Afghanistan’s Deteriorating Healthcare System

Afghanistan’s healthcare infrastructure is crumbling after its foreign assets were frozen and donor organizations pulled funding after the Taliban takeover. The Taliban is a Pashtun Islamic extremist group that is known for imposing strict religious and conservative rule over their areas of operation including Afghanistan and Pakistan. The organization previously served as the government for southern Afghanistan in 1996-2001 during which the healthcare system had collapsed. The child mortality rate was 2x as high as it was in 2012 and polio was widespread. Safe drinking water and sanitation were also nonexistent.

Over the past two decades, non-governmental organizations (NGOs) have historically provided 75% of the funding and supplies to support the healthcare systems in 31 out of the 34 provinces of Afghanistan. As a result, the Middle Eastern country has seen enormous improvements in the healthcare system. As of 2018, with over 3,000 medical facilities staffed and supplied, about 87% of the population were able to receive services. Maternal and child mortality rates also plummeted and infectious disease treatment programs helped decrease mortality rates.  

International donor support started declining even before the Covid-19 pandemic, and Afghanistan’s Ministry of Health and other public health organizations were barely able to compensate. The economic decline at the onset of the pandemic made medical resources even more scarce. Hospitals began charging payment for supplies such as meals and scalpels previously free to patients, and patients were forced to use their own money to buy surgical equipment. In April 2021, President Biden announced that the United States would withdraw all of their 2,500 troops from the Afghanistan, triggering the entire NATO (North American Treaty Organization) alliance to withdraw a total of 7,000 troops. The process was completed in mid-September. Shortly thereafter, the Taliban rose to power once again in Afghanistan.

 A pile of international notes from the United States, Turkey, and Europe.
A pile of international notes from the United States, Turkey, and Europe. Source: Unsplash

The World Bank then froze $600 million in health care aid funded by the US Agency for International Development, the European Union, and others. The $600 million was part of the Sehatmandi project, a global initiative to increase health facilities in Afghanistan, which was a collaboration with the Afghanistan government. The withdrawal shut down 2000 of the 2800 facilities that the project previously funded, leaving healthcare workers and patients out in the wind. Currently, healthcare workers have not received payment in 6 months and do not know when they will receive payment. Many patients struggle to reach the remaining facilities because the trip there is either unaffordable, geographically dangerous, too far, or the route is lined with Taliban conflict. 

If provided now, donors feared that donations and allocations would be misused by the Taliban to generate income for the militant group instead of for healthcare problems. There is speculation that if the funds are released, wages will never reach workers and medical supplies will be bought then sold to the public at astronomical prices. All entities are waiting on instructions or action from other governments to search for a way to transfer donations in order to circumvent the regime’s administration.  

Healthcare for Children 

A toddler girl biting into her shirt sleeve next to her parent.
A toddler girl biting into her shirt sleeve next to her parent in Afghanistan. Source: Unsplash

Hunger is becoming more widespread as inflation rates climb and supply chains grow unsteady. The Integrated Food Insecurity Phase Classification (IPC) reported that half of Afghans will face acute food insecurity before winter arrives.  

Malnutrition and malnutrition-related illnesses are far more dangerous than any other disease for children. Specific types of malnutrition called acute severe malnutrition and child kwashiorkor, a severe protein deficiency, is prevalent in Afghanistan and are caused by eating too little food or not at all. It can be treated by administering Ready To Use Therapeutic Food (RUTF) and oral hydration therapy. Over 2 million children under 5 years old do not have access to this life saving treatment in Afghanistan. At least half of the children in the country are victims of malnutrition and in light of the food scarcity, mothers unable to produce breastmilk have resorted to feeding infants water mixed with sugar. 

Staffing shortages are also insurmountable. Nurses and doctors fled the country fearing what the Taliban’s takeover could mean for their lives. In the main children’s hospital in Kabul, nurses previously caring for 4 babies now have to care for 24 babies each while hospital staff try to squeeze 3 infants into 1 incubator due to equipment shortages. Current staff are overworked and still have to take up jobs at other institutions to get by. Medicinal needs are also not being met for children and adults. Drug cabinets and storage closets become emptier every day as the influx of patients has depleted the resources faster than can be transported into the country. 

