How the Taliban undermined community healthcare in Swat, PakistanBMJ 2012; 344 doi: http://dx.doi.org/10.1136/bmj.e2093 (Published 21 March 2012) Cite this as: BMJ 2012;344:e2093
- Iftikhar Ud Din, public health officer1,
- Zubia Mumtaz, assistant professor2,
- Anushka Ataullahjan, research analyst2
- 1EDO Health Office, Dassu Kohistan, Khyber Pakhtunkhwa, Pakistan
- 2School of Public Health, University of Alberta, Edmonton, Alberta T6G 2T4, Canada
- Correspondence to: Z Mumtaz
Pakistan is in the midst of Islamic militant violence. Although the conflict in the Swat district in northern Pakistan has officially ended, there is a threat of Taliban re-emergence and the Pakistani military continues to fight the militants.1 2
Swat is in the Himalayan region, and its high mountains, green meadows, and clear lakes made it a popular destination with tourists looking for skiing, hiking, fishing, and ancient statues of Buddha. The Taliban invasion during 2006-9 not only destroyed the tourist industry, it unleashed a reign of terror on the local population. A key feature of the Taliban militancy was a systematic attack on people suspected of behaviours that were in violation of the Taliban’s interpretation of the principles of Islam.
The Taliban publicly beheaded residents accused of crimes and hung their bodies in the busiest square of Mingora, the district capital. They prohibited polio vaccination campaigns for children, schooling of girls,3 and women working outside the home. Women working in schools and health centres have either been fired or killed,4 and those in non-governmental organisations have been forced to stop work. Men were killed for shaving their beards, listening to music, and watching movies.
Over the three year siege of Swat, Islamic militants destroyed 165 girls’ schools, 80 video shops, and 22 barber shops.4 They also destroyed infrastructure, including bridges, police checkpoints, and a generating grid station that provided electricity to 1.8 million people.5
Health systems and conflict
Health infrastructure in Pakistan has also been targeted: 29% of health facilities in the province of Khyber Pukhtunkhwa have been damaged in the conflict between the Taliban and the government forces.6 Health workers have been killed inside healthcare facilities as they worked to save people wounded in suicide blasts.7
Women are a key target of Islamic fundamentalists, and there was concern that the female community health workers (known locally as lady health workers or LHWs) of the National Programme for Family Planning and Primary Health Care (box) might be particularly vulnerable. These women deliver services to the doorstep since societal norms restrict women’s ability to attend healthcare facilities.
National Programme for Family Planning and Primary Health Care
Launched in 1994, the programme consists of a network of over 100 000 community based female workers
Known as lady health workers (LHW), the women are residents of the community they serve, have a minimum of eight years of schooling, and receive 15 months of training
Each worker has a catchment area of about 200 families (or about 1000 population)
Primary tasks are to provide family planning counselling and services (condoms and oral contraceptives), health education, and treatment for minor illnesses, mainly in people’s homes. They encourage and facilitate antenatal care and skilled attendance at births
Their work has recently expanded to include polio immunisation campaigns, supporting direct observation therapy short course (DOTS) treatment for tuberculosis, malaria control, and emergency relief activities.
LHWs facilitate functioning of village health and women’s committees
We conducted 30 in-depth interviews with LHWs and their supervisors and managers to determine to what extent they have been specifically targeted by the Taliban.
The women reported being named and shamed on radio broadcasts and subjected to threats of kidnapping, forced marriages, and in some cases death. As a result of such treatment, many resigned, resulting in a near collapse of the programme during the height of Taliban control of Swat.
Our research shows that the Taliban had launched a systematic campaign of abuse and harassment of the primary healthcare programme and its core workforce, which was targeted in a way that went beyond the attacks on the health system more broadly.
The Taliban used a combination of fatwas (religious decrees), threats, and physical assaults. Three fatwas were instituted that had serious implications for the role of LHWs in the community. The first declared that the presence of women in public spaces was a form of public indecency, which affected their ability to travel unaccompanied—a key requirement of their job.
This fatwa also stated that it was a Muslim man’s duty to kidnap LHWs when they paid home visits, to marry them forcibly (even if they were married women), or to use them as sexual slaves. Maulana Fazlullah, the Taliban chief of Swat, even went as far as declaring the LHWs wajibul qatal, meaning that it was acceptable to kill them.
The second fatwa declared that it was morally illegal for Muslim women to work for wages. And the third fatwa declared that LHWs were men because they travelled unaccompanied in the streets like men. Like all non-family men, they should not be allowed to enter homes. Since a key aspect of the LHWs’ work is home visiting and doorstep health services, this fatwa essentially made it impossible for them to work.
Radio was used to turn the population against the LHWs. An important instrument in the ideological campaign aimed at generating support among the local population, the radio broadcasts generally focused on popular social issues such as women’s inheritance and how the Taliban would address these within the framework of Islam. A daily half hour radio programme was dedicated to discrediting the primary care programme and the women who worked in it. Individual LHWs were named and shamed as prostitutes and servants of America.
