ISTANBUL – It was Shaghayegh Amiry’s first pregnancy. She was swollen and uncomfortable but, more urgently, she was struggling to pay her medical bills.
Born in Tehran 28 years ago, Amiry is an undocumented Afghan refugee in Iran, the daughter of Afghans who fled war in the country. Amiry said she used to have a legal residency card, but a computer glitch in the Iranian system erased her name about 14 years ago. Now, like an estimated 2 million other undocumented refugees in Iran, Amiry has no access to benefits.
Those benefits include the government-subsidized health insurance, Salamat, which Iran made available to Afghans more than a year ago. For about $12 a year, Afghan refugees with an “Amayesh” residency card – Iran’s registration system for Afghan nationals – get a big break on their medical bills.
About 110,000 Afghans who are in the greatest need, including widowed women, seniors and the disabled, receive free healthcare from the government, with financial support from the U.N. High Commissioner for Refugees (UNHCR).
Better-off Afghans who are able to pay the annual fee have access to public hospitals and private health institutions that accept Salamat insurance.
For pregnant women, this insurance covers the cost of monthly checkups, supplements and delivery, but some patients have had to pay extra for ultrasound or blood tests in full.
“We’ve had the experience of working with Afghan refugees for 40 years, and there was a dire need for help with maternal health, sanitation and illnesses among these refugees,” said Mohammad Ali Salehi, the deputy director of Iran’s Bureau for Aliens and Foreign Immigrants’ Affairs. “Many women used to give birth at home, and now they have doctors and hospitals available to them,” he said, referring to registered refugees who now have access to insurance.
The UNHCR praised Iran in March for its “exemplary” efforts to provide services to Afghans and Iraqis.
But only about 950,000 Afghans are legal in Iran. The majority, like Amiry, have learned to live on the margins. Undocumented expecting mothers usually borrow money from relatives or friends to cover healthcare costs, or they give birth at home with the help of midwives.
Dozens of Afghan women, who generally have more children than Iranian women, have died from childbirth in Iran in the last 10 years, according to health experts in Tehran.
In Debt and Afraid
One aid worker in Tehran who did not want her name published said that undocumented Afghans are scared to go to hospitals. Even pregnant women are technically liable for deportation if they don’t have documents.
“Those without registration are afraid that accessing medical services may have repercussions with the government,” the aid worker said.
Even registered refugees struggle to pay $12 a year for each member of the family, who must all be covered under the insurance, she said. “It’s a substantial investment for Afghan households.”
One Afghan social worker in Iran said only a few hospitals in Tehran are welcoming to Afghan women. “There have been cases where a mother who just gave birth is released but her newborn is held hostage until she can pay her hospital bill. Many of these women in need of healthcare are in a lifetime of debt,” the social worker said.
Amiry delivered her son, Barbod, in a government hospital in May. Her husband, a laborer, had to borrow money from his relatives. With no insurance, the total cost of her pregnancy and delivery was $1,530 – a huge burden for an Afghan in Iran surviving on wages as low as $15 a day.
The new mother nursed her son as she talked on the phone with News Deeply from her Tehran rental apartment.
“We’ve been wanting to leave Iran and cross to Europe like so many others because there’s no future for us here, but our families insisted we stay for safety reasons,” said Amiry, a high school graduate and former seamstress.
Tens of thousands of Afghans have crossed into Turkey and taken boats to Greece in recent years – more than 42,000 Afghans made the risky Mediterranean voyage in 2016. Meanwhile, Iran has stepped up deportation of undocumented Afghans, aiming to return 600,000 people to Afghanistan this year.
Every few years since the wars in Afghanistan began in 1978, Iran has allowed undocumented Afghans to apply for residency, but there is a severe backlog in applications. Amiry said she has tried to reapply for her residency card, putting her name on the long waitlist of undocumented refugees. Priority is given to refugees whose spouses have cards or are Iranian. Fortunately, Amiry’s Afghan husband is documented and has applied for his wife and newborn son to become legal.
Whether registered or not, Afghans living in Iran face abuse and discrimination, including police harassment and racial slurs, particularly against ethnic Hazara Afghans who look different to most Iranians. Several Afghans interviewed for this article declined to give their names citing fear of the Iranian government.
In 2013, Human Rights Watch published a report detailing the lack of a functioning asylum system in Iran and abuses of refugees, including arbitrary detention.
“We faced considerable pressure from UNHCR over this report, including them urging us not to write it at all,” said Heather Barr, a Human Rights Watch researcher and the co-author of the report. She believes the U.N. and other aid organizations are careful not to criticize Iran out of fear of running afoul of the government and being prevented from continuing their work with refugees. The UNHCR was not available for comment by the time of this article’s publication.
A Little Dignity
Despite deportations and harassment, Iran’s official refugee policies in the past few years have been widely praised and have made life a little more bearable for the refugees that do benefit from them.
In 2015, Iran’s Supreme Leader Ali Khamenei made a historic announcement that every Afghan child, with or without residency, had the right to an education. About 15,000 new classrooms were built to house excited Afghan children in public schools. Soon after, the government made health insurance accessible to refugees.
Some analysts see a political motive behind Iran’s policies. The country shares a 1,000-mile (1,609-km) border with Afghanistan, where Afghans cross daily both illegally and legally, and has a long-running dispute with their neighbor over use of water resources. “These incentives were meant to encourage an exchange: Iran gives Afghan refugees rights with the expectation that Afghanistan should give Iran access to waters from its rivers,” a former Afghan government representative in Iran said.
Whatever the motive, these benefits are a lifeline for many Afghans.
Zahra Dil is six months pregnant with her third child, 11 years after her last child was born. She’s an Afghan homemaker and her husband has worked construction jobs for the last 16 years they’ve been in Iran. The family barely ekes out a living with his fluctuating income, but they do have residency cards.
Dil, 37, said the government gave her free birth control, an intrauterine device or IUD. They could only afford two children, but she became pregnant during the two-month waiting period when she removed her IUD. Unplanned pregnancies are especially difficult in a country in which abortion is illegal unless a doctor says the mother is in medical danger without it.
The couple were worried about delivery expenses so they borrowed money to buy insurance. Even with the insurance, Dil, a diabetic, said the fees for the blood tests and ultrasounds are sending them into deeper debt. It’s costing Dil and her husband more money to have their third baby than their firstborn 16 years ago because of inflation, which has topped 10 percent for most of the past three decades in Iran.
Still, Dil said she’s grateful for the financial discount the insurance gives Afghan families. Since Khamenei’s declaration about Afghans in 2015, Dil said she has noticed a difference in Iranian attitudes toward Afghans in her daily life.
“They’re doing more for us. They have accepted the kids in school. They have finally accepted that we’re a part of this country because we have nowhere else to go,” said Dil, speaking from a relative’s house where she has access to the internet, which she can’t afford on her phone.
“There are Iranians who are ignorant and they treat us badly, but those who know our troubles treat us with respect and dignity.”