War and Health

The Medical Consequences of the Wars in Iraq and Afghanistan

Catherine Lutz, Andrea Mazzarino

• Publisher: NYU Press
• Year: 2019
• ISBN:
  9781479806942
• Topic: Ciencias sociales
• Subtopic: Antropología

Provides a detailed look at how war affects human life and health far beyond the battlefield

Since 2010, a team of activists, social scientists, and physicians have monitored the lives lost as a result of the US wars in Iraq, Afghanistan, and Pakistan through an initiative called the Costs of War Project. Unlike most studies of war casualties, this research looks beyond lives lost in violence to consider those who have died as a result of illness, injuries, and malnutrition that would not have occurred had the war not taken place. Incredibly, the Cost of War Project has found that, of the more than 1,000,000 lives lost in the recent US wars, a minimum of 800,000 died not from violence, but from indirect causes.

War and Health offers a critical examination of these indirect casualties, examining health outcomes on the battlefield and elsewhere—in hospitals, homes, and refugee camps—both during combat and in the years following, as communities struggle to live normal lives despite decimated social services, lack of access to medical care, ongoing illness and disability, malnutrition, loss of infrastructure, and increased substance abuse. The volume considers the effect of the war on both civilians and on US service members, in war zones—where healthcare systems have been destroyed by long-term conflict—and in the United States, where healthcare is highly developed. Ultimately, it draws much-needed attention to the far-reaching health consequences of the recent US wars, and argues that we cannot go to war—and remain at war—without understanding the catastrophic effect war has on the entire ecosystem of human health.

PART I

Afghanistan and Pakistan

1

Childbirth in the Context of Conflict in Afghanistan

KYLEA LAINA LIESE

Decades of social upheaval and protracted violence have taken tolls on both the public sector and private life in Afghanistan. Women, in particular, have endured vulnerabilities and assaults to their personhoods, livelihoods, and bodies. In 2002, Afghanistan’s maternal mortality ratio (MMR) was among the highest in the world at 1,600 per 100,000 live births (Bartlett et al. 2005), with nearly 92 percent of all births taking place without access to a skilled birth attendant (Newbrander et al. 2014). Since 2002, the Afghan government, several nongovernmental organizations (NGOs), and the US government have committed tremendous resources to developing a national healthcare delivery system. The resulting BPHS (Basic Package Health Services) dramatically expanded the reach of maternal healthcare, and midwifery care, in particular. Between 2003 and 2009, the number of Afghans living within a two-hour walk of basic healthcare increased from 9 percent to 85 percent (Ministry of Public Health 2010).1 The number of midwives increased from 467 to more than 4,600 (UNFPA 2014). Afghanistan’s maternal mortality ratio is still among the highest in the world, but vastly lower than it was at the start of the war: 400 maternal deaths per 100,000 live births (WHO et al. 2015).

The reduction in maternal mortality between 2003 and 2009 would not appear nearly as impressive if Afghan women’s health had not been in such a deplorable state prior to 2002. This chapter explores the macro- and micro-aggressions by which war and social instability have made Afghan women among the most vulnerable in the world. Although access to lifesaving obstetric care may be essential to treat complications arising in pregnancy and birth, the maternal mortality ratio in Afghanistan in 2002 indicated the problem went well beyond poverty and infrastructure to the long-lasting and far-reaching impact of violence. Researchers have observed that armed conflicts and postwar conditions amplify the health detriments of poverty and increase risk for maternal mortality through a variety of mechanisms, including reduced access to obstetric care and contraception, increased risk of infectious disease, and higher levels of malnutrition. One study found that the mean adjusted MMR in sub-Saharan African countries subject to recent armed conflict (since 1990) was 1,000/100,000 births, while countries without recent conflict had a mean MMR of 690/100,000 (O’Hare and Southall 2007). What social and historical conditions allowed for such pathology in physiologic childbirth? How do war and violence directly and indirectly jeopardize women’s reproductive health?

