The New England Journal of Medicine, May 22, 2008

Driven to a Fiery Death — The Tragedy of Self-Immolation in Afghanistan

UNIFEM reports that 70 to 80% of female Afghanis are forced into marriages, and 57% are married before 16 years of age; 84% of women are illiterate as compared with 69% of men, and women are half as likely as men to have completed primary school.

Anita Raj

Afghanistan, a country with 32 million residents, has been engaged in constant conflict for the past 30 years. This instability and insecurity have resulted in a stark economic climate and a very low life expectancy. More than half of the people in Afghanistan live in poverty, and 40% of the adult labor force is unemployed. Life expectancy is 44 years, and annual mortality is 20 per 1000 residents. (According to Central Intelligence Agency. World factbook: Afghanistan) The situation in Afghanistan has been grave for more than a generation. Since the 1980s, the country has endured Soviet occupation, civil war, Taliban rule (which means educational and employment restrictions for women), and war with the United States and its allies.

October 22, 2004: Zarah, 19-years-old, shows scars that she suffered when she set fire to herself at the climax of an argument with her husband only three months into their marriage in Herat, Afghanistan. (Photo by Paula Bronstein)

More Photos ( http://www.rawa.org/self_immolation/index.htm )

However, in 2001 a democratic government was established that has since signed on to international conventions and developed federal policies designed to improve health and human rights, particularly for women and girls. In 2001, Afghanistan signed the Bonn Agreement, demonstrating a commitment to the establishment of a fully representative government sensitive to issues affecting women. In 2003, the country ratified the Convention on the Elimination of Discrimination against Women (CEDAW), and in 2004 it signed the Millennium Declaration to promote equality of the sexes and improve maternal and child health. Also in 2004, the Afghan constitution was signed into effect, granting women full citizenship, with legal rights and duties equal to those of men. In 2005, Afghanistan signed the Protocol for the Elimination of Forced and Child Marriage, and in 2006, it put forward the Afghanistan National Development Strategy, which includes as goals the elimination of discrimination against women and the promotion of women in leadership. Today, women make up 27% of the National Assembly in Afghanistan.

Sadly, these commitments and efforts do not appear to be translating into safer and healthier conditions for Afghan women and girls. The United Nations Development Fund for Women reports that 70 to 80% of female Afghanis are forced into marriages, and 57% are married before 16 years of age; 84% of women are illiterate as compared with 69% of men, and women are half as likely as men to have completed primary school. (According to United National Development Fund for Women (UNIFEM). Afghanistan: UNIFEM fact sheet 2007.) Afghan women have a fertility rate of 7.5 births per mother, (According to United Nations Development Programme. Human development reports: Afghanistan, 2007/2008) and with a skilled birth attendant present at only 14% of births, the country's maternal mortality is the second highest in the world.2 Although there are no reliable statistics on the prevalence of sexual or physical violence against Afghan women, the available indicators suggest that it is a major problem, primarily perpetrated by husbands and in-laws. In addition, there is increasing recognition of yet another related tragedy among Afghan girls and women: self-immolation.

Self-immolation is the act of burning oneself as a means of suicide. Although reliable data on the scope of this practice are difficult to obtain in Afghanistan and elsewhere, there are indications that self-immolation is occurring at a notable and steady rate. In 2004, in response to an apparent increase in cases of self-immolation in the country, the Afghan government, the Afghanistan Independent Human Rights Commission (AIHRC), and the United Nations Assistance Mission in Afghanistan undertook separate reviews of identified cases to try to determine why the practice was occurring. Although formal analyses and reports were not generated from these reviews, researchers involved in them report that forced and child marriages, as well as violence perpetrated by husbands, in-laws, and husbands' other wives, were common precursors to acts of self-immolation. More recent data highlight the pervasiveness of the practice: the AIHRC and the Afghan Ministry of Women's Affairs report the identification of 106 cases of self-immolation in 2006; if these events are considered instances of violence against women, they account for 5 to 6% of all such violence reported that year.

In 2006, Medica Mondiale, a German nongovernmental organization dedicated to supporting women and girls in regions involved in conflicts, undertook a more systematic analysis of self-immolation cases, collecting data from all central hospitals — the only hospitals equipped to handle serious burn cases — in Kabul, Wardak, and Herat, Afghanistan. The cases of female burn patients from within each hospital were reviewed, and patients' acts were identified as self-immolation if the burns were nonlocalized and occurred in a pattern indicative of self-infliction, as determined by members of the medical staff. Families or other contacts associated with female victims, or the victims themselves if they survived, were contacted for interviews to obtain information related to the woman's family and her life situation. Data collected during the interviews were reviewed to identify recurrent themes, including poverty, history of violence against women, family conflict or disputes, and migration.

Hospital medical records available for review — for 2005 to 2006 for Kabul, 2000 to 2006 for Wardak, and 2003 to 2006 for Herat — indicate that 77 cases of female self-immolation were reported, 35 of them in Kabul, 5 in Wardak, and 37 in Herat. In Kabul and Herat, the number of cases identified more than doubled between 2005 and 2006 (see graph). All identified cases involved women or girls 12 years of age or older, with more than half of the patients (55%) being 16 to 19 years old. In almost two thirds of the cases (61%), the patients sustained burns over 70% or more of their bodies, and 80% of the cases resulted in death. The majority of patients (80%) were married; 95% reported having little education and low or no literacy.

The predominant causes or precipitating events of self-immolation identified by survivors or contacts were various forms of oppression of or violence against women. Forced marriage or engagement during childhood was identified in almost one third of the cases (29%); bad or badal, practices involving forced marital exchange to settle a conflict between families or tribes, in 18% of cases; and abuse from in-laws in 16% of cases (these categories were not mutually exclusive). Although abuse by husbands was described as a common circumstance in the lives of these women and girls, few identified this abuse as the proximate cause of self-immolation. Often, self-immolation was said to have occurred after victims spoke out against or sought help in alleviating the violence to which they were subjected — but were ignored. As the sister of one victim explained, "My 18-year-old sister did not want to marry this man and asked my father several times not to give her to the farmer. But he ignored her pleas. One day I heard that my sister had taken petrol and committed self-immolation."

These findings suggest that despite substantial efforts toward improving health and human rights in Afghanistan, persistent conditions permit violence against women, and Afghan women and girls continue to turn to the desperate remedy of self-immolation. Women and girls appear to see this horrifying act as a means of both escaping from intolerable conditions and speaking out against abuse, since their actual voices do not bring about changes that would allow them to lead safe and secure lives. More programmatic work is clearly needed to prevent and intervene in violence against women and to support existing policies aimed at improving the lives of Afghan women and girls.

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