Despite the Odds — Providing Reproductive Health Care to Afghan Women
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《新英格兰医药杂志》
The majority of women in Afghanistan have never seen a doctor. Twenty-three years of war destroyed the few existing health care facilities, and women's health has suffered from the violence of warfare, the lack of economic development, and the strengthening of Islamic fundamentalism.
In 1982, in the midst of the Soviet invasion of Afghanistan, I graduated from Kabul University's School of Medicine. After only a four-month residency at the Wazir Akhbar Khan Hospital, I had to flee Kabul for central Afghanistan, where I had been born and which was not yet under Soviet control. I arrived in Jaghori with only a stethoscope, a blood-pressure cuff, and a copy of Medical Current. I began seeing patients immediately, but I often had to run to my book to identify symptoms and treatments, and then I had to find out whether the necessary medicine was even available. I saw women die every day because of incomplete abortion or shoulder presentation of the fetus at delivery: we did not have the proper equipment to deal with these sorts of problems. To reach patients, I sometimes had to walk or travel on horseback or by donkey for three or four hours in each direction. Often, the patient was dead by the time I arrived.
One of my patients was in labor for six days. Villagers carried her on a bed through almost a meter of snow to a hospital run by Médecins sans Frontières. When I arrived, the patient's pulse was barely palpable. The French doctor said it was too late to save her; I suggested giving the woman a shot of epinephrine, but the doctor refused. I took responsibility and administered the injection. I delivered a stillborn baby, but the woman survived.
In 1984, I contracted whooping cough and had to seek treatment in Pakistan. More than 4 million refugees fled Afghanistan for Pakistan during the Soviet invasion and the subsequent civil war. In the refugee camps in Pakistan, virtually no health care was available to refugee women and children. In the urban areas, every political party had a hospital for its male members, but these hospitals would not treat even the families of these members. Fundamentalists, who opposed women's rights and women's health care, dominated the refugee camps.
When I arrived in Pakistan, I began working with the Christian Hospital in Quetta, which had an Afghan refugee branch but was open only from 8 a.m. to 2 p.m. and could not accept emergency patients. One day when I arrived at the hospital, a woman suffering with severe eclampsia was waiting. I ran to find the key to the delivery room and injectable valium to stop her convulsions, but I could obtain neither one. The woman died in front of me in the corridor. As in their home country, Afghan women in Pakistan often died from complications of pregnancy because they could not reach the hospital for treatment. While I was working for this hospital, I traveled to see patients at a refugee camp three and a half hours by car from Quetta. Because of the fundamentalists' opposition to birth control, I had to take IUDs into the camp by hiding them in my bag.
The need for better reproductive health services was painfully clear, and I decided to start a hospital for Afghan refugee women in Quetta to provide such services. I approached one of the donors of the Christian hospital to ask for support, but fearing fundamentalist retaliation, he was reluctant. Ultimately, however, he agreed to provide support if he and the other donors could remain anonymous. When the hospital opened, we distributed some advertisements for it, and more than 100 patients came during our first day of operation. Around the same time, I also started a training program for female nurses. For this, I had to get permission from the Pakistani government, since it was the first program of its kind in the country.
In 1989, while I was in exile in Pakistan, I founded the Shuhada Organization to meet more fully the health and educational needs of Afghan women and girls (www.shuhada.org). Shuhada means martyr and refers to the thousands of people who lost their lives during the many years of conflict in Afghanistan. At the time, the United Nations and the international community were encouraging the formation of nongovernmental organizations, but they tended to support organizations run by men, not women. Today, Shuhada operates four hospitals, 12 clinics, 60 schools, and many other programs designed to empower Afghan women and girls. We have 20 physicians and 1000 other staff members.
In 1988, the foreign minister of Norway visited Pakistan, saw our facilities, and offered us help. I asked him to fund the construction of a hospital in Jaghori, which he did, and that hospital opened its doors in 1993. In 1997, with support from Novib (Oxfam Netherlands), we began building another hospital (Figure), in Behsood, Afghanistan, which is in Wardak Province in the Hazarajat region (see Map). We brought the equipment from Pakistan to Afghanistan's Ghazni Province, which borders on Wardak Province, but the Taliban had set up a blockade in the Hazarajat region. They would not allow Hazaras, members of an ethnic minority group in central Afghanistan to which I belong, to take anything out of any Ghazni city. So we smuggled the equipment to Behsood at night, with men carrying it on their backs.
Nurse Treating a Patient in the Shuhada Hospital in Behsood, Wardak Province, Afghanistan.
The hospital trains nurses, community health workers, and traditional birth attendants in an effort to expand health care services in the region. Courtesy of the Shuhada Organization.
