30 May 2025 | Afghanistan, Asia and Pacific, News and features, Volume 54.01 Spring 2025
This article first appeared in Volume 54, Issue 1 of our print edition of Index on Censorship, titled The forgotten patients: Lost voices in the global healthcare system, published on 11 April 2025. Read more about the issue here.
Over the past 15 years, Bibi Jan has already endured the unimaginable pain of losing four of her children due to malnutrition and inadequate medical facilities. She is now deeply anxious about the health of two of her three surviving children.
I met the 30-year-old in December 2024 at the Zabul Provincial Hospital. I found her sitting beside her two sick children, aged six and three, her face etched with worry. She spoke in a trembling voice.
“Each of [my children] passed away after reaching six months or one year of age,” she told me. “Now, my two other children are also sick. I brought them to this hospital for treatment. The doctors have admitted them. I am staying here while my husband visits us during the day and returns home at night.”
Bibi got married when she was only 15 to a man who was 15 years her senior. “My father gave me away in marriage when I did not consent,” she said. Since then, she has given birth nine times, but only one daughter and two sons have survived.
The women and children’s ward of the hospital was so overcrowded that it was nearly impossible to find any space. Every bed was occupied, and some patients were sharing a single cot or lying on the floor, waiting desperately for medical attention.
Sitting next to Bibi was another woman, 37-year-old Fatima, who had brought her two-and-a-half-year-old child in for treatment. “Due to a lack of sufficient food, my children suffer from malnutrition and one of them is severely ill,” she said. “We barely have anything to eat at home, let alone access to proper medical care.”
The tragic accounts of Bibi and Fatima are just two of countless stories that reflect the dire humanitarian crisis in the southern province of Zabul. Women and children in this province face life-threatening health risks daily. The Zabul Provincial Hospital, which is the only major healthcare centre in the region, is grappling with critical shortages of medicine and medical equipment.
One of the doctors at the hospital, who preferred to remain anonymous, described the grim reality of their struggle: “We are trying to save patients’ lives with the minimal resources available, but we lack adequate medicine and equipment. Foreign aid is not distributed properly, and most of it goes to specific Taliban-affiliated groups. Ordinary people, especially women and children, are deprived of this aid.”
The drastic reduction in international aid following recent political changes has plunged Afghanistan’s healthcare system into an unprecedented crisis. This includes both the reduction of government healthcare assistance within the country since the Taliban’s takeover and recent reductions in foreign aid, particularly from Donald Trump’s administration in the USA and his cuts to United States Agency for International Development (USAID) funding.
Organisations that once provided crucial support to medical centres in Zabul have either suspended their assistance or significantly reduced the resources they provide. Meanwhile, the Taliban lacks the capabilities and infrastructure to manage this growing catastrophe, and has actively enforced policies that make healthcare access harder.
A worsening nationwide problem
According to the United Nations Office for the Co-ordination of Humanitarian Affairs (OCHA), Afghanistan has a maternal mortality rate that is nearly three times the global average – for every 100,000 births, 600 women die.
In a recent report, the OCHA warned that this year nearly half of Afghanistan’s population – or 22.9 million people – will require humanitarian assistance just to survive. The report also stated that 14.8 million people, more than a third of the country’s population, will face acute food insecurity by early 2025.
This crisis extends far beyond Zabul. The Abu Ali Sina Balkhi Provincial Hospital in Balkh is also overwhelmed by the growing number of patients and the worsening economic situation.
At about 4pm one afternoon, a sudden commotion erupted in the overcrowded hallways of the hospital. A 42-year-old man, visibly pale and weak, was lying on a stretcher. He was a roadside vendor who had earned no income that day. His blood sugar levels had spiked dangerously high, leaving him unable to move.
His 12-year-old son and a coworker, both visibly distraught, had rushed him to the hospital. Despite the doctors’ immediate attention, his condition was too severe for him to be saved. About 20 minutes later, a doctor’s voice emerged from his office: “The patient has passed away.”
Hospital officials then turned to his young son and requested that he contacted a family elder to collect the body.
Many of the patients seeking treatment in hospitals across the country have lost their jobs, struggle with chronic illnesses exacerbated by economic hardship, or suffer from the psychological toll of Taliban rule. Additionally, cases of suicide among women, driven by social issues such as domestic violence and forced marriages, have been steadily increasing.
Taliban restrictions further endanger healthcare access
The OCHA has expressed serious concerns over the increasing restrictions imposed by the Taliban on women’s employment and education in the healthcare sector. These policies have drastically limited access to essential medical services for mothers and children across Afghanistan.
According to the OCHA, the country’s economy has shrunk by nearly a third since August 2021. The ongoing political crisis, an inefficient financial system, severe cuts in development budgets and Taliban-imposed restrictions have seriously damaged the country’s ability to deliver basic services.
The organisation highlighted the alarming maternal mortality rate during childbirth in particular, emphasising that the Taliban’s restrictions on women working in healthcare have made access to medical care increasingly difficult.
