Diplomatic efforts are under way to coordinate a humanitarian response to COVID-19 in Afghanistan among the government, Taliban, and international actors. These efforts are also proposing ways to de-conflict the humanitarian response with the ongoing hostilities and peace process.

These efforts address Afghanistan in a national context, but the country has largely open borders and mobile populations of both Afghans and foreigners. This note provides a preliminary overview of regional aspects of COVID-19 contagion and response in Afghanistan and proposes initial measures for understanding and addressing the resulting concerns.

Context

The spread of COVID-19 in Afghanistan is taking place in a regional context in which Iran is the main center of infection. According to the World Health Organization (WHO) as of this writing, Iran has the third largest number of confirmed cases in the world, after China and Italy, with a total of nearly 18,000 cases and more than 1,000 deaths. The effective mortality rate of 6.5 percent probably indicates at least a threefold underestimate of total infections. Those numbers are growing exponentially.

The following vectors are liable to affect regional contagion:

1. According to various reports, between 10,000 and 15,000 Afghans are returning to Afghanistan daily from Iran with little or no monitoring of infection.

2. The Liwa Fatemiyoun, or Fatima Brigades, a militia founded in 2014, has recruited an estimated 10,000-20,000 Shiite young men from Afghanistan to fight in Syria, where serious outbreaks of COVID-19 are reported, especially among displaced people in Northwest Syria. An unknown number of young men are traveling among Afghanistan, Iran, Iraq, and Syria for military purposes. It is unknown if their movements are included in the figures for Afghan returnees from Iran mentioned above.

3. There are numerous unmonitored military, civilian, legal, and illegal population movements among Pakistan, Iran, and Afghanistan in the Baluchistan area shared by all three countries, as well as between the predominantly Pashtun areas of both Afghanistan and Pakistan. Pakistan currently has only 241 confirmed cases, an underestimated number certain to grow. There is little or no medical monitoring at the border even of legal and official population movements.

4. The Taliban are a Pakistan-Afghanistan cross-border insurgency capitalizing on longstanding cross-border population movements. Taliban wounded may be transported from Afghanistan to Pakistan for treatment and fighters move freely across the border in many areas.

The Pakistan military has fenced much of the contested border, which may stop the spread of disease and halt movements of militants opposed to the Pakistan military, but may also hinder populations from seeking or receiving medical assistance.

5. Iran is reported to have released as many as 85,000 prisoners in an attempt to prevent COVID-19 from spreading in places of detention. The number of Afghans in detention in Iran is high, so many of those released may be Afghans, some of whom may have returned to Afghanistan. At least some Afghan returnees from Iran may have been detained in Afghanistan, adding to the risk among the prison population in Afghanistan.

6. U.S. sanctions on Iran are having an impact on Iran’s ability to deal with the crisis. The magnitude of the impact and the responsibility for it is subject to political dispute, but its existence is not. Regardless of the answers to these political questions, it is urgent for both Iran and for Iran’s neighbors, notably Afghanistan, to eliminate any obstacles to humanitarian response originating in the sanctions, even indirectly. In particular it would be worth investigating how U.S. sanctions against Iran are affecting the flows of potentially infected populations between Iran and Afghanistan.

7. Virtually no medical equipment and supplies are manufactured in Afghanistan, so the additional equipment needed will have to come from abroad. China appears to be the main source of such assistance to Afghanistan. Chinese assistance is flown into Kabul or transported overland to Kabul via Pakistan and is therefore under control of the government. It is unknown what mechanisms exist for distributing the materials received to provinces in need or to medical professionals working in areas under Taliban control or influence.

8. The Central Asian states have very few confirmed cases (Kazakhstan reports 36 and Uzbekistan 16) and are trying to close their borders with Afghanistan and Iran. The true situation on these borders is unknown.

9. Treatment of disease and control of contagion are heavily dependent on the supply of electricity and telecommunications, including the internet. Afghanistan is externally dependent for most of its infrastructure. It is unknown to what extent overload of electricity and communications networks may risk limiting supply to Afghanistan.

10. Combat operations periodically interrupt both electricity supply and telecommunications in parts of Afghanistan. It is urgent to halt any such interruptions.

11. The U.S. and NATO are in the midst of implementing a troop withdrawal of Operation Resolute Support (RS) as envisaged by the February 29 agreement between the U.S. and the Taliban. This will involve massive logistical activity inconsistent with social isolation. There are reports of both infection and lack thereof among RS personnel. Some personnel to be rotated into the country are reportedly being kept in quarantine. The humanitarian actors need to be able to integrate accurate information on these measures into their planning.

12. Planned release of detainees by both the Afghan government and the Taliban will have important implications for contagion. Prisons are major hot spots for contagion, and prisoner release is a public health imperative as in Iran. Monitoring of released prisoners will be needed both to guarantee that they do not rejoin the fight and to prevent them from spreading disease from prisons into the general population. While the International Committee of the Red Cross (ICRC) and others are engaged in medical monitoring of prisons, these activities need to be integrated with planning for implementation of commitments to prisoner release in the peace process.

All of the above is based on media reports and speculation. There is an urgent need for accurate information.

Actions

The crisis poses difficult issues of the relation of humanitarian response to political and military initiatives. In order to address concerns about political manipulation of humanitarian concerns and response, it is imperative to address medical issues under impartial humanitarian leadership. At the same time, without measures to address political and military obstacles to the implementation of humanitarian measures, the latter will fail.

China has announced plans for a regional video conference on COVID-19 response with at least ten countries in the Europe-Central Asian region including Afghanistan. At least the WHO, ICRC, and the U.N. Office of the Coordinator of Humanitarian Affairs (OCHA) need to coordinate their approaches in Kabul and approach the relevant political and military actors. Meetings could take place through video conference.

Next, these organizations could reach out to their counterparts in Tehran and Islamabad (Tehran is more urgent) to share information and coordinate measures both at the border and behind the border. For instance, there are reports that the rationing of health care in Iran has led to the denial of care to Afghans, which is likely to accelerate the return to Afghanistan of infected people.

Initially, regional consultations could involve only relevant international organizations and experts invited on an individual basis. The goal would be to reach consensus quickly on required measures and extend the video consultations to include the host governments, as well as the U.S. because of its role in Afghanistan, China as the leading assistance provider, and states active in humanitarian response. While this should not become a reason for delay, it would be desirable to include both the Afghan government’s and the Taliban’s relevant health professionals in the consultations. This would require a change in the Taliban’s refusal to meet with the Afghan government before implementation of the prisoner release. In the changed context of the pandemic, it is necessary to coordinate the prisoner release across conflict divisions in the interest of public health as well as peace. Here again the leadership of impartial humanitarian actors will be essential.

These regional consultations should propose how to monitor cross-border population flows and contagion. Bilateral arrangements for medical monitoring on the Iran-Afghanistan and Afghanistan-Pakistan borders are needed urgently. To the extent possible these should include military personnel movements.

While the humanitarian fact-finding and strategizing should proceed independently of the political processes, they will provide the means to assess how the political-military situation poses obstacles to the required humanitarian and medical action. The humanitarian actors should form a research cell on these political and military issues posed by the medical crisis in order to present them impartially on purely humanitarian grounds to the relevant political and military authorities.

At the appropriate moment it may be necessary to seek action by the U.N. Security Council to provide the necessary authorities for a regional response.