Moving forwards in Afghanistan
Authors: None The Lancet Global Health
Journal: The Lancet Global Health (2021)

We write this Editorial in the week that the last US troops left Afghanistan and a new era of Taliban rule began. Scenes of panic and despair, of women losing their jobs and withdrawing from the streets whilst Western powers sought to deflect blame, have been painful to see. What progress does this most beleaguered of nations stand to lose and what does the future hold for its people's health? In the past 5 years, we have published several major studies from Afghanistan on that bellwether of health systems: maternal and child survival. The first (and only) Countdown to 2015 case study of maternal and child health in Afghanistan found that, between 2003 and 2015, under-5 mortality declined by 29% and neonatal mortality by 27%. Stunting declined by about a third. Findings on maternal death were conflicting, but given an observed concurrent increase in coverage of relevant health interventions—eg, antenatal care attendance, skilled care at birth, and facility-based births—there was reason to conclude that maternal deaths had also declined. The RAMOS-II study of maternal mortality in the capital Kabul and the remote rural town of Ragh further showed declines of 71% and 84%, respectively, between 2002 and 2011. However, it is worth noting that this progress emerged from an appalling baseline. The latest UN estimates still show an under-5 mortality rate of around 60 per 1000 livebirths and a maternal mortality ratio of 638 per 100 000 livebirths, suggesting that the Sustainable Development Goal targets of 25 child deaths per 1000 livebirths and 70 maternal deaths per 100 000 livebirths were likely to be unachievable even without the current threat. And the threat is real and manifold. The Countdown to 2015 study showed that the factors that independently contributed to the observed increases in skilled birth attendance and facility births were maternal literacy, deployment of community midwives, and proximity to a facility. Clearly the continued ability of women to learn, to seek employment in the health sector, and to access the services they need are fundamental to even the most basic levels of maternal and neonatal health. The RAMOS-II study would not even have happened had it not been for the team of educated female interviewers who went door-to-door administering the study questionnaire. If women's rights to education, employment, and autonomy are as endangered as we must assume under the Taliban, given historic precedent and despite the group's vague protestations to the contrary, then it is not only the health of vulnerable Afghans that is under threat, but the recording of it. All this does not even touch on the disruption to humanitarian and medical imports caused by the chaos at Hamid Karzai International airport, the withdrawal of International Monetary Fund and World Bank support, and the freezing of central bank assets held in the USA, all of which will put pressure on citizens already paying substantially out of pocket for health care. Nor does it consider the uncertainty surrounding the future of the dedicated non-governmental organisations (NGOs) on whose support the desperately fragile health system relies. Those NGOs delivering education, contraception, and interventions to reduce gender-based violence are particularly unlikely to be able to negotiate continued service provision under the new regime. Many have already left. Given such a dire outlook, despondency is inevitable. Yet the Afghan people, with their justified feelings of abandonment and betrayal, deserve more than sympathy. Countries, particularly those that have played a key role in the past 20 years of Afghanistan's history, should put domestic politics aside and commit to evacuating and eventually granting asylum to those, particularly women, who are legitimately fleeing for their safety, many of whom risked their lives and those of their families to assist their foreign overseers. For those who find themselves stateless in a country that may struggle to support them, aid agencies and their donors should rapidly surge assistance to countries such as Pakistan and Iran, which have already taken in millions of refugees over the past year. For Afghans who remain, those providing—or funding—humanitarian assistance should abide by the principles of neutrality, independence, and impartiality, and operate under a strictly needs-based and ethics-driven agenda.