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Features May 2007: Volume 4, Number 2

AIDS in Kabul

By Sylvia Tiersten

Photographs by Massoud Hossain/afp


In September 2007, Todd and her fellow researchers published their findings on the prevalence of blood-borne infections among injecting drug users in Kabul. Here she is gathering in the office of Mr. Abdullah, manager of Zindagi Nawin drop-in center.

The day-to-day work environment in Afghanistan is “incredibly frustrating in some ways, ” Todd allows, “but the amount you learn is phenomenal—and you’re learning inventive ways of doing things from people who are constantly short on resources.” Medical crews who lack the proper poles to hook up IV bags, for instance, run tape up the wall and attach coat hangers instead.

Unfortunately, ingenuity and improvisation have their limits. “There simply aren’t enough treatment beds for drug users, and access programs have three-to-six-month waiting lists,” says Todd. “Addicts come back from other countries and say, ‘You don’t have methadone, you don’t have the things I need.’ It makes people feel hopeless. It’s a disincentive for helping them change behaviors when they’re motivated to do so.”

There are some small victories. “I would leave Kabul for six months, and then come back and see differences—more cars on the road, changes in people’s outlook. You cannot finitely measure it, but it was noticeable,” says Todd. She adds that there is access to goods and services, which didn’t exist under Taliban rule with people getting bank loans, taking computer classes and engaging in trade.

The International Rescue Committee (IRC) provides on-the-ground support for HIV/AIDS research in Afghanistan. “Still I worry about our Afghan staff sometimes—especially the ones who are going into very sensitive areas and asking about sex habits and drug use,” says Todd. There have been days when members of her staff in Jalalabad were locked into the office because of instability in Nangahar province.

Language and security issues prevent Todd from micromanaging her numerous projects—even if she wanted to. “I don’t speak Dari, and I don’t speak Pashtu,” she says although she can “get by” in Dari and Arabic when it comes to bartering in the local markets. As for her in-country staff, “There’s a popular saying around here that Afghans pick up another language like other people change their clothes,” says Todd. Several members of her research teams have English-language skills, and a few are even quadralingual.

A recent U.S. State Department advisory on Afghanistan warns of “an ongoing threat to kidnap U.S. citizens and Non-Governmental Organization (NGO) workers throughout the country.” Todd never ventures outside her house alone—not even for a short walk to the local marketplace. Longer distances require a car and driver, and someone watches day and night over the house where she and her husband reside.

* * *

During the couple’s stay in Afghanistan, Yingst was a volunteer for the United Nations Food and Agriculture Organization (UNFAO). As a laboratory expert, he was able to provide informal support for his wife’s numerous projects. One of these projects, which addresses infection screening and interventions for women in labor, “bridges my two interests of reproductive health and infectious disease,” says Todd.

In phase one of the two-part project, investigators looked at the seroprevalence, knowledge and health care behaviors of pregnant women admitted in labor at three Kabul maternity hospitals. (Seroprevalence is the rate at which individuals in a population test positive for particular antibodies, based on blood serum specimens). Investigators also looked at the level of knowledge and testing practices of health providers at those hospitals.

Researchers collected data from 4,452 interpartum women and 113 providers. “No one had really looked at that population to try to find out the prevalence
of HIV, syphilis and hepatitis B,” says Todd. Other unknowns were the women’s knowledge of HIV and its possible transmission through previously used needles.

Preliminary findings showed that no participants tested positive for either HIV or syphilis, and Hepatitis B prevalence was 1.53 percent. Investigators also found low utilization of birth spacing methods, and previous studies have shown a low rate of vaccination completion.
With the data in hand, Todd and her collaborators are analyzing the gaps in knowledge. “We hope to introduce a new role for existing ministry of health employees that focuses on interpartum testing and intensive postpartum counseling,” she says.

Phase two is the intervention component of the project. Todd is currently writing up protocols for review by Syed Alef Shah Ghazanfar from the Afghan Ministry of Public Health and her Afghan mentor for this National Institutes of Health (NIH) funded project. “Things are happening as a result of our research that are pushing social and cultural norms, and I want to be sure these protocols are acceptable and helpful,” she says.

