By Sheyla Medina
The welfare of the Afghan people and their access to adequate healthcare are closely intertwined with the sociopolitical, economic, and cultural factors of the nation. Afghanistan, plagued by long-term instability, is one of the poorest countries in the world with an average life expectancy of 46 years. The distribution of healthcare services for the population is highly influenced by location of residence (i.e. rural or urban environment), socioeconomic status, and gender. Afghanistan faces a continuous struggle to improve access to basic needs and equal rights to all citizens. The social effects of government instability and regional tensions, especially relating to the Taliban regime, intricately affect health development indicators among which maternal mortality is ranked high. Afghanistan is dominated by gender inequality, which provides a lens from which to examine the health situation in the country. Access to healthcare and basic needs for women is contingent on gender and permeating politicized religious values which restrict movement and access to health services and educational achievement. Socioeconomic factors, political instability, and deeply-ingrained traditionalist views have impacted the lives of women, restricting their activities, their access to education, and their availability to healthcare in an already crippled system.
Afghanistan is plagued by one of the worst health profiles in the world. According to the World Health Organization, Afghanistan has the second highest maternal mortality in the world: 19,000 maternal mortality per 100,000 live births1. The issues of healthcare access to women, the history of sociopolitical strife, the intricacies of gender relations, and the radical traditionalist views of recent years have perpetuated the cycle of birthing and maternal death.
Human rights for women in Afghanistan are intricately linked with their undeniable rights to healthcare. Since its independence on August 19, 1919, Afghanistan has undergone turbulent political struggles that have affected the lives of its citizens and have infringed on the liberties of women and their access to health services. Afghanistan continues to recover from 23 years of conflict involving the Soviet War in Afghanistan, the Civil War of 1989-2001, and the political and economic restructuring after the Taliban Regime1.
Following Afghanistan’s independence, the nation has undergone grave political instability and various internal impediments to further development. Due to its strategic location in south central Asia and its exercised neutrality after World War II, the Soviet Union provided the nation with approximately US$2.52 billion in aid while the United States provided US$533 million in economic assistance. Afghanistan’s King Zahir Shah adopted its first liberal constitution in 1964 that allowed for more political openness and established a bicameral legislature. However, instability overshadowed the decade of 1970 with the overthrow of the Shah by Mohammad Daud in 1973 and a military coup in 1978 by the People’s Democratic Party of Afghanistan (PDPA). The PDPA established a pro-Soviet communist government that only exacerbated the regional and tribal differences dominant in Afghan politics and implementation of any reforms. Without stable political sphere in Afghanistan, the government failed in implementing any sustainable structure to provide healthcare services and aid to its people. After the invasion of Afghanistan by USSR in 1979, a 23-year turbulent period began in which numerous people escaped to refugee camps in neighboring countries. Massive displacement prevented rural Afghan locations from remaining outside the conflict. Soviet occupation of Afghanistan severely strained the lives of the Afghan people, the established hierarchies of politics, and the link to scarce resources of care2.
Soviet invasion in Afghanistan marked the commencement of guerrilla warfare throughout the nation. The crippled healthcare system failed to provide hospital or other forms of medical aid to its citizens, driving more than 5 million Afghans to seek shelter in Iran and Pakistan. Due to the war, land and water resources were depleted. Irrigation, for example, declined to 3% of the original volume of water and yet the population continued to increase. Afghanistan’s climate and seasons of drought compounded the problem of uninhabitable locations for the people2. Civilian casualties caused by landmines dramatically increased mortality in Afghanistan, leaving many injured and without access to treatment in rural and remote areas of the country3.
Soviet control prolonged the 50,000 documented casualties in Afghanistan until 1989. The nation was left devastated, with its population displaced and dispersed throughout the region. Women and children faced the most critical consequences of the absence of healthcare, with child mortality as high as 31% and widespread malnourishment affecting the population. Political turbulence continued to plague the nation and was exacerbated by the Taliban’s foothold in Afghanistan.
The Taliban, in response to rampant corruption and abuses in Afghanistan’s political sphere, pushed for full dominance based on Wahhabism, an extreme interpretation of Islam. Despite its hopes to become the key model for governing a population in the Muslim world, the Taliban established itself to the world as perpetrators of human rights abuses and severe restrictions to women. The Taliban’s influence on educational services and healthcare aid to the Afghan population further threatened development and advancement of the people. Physicians and trained medical professionals either fled or were killed by the Taliban in their quest to eliminate any opposition to the “Holy War”. ‘For a large population of 25 million, only 6522 expected health facilities functioned for the public, including centers, district and national hospitals. The Taliban regime did not emphasize the care and sustainability of its healthcare centers: in Kabul, 8 of the 14 hospitals located in that region were not functioning due to the lack of infrastructure, supplies, and staff4.
