Although national statistics on the rate of consanguineous marriages is not available, a 2012 cross-sectional study of 7,140 couples conducted in eight Afghan provinces showed that the prevalence of consanguineous marriages between cousins was 46.2%.²⁵ This high rate of consanguineous marriages may occur as an effort to maintain family ties, thus sustaining long-standing cultural, financial, and societal allegiances. However, this also places families at greater risk of genetic disorders (refer to "Congenital and genetic disorders" section below).²⁶

For information on religions, refer to the “Religious beliefs” section above.

Afghan patients or their families might be more likely than the general U.S. population to:

• Prefer a provider and other health care team members to be of the same gender, including interpreters, particularly if sensitive questions are asked (i.e., reproductive health, menstruation).⁹
• Request Halal meals, foods permissible by Islamic law, during hospital stays.
• Abstain from eating pork and pork-related products, and drinking alcohol.⁸⁹
• Fast during the months of Ramadan, which includes not eating or drinking from sunrise to sunset; people who are pregnant or chronically ill (e.g., diabetic patients) are exempted from this. Medication regimes may need to adjusted during this time.⁹⁰
• Consult with other family members regarding medical decisions.
• Dress more modestly (i.e., wear hijabs, niqabs, or burqas).

Clinicians should:

• Explain the health care system in the U.S. (e.g., 911 emergency response for medical and non-medical emergencies, urgent care, primary care clinics, nurse advice and interpreter service phone lines, preventive medicine visits, how to obtain prescribed medications).
• Ask about use of home remedies, including herbal remedies, given that some may contain lead or other harmful substances and there may be drug-drug interactions.⁹
• Assure that there is a certified medical interpreter present unless all family members are fluent in English.
• Not assume that all Afghan refugees have low levels of education. There are many professionals, including surgeons, teachers, engineers, interpreters among the refugees, SIVs, and other Afghan evacuees.
• Ask and learn about lives and careers left behind. Afghans will proudly share information about their prior careers.
• Understand that some Afghan refugees will be unable to read and write in Dari or Pashto and may not know numbers.
• Review the concept of confidentiality with all family members since it will be a new concept for many Afghans in the context of health care.⁹
• Consider leaving the examination room door open when it is not feasible to have gender-matched medical providers, unless addressing confidential and/or sensitive topics.
• Review the concept of preventative medicine and the need for follow-ups (i.e., well child checks, preventative visits).⁹
• Know that eye contact between members of the opposite sex is usually avoided to show respect and modesty.⁹
• Review U.S. laws around child corporal punishment, domestic, and sexual violence. Discuss with the victim of violence that their immigration status will not be affected when they are seeking help and reporting abuse.
• Realize that marrying first or second cousins in Afghanistan is considered culturally acceptable, is common, and that counseling around genetic risks for future pregnancies is essential in these cases as is considering genetic disorders higher in differential diagnoses for children with developmental delays or other relevant concerns.²⁶
• Be aware of the use of gelatin derived from pork products in vaccines and some medications; however, these products were deemed permissible by Islamic scholars in a seminar sponsored by the Islamic Organization of Medical Sciences in Kuwait and the WHO.⁹¹ The Islamic Organization for Medical Sciences has issued this statement: Judicially Prohibited and Impure Substances in Foodstuff and Drugs (PDF).
• There is scant data around COVID-19 vaccine hesitation. Be aware that the COVID-19 vaccine has been deemed permissible under Islamic law by the Assembly of Muslim Jurists of America.⁹²

Hepatitis A, spread by fecal-oral route and associated with poor sanitation, hygiene, and lack of potable drinking water, is prevalent in Afghanistan.³¹

Though data is limited, Afghanistan is considered to be a country with intermediate prevalence (2-7%) of chronic hepatitis B infection, and a low prevalence of chronic hepatitis C.³² In a study evaluating blood bank samples collected in Afghanistan from 1996-2005 (n=125,832), hepatitis C was identified in 0.06%, and hepatitis B in 2% of samples.³³ In a 2006 evaluation of Kabul blood banks, HIV was reported in 0.07%, hepatitis B in 4%, VDRL in 1%, and hepatitis C in 2%.³⁴ Further, a recent analysis reported that up to 62% of SIV Afghan adults and 26% of SIV Afghan children were susceptible to hepatitis B virus infection and need to be vaccinated [30].

