Drug Use Among Women and Children in Afghanistan: The Complexities of An Important Public Health Issue

Abstract

National surveys of drug use among those living in Afghanistan shows multiple substances are easily accessible and commonly used in combination. The drug use situation in Afghanistan is complex and compounded with concern for its future given that Afghanistan is a country comprised of individuals who almost half (48%) are under the age of 15. The number of women and children reported drug use have been increased alarmingly in last one and half decades. However, drug treatment services expanded in urban areas of Afghanistan but still there is need for evidence based and culturally appropriate drug prevention and treatment program in rural areas and to fulfill the constitutional obligation there is an obvious need for strong institutions to refine coordination of counternarcotic efforts.

Introduction

Afghanistan and its people have strained under conflict for many decades. As security steadily declines and government infrastructure ebbs and flows, the country faces multiple public health challenges. Narcotics/drug production, cultivation, and availability remain challenges for the nation’s security and stability and they have received greater attention than the related and urgent issue of problem drug use [1]. Problem drug use is one of the most critical health challenges faced by men, women and children in Afghanistan. From 2005 to 2015, three drug use surveys have been conducted in Afghanistan; however, the differing methodology of these surveys leads to results that cannot be compared across time. In spite of limitations, there are patterns of how drug use has increased in the country. In 2005, the first ever drug use survey conducted in Afghanistan estimated that 3.8% of all age groups were using drugs with the most common drugs used being were hashish, opium, heroin and pharmaceutical drugs [2]. In 2009, a follow-up survey showed that 8% of the population age 15–64 years were using drugs and there was a 53% increase in the number of regular opium users and 140% increase in the number of heroin users since 2005. This survey also showed that 50% of parents using opium were also giving opium to their children to ease withdrawal, as well as a means to control behavior and/or hunger [3]. In 2015, the Afghanistan National Drug Use Survey [4] found that 11% of Afghanistan population tested positive for drugs using confirmed biological testing and the national adult drug use rate was 12.8%, more than double of the global drug use rate of 5.2% [5]. The most common drugs used in Afghanistan are opioids (4.9%) followed by cannabis (2.2%) and prescription sedatives (almost 1%) [4]. Among those using drugs, 40% reported using two or more than two drugs simultaneously in the past 12 months [3]. Moreover, Afghanistan is facing significant drug use problems among its youth, with at least one person in every three households reporting drug use [4]. The drivers of rising drug production and drug use may include the ravages of four decades of war, easy access to cheap drugs, limited access to drug use disorders treatment [3], prevalent poverty, severe gender inequality, ever increasing civil insecurity, movement of refugees, internal displacement, urban crowding, corruption, an absence of timely or predictable justice, and overall lack of stable governance or security have created conditions [1]. Responses to these drivers have been fragmented and in need of refined coordination. This commentary provides a unique look into the drug use among women and children in Afghanistan with an eye toward future action and refined coordination.

Drug Use among Women

Afghanistan is home for 31.6 million inhabitants and 71.5% of Afghanistan’s population live in rural areas while 23.7% are living in urban areas and 4.8% are estimated to be nomadic. Of the Afghanistan population, 49% are female [6]. The overall literacy rate in Afghanistan is 31.74% and females are less literate than males 17.61% vs 45.42% due to the severe cultural obstacles against females [7]. The 2005 drug use survey estimated that 120,000 women were using drugs and 2015 survey showed that 850,000 of Afghan women are using drugs which shows a tremendous increase of 608% of reported drug use among women in ten years. The most three common drugs used by women are opioids (6.7%), sedatives (1.5%) and cannabis (1.5%) [4]. Another significant finding is that among women who use opium, 78% have given opium to their child and/or another family member. Women who are users of drugs are more likely to be widowed or divorced, have even less education, and more than twice as likely to not have a job compared to women who do not use drugs [3]. Ingesting drugs is the most common (69%) way women report using a drug as it is more socially acceptable than other routes of administration and implies the drug use is for medical purposes. More than half (52.2%) of women reported that they are exposed to drugs for the first time by a close family member, especially a husband and almost half of women who reported using drugs are unemployed. Of those who were employed, they worked as carpet weavers, or in the professions of embroidery or farming [8]. Being born female in Afghanistan can be an added life hardship given that tremendous gender inequality exists. Thus, when girls or women use drugs, there is a double stigma and prejudice against them, even if their own family members introduce them to drugs. Such a situation occurs for females, in part due to the patrilineal family and the notions of honor and shame that define the separateness not equality of gender relations. Women bear the family honor which is borne out by seclusion and chastity and these actions then are controlled by men who govern the female’s relations with the outside world. On one hand, bearing family honor can be a protective factor to prevent drug use. On the other hand, when females are introduced to drugs by family or male “protectors” it can make it even harder for females to find and utilize help. Women play an important role in all dimensions of agricultural production, including an important role in opium production. Even when women’s opium or other domestic production such as carpet weaving forms the main income of the household, they rarely control the marketing of these products, which is most often managed by male relatives.

