Maria Zubair, a third year female medical student in Jalalabad who aspires to general practice, has been unable to attend classes since 18 December 2022 when the Taliban suspended university education for women. “The day after the ban we found that the door to the hospital was blocked for women students by Taliban forces,” she says. Her training hospital has told students that they are “bound by Taliban rules” and that female students are no longer allowed to cross the threshold to the hospital.
Following this stricture, on 24 December 2022, the Taliban also barred female employees of non-governmental organisations (NGOs) from coming to work. The move, although not unexpected, has thrown the global health NGOs that have been at the forefront of the country’s public-private healthcare delivery model (see box) into disarray. Initially, several, including Afghanaid, CARE International International Rescue Committee, Islamic Relief, Norwegian Refugee Council, and Save the Children—organisations long associated with the delivery of primary healthcare services in Afghanistan—decided to suspend operations.
“We cannot effectively reach children, women, and men in desperate need in Afghanistan without our female staff,” Save the Children, Norwegian Refugee Council, and CARE International said in a joint statement.
Médecins Sans Frontières (MSF) “strongly condemned” the Islamic Emirate’s erasure of women from social life in the country. “More than 51% of our medical staff are women,” said Filipe Ribeiro, MSF country representative in Afghanistan, on the ban. “Nearly 900 female doctors, nurses, and other professionals strive every day to give thousands of Afghans the best care possible. MSF operations couldn’t exist without them.”
Anna Elizabeth Cilliers, medical coordinator in Afghanistan for MSF, told The BMJ that the 2021 Taliban takeover had already left “huge gaps” in healthcare provision in the country, particularly in primary care. “Some 70% of the patients who come to our hospitals have not been able to access primary care,” she says. “Rural services in particular have largely been disbanded. Around 80% of the women who come to us to give birth have travelled large distances or have been displaced and have not accessed primary or prenatal care.”
From the trauma centre in Kunduz in northern Afghanistan, Boyd Rutten, a Belgian medic with MSF, told The BMJ that there are no full time female doctors in the centre’s intensive care unit, and only one female nurse. This, Rutten says, has grave implications. “For cultural reasons, female patients are reluctant to be examined by male doctors, and male doctors are reluctant to examine them too,” he says.
Although the Afghan ministry of public health has, since 17 January, allowed women healthcare workers to resume working, it has to be in Sharia law compliant settings—they require a mahram (male family member chaperone) to travel to work. The mahram requirement is preventing some healthcare workers from getting to work and it is preventing female patients from accessing care at all times, including midwifery and obstetrics, when they are in labour.
“My sister was sick recently and when she was travelling to our hospital for a check up, they did not allow her to go because she didn’t have a mahram,” says one MSF employee who asked not to be named. “She stood there for about 50 minutes, outside in the cold. Then my brother came, and they allowed them to leave.” The respondent echoes many in adding that she was struggling with women’s further subordinated status since the Taliban seized power.
Cilliers told The BMJ that MSF are currently studying a suspected rise in involuntary home birthing because of the mahram requirement. “This could be a dangerous hidden crisis,” she says. Before the 2021 Taliban takeover, Afghanistan had one of the world’s worst records for maternal mortality, at 638 maternal deaths per 100 000 births.4
In 2020, Afghanistan had 2.78 doctors per 100 people, compared with around 20 per 1000 people in high income countries.5 Almost two years after the Taliban takeover that number has plummeted to 0.33 doctors per 1000 people.1
The regressive strictures have made it harder for Afghan women to study, practise, and access life saving healthcare in a country with high levels of malnutrition6 and stunting,7 and high maternal8 and child mortality. The latest Taliban bans have frozen the pipeline of female trainees—with a ban on women taking part in higher education since 18 December 2022.
Gulalai Khan, a 23 year old third year medical student, tells The BMJ, “This ban has not just been a problem for students like me but it has also battered healthcare,” adding that she wondered how the country’s enfeebled public health infrastructure would survive this new blow.
Sana,* a nurse who did not want to be named, was working in a province controlled by the Taliban for seven years before she fled to India in 2021 with her family. “Things were bad enough before this latest ruling from the Taliban,” she tells The BMJ. “When I left my house, I felt a million eyes on me, seeing if I was ‘properly’ dressed, my scarf in place. I would feel so scared, like I was a criminal.” Sana believes that, as the Taliban strengthens its grip on the benighted Asian country, few families will want to risk allowing their daughters to study medicine for fear of reprisals and violence.
A junior doctor in Jalalabad, who would not give his full name, told The BMJ that while the Taliban was relying on overseas NGOs to serve as the nation’s de facto healthcare system, and indeed soliciting new NGOs to operate in Afghanistan, the administration was undermining its own population with its series of bans.
“It makes no sense banning women workers if they want to keep the goodwill of Afghanis,” he says. “Why make a bad picture in healthcare—primary healthcare and maternal care in particular—much worse?”
Cilliers says MSF has “voiced its concerns” with the Afghan government. “We are hearing that this ban on women in higher education is temporary and the ministry of health has said that training should start again but we don’t know if this will happen,” she tells The BMJ. “Also, enrolment of women at medical colleges is not happening. How will we have the medical staff in the future?”
On 18 January, Amina Mohammed, the UN’s most senior female member, and Sima Bahous, the head of UN Women, held a meeting with the acting foreign minister of the Taliban government.11 After the meeting Mohammed said that she was “encouraged by exemptions” to the ban on female aid workers in healthcare. She later told the BBC that the UN was advocating for incremental expansions to these job category exemptions for women workers, extending from the healthcare exemption.
Some NGOs are working around the new stringent restrictions. Spark, an employment and training NGO headquartered in The Netherlands, was granted its registration to operate in Afghanistan shortly before the bans. Now unable to offer its core women’s agribusiness training, a product it has offered in Syria since 2015, the NGO plans to offer e-learning modules in healthcare to Afghani women.
“E-learning is a temporary solution for Spark in Afghanistan,” Spark’s Afghanistan country expert Muzhgan Mehr told The BMJ. “It has a lot of [diaspora] tutors to train Afghani women remotely and there are many Afghani women who are stranded at home with a thirst for learning.” The NGO told The BMJ that it was principally looking to offer training in roles such as midwifery, elder care, and nursing, and that covid had offered a “solid test bed” for plugging skills gaps in the field through e-learning.
Cillers says that most of MSF’s provision in the country—which includes nutritional care, maternity care, trauma care, and paediatrics at five sites across Afghanistan12—is managing to operate. The “end goal for everyone,” she says, should be a functioning Afghanistan state.
“As donors will not give to the Taliban run government, donors give to humanitarian organisations who have to provide most services, including healthcare, that the government is supposed to provide,” she says. “The only real improvement—for women and for population health—will come when this situation changes and the sanctions lift.”