Suraya Dalil, MPH ’05, Afghanistan’s former minister of public health, hopes to bring health and gender equality to her war-ravaged homeland.
Hours before Suraya Dalil, MPH ’05, boarded a plane from Boston to Geneva, she reflected on a career in which she has continually swum against a deep cultural current of misogyny. Afghanistan’s former minister of public health, and since 2015 the country’s ambassador to the United Nations, she had just finished a two-week stint as a Richard L. and Ronay A. Menschel Senior Leadership Fellow at the Harvard T.H. Chan School of Public Health. In a featureless conference room, she slowly sipped green tea from a paper cup and answered questions about being a powerful professional in a place where women are nearly invisible.
It was early December 2017. In the United States, women and men were variously horrified, enraged, elated, amused, and jadedly blasé after revelations of America’s own deep-rooted misogyny. Dozens of powerful men in media, politics, entertainment, academia, and other positions had been called out for sexual abuse and harassment, and dozens more would be publicly accused and shamed in the ensuing months. Every news cycle, it seemed, carried a raft of resignations.
Dalil, with a foot in two worlds, was asked: What does she think is the root cause of the global disempowerment of women?
She looked down and shook her head. “The last two weeks here in the U.S., I have watched TV in the evening. I’ve been struck by the resignations,” she said. “This would never happen in Afghanistan. Accused men would offer 100 justifications why they were right and others were wrong. They don’t resign, because they think that controlling women is their right.”
A study by Global Rights, an international nongovernmental organization, found that 85 percent of Afghan women reported having experienced physical, sexual, or psychological violence or forced marriage. “Afghanistan is one of the most difficult places for a woman to be,” says Dalil. Today, only one-third of Afghan women can read and write, and ongoing poverty and violence in the country have disproportionately hurt women.
Late last year, after the Afghanistan parliament approved all 11 men for ministry posts and rejected the only female candidate, Dalil posted on Facebook: “Combat is not only an armed struggle. Saying no to injustice, and saying yes to civilization and inclusion, is also combat that requires courage and determination.” In the December interview, she elaborated: “The fight for gender equality is a battlefield. It is a fight between light and darkness, between backwards and forwards.”
For all these reasons, Dalil is acutely aware of the far-reaching effects of her unique public role. “For me, in Afghanistan, in my culture, in my society, I have to take this journey on. I must be present at the table with men. I must prove that women are capable. We have potential, we can do the job, we are competent, we are serious about our responsibilities, and you can no longer ignore us.”
From Outcast to Ministry Head
When the Taliban ruled Afghanistan, from 1996 to 2001, Suraya Dalil was not permitted inside the ministry of public health. A superstar physician, she had graduated at the top of her class at Kabul Medical University and the top of her general surgery residency entry exam. In her 20s, she had coordinated lifesaving immunization, nutrition, and maternal health programs in her homeland. But the Taliban regime’s extreme interpretation of Islam banned females from virtually every aspect of civil society. Women and girls were forbidden from going to school or studying, working, leaving the house without a male chaperone, showing their skin in public, accessing health care delivered by men, being involved in politics, and speaking publicly.
A decade later, in 2010, Dalil was running the ministry that had been so recently off-limits. The Taliban government had collapsed in 2001, after U.S.-led airstrikes in the wake of the 9/11 attacks. Dalil—having earned her MPH in health care management from the Harvard Chan School—was one of Afghanistan’s young professionals enlisted by the office of the president to construct a functioning health system from the ashes of war. Her background eminently qualified her for the task.
Born in 1970, she grew up in Kabul, the nation’s capital, the eldest child in a progressive, educated family. Both of her parents had earned master’s degrees abroad—her mother in home economics, her father in mathematics. It was a fleeting era of tolerance and openness, as Afghanistan took its first steps toward democracy. The burqa was optional (indeed, a famous photo from 1972 shows women strolling through the capital in miniskirts), and women had access to university-level education, professional careers, and public transportation, and, at least in major cities such as Kabul, occupied a public space.
Dalil’s father, in particular, had a profound influence. “He was kind, caring, forward-looking—somebody who looks far. He loved his country,” says Dalil. “He encouraged me to go to the library, to study books outside of school, to attend sports.” When she needed them, he gave her advanced English lessons and medical textbooks, and even encouraged her when she decided to work in dangerous political and security conditions.
“The good thing about both of my parents was that they never differentiated their daughters from their sons,” she says. “I was never told, in direct or indirect ways, that boys are superior. In my culture, that’s very important.”
That familial security was not always matched outside the family home. Dalil saw the bombs drop in Kabul in 1978 during a coup d’état that established a communist government. That revolution gave way to the 1979–1989 war sparked by former Soviet Union troops that were in the country, then the 1989–1995 Afghan civil war, and finally the Taliban’s devastating conquest in 1996.
