Full interview-Dr Laurence

Laurence Laumonier-Ickx is a doctor and public health professional who has worked in Afghanistan for around 40 years. For a long time, she lived in the villages of the country; she is interested in the population, the culture and the practices.

Can you tell us a little bit about your background?

I have been working for the last 34 years with Management Sciences for Health (MSH), which has been working since the 70s in Afghanistan. That was the first USAID-funded project that introduced the concept of community health workers and working with the ministry. And of course there was a big gap during all of the soviet war, when USAID stopped funding the government. I was then a member of a small french NGO called Aide Médicale Internationale, the small sister of Doctors Without Borders. Six months after the Soviet invasion I did my first medical mission in Afghanistan, meaning clandestinely crossing the border of Pakistan, having found a group of Moudjahiddin  who could take us over, protect us and allow our medical mission to be successful. I did this for seven years during the soviet war. 

So I did that until 86, then I was hired by MSH who was launching a USAID funded project. The Soviets were still in Afghanistan, so we were based in Pakistan in order to develop a health system in Afghanistan. It was a cross-border project. It lasted until 94, when USAID left Pakistan because they discovered that the government had set up a nuclear program without informing them. Two  months later, the Taliban arrived in Afghanistan. I returned to Kabul in February 2002 to start a new USAID-funded project. Since then I have been working in Afghanistan; working meaning supporting the ministry of health to strengthen the health system. I used to say, “We don’t do anything. We allow other people to do things, maybe in a better way, to be more efficient, effective. ” And that’s where we stand today. We have a new project in the rural areas. We work on maternal, newborn, child, adolescent health, nutrition, tuberculosis and pharmaceuticals. 

When did you discover Afghanistan and in which context?

I discovered Afghanistan at the beginning of the soviet war in Afghanistan; I came there to practice medicine. There were two or three of us in a team and first and foremost we worked in villages to educate people that would be able to work once we had gone. Of course, we also treated a population that was missing doctors in most provincial parts of the country. I experienced Afghanistan through villages. I saw all the dynamics that exist between men and women, between residents, between farmers and non-farmers, the way they practice religion, and its importance. I saw women die at home because no-one brought them to the hospital, because there were cultural restrictions that dictated this. I saw a population with incredible and surprising resilience, a population decided on maintaining its liberty, on not being under the yoke of an invader. A population that is proud of its culture, and has a know-how and savoir-faire that marked me profoundly, not only as a doctor but as a human being. 

“A population that is proud of its culture, and has a know-how and savoir-faire that marked me profoundly, not only as a doctor but as a human being.”

At the time I was a gastroenterologist, and I pursued an education in public health because of my visits to these villages. I realised that the medical practice was extremely routine, in the sense that you always saw the same things, but these same things were sometimes dramatic. I saw measles epidemics among children, pneumonia and meningitis epidemics, when tens of children a day were sometimes brought in who were going to die, and because we had a few antibiotics, we saved them. That’s the first thing.  

The second thing is that I wanted female students as part of our team. The local authorities provided us with candidates to be our students. I couldn’t have female students for cultural reasons once again. But the women of the village asked me to give them general education classes, and they were extremely hungry to learn. Not only hungry to learn, but hungry to accept the concepts that I presented them with, which were totally opposite to everything they had heard; from their mothers-in-law, from their mums, their husbands. This was because there was confidence between them and me, simply because I was there, because I was there for them. They all knew it. This confidence allowed me to deliver messages that were important. 

Some couples came to see me during this war to ask for contraception. While I was packing my bags to go to Afghanistan, unpacking tons of medicines to put them in plastic bags so that they would be transportable, at no point did I think to bring contraceptives. And that was my great shame because I realised that well of course, lots of women at the time didn’t really want to be pregnant while running away from bombs. 

And then, unfortunately, there was war surgery. We had to amputate children who had jumped onto landmines that they took for toys. They were little plastic objects in the shape of small butterflies that soviet helicopters dropped onto the ground; the children picked them up in fields and prairies. It exploded in their hand or on their foot. These were some of the horrific things we had to do.

As a doctor, I will tell you honestly – I consider that I practiced the art of medicine. That is to say I had no laboratory, no radiology, I had no means other than my five senses, just like we had learned to do in medical school. And that, for someone who adores medicine, was magnificent. 

“As a doctor, I will tell you honestly – I consider that I practiced the art of medicine.”

Training these students was very important to us and we took time for them, meaning we would announce that the hospital was open until 2pm and starting from 2pm, we directed our attention to the training of our students. They stayed during the night, they were on-call, they accompanied us to all of our consultations. All in all they learned a lot, and there are still many who practice. 