In a 2006 cross-sectional study of pregnant females (n=4,452, age 14-48 years, 67% with no formal education, age of marriage 10-37 years) admitted for intrapartum care to three Kabul hospitals, 1.5% of females were Hepatitis B surface antigen (HBsAg) positive, and 0.3% tested positive for hepatitis C virus antibody (anti-HCV).³⁵

Lack of reliable screening for horizontally or vertically transmitted infections in the Afghanistan blood supply is of concern. Most recent data available, from a 2010-2011 cross-sectional evaluation of 40 high volume blood donor sites, showed that only 52.4% of observed blood donor screenings for HIV, hepatitis B, C, and syphilis occurred appropriately.³⁶

Afghanistan is considered a low prevalence country for HIV with approximately 0.1% of the population aged 15-49 infected.³⁷ However, neighboring Pakistan and Iran have higher prevalence rates and it is unknown if HIV prevalence has increased among Afghan refugees who have resided in or regularly cross borders into these countries.^38,39

Refer to Table 1 for more specific data on prevalence of HIV, hepatitis B, C, and syphilis in SIV adults and children arriving in the U.S.³⁰ However, many recent arrivals from Afghanistan are humanitarian parolees⁴⁰ and did not work for the U.S. military or other western non-governmental organizations; they may be from more rural areas and with less access to formal education. As such, prevalence of horizontally or vertically acquired infections in evacuees may be under or over-estimated if applying data from this study of a more uniform SIV population.

Afghanistan continues to be endemic for cutaneous leishmaniasis, particularly in Herat, Kabul city, Badakhshan, Kandahar, and with lower prevalence in Kunduz and Balkh provinces.⁴⁷ Annual incidence is estimated to range from approximately 100,000-200,000 cases.⁴⁸ One study of Afghan patients (n=64) diagnosed with cutaneous leishmaniasis noted that among cases, 64% were males, 67% were <20 years, and lesion sizes ranged from 0.5 to 10 cm. Most study participants had lesions present on the head (41%), hand (36%), or foot (8%), and 15% had more than one site involved; 88% presented with dry lesions—96% caused by L. tropica and two cases caused by L. major.⁴⁹ Although rare, visceral leishmaniasis does occur and requires urgent treatment and most commonly presents with weight loss, fever, and hepatosplenomegaly.⁴²

More information on diagnosis and management of leishmaniasis:

• CDC Division of Parasitic Diseases: Leishmaniasis
• UMN Afghan Evacuees Health Resources: Leishmaniasis FAQs for Health Care Providers
• MDH Center of Excellence in Newcomer Health: Afghan Humanitarian Arrivals

Malaria

In 2021, WHO reported that Afghanistan had the third highest malaria disease burden globally, and that over 76% Afghans live in at-risk areas for malaria.⁵⁰ Transmission of malaria in Afghanistan occurs from April through December below 2,000-2,500 meters elevation.⁴² Types of malaria in Afghanistan are Plasmodium vivax (95% of cases reported) that can relapse if not treated, and Plasmodium falciparum (5% of reported cases) that causes higher morbidity and mortality, particularly in infants and pregnant females.⁴² A 2015 Afghanistan Demographic and Health Survey showed that only 3% of household had enough insecticide-treated bed nets to cover all household members, with children under 5 years and pregnant females having the least access to appropriate netting.^42,51 There have been confirmed cases of non-falciparum malaria (P. vivax) among Afghan evacuees, and health care providers should be vigilant for signs and symptoms of malaria in newcomers. Fever without known cause in Afghan newcomers should be evaluated with a blood smear and rapid diagnostic test when blood smear results are pending, if needed.⁴² Rigors, myalgia, and headache may also be noted. Children may also present with nausea, vomiting, and diarrhea.

