Caring for patients with covid-19 in Afghanistan—another hard winterBMJ 2022; 376 doi: https://doi.org/10.1136/bmj.o175 (Published 21 January 2022) Cite this as: BMJ 2022;376:o175
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Recently, I visited MSF’s covid-19 treatment centre in Herat, Afghanistan. I was there to see a patient receiving continuous positive airway pressure (CPAP) therapy. This is a tool we had been trying to source for months, but local production of oxygen and international supply chains have struggled to meet demand amid the instability in Afghanistan this year. It was satisfying to see the machine in action and being used.
Walking through the treatment centre in my personal protective equipment (PPE), it struck me that it was quiet. Of three wings of beds, only one is currently open as (at the time of writing) the expected fourth wave of covid-19 was yet to hit Afghanistan. This wing has a 22 bed capacity, but right now only 10 beds are occupied.
The first covid peak
I arrived in Afghanistan in June 2020, when the country was facing its first peak in covid-19 cases. My colleagues from the MSF emergency team had arrived a few weeks earlier to open a covid-19 treatment centre in Herat, which would relieve the packed Ministry of Public Health hospital.
MSF initially set up a triage unit within the Ministry of Public Health hospital to help detect covid-19 cases. Eventually, we opened our own treatment centre at a separate site—the same centre I just visited—but it opened as patient numbers declined and the first wave subsided.
We were frustrated by our slow response and, observing how other countries were already facing second waves, we knew we had to be quicker next time.
We monitored covid-19 numbers around the world, watching what was happening in neighbouring countries and cities that are porous with Herat, such as Iran to our west and Afghanistan’s capital Kabul to our east. Our triage system in the Ministry of Public Health hospital acted as a mini alert system, warning us as covid-19 patient numbers started to climb again in Herat in the winter months of 2020.
When the second wave hit Herat in November 2020, it only took us a week to open the centre. We were already implementing lessons learnt from the first wave. Without physiotherapists in our team, we trained our health promoters to support the prone positioning of patients, having seen the undeniable evidence behind this simple intervention.
We also learnt from MSF teams elsewhere. Our colleagues in Yemen were providing level 3 ICU care to critically ill patients, with warnings that this required an intensity of knowledge and resources we just didn’t have in Herat, so we knew to prioritise severe patients instead, who we would best be able to help. The second wave passed with patient numbers that were always manageable between the Ministry of Public Health’s hospital and our facility.
Scaling up fast
In early May 2021 we had an eye on India, where the Delta variant was tearing through the country with devastating consequences. Our triage system again alerted us to climbing case numbers in Herat; in one day, we opened the treatment centre, which had the capacity to supply 600 L of oxygen per minute. By the end of the third wave, we had doubled this to 1245 L per minute. We knew we had to prioritise flexibility and a prompt scale-up, and it was amazing to see our multidisciplinary teams of doctors, pharmacists, logisticians, cleaners, and supply coordinators come together and react so fast.
The third wave was huge. At its peak, we had scaled our facility up to 74 beds. During the 12 weeks of the third wave, we admitted a total of 437 patients, 51 of them in a single week in mid-July.
It came at the same time as an escalation in fighting across Afghanistan, challenging our provision of supplies and staff as conflict reached the outskirts of Herat city.
The third wave also coincided with the peak of seasonal malnutrition in Herat. Since 2019, MSF has operated an inpatient therapeutic feeding centre in Herat Regional Hospital. With heavy fighting across Afghanistan, it took real dedication and commitment from MSF staff to manage these simultaneous crises as the situation deteriorated.
Our covid-19 treatment centre remains open today in anticipation of the fourth wave.
Covid vaccination rates in Afghanistan are low, with the country’s supply of doses reliant on the slow COVAX vaccine scheme and one-off government donations. As is the case elsewhere, vaccine hesitancy hampers the take-up rate too, leaving people exposed to yet another difficult winter of covid-19.
The new political context in Afghanistan has led to some international governments and donors imposing financial restrictions and other constraints. The Ministry of Public Health covid-19 treatment centre, which has treated the majority of covid-19 patients in Herat, was reliant on funding from the World Bank. But that funding has been frozen since the Islamic Emirate of Afghanistan, also known as the Taliban, took over the country. The facility is now anticipating only having the funding for 50 beds—slashed from the 170 bed capacity it had in the third wave.
Although we are not seeing high numbers of covid-19 patients today, we know the fourth wave is imminent. We keep monitoring the situation and stand ready to increase our bed numbers again—this time to 120 beds. We will also increase our oxygen capacity again—this time to 2524 L per minute.
Afghans have found it difficult to access healthcare for years but now face additional challenges even as their needs increase. We will continue to learn from each other and implement best practice as fast as we can, because patients must not pay the price of political decisions to stop funding healthcare or to hoard vaccines.
Competing interests: none declared.
Provenance and peer review: commissioned; not peer reviewed.