Afghan society has a deep establishment of its traditional gender roles and conservative nature of a male-dominated way of life5. During the mid-1980s, the United Nations High Commission for Refugees (UNHCR) established 191 funded clinics within war-ridden Afghanistan to provide healthcare access to refugees. Even though these efforts helped in providing access to various rural areas in Afghanistan, the slow evolution and progress of maternal healthcare began to appear in 1986 with the project called Management Sciences for Health (MSH). The program focused on immunization initiatives for children and disease control activities5. MSH slowly attempted to introduce more healthcare access to women but the training of female health workers and the availability of personnel in rural areas was limited. The cultural undertones involving the low status of women made the target population inevitably vulnerable to the lack of healthcare access and prioritizing efforts to alleviate issues surrounding maternal health and birth delivery. Due to the political instability within the nation, the MSH program functioned outside of Afghanistan, in the neighboring country of Pakistan. Despite these constraints, Area Health Committees and participating organizations helped train traditional birth attendants in villages and provided more than 100,000 sterile delivery packs in rural areas5. The Maternal and Child Health (MCH) Strategy focused on training of health workers and the establishment of MCH facilities in the hopes of reducing the unexpected complications that arise from 15 to 20 percent of births5. Slowly, health care services were being offered to more women in rural Afghanistan due to MCH programs and traditional birth attendant trainings.
However, with the overwhelming effect of the Taliban and its enactment of 1996 radical decrees, the freedoms and access to education and healthcare for women were severely restricted. In its historical context, the Taliban established strict rules forbidding women of fundamental rights. Women were denied access to healthcare, access to education, freedom of movement without a male chaperone, freedom from violence and abuse, and employment outside the home6. The Taliban continued to enforce radical regulations by subjecting women who deviated from the rules to public beatings, torture, and public executions7.
The political atmosphere of the mid-1990s established a hostile environment for women and their access to healthcare. In a study entitled, “Women’s Health and Human Rights in Afghanistan: A Population-Based Assessment”,’ of the more than 1,000 women surveyed, 21% to 64% reported a lack of access to health care services and an inability to afford care during the Taliban reign8. These attitudes reflected in the survey and the Taliban’s enforcement of the restriction of women”s rights have led to strong socio-cultural beliefs and practices. Taliban guards were stationed by the Virtue and Vice Department and the guards enforced body concealment through the burqa for all female nurses and patients and hospitals and clinics. A female physician was not allowed to leave the home unaccompanied by a man. Taliban regulation of healthcare services transformed the sector into gendered-male healthcare providers9. During Taliban regime, male doctors faced stringent restrictions in caring for female patients to the point that they were not allowed to treat trauma patients due to their gender10. The “religious police,” members of the Department for the Propagation of Virtue and the Suppression of Vice, enacted drastic measures to deny hospital and medical services to women in Kabul, with the exception of the Central Polyclinic. The Central Polyclinic had 36 available beds, no running water, no surgical equipments or technology, thereby making it impossible to provide adequate maternal care10. Even though the ban on hospital and medical services was withdrawn after 2 months of heated negotiations with the International Committee for the Red Cross, only about 25% of surgical and medical hospital beds in Kabul were allotted to women, thereby decreasing their availability of proper care for childbirth. In 1998, the availability of care services decreased to 20% of medical and surgical beds for female adults.
The political instability of the nation has contributed to Afghanistan’s major role as one of 13 countries that account for 67% of all maternal deaths in the world11. The Taliban’s regime and influence on the healthcare sector has affected the health of women. According to the World Health Organization (WHO) report of 2002, only 35% of districts offered any maternal and child health services for its growing population. In addition, WHO claimed that Afghanistan lacked healthcare attendants with only 30% of traditional healthcare attendants available for births. Statistics dating after the Taliban regime ended show that the cycle of poor maternal health services still continues. In 2002, less than 15% of birth deliveries were attended by a trained healthcare provider and most of the healthcare providers were traditional birth attendants instead of physicians or nurses12. The situation of maternal mortality continues to appear dim for Afghanistan with surprising estimates of 50 women dying each day from complications of pregnancy in 2004. The nation faces a lack of consistency in proper immunizations for children, including only 11% of polio vaccination and 35% of measles vaccination.