Women in Afghanistan face constitutional equality but legal inequality. Great discrepancies exist between civil law, customary law and Islamic Law - as well as the informal justice system, which tends to grant women even less rights. Years of conflict and violence have further eroded the protection of women’s rights, and a culture of impunity reigns as far as violence is concerned, including violence against women inside and outside the household. The present deteriorating security situation in many parts of the country constitutes the most serious obstacle to promoting rule of law, reducing the harms of drug use, improving respect for human rights and introduction of legal reform, which would benefit women more than any other group in society [9]. The fertility in Afghanistan is 5.3 per woman and mean household size is eight [10], usually women in Afghanistan are the main caretakers for the entire family. Thus, when a woman’s drug use becomes problematic it can have a radiating effect of compromising family stability. While active harmful drug use by any household member can be destabilizing for the family, Afghanistan lacks any enforced child protection system to ensure that children are physically and mentally safe. A decade back woman using drugs were not visible in society, but the situation has change now and it is more frequent to see women using drugs in the hotspots where many people use drugs (e.g., under the bridge).

Drug Use in Children

Afghanistan has one of the youngest and fastest growing populations in the world. Almost half (48%) of the population is under the age of 15 while adults 65 years or older represent only 3.7% of the nation’s population. Having such a young population is both an opportunity and threat [11] having a ‘youth bulge’ is an opportunity for economic development if youth are provided education and skills, yet it poses a threat as an insurgent group can easily use uneducated youth for their purposes. Every year 400,000 youth enter the job market in Afghanistan but the opportunities for an economically rewarding job are limited [11], and even more limited for females. The 2005 drug use survey estimated that 60,000 children were using drugs [2] while in 2015 the figure jumped to 110,000 [4] which showed an 83% increase in child drug use. In addition to direct drug use Afghan children are facing challenges of second and third hand smoking of opioids. A study conducted by INL from 2008 – 2011 where they tested 30 homes including 20 heroin/opium smoking homes and 10 control homes. The result shows that children as young as nine months old had detectable amounts of morphine in their hair samples. For example, in a sample of hair from a 10 year old girl there was 8350 pg/mg morphine, 4652pg/mg codeine and a heroin metabolite 6-acetylmorphine concentration of 5607 pg/mg. Even large amount of opioids were detected in the home air and surface samples in homes where opium was smoked. Of the hair samples from children in homes where opium was used, 74% of children 2–14 years old tested positive for opiates [12]. Regarding children 0–14 years, among those tested in Afghanistan, 9.2% tested positive for psychoactive drugs, with 90% of them exposed by either their environment or given drugs by their caregivers [4]. Drug use disorders appear to be more problematic with early onset, as there are increased possibilities of damage to the developing brain from use of many psychoactive drugs [13]. The larger the number of adolescents and young adults exposed to experimenting with alcohol, tobacco, and illicit psychoactive drugs as well as controlled psychoactive medications, the larger the rate of increase in a vulnerable population at risk of developing addiction [14]. In addition to drug use, children living in Afghanistan are also exposed to war and traumas. For example, among a sample of children interviewed in Afghanistan (82.4%) reported at least one war-related event during their lifetime and (48.6%) reported experiencing at least one event related to war in the past year [15]. Traumas were also reported by children in their home life. In addition, 10.3% of Afghan children 5–14 years old are involved in child labor, 15% of girls marry under the age of 15 and 40% get married under the age of 18. 74.4% of children in 2–14 years old are disciplined violently faced aggression and/or physical punishment. Thus, there is a need for urgent actions to protect children from such situations [16]. A study also found that children seeking drug treatment have suffered social and psychological problems that need serious attention and at the same time treatment in a residential setting reduced the severity of the problems at treatment discharge [17].