A hand holding a cluster of large, yellow tablets.
A hand holding a cluster of large, yellow tablets that are basic medications that Afghans need. Source: Unsplash

Women’s Health 

The aid cuts have also decreased access to essential healthcare resources for women and girls, including contraception and family planning. Many women carry out risky pregnancies and are subjected to unsafe reproductive procedures without modern medical equipment. Prenatal and postnatal care for infants is not provided, and postpartum care for new mothers is nonexistent. Despite the labor shortages, a great deal of responsibilities for maternal health clinics are on the backs of midwives. Midwives continue to perform complicated surgeries, dangerous deliveries, and other reproductive procedures.  

Expensive medicines and transportation to clinics for health problems are not feasible for the majority of Afghan women. Beginning in early 2017, extremist groups turned their sights on medical facilities in Afghanistan, which led to increase of attacks on aid workers, doctors, and hospitals. Mounting fear against staying in maternity clinics has also driven many women away from seeking help.  

Covid-19 Pandemic 

The lack of data and accountability in Afghanistan makes it difficult to comprehend the extent to which the virus has contributed to the death rate. Around the world, Covid cases are increasing, and the Afghan population is largely unvaccinated. According to the latest data from the United Nations, only 2.2 million of 39 million individuals have been vaccinated, while 1.8 million doses are waiting to be distributed.  

Public health experts worry that an impending 4th wave of the disease will render the healthcare infrastructure irreparable. Dead bodies line hospital morgues and overflow into the outside corridors as the lack of fuel has stopped ambulances from operating. Many sick patients suffering from Covid don’t bother coming to hospitals, because they know they would not be able to receive medical assistance. Hospitals, private practices, and clinics are resorting to hastily assembling makeshift wards outside hospitals to accommodate Covid patients.  

The healthcare situation in Afghanistan has been worsening for years, and in light of the looming public health disaster, much more support from the international community is needed. The snowball effect of international neglect will continue unless major monetary, political, economic, and healthcare interventions are considered. Nonprofit health organizations such as Doctors Without Borders have been tackling both maternal and child healthcare as well as managing Covid cases in 5 provinces, but people can help by donating to Doctors Without Borders, United Nations Children’s Fund (UNICEF), and increasing awareness for the healthcare crisis in Afghanistan. 

Another Battle for Bodily Autonomy in Trans Youth

On February 10, 2021 the Alabama Senate Health Committee voted to criminalize transgender medicaltreatment for minors. With an 11-2 vote, the committee approved Senate Bill 10 (SB-10), a bill that will “outlaw puberty blocking medications and gender-affirming care for minors.” On March 3, the Alabama Senate passed this legislation, and it is currently awaiting Governor Kay Ivey’s approval. SB-10 empowers the legal system to prosecute clinicians and pharmacists with felony charges if they prescribe medication or provide treatment to aid in the transitional processes of minors. Bill sponsor Senator Shay Shellnutt (R-AL) claims that “minors are too young to be making this decision.” The Senator has also admitted that he’s never interacted with a trans teen before submitting the bill. Opponents of the SB-10 refute Shellnutt’s claim by acknowledging this decision is between the medical care provider, the patient, and the patient guardians. As such, SB-10 infringes on the private rights of parents to care for their children with necessary and proper interventions. Shellnut has mentioned that hormonal treatment and other transgender interventions cause long term issues and that a child is not mature enough to be making such a permanent decision. Shellnut’s claims are false; the effects of hormonal drugs that are puberty blockers are reversible. Also, when evaluating long term effects of gender reassignment surgeries, doctors prefer to wait until the patient is at least 18 years old before they perform the surgery.

A person holding a sign with a metaphor describing gender.
Source: www.mindfulword.org

Doctors must take the Hippocratic Oath which defines their ethical conduct and moral reasoning. There are two main tenets of the Oath: “benefitting the ill and protecting patients against personal and social harm and injustice.” Not only does SB-10 force doctors to dishonor the Hippocratic Oath, but it is also medically harmful to the patient pursuing care and prevents them from confiding in their medical care team. Dr. Marsha Raulerson says it will “take away child’s confidence in trusting doctors with their thoughts and to talk candidly.”