For further information on signs and symptoms of malaria and testing refer to UMN Afghan Evacuees Health Resources: Malaria FAQs for Health Care Providers and the webinar on MDH Center of Excellence in Newcomer Health: Afghan Humanitarian Arrivals. Additionally, refer to Table 1 for malaria diagnoses among SIV arrivals.

Soil-transmitted Helminth Infections

Few data are available evaluating prevalence of soil-transmitted parasitic infections in Afghan newcomers. Refer to Table 1 for data on SIV arrivals who resettled to the U.S. between 2014-2018.

Scabies

WHO reports that up 10% of children in resource-poor areas of the world are affected by scabies.⁵² There are no specific epidemiological data on scabies prevalence in Afghanistan or among Afghan refugees. However, cases have been reported among Afghan evacuees. For additional information, please refer to UMN Afghan Evacuees Health Resources: Scabies FAQs for Health Care Providers.

Tuberculosis (TB) disease remains a major challenge for Afghanistan as ongoing conflict disrupts TB care. In 2019, Afghanistan had a TB case rate of 189 per 100,000 population (compared to a case rate of 2.2 per 100,000 in the U.S.), with 1.2 per 100,000 having co-morbid HIV, and 6.4 per 100,000 with rifampicin or multi-drug resistant TB (i.e., isoniazid and rifampicin) and a TB mortality (HIV-negative) of 26 per 100,000. Of 72,000 TB cases diagnosed in 2019, 74% were pulmonary TB. Additionally, 22% were in children aged 0-14 years, 46% in females of reproductive age, and 32% in men (defined as 15 years and older).^27-29 Only 59% had a known HIV status at the time of diagnosis .²⁹

Refer to Table 1 for more specific data on prevalence of tuberculosis in SIV adults and children arriving in the U.S.³⁰

Due to baseline low vaccination rates, less vaccines provided as part of the standard vaccine schedule (refer to "Immunizations" section below), lack of access to routine immunizations (especially in rural areas), and inadequate sanitation in some parts of the country, there is an increased risk for infectious disease outbreaks in Afghanistan. Below is additional information on specific vaccine preventable diseases that are endemic or prevalent in Afghanistan.

Measles

Measles is endemic in Afghanistan.⁴¹ From January-April of 2021, 741 suspected measles cases and 22 deaths were reported in 20 out of 34 Afghan provinces. Children aged 1-5 years made up 64% of total cases.⁴² The World Health Organization (WHO) and UNICEF reviewed national immunization coverage and in 2020 found that approximately 66% of infants had received their first measles vaccine.⁴³ Coverage rate data were not reported for a second dose of a measles-containing vaccine in children or adults.

Polio

Polio is still endemic in Afghanistan, and paralytic polio still occurs.^44,45 Over a 12-month period ending on August 27, 2021, Afghanistan reported 11 wild-type poliovirus infections and 261 vaccine-derived poliovirus cases.⁴⁶ A small percentage of polio cases present with severe symptoms including paresthesia, meningitis, and paralysis. One in four people infected with polio may present with sore throat, fever, fatigue, nausea, headache, and stomach pain. Providers should be vigilant for these symptoms in Afghan evacuees and assure that all children receive a full series of inactivated polio vaccination. For additional information, please refer to UMN Afghan Evacuees Health Resources: Polio FAQs for Health Care Providers.

Varicella

Varicella vaccination is not available in Afghanistan. If an age-appropriate Afghan arrival does not have documentation of varicella vaccination, they should be vaccinated (unless contraindicated) or have serological testing to confirm immunity from infection. For additional information, please refer to UMN Afghan Evacuees Health Resources: Varicella FAQs for Health Care Providers.