I was in Nouristan (around Kamdesh), and in Panjshir – there, the man in charge supported us and recruited candidates from the valley and the surrounding valleys. I couldn’t go to Bamiyan for security reasons. Protecting the people on the mission was very important : we had to leave with groups of guards that could be accountable for foreigners, for a woman, for all the medicines and the surgical equipment that we took with us. 

How were you perceived, seeing as you were a woman and a foreigner?

You have to “agender yourself”. You are no longer a woman. I had people call me Dr Laurence. It was the simplest way for me to interact with everyone. For example, when we were leaving Pakistan for Panjshir, we had 200 Moudjahiddin , 200 mules, and one woman. So I was disguised as a man, primarily so as not to attract attention, and also for security reasons. In the valley, my role was to carry out a medical mission. I was around women who did not have the same status as I did – I was a foreigner, a professional – and yet my role was to interact with them. So I presented myself as a doctor. It was simple for everyone, for the men as well as the women.

“Working without the communities is working with nothing.”

What types of observations did you make with regard to education, access to health or the place of women?

My response will be relatively short because I can only talk about after 2002, when we really started to see health statistics. During the soviet war… personally I didn’t have the health ministry’s statistics. During the last 20 years, there has been absolutely incredible progress. Afghanistan is a “success story”, as they say. It is an example of remarkable public health development due to extremely dynamic ministers and ministries. 

In 2002, it was absolutely fascinating to talk with the minister and deputy-minister, who were people from the field – the deputy-minister had come out of his mountainous region where he had been a surgeon. When we had that conversation about priorities – you can imagine, 2002, the Taliban left two or three months ago, you enter a ministry, there isn’t a single telephone, there are no chairs, the heating doesn’t work, there’s no paper, everything has been destroyed in the Taliban’s flight, we have a new minister and deputy-minister, and we start prioritising. What will we prioritise? An incredible dilemma after 20 years of war (the soviet war, the civil war, the Taliban). We’re beginning a new era in an atmosphere of hope, openness, and finally the future is opening up. 

They made the absolute right decisions from the start, focusing on children younger than five and on women. These were the two big priorities decided on by the ministry and they were extremely wise in their way of looking at the future of health in Afghanistan. They had technical support coming from outside; support, as you know, was important at the time, and still is today. 

This confidence that I was talking about, I believe in it profoundly in all the public health work that I do. When reinforcing health systems within a ministry, the people in the ministry at the central but also the provincial level must establish confidence between themselves and the communities who, because they are resilient, are capable of doing much themselves. I think that no development is possible if there is no confidence. That’s the first thing for me. From that point on, everything is possible.

Afghanistan is a great example because from the start, they decided that a health system with a community base was an essential element of a health system. And that was a reflection of what I saw during my time in the villages. Working without the communities is working with nothing. From that point on, we saw a remarkable reduction in maternal, neonatal and infant mortality over the years. There’s still a lot of work to be done, but the progress over 10, 15 years back then is progress that in other countries, you see over a period of 40 or 50 years.

How do the people around you react when you talk about your experiences in Afghanistan?

Afghanistan is far. And yet, everyone who has been there thinks that Afghans are very close to us. The population is indo-european. Farsi is relatively easy to learn for someone who speaks english or french. Their sense of humour is very close to our own, and it’s a very developed sense of humour. These are things that very quickly make you feel very close to them. But you have to go there, you have to be there. From afar, they’re bearded men who keep their women at home, they’re this, they’re that. But when you live in a village, you realize that the mother has power over all the boys. The wife makes the budget; you see her husband shopping at the bazaar, she gives him a list of things to buy. It’s these little details that show you that it’s just like at home! And yes, there are things that are extremely frustrating and shocking. But they also happen in France! Incest happens in Europe too. We talk about it in the media, in Afghanistan they still don’t talk about it, well, maybe that’s the difference.

What I’m about to tell you is a little silly, but I lived in Pakistan for a long time, like I said, and I lived in Afghanistan. In Pakistan you can’t find any coffee. In Afghanistan they drink coffee. And for me, that’s the border between Afghanistan and Pakistan; Afghanistan faces the West, faces us, and Pakistan already faces the East.

Do you have a dream or hope or vision for Afghanistan?

The hope that the women would have the knowledge they need for their own health and the health of their children. As well as sufficient knowledge to do the necessary things – to use contraception, to avoid all complications during pregnancy, to take their sick children to the health centre in time. There you go, it’s a doctor’s dream. But I am only a doctor. 

“But I am only a doctor.”