Interpersonal Violence in Afghanistan—Beyond a Strictly Public Health Approach

Reports document persistently high levels of interpersonal violence in Afghanistan.¹ Much of this is concentrated in the most conflict-affected areas where systems of education, health, and justice are particularly weak. But even in areas of relative peace, violence is still prevalent, and the attitudes documented by Li et al. in this issue of AJPH (p. 1688) help to explain this, which is an important step toward informing an appropriate response.

STUDY FINDINGS AND PROGRAMMATIC IMPLICATIONS

The study by Li et al. on views relating to interpersonal violence in Afghanistan provides useful insight into the complexity of understanding and addressing attitudes toward violence. The study found general disapproval of interpersonal violence among adolescents and parents, ranging from approximately 60% disapproval of teachers hitting students to 85% disapproval of violence between adolescent peers. Room for improvement remains, and work to increase these percentages is still needed. Furthermore, despite these levels of general disapproval of interpersonal violence, when faced with questions about the justification of violence in very specific situations such as parents hitting daughters for going out without permission, respondents were far more likely to approve of violence. This disconnect between abstract rejection of violence and acceptance of violence in specific circumstances is important for understanding existing data and informing future research.

The study found relatively few associations between sociodemographic factors and attitudes toward interpersonal violence, which was surprising given other studies that have found a range of socioeconomic risk factors associated with attitudes toward interpersonal violence.² In line with the most recent Multiple Indicator Cluster Survey in Afghanistan,³ this study found higher levels of education to be associated with lower acceptance of violence. The programmatic implications are clear—education must be a priority, particularly for girls, whose school attendance is significantly lower than that of boys in this study and elsewhere. This highlights the need for attention to gender norms that may have to be challenged to address violence.

Of note are the differences in attitudes toward violence by gender. In some cases (husbands beating their wives, parents beating their daughters, and teachers hitting students), women were more likely than men to report that violence toward women was justifiable. This finding has important implications for programmatic work to address violence in the study setting: although it is, of course, critical to work with men who traditionally perpetrate more violence than women, work with women to help them assert their right to be free from violence and to challenge historically rooted gender norms that contribute to the perpetuation of gender-based violence is needed.

Also interesting are the intergenerational differences in responses. Studies in other countries have found that younger women are more likely than older women to justify intimate partner violence against women.² In this study, although parents and adolescents were not linked in the analysis, 75% of mothers thought that wife beating was acceptable, whereas 66% of adolescent girls found this acceptable. Although these percentages are both shockingly high, the intergenerational difference suggests that cultural change might be afoot, with younger people less accepting of interpersonal violence in this context.

This work reminds us that violence is socially and culturally located but also that it is modifiable. The attitudes described not only help us understand which types of interpersonal violence might be more accepted in the study region but also contextualize victims’ responses to violence perpetrated against them as well as the community and institutional responses (or lack thereof). All of this can help inform an appropriate response, and it is clear that in addition to education specifically about interpersonal violence, actions must include efforts to address gender inequality, women’s empowerment, and the uptake of education. This moves interventions to address violence beyond the health sector to involve other branches of government as well as civil society.

MULTISECTORAL RESPONSES: A HUMAN RIGHTS APPROACH

The underlying determinants of attitudes toward and perpetration of interpersonal violence highlight the importance of economic and social policy alongside health policy as tools to address violence. Public health studies can identify patterns of and risk factors for interpersonal violence, and these can be used to help inform the multisectoral collaborations and actions needed for an effective response. In conjunction with prevention efforts that may require action across sectors, including health, education, legal, and social development, these also must include the strengthening of the health and legal systems to respond to violence where it does occur.

Situating this study’s findings on attitudes toward violence within a human rights framework helps draw attention to issues related to justice and responsibility. With their focus on government obligations, human rights draw attention to government (in)action in relation to a range of factors underlying violence, including access to education, women’s empowerment, and child protection.

Afghanistan has ratified the Convention on the Rights of the Child, the Convention on the Elimination of All Forms of Discrimination Against Women, and a range of other relevant human rights treaties. The Convention on the Rights of the Child guarantees every child the right to life, survival, and development and obligates countries to take legal, administrative, social, and educational measures to protect children specifically from violence and exploitation.⁴ The Convention on the Elimination of All Forms of Discrimination Against Women General Recommendation 19, an authoritative interpretation of States parties’ obligations under this Convention in relation to violence against women, describes gender-based violence as “a form of discrimination that seriously inhibits women’s ability to enjoy rights and freedoms on a basis of equality with men” and recommends that governments take action to address it.⁵ Such action includes preventing people’s rights from being violated by private actors, including individuals.

There have been efforts by parts of government and civil society in Afghanistan to strengthen the legal framework to protect women and children from violence and bring national laws and policies in line with international human rights obligations. However, these have been stymied by conservative actors. For example, following objection by conservative parliamentarians, the chapter on the elimination of violence against women was removed from the 2017 revised penal code.⁶ Laws exist that protect against child marriage, ban corporal punishment, and allow for removal of a violent spouse from the home, but implementation is limited.⁵ Recourse to traditional mediation remains common, and this must be seen in light of prevailing attitudes about the acceptability of violence, not in a generic sense but in the specific situation of an individual case. Again, this study’s findings are illuminating and suggest that such mediation efforts may not confer the protections that the law was designed to ensure.

In 2017, President Ghani’s wife launched a national plan of action to eliminate early and child marriage, but little funding has been made available for this work, and implementation is slow. The existence of supportive laws and policies around these issues is essential; so too are their funding and implementation.

An effective response to interpersonal violence is predicated on strong national systems, such as education, health, and justice. The challenges of this in conflict-affected countries, even in the least affected regions of the countries, are immense, but human rights can help galvanize the multisectoral action required. Contextualized within an understanding of the international and national legal and policy framework, including the shortcomings in its implementation, the insight into people’s attitudes toward violence that Li et al. provide is critical to informing such a response and tracking its effectiveness over time.