Emerging of New Drugs and Policy Issues

Despite the highest in-home opiates and cannabis production another significant problem on the horizon is the production of Amphetamine Type Stimulants (ATS) and Synthetic drugs. Methamphetamines are being seen in addition to opiates being used [18]. The President of Afghanistan (Ashraf Ghani) told a Turkish news channel in his interview (July 16,2019) that “the relation of Taliban with the criminal economy is a global issue, a regional issue and now it is going to pass heroin to production of Meth and Crystal” [19]. The opium poppy cultivation has not decreased but the synthetic drug production is soaring. Thus, the country is becoming under a double burden of opium and methamphetamines. Now adays no one can deny the existence of drug use in Afghanistan and an alarming increase in prevalence of drug use is happening among women and children in Afghanistan in the last one and half decades. The prevalence of drug use among women increased 608% while drug use in children increased 83%. The government has been made responsible for the Counter Narcotics as described in article 7 of the Constitution of Afghanistan passed in 2004: “The state shall observe the United Nations Charter, inter-state agreements, as well as international treaties to which Afghanistan has joined, and the Universal Declaration of Human Rights. The state shall prevent all kinds of terrorist activities, cultivation and smuggling of narcotics, and production and use of intoxicants [20]. But the efforts of counter narcotics were not effective, and the counternarcotic law of Afghanistan has been revised four times since 2003 [21], without proper enforcement. The fight against illicit narcotics does not appear to be a consistent priority either for the international community or the Afghan government. In fact, the Ministry of Counter Narcotics (MCN) which was a leading agency for counter narcotics in the last one and half decades has been dissolved in other institutions [22].

Future Forward Opportunities for Action

Drug use in Afghanistan is skyrocketing which poses risks for current and future generations and there is a crucial need for evidence-based drug treatment and culturally appropriate drug prevention programs. Afghanistan is making strides in training the workforce of treatment providers and education and treatment coverage has been expanded in urban areas but there is still need for drug treatment and prevention services in rural areas where most of the population resides. Afghanistan has been a country that values education, and education is needed for all citizens, both girls and boys. Thus, investing in universal education that includes literacy and numeracy for all children can help create promise in the country. There is a need for economic stability to develop socially acceptable skilled and unskilled employment opportunities for both women and men. Another way forward is to integrate skills enhancement training and vocational training with provision of micro-credit, supported by market surveys and training in account keeping would help. As mentioned, the Ministry of Counter Narcotics which was the leading agency for the issue of drug has been dissolved in other ministries and the counternarcotic law has been revised four times since 2003 to 2018 without proper enforcement. Now there is need to for a strong institution to coordinate the cross-cutting issue of counternarcotic and to fulfill the constitutional obligations. There is need that the president’s office should take the lead to effectively coordinate and monitor the counternarcotic activities and bring cohesion to the government efforts and international aides. Special attention needs to paid to the production of Amphetamine Type Stimulants and every effort should be made to prevent this emerging issue as early as possible. To address the drug cultivation and problem use in Afghanistan, gender equality and the economy must advance. As the counternarcotic effort is a multi-sectoral issue, there is a crucial need for better coordination among different governmental and non-governmental counterparts. And most importantly, there is a need to address underlying economic and security issues to help address the drug problem. By harnessing the economic power of youth and women, Afghanistan has an opportunity to move forward in the fight against drugs.