Editorials refugees must regularly rely on international ence to US-based studies and international 6. Davidson JRT, Foa EB, eds. Posttraumatic relief organizations for basic necessities, work. C: Stress Disorder: DSM-IVand Beyond. Washing- including water, food, shelter, and sanitation. ton, DC: American Psychiatric Press Inc; 1993. Richard Neugebauer, PhD, MPH 7. Wilson JP, Raphael B, eds. International Hand- Disenfranchised, heavily traumatized, depen- book ofTraumatic Stress Syndromes. New York, dent individuals, fleeing from political perse- Columbia University NY: Plenum Press; 1993. cution or death, may have difficulty under- New York, NY 8. Mollica RF, Donelan K, Tor S, et al. The effect oftrauma and confinement on functional health standing or believing that they are truly free and mental health status of Cambodians living to decline participation in a study approved in Thailand-Cambodia border camps. JAMA. by the hosting relief organization. As is the Acknowledgments 1993;270:581-586. case with other populations judged "deci- The author gratefully thanks the following individu- 9. Gupta L. Exposure to War Related Violence sionally incapable" or compromised, reflec- als for researching some ofthe topics covered in this Among Rwandan Children and Adolescents: A editorial and for commenting on earlier drafts: BriefReport on the National Baseline Trauma tion and research are needed on how to opti- Dorothy Castille, Jennifer Ritsher, Anastasia Yasik, Survey. Kigali, Rwanda: UNICEF Trauma mize meaningful free informed consent.'5 In Bridget Trazoff, Elizabeth Smailes, and Sara Kay. Recovery Programme; February 25, 1996. this process, as with humanitarian assistance An earlier version of this editorial was pre- 10. Newman E, Kaloupek DG, Keane TM, Folstein sented at the Third John Conley Conference on SE Ethical issues in trauma research: the evolu- generally, individuals drawn from commu- tion of an empirical model for decision making. nity-based groups need training that enables Medical Ethics; Center for the Study of Society and In: Kantor GK, Jasinkski JL, eds. Out ofDark- them to join and eventually lead research on Medicine and Program in the History of Public ness: Contemporary Perspectives on Family Vio- these questions. Health and Medicine, Columbia University; Febru- lence. Thousand Oaks, Calif: Sage; 1997: ary 26, 1999; New York, NY. 271-281. Imperiled populations in developing 11. Hoagwood K, Jensen PS, Fisher CB, eds. Ethi- countries include extraordinarily vulnerable cal Issues in Mental Health Research With Chil- individuals ripped from their cultures and References dren andAdolescents. Mahwah, NJ: Lawrence communities and victimized by myriad forms Erlbaum Associates; 1996. 1. Bracken PJ, Petty C, eds. Rethinking the 12. Human Rights Watch/Africa, Human Rights ofabuse and violence. Public health research Trauma ofWar. New York, NY: Free Associa- Watch Women's Rights Project, Federation on violence and victimization among these tion Books; 1998. Internationale des Ligues des Droits de groups must vigilantly guard against con- 2. Murray CL, Lopez AD, eds. The Global Burden l'Homme. Shattered Lives: Sexual Violence tributing to emotional and social harm. Based ofDisease: A Comprehensive Assessment of During the Rwandan Genocide and Its After- Mortality and Disability From Diseases, math. New York, NY: Human Rights Watch; on the extensive field experience and pas- Injuries andRisk Factors in 1990 and Projected 1996. sionate moral commitments of the authors, to 2020. Cambridge, Mass: World Health Organ- 13. Wali S. Women in conditions ofwar and peace: the reports on human rights and health in the ization, World Bank, Harvard University; 1996. challenges and dilemmas. In: Shuler MA, ed. current issue of the Journal develop these 3. Levy BS, Sidel VW, eds. War and Public From Basic Needs to Basic Rights: Women s Health. New York, NY: Oxford University Claim to Human Rights. Washington, DC: themes further. Press, in cooperation with the American Public Women, Law & Development International; The Journal is currently reviewing its Health Association; 1997. 1995:289-302. policies on signed assurances from authors 4. lacopino V, Waldman RJ. War and health: from 14. Beiser M, Hyman I. Refugees' time perspective regarding institutional review board approv- Solferino to Kosovo-the evolving role of and mental health. Am J Psychiatry. 1997; 154: physicians. JAMA. 1999;282:479-481. 996-1002. als and informed consent procedures. There- 5. Benatar SR. Global disparities in health and 15. Roberts LW. The ethical basis for psychiatric fore, we encourage communications from human rights: a critical commentary. Am JPub- research: conceptual issues and empirical find- readers about these issues, both with refer- lic Health. 1998;88:295-300. ings. Comp Psychiatry. 1998;39:99-1 10.

