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Even before U.S. air strikes against terrorist encampments in Afghanistan began to swell new populations of refugees, Afghans made up the world’s single largest group of refugees. Most of these refugees migrate to neighboring Pakistan. Last year, Pakistan pleaded extreme "asylum fatigue" and announced it was fed up with providing asylum to Afghans fleeing war, drought, and economic chaos, with international aid running dry and Pakistan’s own economy slipping into the doldrums.
At the same time, refugee advocacy groups in this country, alarmed by reports of abysmal conditions in some refugee camps, had begun began pressuring the State Department to shoulder more of the burden. The result was that in the days leading up to Sept. 11, the United States made a commitment to substantially raise the immigration ceiling for Afghans, says Hiram Ruiz, senior policy analyst for the U.S. Committee on Refugees.
Last year, only about 1,700 Afghan refugees were resettled in the United States, a number that brought their proportion to about 1 in 19 refugees in this country, according to Ruiz. The State Department had proposed raising the ceiling to 4,000 spaces for the coming year.
That change, if eventually enacted, would still leave Afghans with a relatively small slice of the total U.S. allotment, Ruiz adds. When sorted by country of origin, the biggest group of refugees admitted to America last year were Bosnians, who numbered 19,000. In the No. 2 spot were citizens of the former Soviet Union, at 14,500. Somalis, with 6,000 admitted, occupied a distant No. 3 spot.
Despite the urgency of Afghan refugees’ plight, the coming year almost surely will not bring any Kosovo-style airlifts of Afghan refugees, Ruiz adds. Potential security issues aside, there are simply too many displaced Afghans — 200,000 in just last year’s wave, with another two million settled in Pakistan and more in neighboring Iran and Uzbekistan. Plus, Afghanistan is a much greater distance from the United States than Kosovo is. That means airlifting refugees would be prohibitively expensive, Ruiz adds. "For the price of an airline ticket, you could provide food aid to hundreds, perhaps thousands of people," he says.
On the other hand, it’s reasonable to think that eventually, the hold on decisions about next year’s refugee ceilings will be lifted. If Afghans’ numbers here eventually increase, what will that mean for TB control programs?
Although Afghanistan is listed by the World Health Organization as one of the 22 high-burden countries that account for 80% of the world’s TB cases, precise data on case rates are scarce. According to a recent spot-survey by Medecins Sans Frontieres (MSF), rates of reported smear-positive TB stand at about 146/100,000, with 32,000 new cases per year, says Christa Hook, MD, health adviser to MSF/Holland.
Remarkably, among all TB cases reported in Afghanistan, women appear to be far harder hit by TB than men, accounting for 60% to 70% of reported cases, Hook says. A survey from 1978 found prevalence rates for skin-test positivity were roughly equal among 15-year-old boys and girls. Another survey of latent infection carried out last year among 6-year-olds in Kabul also found no difference. "What seems likely, then, is that progression to disease is more common among women," Hooks says.
There are several possible reasons for the discrepancy, she adds. Under Taliban rule, women suffer poorer nutrition and are confined mostly to the indoors, in sunless, crowded spaces. When they do venture out, Hook says, they still get little sunlight, shrouded as they are in burqas, tent-like garments with only a small mesh opening, or chadors, large scarves that conceal the head and upper body. Some TB experts say there may be a relationship between sunlight exposure and the onset of active TB.
Once resettled in other cultures, Afghan women tend to abandon the all-encompassing burqas, but often only after their husbands give them permission, Hook says. Older women may also unveil with their spouses’ permission.
Women also delay seeking care for longer than men. Finally, they experience more difficulties with compliance, because they can go for treatment only if accompanied by a suitable male escort, Hooks says. As for drug-resistance prevalence and incidence, there are virtually no data on the subject, Hook says. It bodes ill that anti-TB drugs of widely varying quality are sold over the counter at bazaars and markets throughout the country, she adds. "That means when the money runs out, so does the treatment," she says. "There are no controls at all over drugs on the market."
The MSF survey found that government-run TB programs, where they exist, suffer from many problems, including lack of direct observation of therapy, absence of sputum microscopy, and poor record-keeping. Still, nongovernmental organizations (NGOs) such as MSF have managed to establish a handful of good TB programs, such as one in Kabul, Hook says.
Since U.S. attacks began, expatriate staff for all NGOs have been evacuated, but in-country personnel have so far apparently managed to keep TB programs running, Hook says. At least for the MSF programs, drug stocks are adequate — though that may change, she warns. "The fear now is that if things really fall apart, buffer stocks of drugs in those programs will be looted and sold on the black market," she says.
Health conditions in refugee camps in Pakistan are reportedly poor, with new arrivals’ health status most at risk. New arrivals, especially women and children, suffer from poor nutritional status, MSF has found. Many of the recent arrivals also fit into one of the United Nations’ highest-priority categories for those seeking official refugee status because they consist of families headed by females, a condition that makes economic survival extremely difficult not only in Afghanistan but also in Pakistan, Ruiz says.
Despite the fact that the Pakistan border remains sealed, hundreds of Afghans are crossing into Pakistan, often with the help of paid smugglers, according to the UNHCR. There are also reports that many Afghan cities, as well as the densely settled areas around them, have emptied out. Where the people are going is anyone’s guess, Hook says. "They may be going to stay in rural areas. We think some are also making their way toward the borders," she says. "Others are probably hiding in the mountains."