Major political changes in Afghanistan over the last 30 years made Afghan women’s lives and reproduction largely invisible. At the national level, public policies restricting women’s roles in society limited infrastructure and access to reproductive health services. The Taliban issued edicts that shut down medical and nursing schools for girls and women, while also forbidding female doctors from working and female patients from seeing male physicians. Afghan women were also required to wear the burqa and be accompanied by a male relative when outside the home or risk public beatings for disobedience. The consequences of these policies reverberate deeply into the private sphere, reinforcing power dynamics within the family unit. In order to “protect” their daughters from external threats that included violence and kidnapping, families sought earlier marriages than had been the norm (Liese 2009). Marriage conveyed protection for young girls, though their new families also controlled their autonomy and livelihoods. In the absence of trained midwives and doctors, authoritative knowledge of pregnancy and childbirth fell upon family members who lacked healthcare skills but were responsible for helping a woman give birth in the safety of the home. The social context of wartime added meaning to childbirth, protecting and strengthening kin ties during a time when external threats were both unpredictable and pervasive. However, this seclusion also made women more vulnerable socially and physically.

In her notable essay, “Do Muslim Women Really Need Saving? Anthropological Reflections on Cultural Relativism and Its Others,” Abu-Lughod cautions us against conflating the causes of Afghan women’s “continuing malnutrition, poverty, and ill health, and their more recent exclusion under the Taliban from employment, schooling, and the joys of wearing nail polish” (Abu-Lughod 2002, 784). She rightfully acknowledges that throughout South Asia, Africa, and the Middle East, colonialism utilized the notion of liberating women from repressive cultural practices in order to justify itself. The Soviet Union, which occupied Afghanistan from 1979 to 1989, propagated Muslim women throughout Central Asia as a “surrogate proletariat” to be liberated from the shackles of Islam by communist ideology (Northrop 2003). Indeed, it was not the obligation of the burqa or seclusion imposed by the Taliban in the name of religion that caused women in Afghanistan to die during childbirth. Afghan women, particularly those in rural areas, suffered from health disparities common to poverty long before the Taliban took control of the country. The war between the Soviet Union and Afghanistan killed between 900,000 and 1.25 million Afghans (Khalidi 1991). Guerrilla warfare in rural areas by the US-propped mujahedeen and retaliatory air strikes by the USSR leveled villages and decimated farms. By the mid-1990s, the Taliban-installed restrictions, exacerbated by the social history of violence and instability, had additional harmful effects on the health and social lives of Afghan women who had long been vulnerable due to malnutrition, poverty, and ill health.

The dominant public health paradigm views maternal mortality as the result of discrete physiologic causes and individual risk factors, such as maternal age, parity (number of prior pregnancies), education, and socioeconomic status (Maine and Rosenfield 1999). From this perspective, maternal risk is addressed by making obstetric care universally available and accessible to treat obstetric emergencies. Anthropological research on maternal mortality instead focuses on the relationships between the site-specific social context of childbirth (Jordan 1997) and public health efforts to reduce maternal risk. Why would people give birth at home when a hospital could save their life? The answers to this question are multifaceted and overlapping. They range from historically rooted structural inequalities (lack of roads, resources, and education and poverty more generally) to sociocultural complexities (discrimination, tradition, values, beliefs). Despite the high rate of maternal mortality in rural postwar Guatemala, Berry (2010) found that women and their families resisted biomedical intervention because it disrupted the social benefits of a home birth as a time to establish and strengthen essential kin networks. This finding was echoed in Hay’s (1999) work on maternal mortality in Indonesia, where sociocultural forces contributed to the local perception that the biomedical clinic did not represent the most appropriate care in an obstetric emergency.

This analysis is based on ethnographic data collected between 2006 and 2010 in the Badakhshan Province of northern Afghanistan. I draw on data from hospital records and observations, semi-structured interviews with Afghan women, men, and healthcare workers, a district-wide maternal mortality survey using the sisterhood method, and seventeen months of participant observation in the mountainous regions of Gorno-Badakhshan, Tajikistan, and Badakhshan, Afghanistan. I use these data to argue war and extensive periods of instability create social conditions that increase women’s vulnerability during pregnancy and childbirth. They limit access to care directly and indirectly through infrastructure, security, and education. The social context of violence also reinforces insular family dynamics that isolates young women for their own protection, further limiting access to skilled attendance during and following childbirth.

