AFGHANISTAN

1. AFGHANISTAN Civil war / damaged infrastructure Deteriorated public health systems BACKGROUND: Afghanistan's recent history is a story of war and civil unrest. The Soviet Union invaded in 1979, but was forced to withdraw 10 years later by anti-Communist mujahidin forces. The Communist regime in Kabul collapsed in 1992. Fighting that subsequently erupted among the various mujahidin factions eventually helped to spawn the Taliban, a hardline Pakistani-sponsored movement that fought to end the warlordism and civil war that gripped the country. The Taliban seized Kabul in 1996 and were able to capture most of the country outside of Northern Alliance strongholds primarily in the northeast. Following the 11 September 2001 terrorist attacks, a US, Allied, and Northern Alliance military action toppled the Taliban for sheltering Osama BIN LADIN. In late 2001, a conference in Bonn, Germany, established a process for political reconstruction that ultimately resulted in the adoption of a new constitution and presidential election in 2004. On 7 December 2004, Hamid KARZAI became the first democratically elected president of Afghanistan. The National Assembly was inaugurated on 19 December 2005. BACKGROUND: Afghanistan's recent history is a story of war and civil unrest. The Soviet Union invaded in 1979, but was forced to withdraw 10 years later by anti-Communist mujahidin forces. The Communist regime in Kabul collapsed in 1992. Fighting that subsequently erupted among the various mujahidin factions eventually helped to spawn the Taliban, a hardline Pakistani-sponsored movement that fought to end the warlordism and civil war that gripped the country. The Taliban seized Kabul in 1996 and were able to capture most of the country outside of Northern Alliance strongholds primarily in the northeast. Following the 11 September 2001 terrorist attacks, a US, Allied, and Northern Alliance military action toppled the Taliban for sheltering Osama BIN LADIN. In late 2001, a conference in Bonn, Germany, established a process for political reconstruction that ultimately resulted in the adoption of a new constitution and presidential election in 2004. On 7 December 2004, Hamid KARZAI became the first democratically elected president of Afghanistan. The National Assembly was inaugurated on 19 December 2005.

2. Where in the world is Afghanistan? Location: Southern Asia, north and west of Pakistan, east of Iran Geography Note: landlocked; the Hindu Kush mountains that run northeast to southwest divide the northern provinces from the rest of the country; the highest peaks are in the northern Vakhan (Wakhan Corridor) Location: Southern Asia, north and west of Pakistan, east of Iran Geography Note: landlocked; the Hindu Kush mountains that run northeast to southwest divide the northern provinces from the rest of the country; the highest peaks are in the northern Vakhan (Wakhan Corridor)

