Attachments
By Swaraj Parameswaran on 18 Feb 2024
Following the catastrophic events of September 11, 2001, the United States, along with its allies, launched the ‘War on Terror’ in Afghanistan on October 7, 2001. This military campaign was intended to be swift and decisive, aiming to dismantle the Taliban regime, destroy Al-Qaeda, and capture Osama bin Laden, thereby bringing justice to an America still in shock from the most significant terrorist attack in its history. However, the reality of the war diverged significantly from its initial objectives. The US-led mission, dubbed Operation Enduring Freedom, stretched until December 2014 before transitioning to Operation Freedom’s Sentinel. This latter phase sought to enhance the Afghan military and institutional capabilities, lasting until the final withdrawal of American troops on August 30, 2021. This withdrawal left Afghanistan once again under Taliban control, leading many to question the overall efficacy and cost of the long conflict.
This article stays away from a detailed examination of military strategies, the policies of successive American administrations, or the killing of Osama bin Laden. Instead, it focuses on the human cost of the conflict, particularly highlighting the approximately 70,000 innocent Afghan and Pakistani civilians whose lives were claimed directly by the war (The Costs of War, 2023). It also draws attention to the thousands of civilians grappling with mental health issues, the intergenerational trauma affecting women and children, and the extensive physical health problems persisting due to the societal collapse around them. A closer look at the current state of the health system under Taliban rule and the contributions of various international organisations to medical efforts is also provided.
The CrisisToday Afghanistan faces one of the world’s worst humanitarian crises. According to Human Rights Watch (Gossman, 2023), two-thirds of its population live with food insecurity, and 875,000 children face acute malnutrition. What has brought about this crisis in a land once known as the ‘Paris of Central Asia’ (Bumiller, 2009)? According to obstetrician-gynecologist, Najmusama Shefajo, the issue stems from two sources: War and Poverty. She says, ‘Four decades of war has led to increasing poverty, which has a clear effect on health’ (Latifi, 2019). The majority of those in Afghanistan will never have known anything approaching a lengthy peace in their lives. After the Soviet invasion in 1979, Afghanistan descended into chaos, as the American-trained mujahideen countered the might of the Soviet Union through an intense guerrilla campaign.
The war, which lasted until 1989, claimed the lives of between 560,000 and two million civilians, and created a further six million refugees. Following the Soviet withdrawal, various factions of the mujahideen began infighting, and plunged Afghanistan into a civil war that killed 400,000 people (BBC, 2023). In 1996, the Taliban finally emerged victorious from this civil war and introduced their radical interpretation of the Sharia law, which greatly curbed the rights of women and brought into effect punishments such as public executions and death by stoning. 9/11 and the Taliban’s refusal to handover Osama bin Laden to the Americans, meant Afghanistan was plunged into war once again, with death adding to death. Since 2001, out of the 243,000 people killed in war-zones in Afghanistan and Pakistan, more than 70,000 have been civilians (The Costs of War, 2023).
Today, following the Taliban’s recapture of Afghanistan, some 85% of Afghan refugees live in Pakistan and Iran (UNHCR, 2024), with many of the IDPs and refugees living in makeshift camps and plagued by poor health and debilitating poverty.
Effects of the War
Mental Health Trauma
‘I just want someone to hear my voice. I’m in pain, and I’m not the only one.’ The words of an Afghan university student in an interview (Limaye, 2023) that reflect how, after decades of conflict, Afghans today are crippled with mental health issues. Shockingly, it’s believed that more than half the population suffer from depression, anxiety, and post-traumatic stress disorder (Saleem et al., 2021, p. 1). According to a 2018 EU survey, ‘85 percent of the Afghan population had experienced or witnessed at least one traumatic event, and averaged four’(HRW, 2019).