“They announced on FM radio that we are prostitutes. We come out of our houses in the morning, carry condoms with us, go house to house, find clients in these houses, have sex with them, and earn money. After this it was very difficult for us to go to houses to work,” one LHW said.
The Taliban also sent letters and paid home visits to warn women to stop working as LHWs. “I received a letter saying if you continue working, we will send a suicide bomber to your house,” one said.
The homes of LHWs are prominently marked as “health houses,” and according to our participants, the Taliban had visited almost every one. In some cases they had threatened family members—especially male relatives—with beheadings if the women continued working.
“In the evenings they (the Taliban) would go to the LHWs’ houses and knock on the door. The Taliban visited almost all the houses as they were from the same villages and mohallas [neighbourhoods] as the women and asked them not to work as a LHW,” a supervisor said. “In Matta, they stood on the doors of the girls and said that if you leave your house for work tomorrow we will kill your whole family and we will kill you.”
Since beheading was a routine practice of the Taliban, people took these threats seriously. Other workers were threatened with having their children kidnapped and killed.
Unmarried LHWs were threatened with forced marriages since Fazlullah had declared that all girls older than 12 should be married off. Participants reported at least seven forced marriages in their communities, although none among the LHWs.
All our participants gave examples of these threats being carried to fruition. For example, they reported that men had verbally harassed LHWs in the streets, beat them with sticks, and set dogs on them during home visits. The Taliban had fired on some LHWs’ houses and killed colleagues’ family members.
“The Taliban would come. They would call their [LHWs’] brothers or fathers to the door. They used very bad language about the girls and told them to stop this NGO [non-governmental organisation] and family planning job. The brothers cannot tolerate such language about their sisters. So they argued back—that this is their job—the Taliban just killed them,” a supervisor said.
Though the LHWs bore the brunt of the Taliban’s aggression, other parts of the programme were also targeted. The district officers, mostly men, also received letters warning them to resign from their jobs. Offices had to remove their identifying boards as a safety precaution. Programme vehicles were stolen and the drivers were told that it was not worth sacrificing their lives for an NGO vehicle.
Why target the programme and LHWs?
The programme’s mandate to provide family planning services made it an ideological target. The Taliban were hostile to the concept of family planning, believing it was a part of a great conspiracy by Americans and the West generally to eliminate Muslims and Muslim identity. “The Taliban were allergic to the words ‘family planning’. They said family planning means no children. It is an American conspiracy. No children means that our nation will be finished in a few years,” a supervisor said.
They also believe that contraceptives promote vulgarity, obscenity, and extramarital sexual relations. “Maulana [Fazlullah] announced several times on the radio that LHWs are providing condoms to unmarried girls and these girls are then using them. The LHWs want to promote prostitution and sin in our society,” a LHW said.
A second reason the Taliban attacked the programme was that they believed it to be an American funded NGO. All NGOs are considered suspect as they have acquired a reputation of working for donor interests rather than Pakistani national interests. The Taliban did not believe that the West would be interested in protecting children from polio. They cited the Palestinian, Iraqi, and Afghani conflicts as examples of the Americans killing Muslim children, saying that if Americans kill Muslim children in these places they cannot profess to want to save Pakistani children in Swat.
“We were targeted more because the Taliban said our programme is an NGO. The concept of NGO is very bad here. One other thing is that our staff are involved in polio campaigns and they [the Taliban] are against polio drops. They think that these drops are sent by English and Americans for family planning,” an assistant district coordinator said.
LHWs are particularly vulnerable because they work in isolation in remote villages and attacks are less likely to get reported. Furthermore, their work—walking in public spaces, visiting people’s homes—makes them visible. As a group, they are relatively powerless and even unrecognised as health professionals.8 Unlike physicians, LHWs have no representative unions or professional organisation to advocate for their safety. The resurgence of Islamic fundamentalism in the region also means that they lack support. Fundamentalist views that repress women are widespread in Pakistan today and are shared by those who may otherwise not believe in violence or even be particularly religious (box).9
Islamic fundamentalism and women
In Pakistan, two key reasons underlie the Taliban’s focus on women. Firstly, as an ideology, the Taliban movement (and militant Islam generally) merges the concepts of religion, tradition, and nationalism. A selective use of religious texts and the belief that women are the gatekeepers of the Muslim identity9 places the onus of protecting the faith and Muslim identity on women.
Secondly, control of women, their social roles, their movements, and their sexuality forms the core of Islamic fundamentalist views on gender roles and relations. Women’s education (beyond learning the Quran) and notions of equality and freedom are equated with vulgarity, obscenity, and seduction.9 A key goal of the Islamic fundamentalist agenda, therefore, is to limit women’s human and reproductive rights, maintaining their status in the family and society as dependants.10
Impact of the Taliban campaign
The Taliban’s campaign harmed individual LHWs, the programme, and the local population of Swat. The people we spoke to told us that colleagues who had experienced Taliban harassment and violence were living in extreme fear and isolation. Their neighbours and relatives shunned them, resulting in marital discord and mental health problems.