3. Physical Environment Topography If operating above 6,000ft implement high elevation countermeasures Climate Afghanistan is approximated the size of Texas and can be divided into three geographic regions. (1) The Northern Plains, covering about 16 percent of Afghanistan, consist of mountainous plateaus and rolling hills, averaging 2,000 feet above sea level. (2) The Central Highlands are part of the Himalayan Chain, traverse the center of Afghanistan from the northeast to the southwest, cover almost two-thirds of the country, and have peak elevations in the northeast reaching approximately 25,000 feet above sea level. (3) The Southwestern Plateau is a southwesterly sloping, arid plateau, with elevations reaching 20,000 feet above sea level in the east and dropping to about 500 ft above sea level in the west. High Elevation Operations High altitude illnesses can kill. Afghanistan and Pakistan operations occurring at elevations over 6,000 feet can seriously impact unit and individual effectiveness. Serious illness or death can result if you ascend rapidly without allowing for acclimatization. Remain well hydrated; individual water requirements are greater at higher altitudes. When deployed to high mountain areas, be observant of the common symptoms of mountain sickness: headache, nausea, vomiting, dizziness, fatigue, irritability, and coughing. Seek medical attention immediately if you experience any of these symptoms. Pyridostigmine bromide tablets may increase the chance of dizziness or fainting during the first 24 hours at high altitude if you are not acclimatized. Lower oxygen levels at high altitudes (“thin air”) combined with the heavier work requirements when wearing mission-oriented protective posture (MOPP) gear can increase your risk of high altitude illnesses. When wearing MOPP gear at higher altitudes, you may require more time and concentration to perform assigned tasks. For appropriate countermeasures during high altitude operations, see GTA 08-05-062 and GTA 08-05-060, A Soldier’s Guide to Staying Healthy at High Elevations. Lead to next slide …… Afghanistan has a mostly dry climate marked by seasonal and diurnal (daytime) temperature extremes….. Afghanistan is approximated the size of Texas and can be divided into three geographic regions. (1) The Northern Plains, covering about 16 percent of Afghanistan, consist of mountainous plateaus and rolling hills, averaging 2,000 feet above sea level. (2) The Central Highlands are part of the Himalayan Chain, traverse the center of Afghanistan from the northeast to the southwest, cover almost two-thirds of the country, and have peak elevations in the northeast reaching approximately 25,000 feet above sea level. (3) The Southwestern Plateau is a southwesterly sloping, arid plateau, with elevations reaching 20,000 feet above sea level in the east and dropping to about 500 ft above sea level in the west. High Elevation Operations High altitude illnesses can kill. Afghanistan and Pakistan operations occurring at elevations over 6,000 feet can seriously impact unit and individual effectiveness. Serious illness or death can result if you ascend rapidly without allowing for acclimatization. Remain well hydrated; individual water requirements are greater at higher altitudes. When deployed to high mountain areas, be observant of the common symptoms of mountain sickness: headache, nausea, vomiting, dizziness, fatigue, irritability, and coughing. Seek medical attention immediately if you experience any of these symptoms. Pyridostigmine bromide tablets may increase the chance of dizziness or fainting during the first 24 hours at high altitude if you are not acclimatized. Lower oxygen levels at high altitudes (“thin air”) combined with the heavier work requirements when wearing mission-oriented protective posture (MOPP) gear can increase your risk of high altitude illnesses. When wearing MOPP gear at higher altitudes, you may require more time and concentration to perform assigned tasks. For appropriate countermeasures during high altitude operations, see GTA 08-05-062 and GTA 08-05-060, A Soldier’s Guide to Staying Healthy at High Elevations. Lead to next slide …… Afghanistan has a mostly dry climate marked by seasonal and diurnal (daytime) temperature extremes…..

4. Physical Environment KABUL In the west, mean daily highs and lows in summer (Apr-Sep) are 118°F and -4°F and in the winter (Oct-Mar) are 100°F and -3°F, respectively. The rainy season lasts from Oct-Apr. Although rainfall usually is scant, periodic heavy rains combined with melting snow have caused flooding. Generally, no area receives more than 15 inches annually. The country also has the "Wind of 120 Days," which blows from Jun-Sep at velocities that occasionally exceed 110 miles per hour. Next slide is Kandahar…..KABUL In the west, mean daily highs and lows in summer (Apr-Sep) are 118°F and -4°F and in the winter (Oct-Mar) are 100°F and -3°F, respectively. The rainy season lasts from Oct-Apr. Although rainfall usually is scant, periodic heavy rains combined with melting snow have caused flooding. Generally, no area receives more than 15 inches annually. The country also has the "Wind of 120 Days," which blows from Jun-Sep at velocities that occasionally exceed 110 miles per hour. Next slide is Kandahar…..

