One Woman's Perspective: Health in Afghanistan
Photographs show small caves blown apart by bombs and women and children displaced by war. It is almost impossible today to open a newspaper and not see a story about Afghanistan. Amidst the front page columns detailing the ongoing war and the sad life of Afghans under the Taliban regime, the rich culture and strong spirit of the Afghans persevere — especially evident in the hope of Afghan women that through newfound freedom they will carve out safety and health for their families.
Laurence Laumonier-Ickx is a French doctor who understands the plight of these Afghan women. In 1981, at a time when there was no development work being done in Afghanistan, she journeyed thirteen days by foot and horse from the border of Pakistan to the Panjshir valley of northeastern Afghanistan. Upon her arrival, she was introduced to Ahmad Shah Massoud, who later became the leader of the Northern Alliance and was assassinated just two days prior to the attacks of September 11. Dr. Laumonier-Ickx explained to Massoud that she and her colleague, a male doctor, were there to establish a hospital and develop health services for the men, women, and children by training people from the Valley. Massoud was not only supportive of their effort, but he and the other leaders accepted Laurence as a doctor, despite being a woman. Massoud immediately found the doctors a place to live with a family in the village and told her he would find them some students to train.
The next day a man appeared at their door and told them Massoud had sent him to be their translator. The day after that, he returned to take them to the site — the once countryside manor of the King — that Massoud had arranged to serve as their hospital. On the third morning, 17 men stood at their door prepared to serve as their students. The doctors quickly went to work training these men in basic health services while providing care to the people of the valley. The demand was great. People began arriving from all over the valley to wait overnight to see the doctors. On average, they were seeing 80 to 100 patients per day and had to close the doors to the facility in the late afternoon to allow some time for the theoretical training of the local health workers. As word continued to spread, patients traveled great distances to access the doctor's services.
There were other ways in which the community and its leaders demonstrated their commitment to improving health services for their population. For instance, there were only two cars in the entire Panjshir valley. One belonged to Massoud. The other was donated to the medical team for their work. With a car the health team was able to expand their activities and travel throughout the valley implementing a vaccination campaign for the children.
However, "the traditions and social pressures were great." Passing through each village the health team was deterred by emergency after emergency. Dr. Laumonier-Ickx shared that in each case, the emergencies "were always women. They were lying on the ground and in the houses." Their husbands and fathers either would not take them to the hospital because the social traditions prevented the women from being seen, or they weren't transportable because they were in such bad condition. "I felt so bad because this valley was so open-minded." She then goes on to explain. "We were in a war. There were bombs falling on our heads almost every day. Social traditions were reinforced by the war and people were drawing their strength from Islam." Religion was a source of hope for the people. They believed if they were good in the eyes of God, perhaps they would be safe.
This helped to explain some of the challenges the health team faced in trying to provide health care to the population in the Valley. As in much of Afghanistan, Dr. Laumonier-Ickx explains, "the woman's horizon was the village and the fields around the village. As a woman, particularly those near marrying age, she would be seen as a bad woman if she went outside the village and was seen by strangers." For instance, Dr. Laumonier-Ickx and her male colleague lived in the home of a small family — a husband, wife and their daughter. Despite their long stay, the male doctor never once saw the face of the mother or the daughter. However, Laurence had the opportunity to learn from this woman and gain an appreciation for the life of an Afghan woman — her power and control within the family and the constraints of her life in Afghan society.
Shortly after she arrived and built trust among the population, Laurence began to make inquiries about getting a few female students, because the hospital was located outside of the village and the women could not be seen by any of the health workers except Laurence, as she was the only woman. Unfortunately, she was unable to recruit any women for the training program. "To be seen in the hospital by strangers from other villages would ruin the woman's reputation. She would be taking a risk of being seen and no one wanted to take that risk," said Laurence. However, not to be deterred, she quickly found another way to engage the women of the valley in improving both their own health and the health of their families.
In Afghanistan, diarrhea and pneumonia are the main causes of death in children under five years. Laurence realized that many children were sick simply because their mothers lacked the proper health education. By teaching the mothers about drinking safe water and hand washing, she could greatly improve this situation. Laurence decided to propose having health education discussions with them. The leaders were supportive, the women were receptive, and quickly Laurence began educating the women about how to treat a fever and the importance of rehydrating the child in the case of diarrhea. The women were quick to accept Laurence's teachings and apply them in their homes, despite that these lessons were contradictory to the knowledge passed down from their mothers.