There is a high burden of non-communicable diseases (NCDs) among Afghan newcomers. According to Afghanistan’s Noncommunicable Diseases & Injuries Poverty Commission 2019 Report, NCDs and injuries were estimated to cause 45.4% and 21.2% of mortality for females and males, respectively.⁵³ Strikingly, 56.6% and 85.6% of NCDs and injury, respectively, occurred in those under the age of 40 years (Figure 2). 58% of NCDs included hemoglobinopathies (e.g., sickle cell disease, beta thalassemia), chronic kidney disease, congenital heart anomalies, musculoskeletal disorders, depressive disorders, drug use disorders, and injuries due to war (Figure 3).⁵³

Figure 2: Afghanistan and High-income country under age 40 disability-adjusted life years due to non-communicable diseases, 2017

Source: National NCDI Poverty Commissions and Groups. The Afghanistan Noncommunicable Diseases & Injuries (NCDI) Poverty Commission Report, June 2019.⁵³

Figure 3: Afghanistan and High-income country crude disability-adjusted life years by select non-communicable diseases, 2017

Source: National NCDI Poverty Commissions and Groups. The Afghanistan Noncommunicable Diseases & Injuries (NCDI) Poverty Commission Report, June 2019.⁵³

Anemia is a significant issue in Afghanistan, particularly in females of reproductive age and children. Anemia may be due to iron deficiency and/or hemoglobinopathies, including beta thalassemia trait.

A 2014 WHO report looked at anemia prevalence in Afghan refugee infants, children (n=1403, ages 6-59 months, 50% male) and non-pregnant females of reproductive age (n=2346, ages 15-49 years) living in Pakistan found that among infants and children, 55.5% had anemia (defined as hemoglobin [Hb] <11.0 g/dL). Furthermore, of those within anemia (n=845), 19.5% had mild anemia (Hb 11-11.9 g/dL), 15.7% had moderate (Hg 8-10.9 g/dL), and 1.2% had severe anemia (Hg <8 g/dL).⁶⁰ Of note, this study did not specifically evaluate prevalence of iron deficiency anemia.

In the first-ever study evaluating asthma prevalence in Afghanistan, a school-based survey performed in multiple schools located in Kabul from 2010-2011 for a random sample of 1,500 school children aged 6-7 years (50% male) and 1,500 adolescents aged 13-14 years (50% male) and found a prevalence of physician-diagnosed asthma of 12.5% and 17.3%, respectively.⁵⁷ Additionally, a 2013 study noted an increased prevalence of asthma in U.S. soldiers in Afghanistan. This increased prevalence of asthma may be associated with lack of incinerators and burning of waste, including aerosolization of plastic particulates.⁵⁸ Such pollution may also play a role in the overall prevalence of asthma in Afghanistan.

Country-wide prevalence of oncologic disease burden is difficult to ascertain.⁵³ Most cancers are presumed to be undiagnosed and untreated, given lack of mammograms, cervical and colon cancer screening protocols and access to screening. Additionally, there is a lack of access to standard oncologic drugs (oncologic drugs were not included in Afghanistan’s National Essential Medicines List). In the 2019 Afghan NCD Report, 8.9% of disability-adjusted life year (DALY) burden was due to cancers, including leukemia, breast, and stomach cancer.⁵³ In a 2021 Global Cancer Observatory report, the most common cancer in females was breast cancer, followed by stomach, esophagus, and cervical cancer, and in males, stomach cancer.⁵⁹

Consanguineous marriages are common in Afghanistan and likely affect the overall prevalence of genetic disorders.²⁵ In a retrospective evaluation of patient records of children (ages 1 month-<12 years) presenting to a pediatric emergency room in a major pediatric hospital in Kabul from 2002-2003 (N-12,000), approximately 8% had diagnoses that included cerebral palsy, seizures, stroke, hydrocephalus, neural tube defects, neurodegenerative disorders, and muscular dystrophies and approximately 14% had congenital heart diseases and arrhythmias. Of 5850 neonates, 8% presented with birth defects including anorectal malformation, neural tube defects, trachea-esophageal fistula, cleft lip/palate, biliary atresia, and omphalocele.⁶⁴

