Afghanistan: Endangered Health – Analysis
By Sanchita Bhattacharya*
On October 11, 2019, a doctor, identified as Mohammad Ali, was assassinated by Taliban terrorists in the Payencha region of Dolina District in Afghanistan’s Ghor Province. Taliban terrorists have been repeatedly targeting health workers, including doctors and nurses, as well as medical facilities across Afghanistan. Facing constant threat, intimidation and harassment from the Taliban, several healthcare practitioners have resigned and health centres have been shut down, depriving civilians of access to healthcare.
Some of the recent incidents targeting healthcare practitioners include:
September 19, 2019: At least 20 people died after a truck packed with explosives was detonated by the Taliban outside a hospital at Qalat in the Qalat District of Zabul Province. It was the main health facility of the Province.
July 17, 2019: The Swedish Committee for Afghanistan (SCA) stated, “The Taliban forced SCA to close 42 out of 77 health facilities in six out of nine districts of Wardak Province so far, and due to this closure, an estimated number of over 5,700 patients are affected on daily basis.”
May 25, 2019: A bomb exploded outside a clinic in the Jalalabad city, provincial capital of Nangarhar, wounding six people, including women and children.
April 4, 2019: A bombing at a clinic in Puli Khumri, the provincial capital of Baghlan, killed a doctor and wounded 18 others.
Data compiled from the 2011-2018 Annual Reports of the United Nations Assistance Mission in Afghanistan (UNAMA) and Quarterly Report of October 2019, documents 467 attacks on health facilities and workers. However, there have also been dozens of unreported incidents of attack, kidnapping, intimidation and assault on healthcare practitioners, and the actual incidence would be much higher. An August 29, 2018, report quoted Dr David Lai, Afghanistan Health Cluster Coordinator, under the OCHA (United Nations Office for the Coordination of Humanitarian Affairs), stating, “There are many incidences of attack on healthcare that are currently not reported. We need to have good information to address the scope of the problem in this country.”
|Years||Incidents of Attacks on Healthcare Practitioners and Health Facilities|
|2019 (till June 30)||38|
|Source: 2011-2018: UNAMA Annual Reports; 2019: UNAMA Quarterly Report|
Attacks on healthcare facilities during armed violence and internal disturbances tend to fall into four main categories. The first is the deliberate targeting of such places to gain military advantage by depriving opponents and those perceived to support them of medical assistance for injuries sustained. The second category of attack is also deliberate, but in this case for political, religious or ethnic reasons. The third type of attack is unintentional bombardment or shelling – “collateral damage” from a missile or mortar aimed at a military target. The fourth and perhaps most common form of violence committed against healthcare facilities is the looting of drugs and medical equipment.
Interestingly, the Taliban’s reason for attacking health facilities and medical staff is to control the hospitals which fall within their areas of dominance. As Health Ministry spokesman, Wahidullah Majroh, stated, (as reported on September 27, 2017), the Taliban’s intention is to vet surgeons and other medical staff who treat wounded Taliban fighters. Unsurprisingly, Taliban militants have been demanding control over health facilities in their areas of dominance.
According to the quarterly report released on January 30, 2019, by the Special Inspector General for Afghanistan Reconstruction (SIGAR), as of October 22, 2018, there were a total of 74 Districts under Government control and another 145 under its influence, as against 12 under insurgent control and 38 under their influence. The number of contested Districts was 138. Afghanistan has a total of 407 Districts.
Another reason behind the Taliban’s targeting of health service providers is their (Taliban) requirement to have certificates from doctors for their inmates in jail for their release on grounds of illness. Taliban leaders exert pressure on doctors to sign relatively healthy prisoners (Taliban cadres) out of jail, so they could return to fighting. In one such incident, on May 5, 2018, Dr. Mohammad Haqmal was abducted and tortured by Taliban for several days because he refused to follow Taliban dictates. Later he was given asylum in the UK, as reported on May 23, 2019.
The Taliban has also regularly attacked polio vaccination staff, accusing them of collecting intelligence to target militant leaders with drones and other air strikes. In June 2019, Taliban’s military commission alleged that internationally-backed health workers collected information used to find and kill Taliban leaders in Special Forces’ raids and air strikes. The insurgents want vaccinators to stop delivering polio drops door-to-door, and instead to administer vaccines from a central point, such as a village mosque.
Earlier, in October 2017 the International Committee of the Red Cross (ICRC) announced that it would “drastically” reduce its presence in the country after seven of its employees were killed. On February 8, 2017, six employees were killed at an undisclosed location in Jowzjan Province. And later, on September 11, 2017, another aid worker was killed in Mazar-e-Sharif, the provincial capital of Balkh. The decision by the charity, which has been working in Afghanistan for over three decades, underlined the growing dangers for aid workers. The Taliban, in the meantime, accused the ICRC of “suspicious” activities during vaccination campaigns and of failing to monitor conditions in Afghan jails and to provide medical aid to Taliban prisoners.
According to the Afghanistan Crises Situation Reports of the World Health Organization (WHO), between January 2015 and July 2019, at least 241 health facilities were closed due to the ongoing violence in the country. 27 facilities were closed in 2015; 29 in 2016; 42 each in 2017 and 2018 and 101 till July 2019. The trend indicates a steady increase in the shutting down of medical and health facilities. Further, underlining the dire scenario of health expenditure in the country, the World Bank report, Afghanistan: Public Expenditure Update, dated July 2019, noted that the total budgeted health expenditure in Afghanistan was around 1.5 per cent of GDP (USD 8 per capita), whereas the WHO benchmark is 4-5 per cent of GDP or USD 86 per capita.
Ironically, as reported on May 25, 2019, Abdullah Abdullah, the Chief Executive of Afghanistan in an address to healthcare providers stated, “With what we spend on a single day of war, we could build a state-of-the-art hospital.” An October 28, 2019, report notes that, in a country of more than 38.33 million, Afghanistan has just 150 hospitals, including regional, district, and special military hospitals, and a mere three doctors per 10,000 people. Doctors and medical staff suffer from long working hours, low wages and lack of infrastructural support. Often, due to lack of governmental assistance, doctors and nurses become de facto engineers, repairing vital solar power systems, fixing plumbing, and performing a vast range of other tasks, outside their job description. The result is a steady stream of doctors and staff quitting their jobs.
Even after the US has spent nearly USD 877 billion (until March 2019) in its fight against terror in Afghanistan over the past 18 years, the Taliban grows more confident of returning to power. Afghanistan, once again, stands at the crossroads of history, and no one knows what is coming. Sustained insecurity and violence continue to have a tremendous impact on health care in the country. Decades of insecurity have created a physical and mental health catastrophe, even as health workers are exposed to threats and actual violence.
Research Fellow, Institute for Conflict Management