Staring into the darkness: women health workers in Afghanistan

Any limitations on the autonomy and mobility of women and girls will add a significant burden to an already strained healthcare system, write Laura Jung, Lilly Khorsand, Anita Afzali, Mariam Mariam Dahir, Mohammad Yasir Essar, and Roopa Dhatt

In a few days, Afghanistan will go radio silent once again, much like it was under the Taliban’s rule in 1996. But this time there are smart devices everywhere, so we will still hear the voices of those left behind to bear the consequences of the world turning its back on young people in Afghanistan who were promised better lives. Once again in Afghanistan, girls and women under Taliban control have to fear a violation of their dignity and loss of their hard won freedoms, rights, and future. And once again, the rest of the world is looking on.

Everyone involved on the ground and abroad, those who fear for their lives and those working to save the ones left behind, are sharing the same emotions: numbness, anger, and profound sadness. To say that Women in Global Health (WGH) is deeply concerned about the deteriorating conditions as the crisis unfolds and access to healthcare becomes challenging does not scratch the surface. We are outraged by what the situation in Afghanistan ultimately represents. The most vulnerable people, ultimately, have nowhere to turn in times of crisis. 

Female healthcare workers are at the centre stage of this conflict, torn between the increasing health needs of the population and the insecurity they are facing for simply working to do their jobs under Taliban rule. Moreover, future female healthcare workers who are about to enter their profession will suffer a great loss and mental anguish because of this current turmoil, which could put an end to the future they’ve worked so hard for. The loss of dreams, passion, and service within the blink of an eye is devastating. The forthcoming targeting, segregation, discrimination, and punishment of the female health workforce will not only place a high burden on these women, but will most likely threaten the extinction of public health efforts in Afghanistan as a whole.

An end to progress?

Afghanistan’s enormous progress in public health celebrated over the past two decades, most prominently the sharp decline in maternal and child mortality and polio eradication efforts, was only possible thanks to the contribution of women—including, but not limited to, physicians, nurses, midwives, pharmacists, and an inspirational troop of community health workers. Four out of 100 outstanding nurse and midwife leaders across the world in 2020 came from Afghanistan. Women also make up nearly half of Afghanistan’s community health worker (CHW) programme. Those CHWs are volunteers, working in harsh conditions, but providing central services such as management of childhood diseases, tuberculosis, women’s health and family planning to communities in different provinces. We acknowledge that despite this, living conditions were still far from ideal and high rates of poverty and malnourishment were always present, but the wins in public health over the past 20 years (which we have certainly seen) would not have been possible without dedicated Afghan women who took the reigns as healers and leaders in the nation.  

The latest wave of covid-19 cases makes now the worst moment to lose any female health workers, as the pandemic has magnified Afghanistan’s healthcare challenges. The rise of the Delta variant, low rate of vaccinations, and vaccine hesitancy have all added to the strain on Afghanistan’s fragile health system. While the rest of the world is developing national health policies, including ongoing safety measures that will help manage the next surge of covid-19, the people of Afghanistan are contending with both the pandemic and survivorship of a turbulent regime change. This is a humanitarian crisis with no end in sight. 

We are likely to see a public health emergency unfolding, with spiking demand for mass casualty response, trauma care, and cholera and diarrhoeal disease prevention and management, according to the World Health Organization. Any limitations on the autonomy and mobility of women and girls under the Taliban’s strict interpretations of Sharia law threaten access to, and delivery of, equitable healthcare services for everyone in this unpredictable situation. Afghanistan has one of the lowest health workforce densities globally—especially in its rural regions—and exclusion of women from the health workforce will add a significant burden to an already desolate system.

A curb to women’s healthcare contributions

How far the Taliban will go with their restrictions is still unclear at this point, but already the insecurity surrounding anticipated changes is causing distress, as well as self-restriction among healthcare workers. While it was announced that everyone, including women, should continue to go to work, the reality in parts of the country is different. One hospital in Kabul reported that segregation of men and women, for staff as well as patients, had been requested already. Other medical teams noted that roadblocks and gunfire have made it impossible for them to leave their houses for work some days. Women are especially restricted in their freedom of movement and often require male guardians to merely leave their homes. Even midwives have to be accompanied when doing home visits. Due to lack of information, some are stuck at home entirely, waiting for new directions. While women health workers are eager to continue to deliver much needed healthcare for Afghan patients, the restrictions make it harder. 

