Will the Taliban roll back two decades of public health progress in Afghanistan?

Child and maternal mortality have fallen dramatically. Now what?

Since the Taliban retook Kabul this past Sunday, observers around the world have worried about what the religious group’s control will mean for Afghanistan’s women, its internal security, its education system, its religious minorities, and its citizens who aided the coalition occupation over the past two decades.

But relatively little attention has been paid to what the Taliban victory will mean for one of the nation’s biggest accomplishments: the sharp decline in child and maternal mortality over the past two decades.

A study in The Lancet Global Health found that between 2003 and 2015, child mortality in Afghanistan fell by 29 percent. While maternal mortality is difficult to estimate, one data set found that deaths in childbirth fell from 1,140 per 100,000 in 2005 to 638 per 100,000 in 2017, or nearly in half.

This progress was not necessarily all generated by the US-led occupation, with aid from international organizations and Afghan-led initiatives contributing heavily; and these estimates rely on household surveys that are difficult to conduct well, especially in poor, war-torn countries with large nomadic populations, meaning they are likely off to some degree.

But regardless of their origin, these are huge gains to the country’s health, gains that represent hundreds of thousands of lives saved. It would be disastrous if they were to deteriorate, or if progress were to slow, under the new regime.

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To get a sense of where this progress came from, and whether it can be maintained under Taliban rule, I spoke with Gilbert Burnham, a professor at Johns Hopkins’s Bloomberg School of Public Health who has been researching Afghanistan’s health systems and helping conduct public health surveys since 2002. A transcript of our conversation, lightly edited for length and clarity, follows.

Dylan Matthews

When you started in Afghanistan in 2002, the country had been under Taliban rule for five years and was in a state of humanitarian emergency. What was your assessment of the country’s public health compared to other places where you’d worked?

Gilbert Burnham

Without a census, which Afghanistan has never had, it is hard to plot trends. But the health status of Afghanistan had been poor before the Soviet invasion in 1978, with high infant and child mortality. During the Soviet times [1978 to 1989] and afterward, during the conflict with the mujahideen and the Taliban, there was little or no improvement. In 2002, the health status, especially of women and children, was poor by world standards and regional standards. The deaths of women from pregnancy-related causes were some of the worst in the world.

Dylan Matthews

What have been the main trends in public health in Afghanistan over the last two decades?

Gilbert Burnham

The principal health indicators are still worse than the region, but many have shown a remarkable improvement. These include immunization coverage, women delivering with a skilled attendant, death rates of children, and function of hospitals. Especially impressive is the percentage of the population who have access to primary health care, though there are still many households living in isolated and distant locations, and several million nomads with little access to care.

Especially impressive has been the training of health care workers, especially with advanced skills. The number of health care workers with advanced public health training, obtained in the USA, Europe, Asia, and the region, while still insufficient, is remarkable, considering there were few if any in 2002.

Dylan Matthews

If you’re trying to explain the positive trends in child and maternal mortality in Afghanistan, what gets credit there? What kinds of aid or government programs or societal changes are responsible for that?

Gilbert Burnham

Improvement in maternal and child health was a government priority from the beginning, heavily supported by programs such as from USAID and the UN. UNICEF was always an important player.

While strengthening access to care and the quality of care and availability of vaccines is always important, other improvements in water and sanitation, roads, markets, schools, and education of women are important as well. The [US] government and supporting donors such as the World Bank were really single-minded on these maternal and child priorities, and this focus worked. While [maternal and child health in] Afghanistan is still not good compared to neighbors, the change in most public health indicators since 2002 has been quite impressive.

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Dylan Matthews

What has happened with human resources in health care since 2002? How has manpower been boosted for doctors, nurses, and other medical personnel?

Gilbert Burnham

The numbers and quality of health care workers have substantially increased, and some extremely capable leadership has emerged. Yet more developed health systems are always a magnet for migration. Shortages of medicines and delays in salary payment can have a demoralizing effect. A very robust private health sector has been emerging, even in the smaller areas, and this was becoming a preferred source of treatment for many conditions.

Dylan Matthews

What can we expect on public health from a Taliban regime?

Gilbert Burnham

We don’t know yet. Initial promises have sounded like supporting existing programs, and there has been some outreach to international donors and aid organizations encouraging them to continue their work. But these are early days. Maintaining the emerging role of women in the health workforce will probably be a litmus test for [international] donors.

Dylan Matthews

To what extent has aid gone to service provision versus corruption? I know this is a big worry people have about the Afghan government generally; was it a big problem with health specifically?

Gilbert Burnham

Corruption is a problem for most poor countries. As they become more prosperous, this often reduces. In the health sector there are some certain areas in countries where corruption often occurs — medicines, construction, and employment of nonexistent or “ghost workers.” Although an Afghan government inquiry several years ago identified several areas of corruption in the health sector, my impression is that this has not been as big a problem as in other sectors, but this is just my impression.

Dylan Matthews

If you’re looking five years into the future for Afghanistan, what would a good scenario look like? What would a bad scenario look like? What are you hoping for or fearing?

Gilbert Burnham

The best-case scenario would be a continued emphasis on the health of women and children, expansion of the developing public health sector — including nutrition, water, sanitation, and housing — and attention to the emerging problem with chronic or noncommunicable diseases.

The health workforce needs continuing support. Things can go bad if restriction of women, both as a health focus and in the workforce, occurs and ideology starts getting in the way of health programming. The health of Afghanistan cannot move forward without continuing external support, and this is likely to be required for some years to come, regardless of who is the government. A plunge back into war and instability is the very worst case imaginable for the health of the country.