by: Dr Khesrow Sangarwal and Sahar Emran
Is Inter-Cousin Marriage a Public Health Problem in Afghanistan?
Studies have suggested that the prevalence of intra-familial unions in Middle Eastern and Asian populations could be as high as 50% of all marriages . One study has estimated the consanguinity rate in Afghanistan to be in the region of 40-49% . However, there is no documented evidence in the literature showing a scientific survey that has determined the true prevalence of inter-cousin marriages (ICM) in Afghanistan.
Anecdotal evidence is suggestive of a very high rate of marriage between first cousins in Afghanistan. The century’s long history of isolation owing to the extreme climate, mountainous terrain, foreign aggression, fierce competition for space and scarce resources and other factors have led Afghan communities to adopt a very cautious and defensive lifestyle.
One feature of such a guarded way of life in historic and rural Afghanistan is its peoples’ preference to keep marriages within the household. While highly incestuous marriages are strongly prohibited and widely abhorred, and are an almost unheard phenomenon in Afghanistan, marriages between first cousins is commonly practiced, socially accepted, and in a lot of cases an encouraged practice.
Afghan families often find ICM to be a safe and stable approach to building families. Knowing a person for many years and sharing the same social circle is arguably a scenario that is conducive to a more stable relationship; anecdotally speaking, consensual ICM tend to be happier and longer lasting than most other marital arrangements .
Many undocumented personal stories have also suggested that intra-familial marriages are economically more favourable, as both parties, being from the same family, may not charge for the often unaffordable wedding expenses i.e. the ‘Walwar’, and the ‘Jehiz’ (dowry). Moreover, it may be a means of keeping family wealth and property within the family and maintaining the family structure.
ICM increases the risk of autosomal recessive disorders. The manifestation of such diseases requires the presence of two copies of the defected gene; one from the mother and one from the father. In a closed or restricted genetic pool, the number of carriers (that is, individuals carrying one copy of the defected gene) for a given recessive disorder increases with each generation. Therefore, there is an increased likelihood that two carrier individuals, who are themselves unaffected and thus unaware, will have an affected child. Repeated consanguineous marriages within a population are more problematic than isolated cases.
A second, and perhaps secondary, risk is that which concerns population diversity; increased and repeated consanguinity within a population is associated with decreased genetic diversity, which is unfavourable in the face of infectious pathogens, such as tuberculosis and hepatitis. A genetically diverse population can more effectively minimise the detrimental effects of infection, owing to those individuals possessing a genetic profile that makes them less susceptible. These individuals are in turn more likely to survive to have children who may also inherit the protective gene(s).
The genetic health hazards of ICMs are well established in the literature. According to the Royal College of Paediatrics and Child Health reports, “the Born in Bradford study, which followed the health of 13,500 babies born at Bradford Royal Infirmary between 2007 and 2011, has found that marriage between first cousins doubles the risk of children being born with birth defects.”
In Afghanistan, doctors have reported an increased prevalence of congenital diseases in the offspring of first cousin marriages. Thalasaemia Major is one of such conditions, and has cost the lives of many young Afghans, from poor and wealthy families alike.
Some have questioned the significance of the health risks from ICM, arguing that the social advantages far outweigh the health hazards. “The risk of birth defects in children born to first cousins is increased from a baseline of 3-4 percent to 4-7 percent according to the National Society of Genetic Councillors (NSGC). In this modern age, this risk could be mitigated by mandating — as the State of Maine has done — pre-marital genetic testing. The NSGC, however, considers the risk to be so insignificant that it does not recommend additional testing or screening.”
Some participants at today’s discussion suggested that while the health-related hazards of ICM are real and tragic for some families, it is important not to generalise the negative genetic implications of ICM, since those ICM families who have healthy unaffected children may be wrongly labelled.
Proportional and tailored
Others argued that the scale of the problem concerning ICM is trivial compared to much bigger healthcare problems that present-day Afghanistan faces, namely the lack of clean drinking water, infectious diseases, and war-related casualties. Efforts to improve the nation’s health must be proportional and tailored to the degree of threat of these problems.
Burden on the healthcare budget
The healthcare cost of disabilities and health problems resulting from ICM can be vast and unaffordable, both for the individual affected households, and for the national healthcare system. This leads to difficult ethical discussions of justice and equality; some people might argue that a poorly funded healthcare system should not have to pay for the medical costs of treating diseases that have resulted from a lifestyle choice, i.e. the choice to marry a cousin, at the cost of depriving a vast majority from the essential healthcare necessities. There is of course a counter-argument to this, and either way the phenomenon will be a public health issue.
Absence of Evidence
Participants argued that the present lack of evidence-based research concerning ICM and its implications in Afghanistan makes it difficult to have a meaningful debate with regards to dealing with the phenomenon as a public health issue. They advised that the Ministry of Public Health and academic institutions, both within Afghanistan and abroad, should initiate research to determine the scale of the problem. At the moment we may either be over-reacting to something that could be a socially benign phenomenon, or under-reacting to what could be tip of the iceberg in terms of its medical and genetic hazards.
It was also argued that while such evidence is awaited, it is only sensible to extrapolate the existing research from other countries with similar demographics to Afghanistan, and find solutions to what has caused significant problems elsewhere.
The way forward
All participants agreed that despite the lack of evidence-based research in relation to this problem, ICM and its health hazards is a reality, and the state should find ways to reduce its burden, both on the nation’s health and the economy. Some participants advised the Afghan Government to be proactive, and act before the problem potentially escalates into a more expensive and tragic situation. There is a lot that the Government can learn from the experience of other nations who have been dealing with the phenomenon for many years.
The majority of the participants were of the opinion that while it is no one’s place to suggest to ban, or to even discourage ICM, the State must take the essential steps to raise public awareness about the health hazards of ICM. Many Afghan couple and families who enter ICM are unaware of its genetic implications, and only learn about them the difficult way. Raising public awareness will mean that couples will be in a position to calculate their risks and make an informed decision. The free will of well-informed individuals should be respected.
It was further argued that effective family planning, access to genetic counselling, and respect to the ethical, cultural and religious values of people should be at the heart of any public awareness campaign. Such a campaign will not be an easy undertaking as at times it will be a challenge to peoples’ health beliefs, which have centuries-old roots. The general aim should be that people will be able to associate consanguinity to high risk genetic diseases.
Offering genetic screening for couples who enter ICM was raised as an interesting suggestion. The practical issues surrounding genetic screening were also mentioned – for example, not all genetic disorders can be screened for, and since genetic problems are quite dynamic screening will not pick up spontaneous mutations. Genetic testing and screening, however, tend to be very expensive and difficult to maintain. Moreover, some have queried the prioritising of the public health budget towards genetic screening above the other, more urgent, requirements of a war-torn country.
Discourse Afghanistan is working on devising a survey to try to scale the prevalence of ICMs in Afghanistan. It has started the preliminary work in designing a study that will be conducted in Afghanistan. Those interested in getting involved in the study can contact Discourse Afghanistan: firstname.lastname@example.org
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