On the road in a sick nation

The bus makes turn after turn, winding its way through the mountains. I am on my way from Kabul to Bamiyanon a narrow road from the capital to the province in central Afghanistan. Everyone traveling with me is silent and sleepy. All at once, an acrid smell hits my nose. A woman next to me takes a pinch of naswar from a small plastic bag and places it under her upper lip. Naswar is made from crushed tobacco leaves mixed with slaked lime, ash and aromatic substances.

It creates an intoxicating effect when you consume it and is widespread in Afghanistan. I detest the stuff and grimace in disgust, about to turn away. But the woman laughs, and with her mouth full of chewing tobacco, tells me: “I felt the same way when I was young. I thought the stuff was awful. But when I was in labour and almost went crazy with pain, my husband gave me naswar. To this day, I haven't been able to kick the habit.”

Hesitantly, I inquire, “Why didn't you go to the doctor?” She giggles mirthlessly and replies that there was no doctor in the remote region where she came from. When a woman lost a lot of blood during childbirth, she went to the local mullah. He would put an opened padlock in hot water for her to drink. This would stop the bleeding, he said.

“When a woman lost a lot of blood during childbirth, she went to the local mullah”

I ask my fellow traveler how the situation is today. “Unchanged” she replies. “There is no health centre in my village or the surrounding area. When the men get sick, they somehow drag themselves to the nearest hospital, but sick women and children are lost.” 

What she tells me hardly surprises me, because as a journalist from Kabul, I too know all too well how difficult it is to receive medical treatment as an Afghan. According to official figures, there are only 4.6 nurses, doctors or other medical personnel per ten thousand inhabitants in Afghanistan. This figure is far below the corresponding recommendation of the World Health Organisation (WHO), which calls for a ratio of at least ten thousand to 23.

As if the acute shortage of skilled personnel were not tragic enough, many men refuse to let their wives be examined and treated by male doctors. This has consequences: according to a report by the United Nations Population Fund, in Afghanistan, a mother dies every two hours while giving birth to a child or from complications afterwards - that's 638 women out of every 100,000.

“Many men refuse to let their wives be examined and treated by male doctors”

As the bus continues to jolt through the countryside, I let my mind wander, recalling the many examples I collected during my research on the glaring discrimination women and girls face when it comes to health care. Gender discrimination, deeply rooted in traditions, has always played a major role. Boys get more attention and the best possible care from birth when they fall ill. Girls, however, have to take a back seat.

In a hospital hallway, I once observed an argument between a man and the doctor, who tried to explain to him that his newborn daughter would have to stay in the hospital for a few days for follow-up care. The man refuses, because he had wanted a son. The little daughter may die for his sake. The doctor shakes his head sadly and finally agrees to discharge the wife and child.

Often, geographical distances make access to medical care difficult. It is usually a long way to a hospital. Roads are impassable, and the transport infrastructure does not link every remote village. In the past twenty years, a lot has been achieved with international support. A day clinic here, a small health centre there - a basic medical infrastructure has been created.

“If there is an emergency, people make the arduous journey to the nearest hospital by donkey cart”

But with the return of the Taliban in 2021, many of these clinics had to close. Now, when an emergency occurs, people make the arduous journey to the nearest hospital on foot or by donkey cart. Or they hope that traditional methods of treatment will help. Their last hope is often to make a pilgrimage to a sacred burial site.

Women in urban areas have also seen a sharp deterioration of medical care since the return of the Taliban. Public hospitals no longer receive any support from abroad, so they now lack medicines and equipment. In theory, there is still the option of going to a private clinic, but the tense economic situation makes treatment unaffordable for the vast majority of people in the country.

Even if a woman has enough money, a man from her family has to stay with her in the hospital until she is discharged home. One woman tells me about this as she lies in a hospital in the Kahmard district of Bamiyan: “I got badly burned while cooking and will have to stay here for quite a while. But according to Taliban law, I couldn't be hospitalised in the first place without a male escort. That's why my son hasn't been going to school for days, he has to sit with me non-stop.”