“I know a LHW. The Taliban came to her house at night. They beat her father. They burnt all the material regarding the program and books… the father was told that his daughter is a prostitute and he is acting as a pimp,” one LHW said, adding: “After that day the girl has not come out of her house. She has isolated herself and she does not want to meet anyone.”
They shared stories of how some colleagues had burnt their work materials publicly to demonstrate their severance from the programme. Many LHWs simply moved away from Swat.
The programme started feeling the negative effects of the Taliban as early as 2005, although the manager says it is difficult to pin point the cause of the gradual dysfunction. As the Taliban expanded and strengthened their hold, the programme suffered drastically. About 15% of LHWs officially resigned, and many others simply stopped working. Our respondents said that the number of polio cases and maternal deaths had increased. Although it is difficult to conclude that these events were the direct result of the breakdown of the programme rather than the cumulative effect of the conflict, participants attributed them to the Taliban’s systematic campaign.
“One elderly woman used abusive language against a LHW during a polio campaign. She even hit the girl with a big stick and the child in the house could not be immunised. Now the child has polio and is paralysed. The old woman is profoundly sorry and constantly apologises to the LHW,” a supervisor said.
“A lot of people stopped using family planning methods. They said it’s against Islam. They got pregnant. Now the Taliban are gone they are aborting the pregnancies. Abortions are on the rise and women are dying. I joined this programme in 2004. From 2004 to 2007, I saw only one maternal death. But since the Taliban takeover and subsequent routing, I have seen seven maternal deaths,” said another supervisor.
Safeguarding health services
The systematic harassment of health workers occurred despite international conventions in place to stop this. The Geneva Convention (1949) and its two additional protocols (1977) detail the standards of protection for medical infrastructure and health providers in both international and local armed conflict11 and are binding on states and other combatants irrespective of whether the parties have ratified them.12 Our findings suggests that the Taliban violated the Geneva Convention and its protocols.
The best protection for LHWs will come from evidence. The problems facing LHWs first need to be acknowledged and documented. This may sound simple but is actually a daunting task because not all policy makers, most of whom are men, shared our concerns regarding the militant threat to the LHWs when the issue was raised with them. We could not speak to the women most affected because it could have endangered their lives, and the interviews were conducted in an atmosphere of extreme fear as the Taliban were continuously threatening to return. Indeed, the principal investigator had to leave the area early because of the risks. Nevertheless, our research provides a glimpse into the dangers faced by LHWs amid the ongoing militant conflict in Pakistan.
Documenting specific incidents of threats of violence or actual violence or abuse of isolated workers will require extensive resources. The LHWs need to develop an organisation to look after their interests, with a particular focus on their gendered interests. In this they could draw on the extensive experience of national women’s rights organisations who have come up with innovative strategies and responses for dealing with Islamic fundamentalism in Pakistan.9
We used a focused ethnographic approach with in-depth interviews to generate data about the experiences of LHWs. We used purposive sampling to recruit informants with the most knowledge about the research subject.13 However, the LHWs most severely affected by the militants had cut off all contact with the programme and we were told that contacting them could endanger their lives. We were also quite limited in imposing any selection criteria. However, we did require the respondents to have resided in Swat and worked in the national programme between January 2008 and December 2009.
As a result, our respondents were staff attending training sessions or meetings at the programme’s district offices. The 30 respondents comprised eight LHWs, 17 supervisors, three district programme coordinators, one assistant district coordinator, and one driver.
All interviews were conducted in Pushto at the district headquarters of the programme. The principal investigator (IU) conducted the interviews in the presence of the respondent’s immediate supervisor. Verbal consent was obtained since the respondents were unwilling to sign any documents. Participants were assured that all the information collected would be kept confidential. The local programme manager stipulated that interviews should be held in the presence of a supervisor, presumably to protect the respondent, but it is difficult to determine what effect this had on the integrity and quality of the data.
The first four interviews were digitally recorded, but because of threats that the Taliban were about to return the remaining participants were afraid to be recorded. IU therefore made handwritten notes and expanded them later. IU also translated and transcribed the interviews and coded the transcripts with ZM. Ethical clearance for the study was given by the Health Services Academy, Pakistan. We did not offer any incentives to participate.
Cite this as: BMJ 2012;344:e2093
Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author). At the time of research, IU was studying for a masters in public health at the Health Services Academy, Islamabad, Pakistan. The Health Services Academy provided financial and logistic support for his research. ZM was funded by Alberta Innovates-Health Solutions, Canada. They have no other relationships or activities that could appear to have influenced the submitted work.
Provenance and peer review: Not commissioned; externally peer reviewed.