Dalil was determined to be a surgeon—a specialty that itself was a revolutionary choice. “My classmates were saying, ‘Surgery is not a woman’s job.’ That boosted my determination,” she says. But in 1992, when Kabul became an increasingly deadly war zone, Dalil and her family fled to the northern city of Mazar-i-Sharif.
After stints with Médecins Sans Frontières from 1992 to 1993 and the International Organization for Migration from 1993 to 1994, where she focused on medical assistance to refugees, Dalil in 1994 joined UNICEF. This position would transform her from a doctor to a public health visionary who placed gender equality at the center of her mission. As Dalil explained in a Voices in Leadership program last November at the School, “In UNICEF, I saw the linkages between girls’ education and maternal health outcomes, between food security and child survival, between child survival and child development.” [Watch video of Voices interview]
Shocking Statistics on Maternal Mortality
Under Taliban rule, beginning in 1996, the state of Afghanistan’s health deteriorated to one of the worst in the world. Life expectancy was 45 years, one in four children died before age 5, diarrhea and pneumonia were major killers, most trained health professionals left the country, and few functioning medical facilities remained. Chronic malnutrition and micronutrient deficiencies intensified these problems.
In Jalalabad, Afghanistan, a girl looks out as Afghan women line up to receive relief assistance during the holy month of Ramadan in 2017. Seventeen years after the Taliban gave up power, Afghanistan remains one of the most difficult environments for women and girls.
This dire health picture was encapsulated in the landmark Afghanistan Maternal Mortality Study, a massive effort carried out in 2002 and 2003 by the ministry of public health, the U.S. Centers for Disease Control and Prevention, and UNICEF, with buy-in from the U.S. Agency for International Development (USAID) and the World Bank. One of the most important public health studies in Afghanistan’s history, it continues to shape policy decisions today.
The revelations were staggering. In the northeastern province of Badakhshan, out of every 100,000 live births, 6,500 women died—the highest maternal mortality ratio ever documented. Across all of Afghanistan, a woman died from pregnancy or childbirth every 27 minutes.
The factors behind the shocking statistics were obvious: an inadequate number of medical facilities, few skilled birth attendants, no emergency obstetric care, chronic malnutrition. The government’s response to the study was a palette of interventions: competency-based training of midwives and physicians, ensuring emergency obstetric care, making available family planning and contraceptives, and placing maternal health within the newly formulated basic package of health services.
But the practical reality of carrying out those actions was daunting. One hurdle was Afghanistan’s topography, marked by the Hindu Kush—part of the Himalayan region—and its unpaved roads, which makes travel for pregnant women suffering complications nearly impossible. Low female literacy—exacerbated by the Taliban’s ban on girls’ school attendance—meant it was hard to find candidates for midwifery training in the post-Taliban era.
Doing Something Scary Every Day
In 2005, Dalil earned an MPH in health care management through a Harvard Presidential Scholarship. The timing was perfect: a rare interlude of optimism, when Afghanistan was just starting to build its health system from the ground up, after the Taliban regime was defeated.
Attending the Harvard Chan School, says Dalil, “gave me technical and professional credibility”—especially important for a high-ranking woman in the government. For five years—first as acting minister of public health from January 2010 to February 2012, then as minister from March 2012 to December 2014—Dalil worked 14-hour days to put her insights and ideals into action.
A landmark study from the early 2000s revealed that Afghanistan had the highest maternal mortality ratio ever documented. Across the country, a woman died from pregnancy or childbirth every 27 minutes.
Taking office, she inherited a long list of problems. A 2010 study showed that more than 60 percent of Afghans suffered from stress disorders and mental health problems—attributed to extreme poverty, unsafe conditions, violence, and gender disparities. Two-thirds of women gave birth at home without a midwife or skilled attendant; maternal mortality remained unacceptably high; and donor resources were dwindling.
Dalil’s tenure was marked by government stewardship, results-based financing, and public-private partnership. Three major donors—the World Bank, European Union, and USAID—contributed $407 million to the health system from 2013 to 2018. Dalil helped enact private health sector regulation, tobacco-control laws, and introduction of the pneumococcal conjugate vaccine into the country’s routine immunization program.
The successful outcomes were measurable. According to statistics from the World Health Organization and UNICEF, the maternal mortality ratio dropped from 584 per 100,000 live births in 2010 to 396 in 2015, and under-5 mortality also declined.
But every achievement was hard-won. The extremes of Dalil’s official obligations were at no time more evident than on July 10, 2012, when an important donor conference was being held in Tokyo. That day, a cellphone video had gone viral, showing the execution murder in broad daylight of a 22-year-old woman in Afghanistan’s Parwan province, with the male crowd cheering. In Kabul, Dalil held a press conference, at which she said, in a steely voice: “[T]he murder of a woman is a clear symbol of the cowardice and wickedness of her murderers and such a crime is unforgivable in the country.”