Working closely with these women in their own communities and environment, Laurence learned more about their culture, often surprised by her previous misconceptions. A decade later, the expatriate community brought those same misconceptions to Peshawar when they began implementing cross-border programs. The fact that many expatriates did not believe there was a demand for family planning in Afghanistan exemplifies that the assumptions made by foreigners and even former Afghans were often too traditional and outdated. "The expatriate community was more conservative than the reality of the Afghans inside Afghanistan," she notes. "Women did not want to be pregnant as they ran while bombs fell on their heads."
At the time, Laurence had begun working for Management Sciences for Health to implement the U.S. Government funded Afghanistan Health Sector Support Project. When Laurence suggested that a family planning component be added to the training of basic health workers, others in the development community balked and told her that she would be putting women at risk. Of course, the reality was much different. They quickly realized the desire and demand for family planning services. The male health workers were not only willing, but encouraged to serve as the conduit of information for the women. "We used a male system to train females and it worked very well. The men who were delivering the messages were extremely committed. They taught their mothers, their sisters, their daughters and their in-laws." Laurence and her team also trained the health workers to use schools to carry health messages home. These messages included basic information such as the importance of hand washing and what to do in case of cough and fever.
Although some of the health solutions in Afghanistan were basic, like taking care of fevers, some situations were much more difficult, pitting Laurence's medical training against her understanding of the constraints of the Afghan culture. She tells a story that is obviously difficult for her and still fresh in her mind. It is the story of a family who came to her in the middle of the night with their young daughter while she was working in the Panjshir valley. Laurence guesses the young woman was no more than 14 years old. Upon examination, she found the young woman was pregnant and ready to give birth.
Laurence attempted to explain the daughter's situation and at first the mother would not believe her — saying that it impossible. Then the mother became fearful. As the girl's father sat waiting in the hallway, the mother confided in Laurence that if she delivered the baby right there, he would surely kill their daughter. As it is strictly forbidden for a woman to have a child out of wedlock, the father would be forced to kill his own daughter out of disgrace. Although Laurence wanted to protect the health of the girl and her baby by keeping her in the hospital, she understood that she would not be saving this girl's life. Laurence determined that the only way to save this girl, despite her training and beliefs, was to give her something to help delay the childbirth. The girl would not have her child in the hospital and her mother would have more time to think of an alternate way to deal with her daughter's situation.
The family left the hospital and Laurence heard nothing more of the girl, until several months later, when she was traveling on a vaccination campaign through the family's village. A village woman came to Laurence and told her that a new baby had come to the girl's home— a relative of theirs in Kabul had a baby but could not keep her and so the baby had come to live with their family. While for some this story may seem sad because it reveals the plight of these women, for Laurence and others it demonstrates the real creativity, ingenuity and strength of the women in Afghanistan. Laurence gave this mother the opportunity to solve a problem in a way that allowed the husband to save face in the eyes of his community and thereby save the life of her daughter.
This ingenuity, combined with the willingness to learn that she found in Afghan women and coupled with the support that key leaders and other men provided, makes Laurence believe in the potential effectiveness of humanitarian assistance today. Not only is assistance crucial, but it must be done "with sensibility, respect, and using as much as possible those who have experienced Afghanistan before. Newcomers must learn the language — it will help them to communicate and to be able to understand the culture," according to Laurence.
As development assistance once again begins to flood into Afghanistan following the latest chronicle in a history of war and destruction, Afghan traditions and beliefs must be respected, while incorporating modern solutions into the framework of their lives. The years under Taliban rule stripped women of many rights to which they are entitled, and cultural attitudes about these rights can only change through hard work and understanding. Afghan women must be a catalyst for this change, but Laurence's and other experiences demonstrate how the international community can help. By providing critically needed financial and technical support, by educating the people of Afghanistan and helping them to understand their own capabilities, we can not only help them to help themselves but build a brighter future for the Afghan children of tomorrow.