Among 303,812 total deaths recorded in Afghanistan from 1990-2016, congenital birth defects were the second leading cause of death nationwide in children less than 5 years of age. In fact, congenital birth defects accounted for 4% of deaths among females and males of all ages in 2016.⁶⁵

A study looking at birth outcomes from a large urban hospital in Kabul reported an incidence of spina bifida and anencephaly of 60 per 10,000 births.⁵⁴

Iodine deficiency is widespread in Afghanistan, as iodized salt is not widely available or used. This deficiency disproportionately affects the health of children and pregnant females.⁵⁴ Iodine deficiency is associated with developmental delay as well as pregnancy complications, including increased stillbirths and neonatal mortality. In a 2009 study of 794 school aged children (ages 7-12 years,), 71.9% had iodine deficiency, determined by low urinary iodine excretion. Additionally, higher rates of iodine deficiency were noted in children and non-pregnant females of reproductive age living in rural areas outside of Kabul;^54,55 50.9% of children had levels of urinary iodine <50 µg/L. Among non-pregnant females of reproductive age (n=1,063), the median urinary excretion level was 42 µg/L, well below normal levels (normal range, 100-199 µg/L).^55,56

Lead exposure and elevated blood lead levels are of concern for Afghan newcomers, particularly infants, children, and females of reproductive age (specifically those who are pregnant, breast-feeding, or trying to become pregnant). In a study of 312 Afghan females of reproductive age (ages 14-45 years) in a Denver refugee screening clinic, 5% were found to have a blood lead reference value (BLRV) above normal (defined as lead >5 µg/dl).⁶¹* In blood lead level samples in refugee infants and children (n=1406, ages 6 months-16 years) screened in Washington State , 50% of children from Afghanistan (N=124) had elevated blood lead levels (using the BLRV of ≥5 µg/dL).⁶²*

In a 2014-2016 cross-sectional study of domestic medical exam screening data that included Afghan SIV infants and children (N=1825, ages 6 months-16 years), 58.7% of children had BLLs of 5-19 µg/dL*, 19.7% had levels of 20-44 µg/dL, 2% had levels of 20-44 µg/dL, and 0.3% had levels of ≥45 µg/dL (refer to Table 1).⁶³

*Note: These studies were conducted before CDC lowered the BLRV to >3 µg/dl.

With minimal access to mental health treatment in Afghanistan, chronic exposure to war, displacement, gender-based discrimination, and the unprecedented, rapid evacuation of hundreds of thousands of Afghans to other countries after the Taliban-led overthrow of the government, Afghans have significant mental health care needs.⁶⁹

One study of Afghan university students that took place during and after the Taliban-led overthrow of the government (August-November 2021, N=214, 73.7% women) showed self-reported symptoms of post-traumatic stress disorder (PTSD) in 70%, symptoms of clinical depression in 69.7%, and suicidal ideation in 38.6%.⁷⁰ Studies of Afghan refugees prior to the Taliban take-over have demonstrated high rates of trauma exposure, PTSD, anxiety, and depression.^71-73

In an urban study in Nangarhar Province published in 2015, one participant from each household was randomly selected (n=1,200, 25-65 years old, 40% males) and found that 28.4% of men and 29.8% of women had hypertension, 11.4% and 13.4% had elevated blood sugar, and 57.4% and 66.8% were overweight or obese, respectively.⁶⁶ In a U.S. cross-sectional study of overseas medical records of adult SIV arrivals to the U.S. from 2009-2017 (n=12,354, 54.7% male, 95.6% ages 18-44 years), 1.6% had hypertension.³⁰

Hypertension and other cardiovascular diseases have been associated with increased air pollution. In Afghanistan, indoor and outdoor burning of biomass fuels for cooking and heat are of particular concern.⁶⁷