We started another hospital in Yakawlang, Afghanistan, in 1998, soon after the Taliban took over that area (Figure). Despite the dangers, we managed to get equipment to the hospital and were able to work. In December 2000, fighting broke out between Hazaras and the Taliban, and the Taliban looted the hospital. Months later, the Taliban killed three members of our hospital's staff as part of an ethnic massacre in Yakawlang that took the lives of some 300 Hazaras. In June 2001, the Taliban bombed the hospital. Taliban members stole hospital vehicles and medicine from our office in Bamiyan and clinics as well, and they imprisoned our medical director for a year without charges. Despite the violence and Taliban restrictions against women's seeing male doctors and against birth control, we continued to provide reproductive health care to women in all our clinics and hospitals.
Shuhada Hospital, Yakawlang, Afghanistan.
Rebuilt after the Taliban executed staff members and bombed the building, the hospital provides outpatient, inpatient, radiographic, diagnostic laboratory, delivery, surgical, and vaccination facilities for women and children in Bamiyan Province. Courtesy of the Shuhada Organization.
With the fall of the Taliban, we rebuilt the Yakawlang hospital in 2002 and have since started a nurse training program there for women. Because, even now, the ability of women to travel without a male relative is limited, we also train teams of brothers and sisters or husbands and wives as community health care workers who provide information on prenatal care, family planning, and sexually transmitted diseases; assist in deliveries; and identify warning signs of complications of pregnancy.
Although women in Afghanistan can now seek medical care without the restrictions imposed by the Taliban, health care facilities are lacking in most parts of the country. Women have almost no access to emergency or gynecologic care, and they have little knowledge of basic hygiene practices. On average, Afghan women still have seven children apiece, and many become anemic or have miscarriages because of the lack of prenatal care and access to family-planning services and IUDs. Every day, 50 women in Afghanistan die from complications related to pregnancy. The new Afghan government does not have the resources or, as yet, the commitment to establish new facilities for reproductive health care, nor does Afghanistan have sufficient numbers of trained health care providers.
The absence of security in the country also prevents the delivery of services for reproductive health care, since Islamic fundamentalists continue to interfere with the ability of women to receive such care. Those who promote reproductive health care do so at the risk of being labeled "un-Islamic." Still, we continue to provide these services to women and to advocate for women's health care as a basic human right.
Source Information
From the Shuhada Organization; and the Afghan Independent Human Rights Commission — both in Kabul, Afghanistan.(Sima Samar, M.D.)
In 1982, in the midst of the Soviet invasion of Afghanistan, I graduated from Kabul University's School of Medicine. After only a four-month residency at the Wazir Akhbar Khan Hospital, I had to flee Kabul for central Afghanistan, where I had been born and which was not yet under Soviet control. I arrived in Jaghori with only a stethoscope, a blood-pressure cuff, and a copy of Medical Current. I began seeing patients immediately, but I often had to run to my book to identify symptoms and treatments, and then I had to find out whether the necessary medicine was even available. I saw women die every day because of incomplete abortion or shoulder presentation of the fetus at delivery: we did not have the proper equipment to deal with these sorts of problems. To reach patients, I sometimes had to walk or travel on horseback or by donkey for three or four hours in each direction. Often, the patient was dead by the time I arrived.
One of my patients was in labor for six days. Villagers carried her on a bed through almost a meter of snow to a hospital run by Médecins sans Frontières. When I arrived, the patient's pulse was barely palpable. The French doctor said it was too late to save her; I suggested giving the woman a shot of epinephrine, but the doctor refused. I took responsibility and administered the injection. I delivered a stillborn baby, but the woman survived.
In 1984, I contracted whooping cough and had to seek treatment in Pakistan. More than 4 million refugees fled Afghanistan for Pakistan during the Soviet invasion and the subsequent civil war. In the refugee camps in Pakistan, virtually no health care was available to refugee women and children. In the urban areas, every political party had a hospital for its male members, but these hospitals would not treat even the families of these members. Fundamentalists, who opposed women's rights and women's health care, dominated the refugee camps.
When I arrived in Pakistan, I began working with the Christian Hospital in Quetta, which had an Afghan refugee branch but was open only from 8 a.m. to 2 p.m. and could not accept emergency patients. One day when I arrived at the hospital, a woman suffering with severe eclampsia was waiting. I ran to find the key to the delivery room and injectable valium to stop her convulsions, but I could obtain neither one. The woman died in front of me in the corridor. As in their home country, Afghan women in Pakistan often died from complications of pregnancy because they could not reach the hospital for treatment. While I was working for this hospital, I traveled to see patients at a refugee camp three and a half hours by car from Quetta. Because of the fundamentalists' opposition to birth control, I had to take IUDs into the camp by hiding them in my bag.