Healthcare providers are only one pillar of the support system for patients wishing to transition. So, when healthcare providers are unable to provide care to these young individuals, it can harm their mental and physical wellbeing and contribute to gender dysphoria. Adolescent and young adult years are incredibly formative. It’s in these years that young people thrive and when they are in need of a lot of support and care. When their support systems and adequate healthcare is taken away “adolescents can feel alone, stigmatized, and undervalued”. Rejection, discrimination, and stigma during these formative years can put young adults at a higher risk of mental health disorders such as depression and anxiety. The aforementioned mental health disorders can lead to the usage of addictive substances like drugs and/or alcohol, and suicidal ideation. These factors contribute to significant health disparities within the LBGTQ+ community. It’s vital the care they receive is given without stigma and affirms the patient’s sexuality and gender identity, but this care cannot be given with government intervention that holds traces of transphobia.

Protestors gathering against the transgender military ban legislation.
Source: www.britishherald.com

Gender is a very dynamic concept, and there is no binary. It is up to the individual to choose their identity. Gender reassignment treatments and procedures are one way to reaffirm and respect an individual’s choice. LGBTQ+ youth deserve to know that they are respected and that they deserve quality healthcare and treatment. Healthcare providers should not be prevented from fulfilling their responsibilities. They should be able to provide quality care and treatment for their patients. If they can’t, they should be able to refer the patient to a doctor who can provide adequate healthcare. This is not the first time SB-10 has been passed to the full Alabama Senate. It was passed all the way up to the Governor in 2020 to be signed into action and is only back on the table due to COVID-19 complications. Advocacy is an important aspect of healthcare, and providers should be willing to advocate the most for marginalized communities. It is important to lift barriers to care for these groups, instead of continuing to make healthcare inaccessible.

A separate companion bill (HB-391) is currently in the Alabama House. This bill would restrict transgender students from participating in school athletics with the gender they identify with. Lawmakers that support the bill claim that it protects fairness for female and “keeps them from having to compete against transgender athletes who were born male.” The biggest difference to make right now is to call Alabama Senate representatives and tell them the harms these bills will cause to LGBTQ+ youth and to the healthcare providers that try to help them.

Reproductive Justice: Voices Not Just Choices

What Is Reproductive Justice?

Indigenous women, women of color, and trans people have long fought for the right to make decisions about their bodies. Coined in 1994, the term reproductive justice is defined as the “human right to maintain personal bodily autonomy, have children, not have children, and parent the children we have in safe and sustainable communities.”

One way to differentiate reproductive justice from reproductive rights is that the latter is the “legal right to access health care services such as abortion and birth control”. Initially, spokespeople of this women’s rights movement often included educated wealthy, middle class White women. This left marginalized communities and minority women who did not have easy access to their rights with minimized opportunities to voice their problems and experiences. This begs the question of what good are these rights, if they aren’t accessible. Built upon the United Nations human rights framework, reproductive justice is an intersectionality issue where reproductive rights and social justice are combined so the voices of LGBTQ+ people, marginalized women, and minority communities are uplifted.

Abortion as a Voice, Not a Choice

Choice comes from a place of privilege. The chance of deciding reproductive options is more easily accessible to middle class White women, while these same options are typically unavailable or restricted for poor, low-income women of color. These are the same marginalized women who historically bore the burden of unethical research in reproductive medicine from issues regarding the study of gynecology, to sterilization, and everything in between. For example, James Marion Sims, the father of modern gynecology, conducted medical procedures on enslaved Black women, which is unethical in more ways than one. No consent was given. A patient that has no knowledge of what is going on or what is being done to them cannot give consent. As an enslaved person, the patient was not seen as a human being, but rather as property, and therefore no consent was necessary. The medical procedure was purely experimental, and Sims’ likely had poor knowledge of what he was doing which made his actions torturous. Women like the patients Sims practiced on, women of color, women who were and are oppressed and marginalized, women with disabilities, and people of the LGBTQ+ community continue to be exploited, and it is important that their voices are heard now more than ever.

Source: Robert Thom, circa 1952. From the collection of Michigan Medicine, University of Michigan. Sims’ not only purchased Black women to conduct his inhumane experiments on, but he did so on the belief that Black women could not feel pain.