In the same U.S. study of overseas medical records of adult SIV holders, diabetes mellitus was shown to have a low overall prevalence of 0.4%. However, 49% (6,053) were considered overweight (BMI 25-29.99) or obese (BMI >30), 47% (5,806) had a normal range BMI (18.5-24.99), and 4% (494) were considered underweight (BMI<18.5).³⁰

Improved access to health care, work, and residence in the capitol city of Kabul all likely influenced the significantly lower prevalence of reported hypertension in adults with SIV arrivals compared to the randomly selected adult cohort from Nangarhar Province. Similarly, diabetes mellitus prevalence was most likely underestimated in the SIV holder population, given that overseas medical examinations do not include diagnostic testing for non-communicable diseases, including diabetes mellitus.

In the 2019 Afghanistan NCD and Injuries Poverty Commission Report, approximately 4.2% of Afghan NCD burden was due to chronic substance abuse, with an overwhelming majority due to opioid abuse (88%), and the remainder attributable to alcohol use (8%), cocaine use (1%), and 1% amphetamine use (of note, cannabis abuse was not reported).⁵³ In a 2011 World Drug Report, it was noted that 63% of global cultivation of opium was in Afghanistan. Opium use, particularly opium smoking, is more common than heroin use.^53,68 Afghanistan has the highest global opiate use rate, with a 50% increase in opium usage noted between 2005-2009, to 1.9% of Afghanistan’s total population; heroin use also increased by 140%, to 1% of the population, higher than in any country in Europe, with concerns reported that usage rates would continue to increase.⁶⁸

In U.S. cross-sectional study that analyzed overseas medical screening examination records from adult SIV holders who arrived in the U.S. from 2009-2017 (N=12,354, 55% male, 95.6% ages 18-44 years), 10% were current tobacco users and 4% were former users.³⁰ Another 2015 urban study of household members in Nangarhar province (n=1,200, 40% males, 25-65 years of age), 8% of men endorsed cigarette smoking (compared to 0.2% of females) and 13.7% of men used chewing tobacco (compared to 0.6% in females).⁶⁶

With over three decades of war and conflict, Afghanistan’s health care system remains unstable.

From 2002 to 2011, the maternal mortality rate decreased from 1,600 to 327 per 100,000 (for comparison, the U.S. maternal mortality rates as of 2019 was 20.1 per 100,000),⁷⁵ and total births in health facilities increased from 10,580 to 441,683, annually.⁷⁶

Similarly, from 2002 to 2011, the infant mortality rate decreased from 165 to 77 per 1,000 live births, and under 5 mortality decreased from 257 to 97 per 1,000.⁷⁶ Of note, as of 2014, the largest neonatal intensive care unit in Kabul, Afghanistan, had a 40-bed capacity.⁷⁷

As of 2018, 87% of the population had access to some form of a health care facility (totaling 3,135 sites) within 2 hours from their home, with 28% of these sites described as “basic health centers” staffed by 1 nurse, 2 vaccinators, and 1 “community midwife” (to provide “when skills permit, assistance with basic emergency obstetric care and assistance with normal deliveries”).⁷⁸

However, most Afghans still do not have access to primary care and preventive medical care. A May 2021 Human Rights Watch report noted that Afghanistan had only 4.6 health care workers (i.e., physicians, nurses, or midwives) per 10,000 people, and in 2018, there were over 85 documented terrorist attacks on health care facilities.^79,80

Infant and childhood vaccination schedules differ greatly from the U.S., and completion rates remain low for infants and children (Table 2). Adolescent and adult immunization coverage rates are very low overall. Data on routine and supplemental vaccination campaigns and coverage rates are limited.

In 2011, Afghanistan’s Expanded Program of Immunization included Bacille Calmette-Guérin (BCG) vaccine, 3 doses of oral polio vaccine (OPV), 3 doses of pentavalent vaccine (i.e., hepatitis B, diphtheria, pertussis, tetanus, haemophilus influenzae type B [Hib]), and 1 measles containing vaccine before 1 year of age.⁶ Of note, varicella, hepatitis A, mumps, rubella, Tdap, human papilloma virus, meningococcal, and shingles vaccines are not routinely available in Afghanistan.

