Measles poses deadly risk for malnourished children in Afghanistan

KABUL (Agencies): Zainab didn’t sleep well last night. The lights and the incessant beeping of the machines in the intensive care unit would keep anyone awake. But mainly she couldn’t sleep because she was worried about her one-year-old son, Takberullah. He also had a restless, irritable night as he was having trouble breathing until the doctor gave him some medication. “Why is my baby’s foot cold?” Zainab asks a medic, clutching Takberullah’s ankle as she pushes a blanket over his chest.
Takberullah has been in the paediatric intensive care unit of the MSF-supported Boost hospital in Lashkar Gah, Helmand province, Afghanistan, for the last three days. Ten days ago, he and his two sisters developed a fever and diarrhoea, but Takberullah became much sicker than his siblings. After two days a rash appeared, and his mother brought him to Boost hospital where he was diagnosed with measles.
Now he has severe pneumonia, a life-threatening respiratory infection, and hypoglycaemia, meaning his blood sugar is low. These complications explain his cold hands and feet and leave him in a critical condition. “How long will he have to be here?” asks Zainab, “I have other children sick at home, but I don’t know how they are doing.”
Takberullah is being given oxygen, antibiotics and glucose to fight the complications. He is one of over 1,400 children with measles that MSF saw in its projects in Helmand and Herat in February. Half developed a complication that required admission to hospital. The number of measles cases has been extremely high in Boost hospital. From December to the end of February, on average over 150 children with measles came to the hospital each week. Forty per cent of these children have a severe complication like pneumonia and are admitted for treatment.
In Herat, MSF saw almost 800 measles cases in February. At the beginning of the year, the project had eight isolation beds for patients with infectious diseases like tuberculosis or measles. That ward quickly became overwhelmed with measles patients and so 12 beds were added. Rehabilitation work is ongoing to transform an existing building into a 60-bed measles unit, providing intensive care for critical patients and inpatient care for those who are recovering. But even this will likely not be enough. “Sixty per cent of the measles cases we see arriving at Herat Regional Hospital require hospitalisation,” says Sarah Vuylsteke, MSF Herat project coordinator. “Half of those we admit for critical care are also malnourished.”
The situation is particularly alarming as Afghanistan is already facing a nutritional crisis. For months, children receiving treatment in our feeding centres in Helmand and Herat have often had to share beds, as the number of patients exceeds the centres’ bed capacity. Across both projects, from January until the end of February, there were almost 800 children admitted with severe acute malnutrition.
“Most children we see in our feeding centre and intensive care unit have had measles recently,” says Fazal Hai Ziarmal, MSF’s clinical team leader at Boost hospital. “Measles damages children’s immune systems and makes it harder for them to fight complications such as pneumonia.” “If a child is malnourished, as many in Afghanistan are at the moment, their immune system is already very weak and that can lead to a more severe and prolonged measles infection,” continues Ziarmal. “This then damages their immune system even further and makes children very vulnerable. A lot of malnourished children die from post measles complications.”
Measles is preventable through vaccination, but coverage in Afghanistan is low and this is one explanation for the rapid rise in cases. In addition, sometimes several families live under one roof, creating perfect conditions for the rapid spread of the disease. Some children recover from measles by themselves, whilst others need simple medication for their complications. But even this can be hard to find in Afghanistan as many health facilities lack sufficient medicines and supplies. This means many parents have to buy the medication from local pharmacies. “All 12 of my grandchildren got sick but these three are suffering the most,” explains Han Bibi who is waiting for her son in Boost hospital’s measles screening unit, with her grandchildren around her. They look dazed and unhappy; all three have measles.
“We bought some medicine in our village but when the children didn’t improve, we came here,” says Han. “The eldest was crying, saying her chest was painful, and she was vomiting. She’s drinking a lot of water but can’t hold anything else down.” “In our project in Herat, two children are dying every day due to measles complications,” says Vuylsteke. “I dread to think about what’s happening in other parts of the country that don’t have access to more advanced care.”
“The public health facilities we visited in rural areas have the capacity to handle measles patients with mild complications,” continues Vuylsteke. “But the staff in every single one said they wouldn’t be able to help severe or complicated cases, as they don’t have the supplies, staff or equipment. For children who are very sick, the most vulnerable, there’s very little they can do.” “We can increase the number of beds in the places where MSF works, but this won’t fix the problem,” says Vuylsteke. “Unless there’s a widespread vaccination campaign, we will continue to see increasing cases for the next six months, putting yet more pressure on an already fragile healthcare system.”
“In the longer term, the programme for regular measles vaccinations should be strengthened so that children can be vaccinated routinely, rather than in response to flare ups in cases,” Vuylsteke concludes. In Kunduz, MSF financed staff and equipment for a new 35-bed measles ward at Kunduz Regional Hospital. The ward opened on 27 February and, by the next morning, it already had more patients than beds.