5. Physical Environment Kandahar….. Now let’s take a look at precipitation…Kandahar….. Now let’s take a look at precipitation…

6. Physical Environment Kabul Precipitation Kabul Precipitation

7. Physical Environment Kandahar Precipitation Kandahar Precipitation

8. Greatest short term risks associated with ingestion of contaminated food/water; extreme heat/cold; high altitude Greatest long term risks associated with air contamination and chemical contamination of food/water Environmental Health Risk Picture = Afghan Road Key Judgments Environmental contamination may present short- and long-term health risks to personnel deployed to Afghanistan. The greatest short-term health risks are associated with ingestion of food or water contaminated with untreated sewage or runoff containing fecal pathogens. The physical environment in Afghanistan may pose additional short-term health risks from extreme heat or cold, airborne dust or sand, and high altitude. The greatest long-term health risks are associated with air contamination in industrial and urban areas and chemical contamination of food or water Background Environmental pollution issues of highest concern include chemical and microbial contamination of water from untreated municipal and industrial waste, air pollution in urban and industrial areas, overuse of fertilizers and pesticides, and pesticide and microbial contamination of food. Environmental neglect, more than 10 years of war, drought, population growth, agricultural demand, and lack of governmental control have contributed to environmental problems. A decade of environmental neglect by the Taliban rulers, three major wars since 1980, and an ongoing drought have adversely impacted public health and industrial infrastructure. Large movements of displaced persons due to the civil war have further taxed already overburdened and deteriorated public health systems. Basic utilities such as electricity, clean water, and public sanitation are extremely unreliable. Picture = Afghan Road Key Judgments Environmental contamination may present short- and long-term health risks to personnel deployed to Afghanistan. The greatest short-term health risks are associated with ingestion of food or water contaminated with untreated sewage or runoff containing fecal pathogens. The physical environment in Afghanistan may pose additional short-term health risks from extreme heat or cold, airborne dust or sand, and high altitude. The greatest long-term health risks are associated with air contamination in industrial and urban areas and chemical contamination of food or water Background Environmental pollution issues of highest concern include chemical and microbial contamination of water from untreated municipal and industrial waste, air pollution in urban and industrial areas, overuse of fertilizers and pesticides, and pesticide and microbial contamination of food. Environmental neglect, more than 10 years of war, drought, population growth, agricultural demand, and lack of governmental control have contributed to environmental problems. A decade of environmental neglect by the Taliban rulers, three major wars since 1980, and an ongoing drought have adversely impacted public health and industrial infrastructure. Large movements of displaced persons due to the civil war have further taxed already overburdened and deteriorated public health systems. Basic utilities such as electricity, clean water, and public sanitation are extremely unreliable.

9. Environmental Issues Air Contamination Overall, minimal health effects High levels of particulate matter (PM10) able to reach the lungs recorded at Salerno, Kandahar, & Bagram Short-term (less than or equal to 14 days duration) exposure presents a risk of temporary respiratory symptoms such as coughing, wheezing, and reduced lung function Air: The overall risk of adverse health effects from air pollution in Afghanistan is minimal. However, pollution in localized areas may reach levels that can cause acute respiratory symptoms in sensitive persons. Air samples taken at Forward Operating Base Salerno, Kandahar, and Bagram show high levels of respirable particulate matter (PM-10) that were consistently above the 24-hour U.S. Environmental Protection Agency's National Ambient Air Quality Standard of 150 micrograms per cubic meter. PM-10 concentrations ranged from 48 micrograms per cubic meter to 275 micrograms per cubic meter. Short-term exposure to particulate matter at levels above the established standards presents a risk of transient acute respiratory symptoms such as coughing, wheezing, and reduced lung function, especially in asthmatic individuals. Air: The overall risk of adverse health effects from air pollution in Afghanistan is minimal. However, pollution in localized areas may reach levels that can cause acute respiratory symptoms in sensitive persons. Air samples taken at Forward Operating Base Salerno, Kandahar, and Bagram show high levels of respirable particulate matter (PM-10) that were consistently above the 24-hour U.S. Environmental Protection Agency's National Ambient Air Quality Standard of 150 micrograms per cubic meter. PM-10 concentrations ranged from 48 micrograms per cubic meter to 275 micrograms per cubic meter. Short-term exposure to particulate matter at levels above the established standards presents a risk of transient acute respiratory symptoms such as coughing, wheezing, and reduced lung function, especially in asthmatic individuals.