The Impact of Political Conflict on Women: The Case ofAfghanistan

own Viet- The recent war in Kosovo has forced ally trapped the Soviet Union in its Editor's Note. Sima Wali is president of RefWID the plight of refugee women on the world's nam, the legacy of that policy for the Afghan (Refugee Women in Development), Inc, a nonprofit attention. Rape, torture, forced prostitution, people remains. In Afghanistan, as in no other tax-exempt organization that works to empower and an endless string ofunnameable atrocities crisis spot in the world, women have been refugee, internally displaced, and returnee women. awaited many of the victims of the conflict in made to pay a special and painful price. To Ms Wali is the recipient of the 1999 Ginetta Sagan Kosovo. But as the West rallies to shoulder the understand the tragedy ofAfghanistan, and Award from Amnesty International for her work on Kosovars after a short of the unprecedented levels of strife and Afghan women and human rights. Under contract to burden ofthe displaced Afghanistan military engagement, it should be understood violence throughout the decade of the CBS News, Paul Fitzgerald traveled to 1990s in many parts of the developing in 1981, the first American journalist to enter Kabul that a larger and longer-standing human since the expulsion of all Western media in February tragedy continues in Afghanistan-a tragedy world, it is essential to grasp the inextricable 1980. He returned to Afghanistan in 1983 with Eliz- that is a direct legacy ofAmerica's Cold War link between these humanitarian disasters abeth Gould for ABC's Nightline. Their forthcoming foreign policy of the 1970s (P Fitzgerald and and the political circumstances that caused book TheApostle's Diary, which will be serialized in E. Gould, unpublished data, 1999). them. Without such an understanding, a solu- a documentary on Foreigntv.com, chronicles the his- Now that the Soviet Union has been tion to the worldwide crises in women's tory ofAfghanistan and the country's importance to defeated through the US policy that intention- health and human rights is unattainable. both the geopolitics and the spirit ofthe West.