Furthermore, the rural population, which comprises 73% of the population, has been disproportionately affected (Kovess-Masfety et al., 2021, p. 2). Speaking to Limaye (2023), psychologist Dr Alam said, ‘We have a pandemic of suicidal thoughts in Afghanistan. The situation is the worst ever, and the world rarely thinks or talks about it’. Mental health issues are also more common among women than men. Along with living in a conflict-ridden zone, they are subject to unfair, brutal social standards that take a tremendous toll on their mental health, a toll only fuelled by widespread intimate partner violence that all too often occurs in conflict settings (Jewkes et al., 2018, p. 2).
Children and Women
According to Save the Children (2019), 20 million Afghan children wake up daily, afraid of being killed or maimed from explosive remnants of war; 3.8 million of them are in need of humanitarian assistance and 600,000 suffer from acute malnutrition. To add to this, the Asia foundation (Akseer, 2020, p. 86) estimates 17% of Afghan children are living with some disability. As a result of the economic and security disruptions in the country due to war, the mental health of Afghan children is also in jeopardy (Shoib et al., 2022, p. 1046).
Conflict and war have disrupted children’s education, and forced many of them to work as child laborers in construction sites, cleaning facilities, and sometimes even pursue sex work, with female children suffering worse conditions than their male counterparts. A conflict environment has also resulted in children taking up arms, turning to drugs, and engaging in other criminal activities (Qamar et al., 2022, pp. 397-400).
Many children are prevented from accessing mental health services due to the religiosity imposed upon them by their parents and society, which stigmatises seeking help for mental illnesses and glorifies suffering, while girls are unable to access healthcare for even physical issues due to an unavailability of female staff (Eggerman and Panter-Brick, 2010, pp. 71-83). And with half of Afghanistan’s 30 million population under the age of 18, there is growing urgency to provide them with the mental health assistance and medical help they require (UNICEF, n.d.).
Despite the destruction and trauma of war, it wasn’t all negative. According to Liese (2019, p. 41), in 2002, with 1600 per 100,000 live births, Afghanistan had one of the world’s highest Maternal Mortality Rates. But with US aid assistance and cooperation between NGOs and the Afghan government, this rate was significantly reduced to 400 per 100,000 live births by 2009. Ray (2022) asserts that since the fall of the Taliban in 2001, ‘Despite mixed outcomes, there were some key wins, such as an increase in longevity from birth (by eight years for women from 2000 to 2019), improved access to healthcare, a decrease in maternal mortality, an increase of births supervised by specialists and more demand for family planning services.’
It is important to note, however, that while these were certainly positives, in no way did American intervention herald dramatic improvements in healthcare for women. According to UN Women (2016, p. 2), 87% Afghan women experience some form of violence during their lifetime, while 62% experience it multiple times. It also notes that 59% of the women are forced into marriages, and 57% are under the age of 16 when they are forced to wed. According to Tharwani et al. (2022, p. 2), ‘The war on terror and political instability in Afghanistan has made health care resources inaccessible to most of the population. This has left nearly four million women and girls in need of urgent humanitarian assistance.’ They further add, ‘The socio-economic status; low literacy rates, particularly in women (9.8%) as compared to men (55%); and the cultural norms of the country prove to be another obstacle for women when acquiring medical assistance.’
Life under the Taliban*
Since the Taliban takeover in 2021, this struggle for healthcare in Afghanistan has only worsened. Following the takeover, international donors, who were crucial in supporting a fragmented Afghan healthcare system, initially refused to provide funding through government channels, and this, combined with Taliban’s financial policies, crashed the Afghan economy (Glass et al., 2023, p. 2). This created mass unemployment and brought a large populace of Afghans close to starvation. To prevent an even greater humanitarian crisis, international aid through NGOs and UN channels was approved by the Taliban, though this was far below previous aid levels. According to Lee (2022), in 2022, ‘only 17% of Afghanistan’s healthcare facilities supported in part by the World Bank were fully functional.’