10. Environmental Issues Cont. Soil Contamination Localized to specific areas around industrial facilities, waste disposal ditches, and open sewage ditches Significant exposure is unlikely Water Contamination Contaminated with raw sewage One of the most significant health threats to deployed personnel Sewage contamination of drinking water in urban areas is common Soil: Soil contamination in Afghanistan is localized to specific areas surrounding industrial facilities, waste disposal sites, and open sewage ditches. Even in such areas, significant exposure to contaminants in soil is unlikely in the absence of windblown dust, active digging, or migration of contaminants from soil into groundwater. As a result, soil contamination usually presents a low risk to human health. WATER: Water pollution from raw sewage is the most significant environmental contamination problem in Afghanistan and is one of the most significant health threats to deployed personnel. Although septic tanks and pit latrines are available in some urban areas, discharge of untreated sewage into surface waters and indiscriminate disposal of human waste and refuse contribute to microbial contamination of nearly all surface water sources in Afghanistan. Kabul is the only city in Afghanistan that has any form of sewage treatment system; the system is only available in two areas of the city.  Sewage contamination of drinking water in major urban areas of Afghanistan is common. A U.S. study of bacterial contamination in water sources found that 65 percent of protected, closed wells and 90 percent of open wells (the most common drinking water source in many areas) were contaminated with coliform bacteria. Coliform bacteria = Widely distributed micro-organisms found in the intestinal tract of humans and other animals and in soils. Their presence in water indicates fecal pollution and potentially dangerous contamination by disease-causing micro-organisms.Soil: Soil contamination in Afghanistan is localized to specific areas surrounding industrial facilities, waste disposal sites, and open sewage ditches. Even in such areas, significant exposure to contaminants in soil is unlikely in the absence of windblown dust, active digging, or migration of contaminants from soil into groundwater. As a result, soil contamination usually presents a low risk to human health. WATER: Water pollution from raw sewage is the most significant environmental contamination problem in Afghanistan and is one of the most significant health threats to deployed personnel. Although septic tanks and pit latrines are available in some urban areas, discharge of untreated sewage into surface waters and indiscriminate disposal of human waste and refuse contribute to microbial contamination of nearly all surface water sources in Afghanistan. Kabul is the only city in Afghanistan that has any form of sewage treatment system; the system is only available in two areas of the city.  Sewage contamination of drinking water in major urban areas of Afghanistan is common. A U.S. study of bacterial contamination in water sources found that 65 percent of protected, closed wells and 90 percent of open wells (the most common drinking water source in many areas) were contaminated with coliform bacteria. Coliform bacteria = Widely distributed micro-organisms found in the intestinal tract of humans and other animals and in soils. Their presence in water indicates fecal pollution and potentially dangerous contamination by disease-causing micro-organisms.

11. Infectious Disease Risk HIGH RISK for infectious diseases Inadequate force health protection (FHP) measures, will seriously jeopardize mission effectiveness

12. Infectious Diseases Foodborne and Waterborne Diseases HIGH RISK = Diarrhea, hep A, typhoid fever INTERMEDIATE RISK = brucellosis, cholera, hep E FHP Priorities Deploy appropriate PM personnel and equipment Consume food, water, ice only from US-approved sources Operate food preparation facilities in accordance with Army doctrine Ensure proper hand washing facilities near all latrines and dining facilities and enforce Sanitation is extremely poor throughout the country, including major urban areas. Local food and water sources (including ice) are heavily contaminated with pathogenic bacteria, parasites, and viruses to which most US service members have little or no natural immunity.Effective disease surveillance does not exist within the country. Only a small fraction of diseases are identified or reported. Diarrheal diseases can be expected to temporarily incapacitate a very high percentage of personnel within days if local food, water, or ice is consumed. Hepatitis A and typhoid fever can cause prolonged illness in a smaller percentage.In addition, though not specifically assessed in this document, viral gastroenteritis (e.g., norovirus) and food poisoning (e.g., Bacillus cereus, Clostridium perfringens, Staphylococcus) may cause significant outbreaks. The diseases of high risk are listed first, in descending order of expected impact. Diseases of intermediate risk, with a lower or unknown likelihood to degrade operations, are listed alphabetically in tabular form. Sanitation is extremely poor throughout the country, including major urban areas. Local food and water sources (including ice) are heavily contaminated with pathogenic bacteria, parasites, and viruses to which most US service members have little or no natural immunity.