Public Policy, Education, and Healthcare Infrastructure

Changes in healthcare for Afghan women over several decades of civil war reflect larger sociopolitical instability occurring throughout the nation. During the 1970s and 1980s, female physicians, scientists, civil servants, and educators served the Afghan public alongside their male counterparts. With the collapse of the Democratic Republic of Afghanistan in 1992, and subsequent integration of Gulbuddin Hekmatyar as prime minister of the Islamic State of Afghanistan in 1996, the stature and visibility women had gained in the public sector during the communist era quickly eroded. In 1998, the government of Afghanistan issued a decree ordering “householders to blacken their windows, so women would not be visible from the outside” (Rashid 2000). Under the state authority of the Taliban from 1996 to 2001, women were forbidden from working, attending school, or leaving the house without an appropriate male escort. They were instructed in how they should dress, behave, and interact, in order to preserve their honor and that of their families. Judgments about women’s movements and propriety were handed out by local thugs who threatened offenders with violent beatings on the street. This state of pervasive instability and extrajudicial violence had both direct and indirect effects on women’s ability to receive reproductive healthcare.

The Feyzebod District Hospital is the only hospital in the vast mountainous province of Badakshan. Due to threats of landslides, avalanches, and mudslides, the road to the hospital was only accessible to many parts of Badakhshan a few months of the year. When it was open, the journey from districts near the Tajikistan border could take up to ten days along narrow trails. During the Soviet-Afghan war (1979–1989) and subsequent Afghan civil war (1989–1996), vandals and improvised explosive devices (IEDs) made the road even more perilous.

The hospital suffered a lack of regular personnel and equipment. In order to safely perform a life-saving cesarean section, an obstetrician and anesthesiologist were as vital as medication, surgical equipment, electricity, and running water. But as the civil war stretched from years to decades, medical personnel, supplies, and basic infrastructure dwindled. Because women were forbidden to receive medical care from male doctors, a few female physicians were permitted to practice, but within a climate of fear, violence, and surveillance. One female physician in the northern province of Badakhshan arrived at the Feyzebod District Hospital, where she worked as an obstetrician, wearing an “Arab-style” abaya that covered her entire body except her face, instead of the burqa.2 She was met at the entrance by a mujahideen who pressed his Kalashnikov against her forehead, telling her he would remove her face if she did not cover it. Threats and harassment like this kept the majority of capable female physicians confined to their homes and away from practicing medicine. Some physicians who had resources chose to leave the country, creating a “brain drain” from which the country has yet to recover.3 As a result, even if a woman who had permission and an escort to the hospital during an obstetric emergency managed to survive the long journey, she could be sure neither that a provider would be there to treat her, nor that necessary supplies would be available.

By excluding women from attending work and school, the Taliban not only directly prohibited women from access to healthcare, but also stunted the country’s ability to meet healthcare needs in the future. For more than five years under the Taliban, female students were prohibited from attending medical or nursing colleges, while male medical students lacked basic educational materials and reported daily harassment and deplorable conditions (Radio Free Europe / Radio Liberty 2006; Rashid 2000).4 The Taliban’s prohibition of girls attending school may have indirectly increased maternal mortality. One study found female secondary school education and trained delivery assistance to be the strongest predictors of national maternal mortality, even when controlling for income per capita (Shiffman 2000). This finding is supported by national survey data collected in 2010–11 by UNICEF and the Afghan government’s Central Statistics Organization. The more educated an Afghan woman is, the more likely she is to give birth with a skilled attendant, and therefore more likely to survive childbirth. She is also more likely to delay marriage and pregnancy, further reducing her maternal risk (Oates 2013). In 2006, only 18 percent of Afghan females ages 15 to 24 were literate enough to understand short, simple written sentences on their everyday life (UNESCO Institute for Statistics 2016).5

There are likely several mechanisms by which female education protects women’s reproductive health. Education increases women’s visibility and engagement with public institutions, officials, and bureaucracies, increasing society’s accountability toward women. Education empowers individuals and may help women to recognize complications, negotiate assistance, advocate for skilled care, and utilize family planning—all of which decreases maternal risk. One woman in Afghan Badakhshan described the labor of her daughter-in-law: “She had pain in her back and in her stomach. She sat like that for four days. The old woman told her to walk around the room but she was bleeding. We gave her some tea and some opium because it was cold, but she died. The baby did not come out” (Liese 2009). Access to obstetric care necessary to save this woman’s life ultimately may have been determined by structural inequalities, including poor road conditions in her district and the unavailability of medical resources within the nearest hospital. Nevertheless, when women are educated, they are more likely to recognize obstetric complications sooner. Earlier recognition of this woman’s obstructed labor may have given her time to be transported to a facility. Likewise, education increases the access and availability of skilled providers, minimizing delays and structural barriers to care. Access to skilled providers, such as trained midwives, within the community improve chances of surviving an obstetric emergency, but to accomplish this distribution, girls from rural commun...