The situation is particularly dire for women, who can’t travel without male guardianship, which subsequently restricts their access to healthcare. Though Rasikh and Sharkey (2023) say the Taliban has shown greater leniency than their previous rule in permitting the deployment of women healthcare workers, Lee (2022) mentions how cultural and familial barriers could be a bigger obstacle than Taliban decrees for ordinary women to access healthcare. Women are also forced into child marriages with Taliban fighters, and the very young maternity ages also leads to complicated pregnancies (Ibid.).
According to a study by Glass et al. (2023, pp.6-7), ‘40.4% of health workers reported that the availability of maternal and child healthcare has “decreased a little” to “decreased a lot” in their community since August 2021’, while ‘approximately one-third (31.4%) of health workers perceive that maternal mortality has increased since August 2021.’
Clinics providing emergency obstetric care and Caesarian services are also facing insufficient funding and a scarcity of medical supplies, which puts the lives of many women at risk (WHO, 2022). The healthcare system also faces challenges due to the evacuation of 124,000 people following the Taliban takeover, with many of the evacuees being medical staff (Safi et al., 2022, pp. 1179-1180).
With only 9.4 healthcare workers per 10,000 patients – compared to the 22.8 that the WHO recommends – it is fair to say that Afghanistan’s health care system is in chaos, facing urgent need for foreign aid and medical assistance (Tao et al., 2023, pp. 1-2).
The role of international organisations
Despite the tremendous decrease in funding since August 2021, there are many international organisations still active in providing medical aid in Afghanistan. In 2022, the International Medical Corps (2023), along with providing trauma care-services and health consultations to 596,458 people, also provided reproductive health services to 43,337 women and curative and preventive nutrition services to 94,882 children under the age of 5.
Medicins Sans Frontieres (MSF, 2023), in collaboration with the MoPH, aims to ‘reduce paediatric and neonatal mortality rates’, and admits an average of 3000 critically ill children to the paediatric emergency room every month.
Despite best efforts, the country still struggles with bed shortage and a scarcity of resources. Things are being done to address this. The ICRC (2023) conducts a Hospital Resilience Program, that pays the salaries of 10,900 Afghan medical staff and the expenses of the hospitals, along with procuring drugs and other medical supplies. It also supports seven rehabilitation centers that annually treat over 150,000 physically disabled people. Since 1994, the EU has provided almost 1.7 billion Euros in aid to Afghanistan, with 174 million in 2022 alone. This aid aims to provide healthcare and nutrition, education, water and sanitation facilities, and emergency food assistance to the Afghan population (European Commission, 2023).
USAID (2023), through the Afghanistan Reconstruction Trust Fund, ‘supports the delivery of basic health services to over 2,300 health facilities across the country.’ It mainly focuses on providing aid to mothers and children, and helped bring down the under 5 mortality rate from 97 to 50 per 1000 children between 2010-18. It also provides care for tuberculosis, malnutrition, diarrhoea, and polio.
Today, two-thirds of the Afghan population lives in need of humanitarian assistance. The supply of foreign aid is crucial to this population. According to Qazizada (2023), aid generates short term employment, and prevents the shortage of goods and the collapse of the economy. But the long-term viability of this funding is precarious and also liable to access granted by the Taliban.
Conclusion
The aftermath of 9/11 and the ensuing war have left indelible marks on Afghan society. With a significant portion of the population in dire need of humanitarian aid, particularly women and children at risk of inadequate healthcare, the importance of continued foreign assistance cannot be overstated. This reflection on the human costs of the conflict underscores the urgent need for comprehensive support and healing in Afghanistan.
As Dr Iain Overton of Action on Armed Violence says: “The staggering loss of over 70,000 innocent lives in Afghanistan and Pakistan is a stark reminder of the devastating consequences of conflict. Our report aims not only to quantify this loss but to humanise it, shedding light on the psychological, physical, and societal tolls borne by survivors. As we advocate for peace and rehabilitation, it is imperative that international efforts prioritise the healing and support of these communities, ensuring that the legacy of war does not continue to cripple future generations.”