In addition to these policies, last year the Taliban also banned women from studying in medical institutes, further depleting the already inadequate number of female healthcare workers and stopping them from being able to train in professions such as nursing, midwifery and dentistry. These were some of the only educational avenues left for women.
The desperate need for female doctors
In Badakhshan province, women are particularly affected by the shortage of female doctors. Fatima, a 24-year-old woman, expressed her deep concerns: “I always accompany my relatives who come from remote areas to the central hospital in Badakhshan because they don’t know the way. The situation is truly worrying. There are so many patients but not enough female doctors. We must wait for hours just to get seen by one.”
She recounted the harrowing experience of one of her neighbours who suffered severe complications due to a lack of doctors.
“Several specialised doctors we had have all left the country,” she said. “My neighbour had to undergo surgery in the absence of specialists, but due to severe bleeding she had to go through another surgery within a week. She nearly died.”
Dr Noshin Gohar Karimi, who works at Faizabad Provincial Hospital, voiced similar concerns on his Facebook page: “The workload in Faizabad Provincial Hospital has exceeded the capacity of the staff. Unfortunately, due to a lack of budget, increasing bed capacity and staff recruitment are not possible. The hospital was originally designed for 128 beds, but today more than 310 patients are admitted. In the paediatric ward, which has only 30 beds, 120 sick children and their mothers are currently being treated.”
The healthcare workforce crisis
The shortage of medicines and lack of funding remain among the most pressing challenges in Afghanistan’s healthcare system. A nurse at a government-run, public hospital in Kabul highlighted the ongoing crisis: “We used to have more staff, but over the past two years the workforce has decreased significantly. Now, one person has to do the work of several people and, as a result, patients do not receive adequate care. In addition to that, doctors and nurses face persistent delays in their salaries.”
She added: “Before the Taliban took over, medical equipment was already scarce but, after that, even that small supply stopped. Many machines have become old and worn out, and hospital officials say they have no budget to replace them.”
A nurse at a private hospital in Kabul also reported severe staff shortages in various departments. “There is a lack of personnel in all sections. In the nursing department, especially, we do not have enough staff and are forced to do the work of several people alone, while our salaries have also been reduced.”
With a collapsing healthcare system, increasing restrictions on women and dwindling international aid, Afghanistan faces a healthcare catastrophe that threatens the lives of millions.
Additional reporting by Rukhshana Media reporters
15 May 2025 | Europe and Central Asia, News and features, United Kingdom
This article first appeared in Volume 54, Issue 1 of our print edition of Index on Censorship, titled The forgotten patients: Lost voices in the global healthcare system, published on 11 April 2025. Read more about the issue here.
For those regularly subjected to racial discrimination, it can be exhausting to encourage people without this firsthand experience to see things from their perspective. Convincing others that certain behaviours or attitudes are harmful can be frustrating, difficult and ultimately lead to hostility – and nowhere more so than within large organisations, where prejudice may be deeply embedded.
The National Health Service (NHS) is one of the UK’s most loved and largest institutions, employing more people than any other organisation in the country. But, as a result, it is not exempt from societal issues.
Institutional racism within the NHS, impacting both staff and patients, has been well documented. A report compiled last year by Middlesex University and the charity Brap found that “racial prejudice remains embedded in the health service despite initiatives to remove it”.
The NHS has failed to “provide a safe and effective means for listening to and dealing with concerns” raised by Black and minority ethnic (BME) staff, and it noted a “culture of avoidance, defensiveness or minimisation of the issue from their employer if they did so”.
Nearly three-quarters of UK- trained staff had complained of race discrimination, according to the study. A survey commissioned by the membership body NHS Confederation in 2022 also reported that more than half of its surveyed BME NHS leaders had considered leaving in the three years beforehand as a result of racist treatment they had experienced while doing their jobs. Black patients also often find their concerns ignored by healthcare professionals, with potentially deadly consequences.
Dr Annabel Sowemimo, a doctor of sexual and reproductive health and author of the book Divided: Racism, Medicine and Why We Need to Decolonise Healthcare, has spent many years facing and exploring this prejudice, and has seen her own concerns ignored as both a patient and a practitioner. Speaking to Index, she told a story from her time as a junior doctor working in the paediatric accident and emergency department, when a Somali child came in experiencing abdominal pain but with “atypical symptoms”. An experienced nurse said the child needed to go home with antibiotics, as they had a urinary tract infection. But Sowemimo was not convinced by this diagnosis.
“I saw the patient and I said, ‘I don’t really think that this child has an UTI’,” she said. “The dad didn’t really speak great English so it was difficult to communicate.” Ultimately, the child was diagnosed with severe appendicitis and needed surgery. “If they had not had surgery [the appendix] probably would have ruptured – that’s what the surgeon said to me,” Sowemimo added. “It was really hard, because I was a really junior doctor, I had been in the department for only a few weeks, and the nurse was quite senior and I didn’t want to be seen to be going against what she said.”
Sowemimo, who is from a Nigerian background, believes that a combination of cultural bias from staff and culturally influenced self-censorship by patients can play a collective role in misdiagnoses. “I don’t think that nurse was being racist, but there were certain things that made this child more vulnerable,” she said. “Culturally, I think the child had probably been raised in an environment like mine.