Typically, pregnant Afghan women are not tested for blood-borne diseases such as syphilis and Hepatitis B, as women routinely are in the West. “We wanted to know why,” says Todd. “Is it because the testing is unavailable, the testing is not offered or the women refuse to be tested.”

Todd’s data revealed a mixture of reasons: the unavailability of testing due to expense or lack of supplies, or the perception that all of these diseases are rare in Afghanistan and not cost effective to test for them.

About 97 percent of the women eligible for the study were willing to participate. The carrot for them was free testing in a hospital setting, immediate access to test results and treatment in the event that they tested positive for HIV, syphilis or hepatitis B.

Despite Afghanistan’s 36 percent adult literacy rate, half of the women tested were aware of HIV—and 20 percent had correct knowledge of the virus. “Their main source of information was TV and radio,” says Todd. “Care is taken that when health messages are broadcast they are accurate and comprehensible to everybody who listens to them.”

* * *

From 2001-2006, the United States committed over $12 billion to the Afghanistan reconstruction. At an international donors’ conference in Berlin in April 2004, donors pledged a total of $8.2 billion for the period 2004-2007.

“People rushed in without a clear picture of the history of the region,” says Todd. “The perception in the West is that there will be a quick fix for all these conflicted countries— that you can temporarily throw money at them and have them disappear off the radar screen.

“You have to be willing to make a long-term commitment,” Todd continues. “Once you obligate aid money to a certain region or country, you must be willing to invest until there is concrete evidence that the country is able to sustain itself.”
But that hope of sustainability dims a little more with each new atrocity and act of violence. “A lot of this has been deliberate. They target people who will be the most demoralizing to lose,” says Todd of the insurgents. Terrorists have bombed girl’s schools to discourage families from sending their daughters. Teachers and medical workers are also targets for maiming and killing. “It’s incredibly undermining to a community’s sense of well being if some of the most productive members of the society are being lynched,” says Todd.

In the wake of so much misery, “many Afghan women have forgotten how to cry,” says Todd. She worries that they are also forgetting how to hope. And that is something she is determined to do something about.

Research Projects
Catherine Todd, M.D., is currently working on four major research projects in Afghanistan. Support for these projects comes from several sources, including the International Rescue Committee, Walter Reed Army Institute of Research, U.S. Naval Ambulatory and Medical Research Unit (NAMRU-3), Doris Duke Charitable Foundation, and Fogarty International Center, National Institutes of Health.

A Brief History
The Islamic Republic of Afghanistan—a landlocked country of rugged mountains; parched deserts; multiple tribes and ethnic groups; and an estimated 25 million people—is struggling to recover from three decades of war and terrorism. A bloody Marxist coup ended the Afghan monarchy in 1978, followed by a full-scale Soviet invasion. During the 1980s, Afghan freedom fighters (conservative rural tribesmen known as mujahidin) received weapons and training from the United States to oppose Soviet power.
Russia withdrew from Afghanistan in 1989, and the civil war devolved into anarchy with warlords seeking to establish local control.

Into the breach came the Taliban, an Islamic fundamentalist group that seized Kabul in 1996 and eventually occupied about 90 percent of the country. They barred women from getting an education or working outside the home, compelled them to wear the burqa (a robe that covers the body from head to toe), banned music and kite-flying, and forced men to grow beards.

The Taliban offered sanctuary to Saudi national Osama Bin Laden—providing a base for his Al Qaeda group and for other terrorist organizations. When the Taliban refused to expel Bin Laden and Al Qaeda after September 11, 2001, a U.S.-led army launched a military invasion.

The Taliban were crushed—at least for the moment, and Kabul fell in November of that year.

In 2004, Afghanistan held its first national democratic presidential election. The winner, Hamid Karzai, was inaugurated for a five-year term.

Now, six years later, Afghanistan is slipping backward, and the Taliban are staging a comeback. The war in Iraq diverted money and attention from reconstruction in Afghanistan. Beyond Kabul, the influence of Karzai’s central government is weak to non-existent, and corruption and lawlessness are rampant in many parts of the country. Poppy cultivation and drug trafficking have returned and are likely to continue— unless the central government and the international community provide alternative sources of income for impoverished Afghan farmers.

Sylvia Tiersten is a freelance writer based in San Diego.


International Health & Cross-Cultural Medicine, UCSD


Afghanistan provides 92 percent of the world's heroin supply.