January 25th, 2010
In the reaction to President Obama’s decision about Afghanistan – and in the months leading up to it – the administration, pundits and journalists have focused on troop levels and deadlines for withdrawal. Yet wars such as these are not won or lost on the battlefield alone. They are won or lost in the hearts and minds of the people, who must choose whether to support an insurgency or to reestablish the legitimacy of the government. As the president and policymakers in Washington and Kabul roll out plans for further engagement, and ultimate withdrawal, from Afghanistan, I urge them to leverage the strategic role of health care as a vital component of our Afghan policy.
In addition to a military strategy, Mr. Obama calls for a civilian surge to reinforce positive action and defeat the insurgency. He commits the U.S. to providing assistance in areas that can make an immediate impact in the lives of Afghan people. What could be more powerful than delivering health care to the Afghan people and helping them rebuild their health care infrastructure? The U.S. government already is spending more than $80 million on health programs and infrastructure in Afghanistan this year, but we can do much more. This investment is not only the humanitarian thing to do. It is sound foreign policy.
Decades of war, corruption and a hobbled Afghan central government have resulted in inadequate resources to deliver health care, education, clean water, sanitation, and to develop other basic infrastructure services. The result: deep distrust of the central government and an open door for the insurgency to gain the support of Afghan citizens.
The Taliban clearly understands that providing health care is crucial to gaining the trust and loyalty of the Afghan people. Witness the insurgents’ brutal targeting of health care workers for assassination. Warlords in Afghanistan have consolidated their power in some provinces by providing health care at the local level, in direct counterpoint to the central government’s inability to do so.
The battle to stabilize Afghanistan will take place family to family, village to village. Providing medical care, expertise, supplies and capacity-building thus occurs at the grassroots level. By expanding this strategy, we will wean popular support away from the insurgency, undermine the rhetoric of terrorists, and foster long-term stability. In helping to improve health and human dignity, in offering Afghans new hope and opportunities, America also engenders loyalty and wins life-long friends, not generations of fervent enemies. I call this medical diplomacy. I call this common sense.
The Alarming State Of Health In Afghanistan
Despite help from the U.S. and others, Afghanistan’s health indicators remain alarming. In fact, several weeks ago Daniel Toole, UNICEF regional director for South Asia, reported, “Afghanistan today is without a doubt the most dangerous place to be born.”
UNICEF reports that Afghanistan has the highest infant mortality rate in the world. The mortality rate of children under age five also is among the world’s highest. More than half of Afghan children under age 5 are malnourished, and many children go without crucial vaccinations for polio, measles and other life-threatening diseases. More than two-thirds of Afghan citizens do not have enough food to stay healthy or are at high risk for food insecurity, and 70 percent lack access to clean water.
Afghanistan also has one of the world’s highest maternal mortality rates. In 2006, the rate of maternal death during pregnancy or childbirth in northeastern Badakhshan Province was the highest recorded anywhere on earth. Lack of clean water and basic sanitation, inadequate stocks of drugs and medical supplies, a shortage of health care facilities and an acute shortage of female health care workers place pregnant and postpartum women at extremely high risk. One third of them receive no prenatal care, and up to 80 percent give birth without skilled health care assistance.
Our challenge must be to continue to help Afghan citizens achieve the promise that democracy represents, after so many years of oppression, poverty and strife. We must strengthen our partnership with the many honest and dedicated people and departments within the central government in Kabul, such as the Ministry of Public Health and the Afghan Institute of Health Sciences. We also must expand our partnerships with the thousands of other hardworking, honest people at the provincial and local level to support Afghan families and communities even more effectively through provision of these most basic services.
The Way Forward
If we want to succeed in stabilizing Afghanistan at the grassroots level, I urge the Obama administration, Congress, and military and civilian planners to consider the following actions:
- Don’t just pay Taliban commanders to switch sides. Offer their communities the chance to decide how to spend small grants locally, especially on health care and clean water projects.
- Enlist more local religious leaders in the campaign against infant and maternal mortality, especially to persuade families to educate their daughters and allow them to receive training as midwives or community health workers.
- Provide funding to embed physicians, nurses, dentists and other uniformed professionals from the U.S. Public Health Service in Provincial Reconstruction Teams. Properly deployed and protected, these health workers can offer hands-on care, train others to build local capacity, and serve as expert advisers to local Afghan officials.
- Allow health care professionals enrolled in the National Health Service Corps to do rotations in more secure areas of the country.
- Amend the Afghan Freedom Support Act to make it easier for the U.S. Agency for International Development and the U.S. Department of Health and Human Services to accept donated medical supplies, and allow them to use already appropriated funds to ship the supplies to Afghanistan. In addition, streamline the Denton Program to permit humanitarian supplies to travel on a space-available basis on U.S. military transport, and better coordinate these shipments with U.S. government programs on the ground.
I fully support the president’s recognition of Afghanistan’s geopolitical and national security importance to the United States. In detailing his strategy, Mr. Obama said, “America will have to show its strength in the way we end wars and prevent conflict.” As the U.S. invests more lives and more financial resources in Afghanistan, as we lay the groundwork for sustained recovery and renewed development, I encourage Mr. Obama to remember the strategic value of health care in improving lives, engendering loyalty, and fostering long-term social, economic and political stability.Email This Post Print This Post
Don't miss the insightful policy recommendations and thought-provoking research findings published in Health Affairs.