Within a decade of the Soviet invasion of Afghanistan, 2.3 million Afghan refugees arrived in Pakistan’s North West Frontier Province (NWFP). They lacked immunity to malaria, which is highly endemic in Pakistan. Research by HealthNet International examines changes in the pattern of malaria in Pakistan during this time.

Migration of refugees from one country to another can affect the distribution and incidence of malaria in various ways:

• Refugees may transport malaria or import new strains of the parasite into the host country.
• When coming from a non-endemic area to an endemic region, refugees are more vulnerable to local transmission than the host population.
• Epidemics arise when the host country’s health services are overstretched and non-immune refugees settle in areas able to support mosquito breeding.

In 1991 the annual burden of malaria among refugees was 118 000 – more than for the entire Pakistani population of 110 million. By the late 1980s, a third of camps in NWFP had developed a big enough malaria problem to warrant vector control measures by United Nations High Commissioner for Refugees (UNHCR).

Researchers analysed the records of malaria diagnosed at refugee camp basic health units (BHUs) run by the UNHCR Afghan Refugee Health Programme between 1990 and 1997. They compared this with malaria records of Pakistani government health facilities. They found evidence for a change in health-seeking practices among refugees who remained in Pakistan:

• 62 per cent of BHU closed down during this time due to cuts in aid. In camps where this happened, the average distance to the nearest BHU increased from 1 to 16 km.
• Where camp BHUs still existed, the refugees used these convenient and free health services and the caseload reported by Pakistani health facilities remained low.
• In camps without a BHU, some refugees turned to the Pakistani health system for treatment and the reported caseload rose.
• Most Pakistanis continued to use the private sector.

There is no evidence that the spatial distribution of malaria in NWFP changed during the 1990s or that the presence of refugees increased the malaria burden in the Pakistani population. Over the decade, malaria incidence in the refugee camps decreased by 25 per cent as a result of control activities. As refugees gradually return to Afghanistan and camps become smaller, malaria should diminish further.

In Pakistan as a whole, however, the annual number of malaria cases has gradually risen since the late 1970s, even in the eastern provinces (Punjab and Sindh) where refugees never lived in large numbers. Chloroquine-resistant malaria spread rapidly across Pakistan during the 1980s.

The researchers conclude that it is easy to misinterpret health trends when parallel health services operate. The national burden of malaria in Pakistan is probably several times greater than that reported through the public health sector. They recommend improvements to the national system of malaria reporting including:

• a more representative range of treatment providers
• independent means of checking results, such as cross-sectional parasite surveys or household surveys.

Source(s):
‘Afghan refugees and the temporal and spatial distribution of malaria in Pakistan’, Social Science and Medicine 55: 2061-2072, by M. Rowland, M. Rab, T. Freeman, N. Durrani and N. Rehman, 2002
HINARI subscribers can access the full-text article here. Full document.

Funded by: European Commission; UNHCR; WHO Special Programme for Research and Training in Tropical Diseases; Gates Foundation; UK Department for International Development

id21 Research Highlight: 10 April 2003

Further Information:
Mark Rowland
London School of Hygiene and Tropical Medicine
Keppel Street
London
WC1E 7HT
UK

Tel: +44 (0) 20 7299 4719
Fax: +44 (0) 20 7299 4720
Contact the contributor: mark.rowland@lshtm.ac.uk

HealthNet International

London School of Hygiene and Tropical Medicine, UK

Other related links:
'Controlling malaria in times of emergency: East Timor’s experience'

'Unsafe haven? The risk of malaria in refugee camps'

See id21's collection of links relevant to infectious diseases.