In the 2018 Afghan Health study conducted by the Royal Tropical Institute (KIT), approximately 50% of children aged 24-35 months were fully vaccinated, per Afghan standards, as determined by mother’s report or vaccination card.⁶

In a 2020 study of children 12-23 months (N=5,708) that looked at nationally representative data from the 2015 Afghanistan Demographic and Health Survey, 74% had received the BCG vaccine at birth; 58% had received the 2-, 4- and 6-month doses of the pentavalent vaccine; 65% had received 2-, 4-, 6-month doses of OPV, and 60% had received 1 measles vaccine. Only 46% of children 12-23 months had completed all of Afghanistan’s minimum required vaccinations; 41% had partial vaccination status, and 13% had no vaccines.⁸¹ Vaccination after age 2 years is assumed to be quite low (the 2018 Afghan Health Study data showed only approximately 50% of 24–35-month-old children were fully vaccinated per Afghanistan’s basic standards.

Table 2: Percentage of children 12-23 months of age immunized by vaccine type, per maternal report or vaccination card (Penta=DTP, Hib, and Hep B)

Source: KIT Royal Tropical Institute. Afghanistan Health Survey 2018, April 2019.⁶

The 2018 KIT Afghan Health Survey (Figures 4 and 5) showed that of children under 5 years of age (N=23,141), 36.6% were stunted, 17.3% were severely stunted, 5% were wasted, and 1.5% were severely wasted.⁶ Analyses of U.S. anthropometric measurements collected from 2009-2017 on the SIV population during domestic screening examinations also found increased rates of stunting, with below average mean height-for-age (mean z-score = -0.68) among Afghan children ages 5 to <18 years.⁸²

Child mortality

In 2018, the leading causes of death for children under 5 years (n=23,166) were premature birth (20%), pneumonia (17%), and sepsis/meningitis (20%). Overall, deaths attributed to infections (63%) caused the highest mortality of all causes (Table 3).⁶

Child feeding practices

The 2018 KIT Afghan Health Survey reported that among 2,223 infants born from 2015 to 2017, 58% were exclusively breastfed from ages 0-5 months. Of the 934 not exclusively breastfed, 40% were given water, 8% sweetened water and/or juice, and 21.3% milk (other than formula or breast milk). Similarly, for 1,403 infants 6-9 months of age, 8% were given sweetened water and/or juice, and 21% were given milk.⁶

Figures 4 and 5: Proportion of children under 5 years with wasting and stunting

Source: KIT Royal Tropical Institute. Afghanistan Health Survey 2018, April 2019.⁶

Table 3: Mortality of infants and children 0-<5 years old

Source: KIT Royal Tropical Institute. Afghanistan Health Survey 2018, April 2019.⁶

Many females and males of reproductive age lack basic knowledge of sexual and reproductive health due to stigma. Comprehensive sex education is not included in Afghanistan’s educational curriculum other than basic reproductive anatomy and biology taught in high school.⁷⁹ The lack of information on contraception directly influences Afghanistan’s fertility rate—5.1 children per female of reproductive age (aged 12-49 years, per study definitions.⁷⁹

Contraception

In 2018, only 17% (n=7,762) of ever-married Afghan females of reproductive age (defined in the study as those females aged 12-49 years) who had a live birth in 2015-2017 reported using effective contraceptive methods (i.e., intrauterine device, contraceptive pills or injection, condom, or female sterilization).⁶ Of those surveyed, 18% reported using birth control methods with high failure rates (i.e., 13% withdrawal, 3% reported periodic abstinence, 2% lactational amenorrhea) (Figure 6).⁶ Only 32% of females of reproductive age (ages 12-49 years) were aware of available contraceptive methods. Additionally, many facilities in Afghanistan require a husband’s consent before providing contraceptives.⁷⁹

