Vol V: Unanswered Questions and Ethical Dilemmas from Afghanistan: Unheard Voices and Enduring Suffering of Women Affected by Violence

This article was originally published in the 2016 Spring Issue, and can be read here.
Author: Sakiko Yamaguchi
Based on reflecting on the experience of working with an Afghan widow, this essay unfolds the challenges and dilemmas of providing aid for vulnerable populations whose voices are rarely heard. Though global health policy makers and practitioners are fully committed to achieving universal health care, it is easy to overlook the fact that people’s suffering and emotional pain from conflicts and structural violence are multi-layered. The expression of their painful feelings, illness as a result of suffering, and help-seeking are deeply embedded in particular socio-cultural contexts and historical processes. This essay shows the limitations of uncritical applications of Western biomedical concepts in addressing the gap of mental health needs for people affected by violence.

Walking together in the backyard, surrounded by blooming red and pink roses and a distant view of dark blue mountains capped with white snow, I spoke with Bibi Sherin* about the weather and our families. The beautiful landscape and good company made it easy for me to forget the ominous uncertainty, lethal violence, and fragility Afghanistan faced.

On that day, Bibi Sherin unexpectedly started to unfold her past memories. Using her limited English and my limited Dari, when I heard her say, “Shohare” “Talib” “Da da da da da.” I had no idea what this was about. Nevertheless, helped by her unusually strong voice, I gradually put the pieces together: a long time ago, her husband was shot by Taliban fighters. The tears that streamed down her cheeks revealed the painful emotions she had before since suppressed, especially regarding the death of her loved one. Walking in silence, side by side with her, I could find no words to ease her suffering and sense of loss.

So what? In order to address mental health needs for vulnerable populations affected by violence, it is important to understand that human suffering is multilayered. Suffering should be understood from a broad macro-perspective as well as at individual and collective levels in particular socio-cultural contexts.

The NATO helicopters flying noisily above us reminded me that peace was yet to come in Afghanistan. Has she always kept the lid on her emotions, as well as her agonizing memories? Is it a conscious reaction to actively forget her past? If so, how can her emotional pains heal?

When Taliban roadside bombs and suicide attacks kill civilians on a daily basis, how can those affected by this victimization express their collective sorrow? How has the daily precariousness of this ongoing conflict affected people’s mental health?

Bibi Sherin, an Afghan woman, worked as a housekeeper in the office of a technical assistance project provided by the Japanese government in Afghanistan. One of her tasks was cooking lunch, a highlight of the day for all of the staff and what seemed to be the time and space where she could release herself from daily stress, as well as uniquely express herself. Each time I told her that her dishes were tasty, she would bashfully return a pleased smile. That smile eased the stress and frustration I felt while working under such instability and uncertainty. Of the one million vulnerable Afghan widows, as estimated by the Ministry of Women Affairs , whose voices are rarely heard in a male-dominated closed society, she was lucky to have a paid job. Unfortunately, our project was about to end.

Knowing this fact, she told me, “The project ends. No job.” Although I responded that I would talk with my boss, I was unsure whether we could find another job for her. I could sense her growing concern and anxiety at losing her precious source of income. As a breadwinner, despite having the extreme disadvantage of being an illiterate woman, she was under enormous pressure to find another job. I can recall my shock when I once noticed, as she removed her scarf to fix her hair, that her dark locks had started to turn white. I wondered if her white hair showed not only the direct impact of protracted violent conflict, but also the suffering endured from such economic hardships and distress.

As the project drew close to an end, Bibi Sherin started to become absent from work. One day, when I asked about her absence, she told me that she sometimes felt chest pain. Several days later, she took an unpaid leave to go to Pakistan with one of her sons to see a doctor.

Will vulnerable populations, such as illiterate widows, be kept confined to impoverishment as victims of structural violence? To what extent are Afghan religion, culture, or traditional values reflected in the Western notions of human rights, gender equality, and empowerment of vulnerable populations?

As the project drew close to an end, Bibi Sherin started to become absent from work. One day, when I asked about her absence, she told me that she sometimes felt chest pain. Several days later, she took an unpaid leave to go to Pakistan with one of her sons to see a doctor. Considering the extra expenses of her trip to Pakistan, instead of seeing the closest Afghan doctor in Kabul, it was not an economically rational choice.

Is her help-seeking behavior signaling a gap between the people’s need and what the Afghan Ministry of Health and the international humanitarian assistance have been trying to provide?

In countries like Afghanistan where the government budget heavily relies on foreign aid, health resources are barely available, and the insecurity hinders access to available health services, is the concept of universal health care a pipe dream in the end?

On my last working day in Afghanistan, I visited Bibi Sherin to say good bye. Luckily, despite her concerns, she had been given a new post in another project. When I informed her that I was going to study mental health, another Afghani member of staff who translated for me explained, “When Bibi-san (Bibi Sherin’s moniker) went to Pakistan, the doctor told her that the chest pain is caused by her mental illness. It is great to hear that you are going to study about these conditions. Mental health is important in Afghanistan because many people are suffering.”

Are Bibi Sherin’s white hair and chest pain an embodiment of her attempt to actively forget the agonizing memories and cope with the psychological distress?
Is her help-seeking behaviour reflective of the challenges being faced in the realization of a universal health care system in Afghanistan?

Would the medication prescribed for her chest pain also take her psychological suffering away, even if her current situation keeps a lid on her emotions?
Who will hear the voice of vulnerable populations, such as illiterate widows like Bibi Sherin, and how can we help them heal their collective emotional pain?

I left Afghanistan in the summer of 2011 with these questions unanswered. My days with Bibi Sherin have made me recognize the need for an in-depth understanding of the distress and illness that are embedded within historical and socio-cultural contexts that differ from our Western premises. Cultural context is sometimes overlooked in favour of biomedical evidence when explaining health outcomes. To adequately address these unanswered questions, we must recognize that Western biomedical concepts may fail to consider the way people affected by violent conflict suffer.

*The names used in this article by the author were used with permission.


I would like to thank Dr. Duncan Pedersen, who powerfully inspired me to develop critical insight within the field of Global Mental Health. I also thank my Afghan and Japanese colleagues for their constant support and encouragement throughout my time in Afghanistan.


  1. Ibrahimkhel, Shakeela. Ghor Girl Dies After ‘Public Lashing.’ TOLO News. [Internet]. 2015 Nov 20. [cited 2015 Nov 22]: Available from: http://www.tolonews.com/en/ afghanistan/22428-ghor-girl-dies-after-public-lashing
  2. Ministry of Women Affairs. Men and Women in Afghanistan: Baseline Statistics on Gender. [Internet]Kabul: MoWA. 2008. [cited 2015 Nov 22] Available from: http://www.refworld.org/pdfid/4a7959272.pdf
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