No. 10 1474 American Journal of Public Health October 1999, Vol. 89, Editorials

A Wall ofSilence definition of health for women includes not The United Nations' (UN's) 1990 only their physical well-being but also the Human Development Report defines human It is hard to believe that 20 years after the ability to exercise more control over their development as a process of widening the Communist coup that overthrew the Afghan lives and relationships and the ability to range of people's choices.9 The 1994 report Republic, the basic human rights ofAfghan access information and resources that will expands this definition, stating that human women are still being violated. But then, the allow them to take responsibility for their development should "empower people Afghan war began behind a wall of silence that own health and that oftheir family. But since enabling them to design and participate in separated the political events ofthat era from the Taliban militia took over Afghanistan in the process and events that shape their their huma consequences. Today, it is tius wall 1996, these goals have been unattainable; lives.""'l"") However, women victimized by ofsilence that forbids the linng ofhumanitar- instead, Afghan women have been brutally conflict cannot avail themselves of even the ian crises to the lger political issues that pro- and systematically suppressed. basics ofhuman survival, and world institu- voked them It is this wall ofsilence that divides Poverty and unequal access to resources tions have failed to protect them from the the peace negotiator from the humanitarian are often at the heart ofwomen's neglect and most fundamental human rights violations. activist and the activist from the solution. It is abuse, and this is especially true in war econ- With hundreds of regional conflicts taking this wall ofsilence thatperpetates humanitarian omies. Resources such as food and medical the place of the monolithic East vs West crises and fustrtes reliefworkers and activists attention are often withheld from women and conflict of the Cold War, the world commu- in their efforts to end crimes against humanity. diected to male soldiers. The results are high nity has not evolved to meet today's chal- And it is this wall ofsilence tat; like the Berlin levels of malnutrition, hunger, and hunger- lenges, a fact that not only hinders the reso- Wall, must come down ifwe are not to be over- related diseases that will affect that society for lution of existing problems but threatens to whelmed by the long-term dependence ofwar generations.4 Sixty-two percent ofAfghan institutionalize these problems for future victims on outside reliefassistance. women-both residents of Kabul and ref- generations. As a consequence ofthe division between ugees in Pakistan-who were surveyed by the For example, critics of the UN's claim humanitarian crises and the political discourse organization Physicians for Human Rights that Afghan women's rights have been that would alter them, conflicts remain unre- reported that they were employed before the placed after the UN's need to ensure its pres- solved, leaving the victims exposed to multiple Taliban takeover; only 20% of these women ence, maintain its operations, and continue a abuses. Today, instead of working toward a were employed during their last year in dialogue with the Taliban in Afghanistan. common goal, reliefand human rights workers Kabul.5 Although they may be well intentioned, must compete in an environment ofconflicting The war in Afghanistan has devastated deals that diminish or deny Afghan women's empowerment models. The continuum of the lives not only of women but of children rights-to a safe and productive livelihood; humanitarian involvement-from reliefefforts as well. A majority ofAfghan children sur- to access to education, health, and mental to assistance with social and economic devel- veyed by UNICEF are suffering from severe health services; to freedom from hunger; to opment-is not defined, and the concept of stress as a result of witnessing acts of vio- safety; to freedom of expression; to access empowerment of victims does not exist. The lence, including the killings of their parents to international and human rights entities; to absence of such a concept perpetuates war- or relatives. Between 1992 and 1996, 72% of participation in peace discourses; to free- lordism and levels of destructiveness that the children surveyed had lost a family dom of association; and to freedom of threaten in some regions to altogether undo member, and 40% ofthose children had lost movement-disillusion those who put their established societies and cultures. a parent.6 According to the 1996 Interna- trust in global institutions and the rule of tional Committee for the Red Cross, Afghan- law. Furthermore, the lack ofexternal moni- istan is the world's most heavily land-mined toring permits the Taliban to flout interna- Health, Mental Health, Gender, country. The Afghan Campaign to Ban Land tional covenants signed by previous govern- and Human Rights in Conflict Mines reports that 10 to 12 Afghans, many of ments in Afghanistan. Situations them children, are killed or maimed by land There has been much discussion about mines every day. Afghan women bear the reforming existing institutions or creating responsibility of caring for these disabled new ones to meet today's challenges. There In the Afghanistan crisis, a multitude of children, while they themselves are trauma- is a critical need for an institution that is women have undergone war-related trauma.' tized and malnourished. responsive to the needs ofwar-affected peo- Worldwide, women and girls make up more The already inadequate resources ple, that operates under the auspices of the than half of the estimated 44 million ref- assigned to health services for women have United Nations, and that works in partner- ugees, asylum seekers, and internally dis- been fiurther reduced since the advent of the ship with Afghan-led civil institutions, inter- placed persons.2 These women and girls suffer Taliban regime, which actively denies women national human rights entities, and women's lifelong trauma from such abuses as multiple care in hospitals and clinics.5 This discrimi- organizations. Such an institution must be rape, forced prostitution, slavery, and other nation against Afghan women has long-term prepared to acknowledge newly emerging forms ofgender-related violence. In addition, consequences and threatens a worsening of human rights concerns and elevate them to sexual violence substantially increases already poor health indicators. Maternal and higher levels of importance. For example, women's risk for sexually transmitted dis- infant mortality rates, for example, are the violation ofwomen and girls has histori- eases. Although women are not immune to already high as a result of unhealthy birth cally been dismissed as a byproduct of war- violence in times ofpeace, female victims of spacing to replenish lost fighting forces. fare. However, during the 1980s in Cambo- war are subjected to violence in the most Afghanistan is the lowest-ranking country of dia and Vietnam, mass rape was used as a extreme forms. 130 nations listed on both the United Nations calculated weapon of terror." The practice The World Health Organization (WHO) Human Development Index7 and the United of "ethnic breeding" (forcible impregnation defines health as a state ofcomplete physical, Nations Development Program Gender Dis- of women and girls by opposing factions) mental, and social well-being, and not merely parity Index. Its maternal mortality rates are imposed on Bosnian Muslims in the early the absence of disease or infirmity.3 WHO's among the highest in the world.8 1990s set the stage for the current abuses