Also, in a 2018 study of ever-married females aged 12-49 who were currently pregnant (n=2,789), 25% reported that they had either wanted to become pregnant later or not at all (16% and 9%, respectively).⁶

Figure 6: Percentage of females of reproductive age 12-49 years with a live birth in 2015-2017 using contraceptives, by age (may report more than one method), n=7,762

Source: KIT Royal Tropical Institute. Afghanistan Health Survey 2018, April 2019.⁶

Pregnancy care

The 2018 Afghan Health Survey showed that 35% (n=10,466) of ever-married females (as defined as aged 12-49 years with at least one child or currently pregnant) had no prenatal visits, 13.8% had one antenatal visit, and 21% had four or more visits. Of these females, 41% had delivered at home and were aided by a trained birth attendant, relative, neighbor, or friend.^6,79 In the same 2018 survey (N=8,510 respondents), 59.7% reported that they had received no postnatal care.⁶

In a 2008 survey of Kabul-based medical providers (n= 114, physicians and midwives) caring for pregnant females, none performed universal testing for HIV, hepatitis B, or syphilis during management of pregnancy.⁸³

Most recent data from 2018 shows that the leading causes of death among females 12-49 years (n=77) were infection (24%), obstetric hemorrhage (23%), abortion complications (19%), neoplasm other than breast cancer (12%), breast cancer (4%), pregnancy induced hypertension (2%), and assault (1%).⁶ Of the 8510 ever-married females age 12-49 years with a live birth from 2015-2017, 60% of ever-married females of reproductive age reported receiving no postnatal care.⁶

Sexual and gender-based violence (GBV) is reportedly common in Afghanistan. However, due to cultural stigma, fear for safety, financial dependence, and concerns for welfare of children, the extent of these crimes is presumed to be grossly underreported.⁸⁴ In 2020, the United Nations documented only 271 cases of GBV in Afghanistan, of which 18 cases were confirmed sexual violence (nine boys, four girls, five women).⁸⁵ Five cases of sexual violence against boys were due to bacha bazi, a known practice of sexual abuse of young boys by men in power.

Honor killings, the murder of females for allegedly dishonoring the family, occur in Afghanistan, though they are likely underreported. The Afghan Independent Humans Rights Commission noted that of the 238 murders of females reported in 2019, 98 of them were honor killings.⁸⁶

While illegal in Afghanistan, child marriage remains a common practice. According to a USAID study of ever-married females of reproductive age (N=29,491, ages 15-49) conducted from June 2015-February 2016, the mean age of first marriage was 18.5 years, with 34.8% (n=10,262) married before 18, and 8.8% (n=2,595) married by age 15.⁸⁷

GBV also has been reported among Afghan refugees. One 2009 survey of married Afghan refugee females and males aged 15-49 years (122 males and 62 females) in Pakistan found that 49% of females reported physical abuse, 14% reported sexual abuse by their husbands, while 69% of married males reported physical abuse and 6% reported sexual abuse of their wives.⁸⁸

Adapted from Kumar et al 2020. Plos Medicine. Health of Special Immigrant Visa holders from Iraq and Afghanistan after arrival into the United States using Domestic Medical Examination data, 2014–2016: A cross-sectional analysis.⁶³

* Proportion not screened: LTBI (3% adults, 27% children); HBV (2% adults, 12% children); Hepatitis C (40%); malaria (74.4%); Strongyloides (57.9%); intestinal parasites (33.1%); syphilis (44.9%); HIV (17.6%)
**most SIVs resided in Kabul prior to arrival, where soil-transmitted parasitic infection rates are most likely lower than in those arrivals coming from rural areas. SIVs did not routinely receive predeparture presumptive parasite treatment. Other Afghan populations were not included in this dataset, including the newly defined Afghan Humanitarian Parolees. Therefore, it is possible that rates of infection are higher in this parolee population. Newer data on these populations are needed to accurately quantify prevalence.
***When this health profile was published, CDC’s BLRV was defined as 5 mcg/dl. It has been lowered to 3.5 mcg/dl.⁷⁴