During the Taliban’s previous rule, physicians were not allowed to see patients of the opposite sex, restricting the type and amount of care patients were receiving. Forcing women out of the health workforce completely or limiting who they can care for could bring most services to a halt and complicate medical care, especially for female patients, who will already be dependent on male family members giving them permission to be treated. This again poses exacerbated risks—particularly for maternal and newborn health, with a predicted increase in home deliveries and support by unqualified staff, as seen in other regions during civil war and political turmoil. 

A lost generation of female health workers     

While female healthcare workers fear for their own future, the situation is even more dire for the next generation of healthcare professionals. Disruption of women’s education and training, in addition to trained health workers fleeing Afghanistan, could mean a long term shortage of female healthcare staff in the country. Currently, 40% of students in Afghanistan are female (with stark differences between urban and rural areas), but with the Taliban’s restrictions on women’s education and training, including recently announcing gender segregated classes and education in one province, this certainly will seriously disadvantage female healthcare students and their career aspirations. Under the last Taliban rule, female students were not permitted to attend medical school, and women have only been graduating again in medicine since 2006. This progress is now under threat again. Instead of planning for their careers, frightened Afghan women are burning their certificates and diplomas, destroying everything they have been working for in the past two decades. They are trying to make their achievements invisible overnight in a desperate attempt to save their lives.

The exclusion of Afghan women from public decision making will silence women’s voices further when it comes to national and international priority setting for health and lead to the collapse of supportive platforms for women. While it is yet unclear who will be in charge of public health in the country, there is a relative certainty that women’s issues will once again be sidelined under the new rule. Gender equity had not been reached in the former administration and women were lacking in international policy making and peace talks. However, at the start of 2021 27% of parliamentarians in Afghanistan were women, the same percentage as in the US. Now it is even more unlikely that women’s expertise and perspectives will be adequately represented in health decision making, government, or public health policy—including women’s health.

A global threat to health

Finally, this is about more than Afghanistan. With the political turmoil, insecurities, and violence throughout the country, public health initiatives came to a halt, and it is yet uncertain if or how they will resume. Most prominently, this affects covid-19 measures and vaccination campaigns, which have seen a sharp decline after the Taliban’s conquest of Kabul

Another victim of the instability is the global polio campaign. Vaccinations restarted in July after disruption due to covid-19 but are now pending again. In the past, the Taliban had often opposed and blocked vaccination services, which they linked to American rule. The stance the Taliban will take on polio is not yet determined, but even if they allow the campaign to go forward, restriction on women’s movement, as both vaccinators and mothers, will severely slow progress. The success of public health campaigns depends on women who deliver these services, and also on women in the communities being able to access them. Limitations on the autonomy of women and girls is a threat to infectious disease prevention, with an impact that could be felt globally. 

The current instability in the country and the lack of information leaves female health workers in Afghanistan hanging off a cliff. At a time when their country is facing more than one public health crisis, women in the health workforce are being restricted, threatened, and left in fear. Dreams, career aspirations, and passion and talent for the profession of medicine and service for the people are being erased and forbidden for so many women in the country. Even the risk of speaking out is too high for many female health workers in Afghanistan or in the diaspora at the moment, as they are fearing for the lives of themselves and their loved ones. This piece is also an account of the testimonies we received from multiple women who therefore don’t want to be named. We cannot leave them hanging in that moment full of fear, where every day brings new dilemmas and new rules restricting their freedoms.

Urgent actions are required to avoid any further exacerbation of the public health crisis and to protect everyone in need, as outlined by colleagues. For female health workers specifically, all measures must be taken to enable them to live and work safely, with dignity and without harassment, wherever they choose to live. This includes immediate evacuation of women and their families trying to leave the country, as well as the provision of safe places for them to go. It also means we must stand our ground on girls’ and women’s rights and not compromise on hard earned freedoms. 

Without women, Afghanistan is at high risk of losing public health gains. The exorbitant impact of forcing women out of the health system will be paid by men, women, and children in the entire country and possibly the world. Health services and international organisations must ensure continuous provision of care to those affected by the conflict and its consequences. Afghan women, and with them the whole country, are hanging off a cliff— we cannot turn away from them.

In the name of Afghan health workers, who choose to remain unnamed for the safety of their loved ones

Laura Jung, medical doctor and research associate, Women in Global Health

Lilly Khorsand, research and communications associate, Women in Global Health 

Anita Afzali, professor of clinical medicine, Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center

Mariam Dahir, medical doctor and member of Women in Global Health Somalia 

Mohammad Yasir Essar, Kabul University of Medical Sciences, Kabul, Afghanistan

Roopa Dhatt, co-founder and executive director, Women in Global Health

Competing interests: none declared.