Back in the paediatric intensive care unit at Boost hospital, medical staff crowd around what used to be Takberullah’s bed, trying to save the life of a new patient. Meanwhile, Zainab has packed up her things and travels home, alone, to be with her remaining children. Babies continue to be born in Afghanistan, against the backdrop of political upheaval and its consequences on healthcare and the economy. In MSF’s Khost maternity hospital, women remain at the fore, providing much-needed care to new mothers and their babies.
We first opened this specialised maternity hospital in 2012, to provide safe and free maternal and neonatal care to women and their babies in the eastern part of the country. In rural areas and away from the big cities, the majority of women do not have adequate access to essential obstetric care, and this is further exacerbated by the shortage of female midwives and doctors.
Due to our private funding, we are not behest to the political whims of governments. While we continue to provide care in Khost and elsewhere in Afghanistan, we witness critical funding cuts on the Afghan health system along with economic measures taken against the new government that have contributed to a financial crisis.
The suspension of funding to the health system in August meant that even when female midwives and doctors were available, they were deprived of supplies and salaries. Although some funding has been restarted, the Afghan health system is receiving less than before, so there will be no improvements to a system that for years failed to meet people’s needs. In our maternity in Khost, almost all the medical team is female. It has been described as a “hospital of women, for women”. MSF is one of the largest employers of women in the province, and out of 450 staff at the moment over half are female with jobs that range from doctors and midwives to cleaners and nannies.
Having a team of women is important in this area of Afghanistan to ensure the separation of the sexes, but also so that the patients feel at ease. It’s a place where families know that their wives, mothers and daughters will be well looked after.
Khost maternity comprises an inpatient department of 60 beds; an 8-bed delivery unit; a 28-bed newborn unit that includes a 10-bed neonatal intensive care unit, two operating theatres and a dedicated kangaroo mother care area (in which mothers are encouraged to make skin-to-skin contact with their babies). We also provide vaccinations for newborn babies, family planning services, and undertake health promotion activities.
Since inception, the maternity has focused on providing healthcare to pregnant ‘complicated cases’ – women who are experiencing some form of birth complication. However, in August, we decided to expand our admission criteria as there was widespread disruption and uncertainty in the country following the change in government. Markets and transportation systems were closed, people were staying at home and many weren’t sure if health facilities were still open. Although most of these issues are now resolved, a lack of funding has left pregnant women again struggling to give birth safely.
“Very quickly, we saw that the capacity of the health system was deteriorating,” says Lou Cormack, MSF Khost project coordinator. “Public facilities had fewer and fewer drugs, as the supply chain was broken. Staff weren’t getting paid,” she says. “We even heard that a local hospital was performing operations by torchlight. The public health system, which was already struggling before the suspension of funding, was barely functioning anymore.”
Our team assisted nearly 1,650 deliveries in September, and over 2,000 deliveries in November. “We’ve had so many patients lately, we had 73 deliveries in one shift, and patient numbers have been increasing over the last few months,” says Aqila, one of MSF’s locally hired midwives. “We know this is happening because public health facilities are closed, and private doctors are very costly.
“When women can’t afford to come for healthcare and give birth at home, they risk bleeding complications or severe high blood pressure disorders related to pregnancy, with no-one there to diagnose it.” Healthcare workers have done their best to keep providing care to pregnant women despite their facilities being deprived of much-needed funds.
“In the public system, we’ve heard of people pooling their money to buy medical items to keep their facilities open,” says Cormack. “If a woman needs a caesarean-section they all chip in to buy enough fuel so the generator can run during the procedure. This is despite the fact that healthcare workers and other civil servants haven’t been paid for months,” she says.
“We have been providing support to the delivery units in eight local healthcare facilities in rural districts in Khost. Recently we’ve been doing extra maintenance to make sure they keep running, adding a bit of fuel so that they can function at night, and we’ve also supplied kits for normal deliveries that include a few drugs, hygiene items and a hat to keep the baby warm.” The organisation that runs many of the local health centres in Khost’s districts has now received funding until January. Once these centres are fully functioning and used by the community again, our maternity will revert to its original admission criteria, focusing on pregnant women who are experiencing birth complications. However, what’s going to happen after January remains unclear.
At an uncertain time for Afghanistan, and with people facing huge challenges in accessing healthcare, Aqila says she finds great comfort in helping the women in her community. “I like to help the women who deliver in Khost. The MSF maternity is a safe and great place for them, I delivered my own baby here,” she says. “I love being a part of it, to help deliver babies and to help mothers. I really have a soft spot for mothers, because they suffer so much.”
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