13. Infectious Diseases Cont. Vector-borne Diseases HIGH RISK = Malaria INTERMEDIATE RISK = Crimean-Congo hemorrhagic fever, leishmaniasis, sand fly fever, typhus, West Nile fever FHP Priorities Use DEET on all exposed skin Treat field uniforms with permethrin Use bed nets in field conditions, treat with permethrin Enforce malaria chemoprophylaxis as appropriate During the warmer months (typically March through November), the climate and ecological habitat support populations of arthropod vectors, including mosquitoes, ticks, and sand flies. Significant disease transmission is sustained countrywide, including urban areas. Serious diseases are not recognized or reported due to the lack of surveillance and diagnostic capability.Malaria is the major vector-borne risk in Afghanistan, capable of debilitating a high percentage of personnel for up to a week or more. In addition, other vector-borne diseases are transmitted at low or unknown levels, and may constitute a significant risk. During the warmer months (typically March through November), the climate and ecological habitat support populations of arthropod vectors, including mosquitoes, ticks, and sand flies. Significant disease transmission is sustained countrywide, including urban areas.

14. Infectious Diseases Cont. Animal-contact Diseases HIGH RISK = Rabies, among the highest in the world INTERMEDIATE RISK = Anthrax, Q-fever FHP Priorities Avoid animal contact, especially if the animal exhibits strange behavior No mascots Report all animal bites and scratches Rabies risk is assessed as among the highest in the world; personnel bitten by potentially infected reservoir species are at high risk for developing rabies in the absence of appropriate prophylaxis. The circumstances of the bite should be considered in evaluating individual risk; bats or wild carnivores should be regarded as rabid unless proven otherwise. Very severe illness with near 100% fatality rate in the absence of post-exposure prophylaxis. The anthrax referred to here is naturally occurring and not a biological weapon.Rabies risk is assessed as among the highest in the world; personnel bitten by potentially infected reservoir species are at high risk for developing rabies in the absence of appropriate prophylaxis. The circumstances of the bite should be considered in evaluating individual risk; bats or wild carnivores should be regarded as rabid unless proven otherwise. Very severe illness with near 100% fatality rate in the absence of post-exposure prophylaxis. The anthrax referred to here is naturally occurring and not a biological weapon.

15. Infectious Diseases Cont. Sexually Transmitted Diseases INTERMEDIATE RISK = gonorrhea, chlamydia, HIV, Hep B FHP Priorities Avoid sexual contact Use latex condoms if sexually active

16. Infectious Diseases Cont. Water-contact Diseases INTERMEDIATE RISK = leptospirosis FHP Priorities avoid unnecessary contact with lakes, rivers, streams, and other surface water

17. Infectious Diseases Cont. Respiratory Diseases INTERMEDIATE RISK = tuberculosis FHP Priorities Tuberculin skin test before and after deployment 72 sqft/person and head-to-toe sleeping arrangement Cough or sneeze into your upper sleeve instead of your hands Wash hands at every opportunity Avoid close contact with local population