Fundamentalist Islamic ideals and ongoing violent struggles in Afghanistan have impeded a steady and ongoing progress to alleviate the issue of maternal mortality. In 2000, Afghanistan was ranked 173rd in a list of 191 nations regarding the assessment of its overall healthcare system13. Through the examination of Afghanistan’s deeply ingrained traditions, gender discrimination, and its effects on women’s access to healthcare and maternal health services, we acknowledge the case of a nation crippled by constant warfare and instability that is slowly working for change. The significant involvement of non-governmental organizations and volunteer groups in Afghanistan has helped to educate rural inhabitants in traditional birth assistance and to establish maternal and child health clinics in the usually forgotten rural areas. The work of volunteer organizations is slowly gaining foothold in Afghanistan with a goal of increasing access above the 35% of 330 districts that have maternal and child health services13. With limited resources to date, the United Nations and NGOs have received 40% of funds to provide primary health services to the Afghan population13. Afghanistan is in the midst of change. The continued development of critical health services and preventative measures are imperative to improve the health situation for women in the country.
Sheyla Medina is currently attending the University of Pennsylvania, School of Arts and Sciences. With her interest in public health and international affairs, she is pursuing her undergraduate degree in Health and Societies with a concentration in International Health. She has been actively involved with Women’s Campaign International and the Congressional Hispanic Caucus Institute. As a Ronald E. McNair Scholar, Sheyla is producing a research project on dietary habits among school-aged girls in Lima, Peru. She can be contacted for questions or comments at sheylam@sas.upenn.edu.
References:
1 Library of Congress. “A Country Study: Afghanistan.” Mar. 1997. . Accessed on March 3, 2007.
2 National Human Development Report (NHDR) 2004: Security with a Human Face. Centre for Policy and Human Development. http://www.cphd.af/nhdr/nhdr04/nhdr04.html. Accessed on March 5, 2007.
3 Bhutta, Z. A. “Children of War: The Real Casualties of the Afghan Conflict.” BMJ (Clinical Research Ed.) 324, no. 7333 (Feb 9, 2002): 349-352.
4 Sharp, T. W., F. M. Burkle Jr, A. F. Vaughn, R. Chotani, and R. J. Brennan. “Challenges and Opportunities for Humanitarian Relief in Afghanistan.” Clinical Infectious Diseases : An Official Publication of the Infectious Diseases Society of America 34, no. Suppl 5 (Jun 15, 2002): S215-28.
5 O’Connor, Ronald W. Health Care in Muslim Asia : Development and Disorder in Wartime Afghanistan. Lanham, Md.: University Press of America, 1994, p. 44, 45, 169.
6 Agosín, Marjorie. Women, Gender, and Human Rights : A Global Perspective. New Brunswick, N.J.: Rutgers University Press, 2001, p. 107.
7 Revolutionary Association of the Women of Afghanistan (RAWA). “On the Situation of Afghan Women” RAWA article. Mar. 2007. http://rawa.org/wom-view.htm. Accessed on March 3, 2007.
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9 Rasekh, Z., H. M. Bauer, M. M. Manos, and V. Iacopino. “Women’s Health and Human Rights in Afghanistan.” JAMA : The Journal of the American Medical Association 280, no. 5 (Aug 5, 1998): 449-455.
10 Schulz, John J. and Linda Schulz. “The Darkest of Ages: Afghan Women Under the Taliban.” Peace and Conflict 5, no. 3 (1999): 237-254.
11 Abou Zahr, C. “Global Burden of Maternal Death and Disability.” British Medical Bulletin 67, (2003): 3.
12 World Health Organization. “Mortality Country Factsheet 2006.” Afghanistan. (2006). Via World Health Organization http://www.who.int/whosis/mort/profiles/mort_emro_afg_afghanistan.pdf. Accessed on March 5, 2007.
13 Sharp, T. W., F. M. Burkle Jr, A. F. Vaughn, R. Chotani, and R. J. Brennan. “Challenges and Opportunities for Humanitarian Relief in Afghanistan.” Clinical Infectious Diseases : An Official Publication of the Infectious Diseases Society of America 34, no. Suppl 5 (Jun 15, 2002): S216.