Part of her cabinet job was suasion. “When you speak to the minister of finance, you don’t speak about maternal mortality—you speak about productivity, jobs created, revenues that will come to the system,” she says. “When you speak to the parliamentarians, you have to convince them why financing for health care should be increased, why maternal and child nutrition is important, why family planning benefits go beyond the health sector.” As Dalil speaks, her right hand becomes a small, clenched fist, striking the table softly without making a sound—a physical metaphor, perhaps, for what became her negotiation style.
Other demands of the role were more intangible. One was overcoming her own unacknowledged fears. She quickly realized that she could skate along in the job doing simple bureaucratic tasks such as signing endless numbers of official documents. “I realized: At the end of the day, what is the result? What have I produced? Signatures on a piece of paper?”
So she set a more ambitious goal: “I made a commitment to myself that I will do one thing every day that scares me—something that I normally don’t do or I’m not very comfortable doing, but it is important for the job and for the people.”
One of these ambitions was to be on the scene, with a hands-on and highly public presence, during emergencies. In October 2012, a suicide bomber struck a mosque in the northern city of Maimana, killing dozens of people just after the prayers of Eid al-Adha, one of the holiest days in the Islamic calendar. Dalil received the news at 9:30 am, was on a helicopter by 1 pm, and arrived at the scene by 5 pm.
“Hands-on, real fieldwork,” she remembers. “Organizing a volunteer blood-donation campaign, helping the emergency ward to do the triage, organizing flights and helicopters to take patients to other facilities for major surgery, preparing data and communication.” She stayed for the entire three-day Eid holiday, issuing orders and lending moral support.
In 2013 and 2014, such suicide attacks increased dramatically. By the end of her ministerial tenure, Dalil had personally visited 27 of Afghanistan’s 34 provinces—more than any other minister of public health. She attended groundbreaking ceremonies for provincial hospitals; handed out diplomas at community-based midwifery programs; and coordinated emergency responses to natural disasters such as floods and earthquakes.
“The new face of Afghanistan”
As U.N. ambassador, Dalil speaks on behalf of her government to the international community. Yet one of her top concerns is the same one that animated her career more than a quarter-century ago: gender equality.
She fears that violence could undo the fragile gains made since the last Taliban regime. In the past year, major attacks from both the Taliban and the so-called Islamic State, and the resulting casualties among civilians, have steeply increased. So have disease outbreaks and the closing of health facilities, with women and children disproportionately suffering the effects.
Last December, the U.N. Office for the Coordination of Humanitarian Affairs described Afghanistan as “one of the world’s most complex humanitarian emergencies,” with more than 1 million people living in new and prolonged displacement, violations of international humanitarian and human rights laws, and frequent reports of summary executions, kidnappings, and attacks on civilian infrastructure. The agency also noted that between 2014 and 2016, two-thirds of civilian casualties were women and children.
Asked in the Voices of Leadership event why she had stayed in Afghanistan as a young professional when her stellar credentials could have landed her in a safer and more remunerative position abroad, Dalil said: “Deep down, I had a sense and a strong feeling that if I leave the country, somehow, down the road, I will feel incomplete and unfulfilled. Second, I firmly believe that Afghanistan should be built by Afghans. There’s no option.”
In December, finishing her cup of tea, she elaborated. “What Afghanistan has today is a young, vibrant, dynamic generation—men and women. This young generation is committed to a country that is prosperous, that’s at peace, and that enjoys good governance and social justice. These young Afghans are not all in the government; some are in academia, some in civil society, some in media, some in the parliament. They want to see a different future for this country. What gives me hope is the young generation.”
Dalil—who is married to psychiatrist Sayed Azimi—has three daughters, ages 21, 16, and 11. “I want them to be strong women,” she says. How? “By education. By making them feel strong at home. By making them feel strong even as children. That sense of being strong should be deep-rooted in them.”
During her tenure at the ministry of public health, at the end of a long workday, an 18-year-old girl was ushered into Dalil’s office. The girl told Dalil that she had followed Dalil’s career and had decided that she, too, wanted to someday be minister of public health. Dalil was moved but raised the bar. “I said, ‘That’s not enough. You should try to achieve more than that. You could become a minister, a governor, a vice president, and a president of Afghanistan.’”
As she puts it, “My success or failure in the office will not be individual. It will have an impact on decisions that girls and women and the young generation of Afghanistan will be making for themselves. That is transformation. That is when you create demand. That is when you create change.”
Madeline Drexler is editor of Harvard Public Health
Photo: Sarah Sholes/ Harvard Chan