The tremendous uncertainty that surrounds the health status of millions of refugees in exile underscores the need for health referral data for this population. Currently, the worldwide occurrence of non-communicable disease is 43%, but is expected to increase to 60% and cause 73% of all deaths by 2020. Most of this will occur through epidemics in developing countries such as Iran, especially among refugee populations[28–31].
Age and gender
Afghanistan is in the early stages of demographic transition, which will become more evident by 2025[28, 32]. The percentage of the population 65 years of age and older will increase from 2.1% in 2000 to 2.9% in 2025. Older residents are more likely to be affected by NCDs, and it is expected that disease rates will rise commensurate with aging.
The most common cause of referrals among 0–14 year olds was perinatal disorders, which are documented as communicable diseases in Afghanistan and Iran. In this age group, referral rates for males and females are identical. Better health status, along with greater access to health services in Iran, are thought to have resulted in reduced referral rate for refugees in this age group, compared to similar populations in Afghanistan. However, because medical costs are higher for refugees compared with citizens in Iran, limitations may eventually restrict access.
Those15-59 years of age had 54% of referrals and constitute the largest number of Afghan refugees. Ophthalmic diseases were the most common cause of referrals. Because this age group represents the bulk of the workforce in the diaspora, the impact of these diseases is clear. Referral rates in this group were higher for females. This can be attributed to the role of women as the head of the household, as well as to the documented reluctance of men to seek medical care due to the high cost.
In our study, only 17% of referrals were by refugees aged 60+. The most common condition was ophthalmic, followed by cardiovascular disease. Referral rates were higher for women in this age group, which may be attributed to two factors. Afghan women in Iran have been traditionally involved in handicraft, which has been associated with greater occurrences of ophthalmic diseases[34, 35]. In refugee settings, men are also seen to use health care services less frequently than women.
Chronic diseases such as heart disease and stroke are prevalent among elderly populations, including refugees[36, 37]. However, the reduced number of chronic cases in our population may be attributed to factors such as a) language barriers and incorrect interpretation and translation services, b) cultural and structural barriers, and c) the lack of access for preventative care and treatment.
The Hazara, Tajik, Fars and Sadat ethnic groups incurred the most referrals for ophthalmic diseases, probably as a result of their trade and livelihood, e.g. construction workers, handicraft jobs[34, 35]. The number of referrals for smaller groups such as the Pashtun and Baluch may not be truly representative, as they reside mainly in the south and southeast of Iran, and data for these populations may be incomplete.
Afghan refugees are uniquely distributed in neighboring countries for several reasons. With the communist takeover of 1978, their migration has been heterogeneous in regards to race and religion. History, culture and religious differences have had a significant impact on where Afghans have settled. Pashtuns have more often migrated to Pakistan because of ethnic, linguistic and religious similarities. Nearly 40 million Pakistanis in the region bordering Afghanistan are of Pashtun origin, speak Pashtu and are Sunni Muslims, germane to their Afghan refugee counterparts. The Hazara are mostly Shiite, speak Farsi, and live mainly in the northern and northeastern regions of Afghanistan. This religious and linguistic proximity draws them disproportionately to Iran (55% vs. 40.47% of all refugees).
The retrospective analysis of data from UNHCR offices in Iran limits our choice of variables, and may be inferior to a prospective, active data collection research paradigm. Most retrospective studies rely on the accuracy of data records, and/or the recollection of individuals. Similarly, our study has relied on the accuracy of data entry by interviewers. Moreover, inconsistencies in record keeping between UNHCR offices did not allow comprehensive data to be compiled for the entire country of Iran. Referral rates were calculated assuming equal access to referrals by all Afghan refugees, and on the homogeneous distribution of age groups in the country.
There are more than 2 million unregistered foreigners in Iran, mostly Afghan and Iraqi nationals, who were not included in this study. This report also does not consider communicable, diarrheal and parasitic diseases which are prevalent in Afghanistan and are considered a major part of the healthcare burden in Iran. These conditions may be mitigated by access to safe drinking water and vaccination, and allocation of resources to costly in-patient treatment and care.