“I would, as a kid, never make a scene in public because my Nigerian parents just wouldn’t stand for that kind of thing. So sometimes, if I was uncomfortable, even around adults, I’d just hold that energy in, whereas other children could probably express that more.”
Sowemimo believes that self-silencing can be particularly pervasive among Black patients, who may have fears around their expressions of pain or discomfort being construed as “aggression” by healthcare professionals. “We change our behaviour,” she said. “We’re worried about being seen as ‘angry, Black women’ in particular. So even if I am in pain, I’m not going to feel comfortable yelling and writhing around. It doesn’t mean that I’m [less] in pain [than] the next person, just that I’m acutely aware that sometimes things get misread.”
A misguided belief that Black women “exaggerate” their symptoms has also proven to be fatal, and nowhere more so than in maternity care. Black women in the UK are nearly four times more likely to die in pregnancy and childbirth than their white counterparts. In 2023, an investigation into the death of a pregnant Black woman in Liverpool found “cultural and ethnic bias” played a part in her late diagnosis and death. Hospital staff had neglected to take some observations because she was “being difficult”, according to comments in her medical notes. This delayed her diagnosis and treatment and led to her baby dying, and then to her own death two days later.
Such biases are endemic in many countries, and ethnic minorities faced higher mortality rates during the pandemic. Black American doctor Susan Moore documented on social media how her pain and requests for medicine were ignored when she was in hospital with Covid-19 in 2020. She said she was made to feel like a “drug addict” for requesting remdesivir, the antiviral drug used to treat Covid patients. She later died due to complications from the virus. In May 2020, the British Medical Association (BMA) reported that more than 90% of all doctors and consultants who had lost their lives from Covid- 19 up until that point had been from minority ethnic backgrounds.
Sowemimo believes that “biology” is weaponised in healthcare settings, with doctors and nurses often concluding that Black people are more likely to die from certain illnesses due to genetics. There are many complex factors that play into higher death rates, she said, including later diagnoses and a lack of clinical research.
“With some reproductive cancers or endometrial cancer, it seems that Black people present later, and with prostate cancer we have worse outcomes,” she said. “We’re trying to direct research towards these issues to actually work out what is going on, but ultimately [research isn’t funded] towards groups that are not seen as politically mobile, who are more disenfranchised and impoverished.
“Often, people keep telling you that it’s biological, that we’re all biologically flawed in some way, and this is making us more predisposed to all these things. I think that’s actually even more sinister – how people keep on pathologising Blackness rather than addressing the systemic problems that exist.”
Beyond the treatment of individuals, systemic issues around resource allocation “compound” the discrimination facing minority groups, she says. In what think-tank The King’s Fund refers to as the “inverse care law”, those who most need medical care are least likely to receive it. For example, people who live in the most deprived areas of England are twice as likely to wait more than a year for non-urgent treatment, and there are fewer GPs per patient in more deprived areas. BME people are over-represented in the most deprived areas, and are two to three times more likely to be living in persistent poverty.
Disparities in care are caused by complex societal problems that reach far beyond the realms of healthcare services alone. So changing the behaviour of NHS staff is only the first hurdle, and a high one at that. “I make this argument a lot in my work, that it’s really hard to change something that has been embedded for such a long time,” said Sowemimo. “And I think a key part of why we have a lot of these issues [is that] people are just not willing to change their practice.”
Broaching inappropriate behaviour can be difficult, given that most NHS staff have good intentions and want to help people. “People… feel like they’re underpaid, and they do work particularly altruistically,” Sowemimo said. “So telling them that they’re not being altruistic, that they might be being biased or discriminatory, people are going to [think that’s] quite rude.”
In recent years, there has been increasing political scepticism from the government surrounding the need to address inequalities in the NHS. In 2023, for example, the then health secretary Steve Barclay ordered the NHS to stop recruiting for roles by focusing on diversity and inclusion. Health equity commitments have also been discarded – the Maternity Disparities Taskforce set up under former Prime Minister Boris Johnson in 2022 met only twice in 2023 rather than the scheduled six times, and reported little progress.
But there is hope on the horizon: the current Labour government has committed to a Race Equality Act, which includes several provisions around improving healthcare outcomes for BME people, including closing maternal health gaps and improving diversity in clinical trial recruitment. However, the current geopolitical climate could reverse efforts. US president Donald Trump’s executive order banning diversity, equity and inclusion (DEI) programmes across the federal government may have a ripple effect for UK organisations, from which the public sector may not be exempt.
“There’s a lot of momentum around the push-back; we’re very much influenced by US politics,” Sowemimo said. Despite the hurdles, she isn’t going to stop banging the drum about healthcare inequalities. “I’ve always said that, sometimes, the work we’re doing is just to stand still,” she said. “It’s really hard when you’re in a time where you’re not actually fighting for progress, and no one’s going to say, ‘You’re the person that got that bill [or] that got these people their rights’. In fact, you just fought to make sure their rights weren’t removed.”
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