The need for better reproductive health services was painfully clear, and I decided to start a hospital for Afghan refugee women in Quetta to provide such services. I approached one of the donors of the Christian hospital to ask for support, but fearing fundamentalist retaliation, he was reluctant. Ultimately, however, he agreed to provide support if he and the other donors could remain anonymous. When the hospital opened, we distributed some advertisements for it, and more than 100 patients came during our first day of operation. Around the same time, I also started a training program for female nurses. For this, I had to get permission from the Pakistani government, since it was the first program of its kind in the country.
In 1989, while I was in exile in Pakistan, I founded the Shuhada Organization to meet more fully the health and educational needs of Afghan women and girls (www.shuhada.org). Shuhada means martyr and refers to the thousands of people who lost their lives during the many years of conflict in Afghanistan. At the time, the United Nations and the international community were encouraging the formation of nongovernmental organizations, but they tended to support organizations run by men, not women. Today, Shuhada operates four hospitals, 12 clinics, 60 schools, and many other programs designed to empower Afghan women and girls. We have 20 physicians and 1000 other staff members.
In 1988, the foreign minister of Norway visited Pakistan, saw our facilities, and offered us help. I asked him to fund the construction of a hospital in Jaghori, which he did, and that hospital opened its doors in 1993. In 1997, with support from Novib (Oxfam Netherlands), we began building another hospital (Figure), in Behsood, Afghanistan, which is in Wardak Province in the Hazarajat region (see Map). We brought the equipment from Pakistan to Afghanistan's Ghazni Province, which borders on Wardak Province, but the Taliban had set up a blockade in the Hazarajat region. They would not allow Hazaras, members of an ethnic minority group in central Afghanistan to which I belong, to take anything out of any Ghazni city. So we smuggled the equipment to Behsood at night, with men carrying it on their backs.
Nurse Treating a Patient in the Shuhada Hospital in Behsood, Wardak Province, Afghanistan.
The hospital trains nurses, community health workers, and traditional birth attendants in an effort to expand health care services in the region. Courtesy of the Shuhada Organization.
We started another hospital in Yakawlang, Afghanistan, in 1998, soon after the Taliban took over that area (Figure). Despite the dangers, we managed to get equipment to the hospital and were able to work. In December 2000, fighting broke out between Hazaras and the Taliban, and the Taliban looted the hospital. Months later, the Taliban killed three members of our hospital's staff as part of an ethnic massacre in Yakawlang that took the lives of some 300 Hazaras. In June 2001, the Taliban bombed the hospital. Taliban members stole hospital vehicles and medicine from our office in Bamiyan and clinics as well, and they imprisoned our medical director for a year without charges. Despite the violence and Taliban restrictions against women's seeing male doctors and against birth control, we continued to provide reproductive health care to women in all our clinics and hospitals.
Shuhada Hospital, Yakawlang, Afghanistan.
Rebuilt after the Taliban executed staff members and bombed the building, the hospital provides outpatient, inpatient, radiographic, diagnostic laboratory, delivery, surgical, and vaccination facilities for women and children in Bamiyan Province. Courtesy of the Shuhada Organization.
With the fall of the Taliban, we rebuilt the Yakawlang hospital in 2002 and have since started a nurse training program there for women. Because, even now, the ability of women to travel without a male relative is limited, we also train teams of brothers and sisters or husbands and wives as community health care workers who provide information on prenatal care, family planning, and sexually transmitted diseases; assist in deliveries; and identify warning signs of complications of pregnancy.
Although women in Afghanistan can now seek medical care without the restrictions imposed by the Taliban, health care facilities are lacking in most parts of the country. Women have almost no access to emergency or gynecologic care, and they have little knowledge of basic hygiene practices. On average, Afghan women still have seven children apiece, and many become anemic or have miscarriages because of the lack of prenatal care and access to family-planning services and IUDs. Every day, 50 women in Afghanistan die from complications related to pregnancy. The new Afghan government does not have the resources or, as yet, the commitment to establish new facilities for reproductive health care, nor does Afghanistan have sufficient numbers of trained health care providers.
The absence of security in the country also prevents the delivery of services for reproductive health care, since Islamic fundamentalists continue to interfere with the ability of women to receive such care. Those who promote reproductive health care do so at the risk of being labeled "un-Islamic." Still, we continue to provide these services to women and to advocate for women's health care as a basic human right.
Source Information
From the Shuhada Organization; and the Afghan Independent Human Rights Commission — both in Kabul, Afghanistan.(Sima Samar, M.D.)