October 1999, Vol. 89, No. 10 American Journal of Public Health 1475 Editorials against Albanian Kosovar women. Thus, the War between superpowers and must now be 2. World Refugee Survey. Washington, DC: US international community must adopt an analyzed in the context of that war. In this Committee for Refugees; 1995. entirely new standard. The public violence context, it is imperative that the gender 3. Cook RJ. Women s Health and Human Rights. directed against Afghan women who do not apartheid policies and practices ofthe Taliban Geneva, Switzerland: World Health Organiza- tion; 1994. conform to the Taliban's view of Islamic and the current level of violence against 4. Wali S. Hunger among uprooted women and practices must be challenged. Afghan women be linked to the larger geopo- children. In: Hunger 1993: Uprooted People. litical decisions made at the start ofthis con- Third Annual Report on the State of World flict. In particular, it must be frilly recognized Hunger. Washington, DC: Bread for the World Conclusion that the United States' support for the most Institute; 1992:54-59. radical elements of Islamic fundamentalism 5. Rasekh Z, Bauer H, Manos M, lacopino V. Women's health and human rights in Afghan- The United Nations Development Pro- throughout the 1980s slowly brought about istan. JAMA. 1998;280:449-455. gram's 1994 Human Development Report the destruction ofthe cultural framework that 6. Gupta L. Survey on Afghan Children. New describes "human security" as a necessary defined and maintained the time-honored York, NY: United Nations Children's Fund condition to peace. The report states: "The role ofAfghan women. ForAfghanistan to be (UNICEF); October 1997. world can never be at peace unless people at peace, this role must be returned to Afghan 7. Human Development Report 1996. New York, have security in their daily lives. The search women, and that is something only the NY: United Nations Development Program; 1996. for security in such a milieu lies in develop- United States and the world community have 8. Human Development Report 1995. New York, ment, not in arms."10(p) the power to do. D NY: United Nations Development Program; 1995. As the majority of the displaced and 9. Human Development Report 1990. New York, refugee populations, women who are war Sima Wali, MA NY: United Nations Development Progam; 1990. victims hold a major stake in securing peace. Elizabeth Gould, BS 10. Human Development Report 1994. New York, Across the globe, women are among the first Paul Fitzgerald, BA NY: United Nations Development Program; in to 1994. to engage dialogue, effect reconcilia- 11. Mollica R. The trauma story: the psychiatric tion, and to promote values aimed at creating References care of refugee survivors of violence and tor- a culture ofjustice and peace. 1. Women in Afghanistan: A Human Rights Catas- ture. In: Ochberg F, ed. Post-Traumatic Therapy The health and human rights crisis in trophe. New York, NY: Amnesty International; and Victims of Violence. New York, NY: Brun- Afghanistan was brought about by the Cold November 3, 1995. ner/Mazel; 1998:295-314.

Welfare Reform as a Human Rights Issue

The internationally recognized human Declaration ofHuman Rights, but the United nomic and social rights, particularly the right right to health is grounded in a wide array of States in particular was a primary architect of to health; (2) the prohibition on retrogression human rights instruments, one of the earliest the document. Moreover, while in recent in the realization of economic and social being the Universal Declaration of Human years it has been reluctant to ratify the Inter- rights; (3) the right to be free from gender Rights. According to the Declaration, "Every- national Covenant on Social, Economic, and discrimination; and (4) direct violations of one has the right to a standard of living ade- Cultural Rights, the United States has indeed economic and social rights, particularly quate for the health and well-being of signed that treaty, thus obligating itselfnot to rights to reproductive health. [her/him]self and of [her/his] family, includ- take any action that would violate the "spirit ing food, clothing, housing and medical care or purpose" of the treaty. The United States and necessary social services, and the right to has also recognized the binding character of Monitoring ofRights security in the event of unemployment, sick- economic and social rights in many human ness, disability, widowhood, old age or other rights instruments-such as the Platform for Wise et al. recognize the relationship- lack of livelihood in circumstances beyond Action agreed upon at the Fourth World Con- or, in human rights parlance, "the indivisi- [her/his] control."' ference on Women in Beijing-and made bility"-between an adequate standard of It is telling that, from its inception, the broad commitments to ensuring the right to living and health, as does the Universal human rights community conceived of the health. Declaration of Human Rights. From neither right to health as inextricably tied to the wide In this editorial, I focus on how welfare a public health perspective nor a human range of social and economic rights without reform meets or fails to meet the standards rights perspective can the right to health which an adequate standard of living cannot set by these international human rights be "decoupled" from the provision or lack be ensured. This approach is consistent with instruments, in light of the conclusions thereof of basic social protection and social the fundamental concept of "indivisibility" of reached by Dr Paul Wise, Dr Wendy Chav- security so long as an individual's standard human rights. This principle recognizes that all kin, and Diana Romero in their accompany- human rights are linked and affect one another. ing article (p 1514). In particular, I touch on Not only have almost all nations agreed 4 human rights issues: (1) monitoring of the Editor's Note. See related article by Wise et al. to be bound by the principles ofthe Universal extent ofrealization or nonrealization ofeco- (p 1514) in this issue.

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