18. Hazardous Animals & Plants Animals Rabid dogs, snakes, centipedes, scorpions, spiders Plants Mexican Poppy, Fetid Nightshade FHP Priorities Do not handle animals Shake out boots, clothing, & bedding Do not touch, chew, eat, or burn unfamiliar plants HAZARDOUS ANIMALS AND PLANTS Several species of highly poisonous snakes, which are well camouflaged and very aggressive, live in the region. Consider any snake encountered as poisonous, and do not handle. Seek immediate medical attention if bitten; untreated snakebites may cause serious illness or death within 1 hour. Several species of scorpions and spiders, some with potentially fatal venom, are present throughout the region. If possible, avoid sleeping on the ground. Shake out boots, bedding, and clothing prior to use, and never walk barefoot. If bitten or stung, seek medical attention immediately. Some regional plants have thorns, stinging hairs, or toxic resins that may puncture the skin or introduce poison into the skin causing skin irritation, rashes or infections. Avoid skin contact with plants when tactically feasible. Contact with the smoke from the burning of some plants can also cause skin rashes and damage to your lungs. Clean your clothing after contact with harmful plants. Decontaminate clothing by washing with soap and water. Some regional plants may cause systemic poisoning if leaves, berries, flowers, or other plant parts are chewed or swallowed. Symptoms include dizziness, vomiting, irregular heartbeat, and delirium or hallucinations. Snake Picture = McMahon's Viper. Sandy buff color dominates the body with darker brown spots on the side of the body, apparently rare and seldom seen. This viper is very irritable; it hisses, coils and strikes at any intruder. Venom is highly hemotoxic, causing great pain and tissue damage, hides during the day and active at dusk. Plant Picture = Mexican Poppy. Entire plant contains alkaloids - (can be transmitted through milk). Has caused "epidemic dropsy" (vomiting, diarrhea, glaucoma, abdominal swelling). Prickles cause irritation of skin. Found in arid areas. Other names Coffeeberry, alder buckthorn, common buckthorn, cascara. HAZARDOUS ANIMALS AND PLANTS Several species of highly poisonous snakes, which are well camouflaged and very aggressive, live in the region. Consider any snake encountered as poisonous, and do not handle. Seek immediate medical attention if bitten; untreated snakebites may cause serious illness or death within 1 hour. Several species of scorpions and spiders, some with potentially fatal venom, are present throughout the region. If possible, avoid sleeping on the ground. Shake out boots, bedding, and clothing prior to use, and never walk barefoot. If bitten or stung, seek medical attention immediately. Some regional plants have thorns, stinging hairs, or toxic resins that may puncture the skin or introduce poison into the skin causing skin irritation, rashes or infections. Avoid skin contact with plants when tactically feasible. Contact with the smoke from the burning of some plants can also cause skin rashes and damage to your lungs. Clean your clothing after contact with harmful plants. Decontaminate clothing by washing with soap and water. Some regional plants may cause systemic poisoning if leaves, berries, flowers, or other plant parts are chewed or swallowed. Symptoms include dizziness, vomiting, irregular heartbeat, and delirium or hallucinations. Snake Picture = McMahon's Viper. Sandy buff color dominates the body with darker brown spots on the side of the body, apparently rare and seldom seen. This viper is very irritable; it hisses, coils and strikes at any intruder. Venom is highly hemotoxic, causing great pain and tissue damage, hides during the day and active at dusk. Plant Picture = Mexican Poppy. Entire plant contains alkaloids - (can be transmitted through milk). Has caused "epidemic dropsy" (vomiting, diarrhea, glaucoma, abdominal swelling). Prickles cause irritation of skin. Found in arid areas. Other names Coffeeberry, alder buckthorn, common buckthorn, cascara.

19. SUMMARY Physical Environment Infectious Diseases = High Risk Hazardous Animals and Plants FHP measures are simple and effective Use and Enforce Will conserve the fighting strength Protecting unit personnel from disease and non-battle injury (DNBI) is critical to maintaining operational readiness, particularly on deployments. It is a medical responsibility to identify health threats and recommend appropriate countermeasures. Use the recommendations presented here to protect your health. The recommendations are useless without emphasis and action.Protecting unit personnel from disease and non-battle injury (DNBI) is critical to maintaining operational readiness, particularly on deployments. It is a medical responsibility to identify health threats and recommend appropriate countermeasures. Use the recommendations presented here to protect your health. The recommendations are useless without emphasis and action.