Elsevier

Social Science & Medicine

Volume 55, Issue 11, December 2002, Pages 2061-2072
Social Science & Medicine

Discussion
Afghan refugees and the temporal and spatial distribution of malaria in Pakistan

https://doi.org/10.1016/S0277-9536(01)00341-0Get rights and content

Abstract

Influx of refugees and establishment of camps or settlements in malaria endemic areas can affect the distribution and burden of malaria in the host country. Within a decade of the Soviet invasion of Afghanistan and the arrival of 2.3 million Afghan refugees in Pakistan's North West Frontier Province, the annual burden of malaria among refugees had risen ten fold from 11,200 cases in 1981 to 118,000 cases in 1991, a burden greater than the one reported by the Pakistan Ministry of Health for the entire Pakistani population. Political developments in the 1990s led to over half the refugee population repatriating to Afghanistan, and the Afghan Refugee Health Programme (ARHP) was scaled down proportionately. Districts in which the ARHP recorded a reduced incidence of malaria began to show an increased incidence in the statistics of the Pakistan government health programme. This and other evidence pointed to a change in health seeking practices of the refugees who remained in Pakistan, with many turning from ARHP to Pakistani health services as aid declined. Comparison of the two sources of data produced no evidence for the spatial distribution of malaria in NWFP having changed during the 1990s. Nor was there any evidence for the presence of refugees having increased the malaria burden in the Pakistani population, as is sometimes alleged. This highlights the risk of misinterpreting health trends when parallel health services are operating. Over the decade incidence in the refugee camps decreased by 25% as a result of control activities, and by 1997 the burden among remaining refugees had fallen to 26,856 cases per annum. These trends indicate that the burden would continue to fall if political conditions in Afghanistan were to improve and more refugees returned to their homeland.

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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