“Most Afghan women are not allowed to make independent decisions - even about their own bodies”

Basically, Afghan women are under pressure from all directions. Traditional values and norms that have long favoured men have been exacerbated by new laws passed by the Taliban. Added to this is their economic dependence on the head of the family. Most women are not allowed to make independent decisions about their own bodies and health, leaving them effectively at the mercy of their husbands.

I learn from a doctor in Kabul that the men even determine the circumstances of childbirth: “If I explain to a woman that a Caesarean section is necessary, a male guardian must sign the necessary authorisation. Misinformation and rumours unsettle many men, which is why most don't want their wives to have surgery.”

The doctor describes a particularly distressing experience to me as follows: “A patient was undergoing treatment with me because a natural birth was out of the question due to her very narrow pelvis. She already had three children, all of whom were delivered by cesarean section. When she was pregnant for the fourth time and came to me in severe pain, I explained to her that we would have to operate on her this time as well.

But her husband was against it. He took her to another hospital where the same diagnosis was made. Thereupon, her husband angrily took her home - despite her hellish pain. There she suffered a ruptured uterus. She lost her child and is now in a coma with kidney failure.”

“There is a lack of female medical staff everywhere”

Some husbands categorically refuse to allow even simple medical examinations of their spouses to be performed by male doctors. The big problem is that female medical personnel are lacking everywhere in Afghanistan - especially in rural areas. When the earth shook in Paktia and Khost provinces in June 2022, there was not a single female doctor in the region to attend to women in need of treatment. Most men forbade their wives to seek treatment from doctors. They would rather risk the health of their injured partners by going to neighbouring provinces in search of female doctors. 

One nurse explained to me why there are so few women in health care in rural areas: “Nurses, orderlies and doctors are not allowed to work in the provinces without male protection - only in Kabul and a few other big cities is it still possible.” In addition, she said, it is extremely dangerous for women to work in the health sector. She went on to say that she had witnessed how dissatisfied relatives of sick people stormed into a clinic or hospital armed and threatened or even beat up female doctors and nurses.

Also playing a role is the fact that it is considered shameful for women to say they are unwell. They are quickly accused of “licentiousness”. Eighteen year-old Mineh from Kapisa province has had to experience this many times and tells me about it: “I suffer very badly from my period. One day my pain was so unbearable that I asked my mother to talk to my father so that he would accompany me to the gynecologist.

My father was seething with anger when he heard this. Turning to my mother, he said, 'Your daughter is infinitely shameless! Unmarried women are not allowed to go to the doctor.' So now I try to endure my pain every month, and the most I can do is drink herbal tea which only gives me a little relief.”

“A woman with 10 children tells me she's not allowed to use contraception”

When I ask her what hygiene products she uses during her period, she just laughs. She has never heard of sanitary pads. She cuts pads out of worn clothing, washes them when her period is over, and reuses them the next month.

Women make up half of society, but have little say in Afghanistan - not least about their own bodies. In Kapisa province, a woman who already has ten children and has suffered four miscarriages tells me she is not allowed to use contraception. The men in her family forbid her to do so. Her husband says that if she secretly takes contraceptives, he will never forgive her and marry a second wife.

When I ask if her husband allows her to go to the doctor when she is sick, she just laughs. “Of course not. My husband thinks women are never actually sick, and if they are, they're faking it because they want to draw attention to themselves.”

My husband's voice snaps me out of my thoughts; “We're here,” he says. Sure enough, the bus has come to a stop. I'm amazed: Did I really spend the three-hour drive to Bamiyan thinking? And I wasn’t even able to dwell on all the problems that women here have to deal with! I shake my head but, as always, draw hope from the idea that things can't stay thisway they are forever. “Things have to get better,” I tell myself as I pack up my things and slowly step off the bus. “One day Afghanistan will be a paradise, even for us women.”

Translated by Jutta Himmelreich and Jess Smee.

Reading tip: A short story by Parand appeared anonymously in the collection “My Pen Is the Wing of a Bird: New Fiction by Afghan Women“ (2022, MacLehose Press). The anthology collects eighteen stories by Afghan women writers about family, work, childhood, friendship, war, gender identity, and cultural traditions, edited by “Untold - Afghanistan.“