DiscussionAfghan refugees and the temporal and spatial distribution of malaria in Pakistan
Introduction
Migration of refugees from one country to another can affect the distribution and incidence of malaria in various ways. When coming from a malaria endemic area, refugees may transport malaria parasites or new strains of parasite to the host country. The parasites may stimulate outbreaks if the new environment is suitable for transmission (Najera, 1996). When coming from a non-endemic area to an endemic area, refugees may be more vulnerable to local transmission than the host population, since refugees will lack natural immunity to native strains and have added problems of malnourishment and stress to compound the risk (Toole & Waldman, 1990; Boss, Brink, & Dondero, 1987). Epidemic conditions arise when the health infrastructure of the host country is over-stretched and non-immune immigrants are settled onto sites capable of supporting mosquito breeding.
When two and a half million Afghan refugees fled to Pakistan between 1979 and 1982 to escape the war with the Soviet Union, they were leaving a country which until that crisis had one of the more successful malaria control programmes in Asia (Buck et al., 1972). Pakistan, on the other hand, was emerging from a malaria epidemic in the mid 1970s that had produced over two million cases in the Punjab (Zulueta, Mujtaba, & Shah, 1980). The refugees had arrived in a country where malaria was highly endemic, and with a health system that was unable to cope with the influx. The refugees were rapidly settled into more than 300 camps sited on marginal lands running the length of NWFP and Balochistan provinces. Camps unfortunate enough to be sited on the waterlogged margins of rivers, or adjoining rice irrigation, were particularly prone to mosquito breeding and malaria, whereas camps situated only a few kilometres away on dry wasteland or scrub had little or no malaria (Rowland, Hewitt, & Durrani, 1997b; Rowland, 1999). Kazmi and Pandit (2001) have recently undertaken a spatial analysis of the distribution of malaria in NWFP that uses administrative districts as the unit of resolution. Using consolidated records of the Pakistan Malaria Control Programme and public health services, they show changes in the pattern of malaria between districts during the period 1972–1997. They argue that the 20-year presence of refugees has wrought environmental degradation and long-term changes to the ecology and distribution of the disease in the country.
Such opinions are not new. In the decade after arrival Afghan refugees were sometimes blamed for bringing malaria to Pakistan when there was little hard evidence for this. On the contrary, systematic parasite surveys indicated that new refugees lacked immunity and were more vulnerable to malaria transmitted within Pakistan than the local inhabitants appeared to be (Suleman, 1988; Zulueta, 1989; Bouma, 1996). The broad brush, district resolution analysis of Kazmi and Pandit (2001) is unable to take into account local variation in malaria between camps within the same district. Such variation may be considerable and is important to the argument. District-level analysis would be more acceptable if the data captured a representative sample of the malaria occurring within each district. Unfortunately their data can only tell part of the story because only the records of public sector facilities run by the Pakistan Ministry of Health (MoH) were accessed, whereas refugees more often used the health facilities run by the United Nations High Commissioner for Refugees (UNHCR) and non-governmental organisations (NGO) inside the camps (Shah et al., 1997), and records from those facilities were reported to a different health authority unaccessed by Kazmi and Pandit (2001).
In the study reported here we analyse the records of malaria diagnosed at refugee camp basic health units (BHU) between 1990 and 1997, a period in which malaria was being routinely and reliably diagnosed by microscopy and records systematically collated by the UNHCR Afghan Refugee Health Programme (ARHP). We compare this database with the malaria records of government health facilities run by the Pakistan MoH in the same districts. We show an inverse correlation in district-level incidence recorded at MoH facilities compared to that recorded at ARHP facilities. We find no evidence for significant changes in the spatial distribution of malaria in NWFP during the decade. However, in Pakistan as a whole, there is evidence for a long-term, gradual increase in reported malaria, even in the two eastern provinces of the country (Punjab and Sindh) where refugees were never residing in large numbers.
Section snippets
Conflict and refugees
The 23-year conflict in Afghanistan has gone through several stages. On taking power in 1978 the new communist regime of the People's Democratic Party (PDPA) began imposing unpopular social reforms with unwarranted severity (Gilardet, 1998). These were followed by purges, arrests and assassination of dissidents from across Afghanistan's political and religious spectrum. This provided the impetus for a nationwide uprising by rebels (or mujahideen as they became known). Soviet troops invaded in
Results and discussion
Since the late 1970s the annual number of cases of malaria recorded by each of the 4 provincial departments of malaria control has gradually risen (Fig. 4a). Punjab province reported a sharp increase up to the mid 1980s, a downturn in the late 1980s, and a further increase in the 1990s. Sindh province and NWFP reported a steady increase in cases throughout the period, whereas Balochistan reported an upsurge during the 1990s. By themselves these trends would not be wholly convincing since they
Acknowledgements
HealthNet International's Malaria Control Programme obtains financial support from the European Commission (DG1), the United Nations High Commissioner for Refugees, and WHO/UNDP/WB Special Programme for Research and Training in Tropical Diseases. Mark Rowland is supported by the Gates Foundation and the Department For International Development of the United Kingdom.
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