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Keywords: Afghanistan, Neural Tube Defects, Folic Acid Fortification

Background: Afghanistan suffers from one of the highest burdens of neural tube defects (NTDs) in the world, estimated to be seven times higher than in the United States. Neurosurgical capacity-building initiatives between NeuroKids and Mass General Brigham Global Neurosurgery trained Afghan neurosurgeons in pediatric endoscopic procedures to address NTD complications. Successful project implementation in the city of Jalalabad, in Nangarhar province, catalyzed a systems approach to addressing NTDs across the care continuum. Downstream interventions include strengthening neurosurgical capacity and pediatric care in Afghanistan. Upstream interventions include folic acid fortification – an intervention shown to decrease NTD prevalence by 50-70%.

Objectives:

1. Characterize clinical (downstream) opportunities for improvement along the pediatric neurosurgical pathway
2. Develop a policy framework for folic acid fortification as a primary prevention strategy
3. Design a hospital-based NTD monitoring and surveillance system at Nangarhar Regional Hospital
    

Design: A mixed-methods landscape analysis was conducted through literature review and semi-structured interviews with key stakeholders (neurosurgeons, program administrators, NGOs, public health officials). Findings were synthesized to inform policy briefs, implementation planning, and monitoring and evaluation frameworks for NTD prevention and pediatric post-surgical care in Jalalabad, Afghanistan.

Impact/Effectiveness: The landscape analysis identified wheat as a feasible fortification vehicle for addressing folic acid deficiency. A policy brief was developed in May 2026, with positive preliminary stakeholder engagement. Policy adoption and scale-up are expected to reduce NTD prevalence in Jalalabad by 50-70%, based on global evidence. The proposed timeframe for implementation and assessment of impact is 3-5 years. Key downstream systemic bottlenecks were identified: pediatric hypothermia, limited pediatric intensive care unit (PICU) capacity, and inconsistent pediatric sepsis protocols. Stakeholder meetings were initiated in April 2026 to discuss implementing high-impact, low-cost Embrace warmers to decrease mortality due to pediatric hypothermia.

Lessons Learned: Addressing NTDs in Afghanistan requires a cross-sector approach involving neurosurgery, pediatrics, maternal health, nutrition, and agriculture. Advanced tertiary care — often deemed unfeasible in low-resource and post-conflict countries — can serve as a critical entry point for health systems strengthening. Meaningful engagement of local stakeholders is essential for sustainable implementation.

Summary: This project operationalizes a systems-level approach linking neurosurgical capacity-building and public health nutritional interventions to decrease NTDs in Jalalabad, Afghanistan. The integration of specialized clinical care, policy development, and local stakeholder engagement provides a framework to reduce NTDs in similar low-resource, post-conflict settings.