Often there are misguided notions that reproductive justice is just about abortion, and while access to abortions is a major component of the movement, the movement does not end there. Reproductive justice also goes on to include access to proper sex education, inclusive to all genders and sexualities, affordable contraception, and access to safe and healthy abortions. It’s not enough for abortion to be legalized. “Access is key,” meaning that the cost of the medical procedure is bearable. Medical expenses include travel to a medical provider, paid time off from work, prescription costs, dietary expenses, relocation, etc. all of which can cause difficulty in accessing care. As something that women of color, women with low incomes, and the LGBTQ+ community have brought to attention, reproductive justice is an umbrella that goes beyond the pro-choice versus pro-life debates. It calls into light that factors such as race and class in society affect each woman and LGBTQ+ persons differently. This means not every person has the choice to choose or not choose a pregnancy due to lack of access to services, stigma, or historic oppression, which is where the pro-voice movement intercedes.

The pro-voice movement is meant to “replace judgement with conversation” from both pro-choice and pro-life advocates. Abortion is an incredible emotionally and morally draining topic to converse on, and it’s a decision that should be void of politics and instead filled with empathy and compassion so an individual can make the healthiest choice and live their healthiest life. It is important to validate a person’s lived experiences and to acknowledge that they made the best decision they felt like they could with the resources available to them at the time.

Stigma Around Reproductive Health

There is lack of access to the topic of reproductive health due to incomprehensive sexual education in school systems. Access to this information, access to proper medical care, access to contraception and abortion “is a political, human rights and reproductive justice issue.” Some educational systems fail to mention how to obtain contraceptive methods, how to use them, and which methods are more suited for an individual. This lack of information and stigma around sexual education does not reduce the incidence of unsafe and “unprotected sex or rates of abortion.” In fact, lack of education around contraception and restrictive abortion practices leads to more unsafe abortions globally due to financial burdens as well as social and cultural stigma.

Source: Maria Nunes. An LGBTQ+ Pride event takes place in the Caribbean.

Another issue is heteronormativity which is the trend in sex education focusing “on straight, cisgender young people, but ignores LGBTQ+ youth.” These conservative views that do not cater to a whole population of young adults exacerbates this stigma around sexual and reproductive health. This leads to people feeling like they cannot ask questions due to fear of social repercussions or that their sexuality is abnormal. Not being provided with “information to address their health needs, leaves the LGBTQ+ youth at risk for sexual violence and unprotected sex,” making them more vulnerable to various sexually transmitted diseases, teen pregnancy, and mental health disorders. As important as it is it to address reproductive justice and reproductive health as a women’s issue, it’s even more important to know that LGBTQ+ people “can get pregnant, use birth control, have abortions, carry pregnancies, and become parents.” Part of fighting for and providing reproductive justice involves activism against controlling reproductive voices, and often controlling sexualities and gender expressions are synonymous with gatekeeping those voices.

Providing access to sexual and reproductive healthcare to LGBTQ+ people is one way to ensure that all communities are able to have information, resources, and the power to make their own decisions about their bodies, genders, sexualities, families, and lives. Access to reproductive healthcare can come in the form of gender affirming care and treatment for transgender, nonbinary, and gender nonconforming individuals. Having free access to reproductive education is a foundational piece within the reproductive justice movement. Talking about the framework around sex and reproductive justice is so much more than sex. It involves intersectionality and considerations of reproductive health regarding pregnancy, abortions, racial and class division and discriminations, maternal mortality rates, and environmental conditions. It’s about the dichotomies between oppression and liberation, individuality and collectivity, and most importantly choices and voices.

Source: Terry Moon for News and Letters. An individual in Chicago attends a protest in support for Planned Parenthood.

What Are Three Things I Can Do?

  1. Understand that it’s not about being pro-choice or pro-life. Understanding abortion is about validating people’s stories and experiences. If you haven’t experienced abortion or don’t know of someone who has, the first step is to come from a place of compassion and empathy.
  2. Know that reproductive justice goes beyond being a women’s issue. The same resources and information given to women need to be disseminated throughout the LGBTQ+ community.
  3. Research organizations such as SisterSong, Planned Parenthood, and URGE to start your activism and make your impact.