President Obama has set our nation on the course of escalation of our war in Afghanistan-Pakistan. What should be the concerns of health workers in this current juncture? As health workers, we should concern ourselves with the health and human rights implications of the war that our nation is conducting. For one, we should care about what happens to the Afghan people, whose life expectancy is 45 years for women and 47 years for men, and 191 out of 1000 children die before they are 5 years old (1). It is our responsibility as Americans to care about what happens to Afghan people in the course of this war that our nation has been waging since October 2001, particularly when they are injured or killed by our dint of American arms. The effects of war extends to consequences of war, such as the collapse of health services, lack of access to water and food, and damage to infrastructure, economies, and societies. We should keep in mind that Afghanistan is a country that has had ongoing conflict and civil turmoil since 1979.
As noted by Rubenstein and Newbrander, primary care services ensured by the Afghan Ministry of Public Health have improved since 2002.
[T]he number of health facilities has doubled and the number of trained midwives quadrupled. The share of health facilities with at least one female health worker has climbed to 83 percent. The number of children dying in infancy or before age 5 has declined nearly 25 percent, which translates into nearly 100,000 fewer infants and children dying this year, compared with 2002.
These initiatives have strengthened the foundations of a state that can serve its people. Rather than providing or contracting for services directly, USAID, the World Bank and the European Commission have strengthened the capacity of the Ministry of Public Health to develop and implement health policies, oversee programs, manage resources, engage communities and control the delivery of services. In contrast to the corruption obvious elsewhere, the health ministry has shown a level of transparency and accountability that allows U.S. funds to flow directly to the government for the provision of basic health services. (2)
The Ministry of Public Health defined a basic package of health services such as immunization, prenatal and obstetrical care, family planning, and care for childhood illnesses. The Ministry contracts with NGOs, 27% of which are international NGOs, to deliver the basic package to a specified geographic area. (3)
In an October 5 CNN joint interview, Robert Gates and Hillary Clinton call for an increase in the proportion of American civilians to military involved in Afghanistan. (4) It is evident that they envision using agencies such as the US Agency for International Development (USAID) essentially as a "force multiplier" or the "hearts and minds" component of their military objectives in Afghanistan. The proposed director of the USAID Rajiv Shah, a physician, tells the Senate Foreign Relations Committee, “If confirmed, I look forward to working with this Committee and my colleagues at USAID and the State Department to assess USAID’s contribution to counterinsurgency and stabilization operations.” (5)
Rubenstein and Newbrander note that the Washington is planning to divert USAID funding to “quick-impact” projects such as building health facilities or providing medical equipment in direct support of military operations.
Yet there is no evidence that expensive "quick impact" health projects that are not integrated into a larger strategy, or that do not actively engage locals, either contribute to security or wean populations from the enemy.
Quick-impact projects, such as clinic construction or the provision of new medical equipment, are rarely sustainable and seldom based on the community engagement needed for long-term effects. These simplistic and immediate interventions have been known to backfire. One military health analyst has criticized "drive-by" health interventions as "Band-Aid" operations that raise — and then crush — local expectations and ultimately lead to greater dissatisfaction and distrust. Moreover, as resources are diverted from the Afghan-led effort to build a system of effective and responsive primary care services, the emergence of a legitimate state will be compromised. (6)
Health workers should resist such attempts to co-opt the humanitarian community. Association with the military gives people the impression that humanitarian workers are furthering military objectives or U.S. foreign policy – threatening the security of aid workers and those that they are trying to assist. (7) Furthermore, health workers should refuse to participate in counterinsurgency.
On October 18, the New York Times Magazine ran a sympathetic story on General Stanley McChrystal’s plans for turning the war around in Afghanistan. (8) Under the rubric of counterinsurgency, the plans are to clear areas of Taliban by force of arms, then maintain control long enough (on the order of years) to reconstruct so-called “civil society.” By this is meant the elimination of corruption, the establishment of good governance, the rebuilding of infrastructure, schools, health care, economic development, the elimination of poppy cultivation, and so on.
While McChrystal’s role in Iraq was as commander of Joint Special Operations, that is, overseeing Delta Force and Navy SEALs in covert ops such as the successful killing of the leader of al Qai’da in Iraq al-Zarqawi by bomb strike – in Afghanistan, McChrystal now upbraids a subordinate European general for bombing a target that might cause harm to civilians. Indeed, limiting the use of artillery and airstrikes reflects a recognition that they alienate the populace. As Vietnam, winning the “hearts and minds” of the Afghan population is the current logic.
But watching General Stanley McChrystal’s counterinsurgency principles on display in the Frontline episode, Obama’s War, (9) where Marines are shown trying to convince villagers in Helmand Province to come shop at a market under U.S. control, it is evident that they are making little headway. Well-meaning they may be, but it is painful to watch Marines try to be goodwill ambassadors. Retired Marine John Bernard is critical of the rules of engagement that he believes led to the death of his son, Lance Corporal Joshua Bernard on August 14 in Helmand Province. John Bernard notes that Marines are not trained to be police officers and nation-builders, but rather “kill people and break things.” (10)
Indeed, by July 2006, three years into the U.S. invasion of Iraq, the best estimates for deaths among Iraqis are those of the July 2006 survey that reported 655,000 deaths as a consequence of war. (11) Our recent experience in Iraq should make it abundantly evident that the U.S. military is not adept at reconstructing civil society.
Secondly, let us consider unmanned aerial vehicle strikes in the Federally Administered Tribal Areas of Pakistan the FATA. The CIA is conducting a program targeting Al-Qaeda leaders and enemies of the Pakistani government with missiles launched from unmanned aerial vehicles (UAVs) with names such as Predator and Reaper. (12) Together with the surge of troops in Afghanistan, the Obama administration is stepping up these attacks. Although an unnamed U.S. government official claims that only 20 or so civilians have been killed (13), Pakistani sources report that of 701 people killed in 60 attacks between January 2008 and April 2009, only 14 were suspected militants (14). To assassinate Pakistani Taliban leader Baitullah Mehsud on August 5, 2009, sixteen missiles were launched over fourteen months, resulting in between 207 and 321 additional deaths. (15)
Why are such air attacks on civilians not considered war crimes? Air attacks are not as accurate as they are portrayed. Non-combatants, including women and children, are often killed by air attacks. Homes and neighborhoods, shelter, water and sanitation, people’s livelihoods are destroyed. In the military parlance, this is called merely “collateral damage.” We should also recognize that bombing from the air, turn people against those responsible. (16) If we turn back to drone attacks on Pakistani borderland with Afghanistan, an August 2009 Gallup poll revealed that 59% of Pakistanis perceive the U.S. as the biggest threat to Pakistan, compared to 18% who named that India and 11% who named the Taliban. (17) The Pakistani newspaper Dawn reports that Peshawar residents hold the U.S. responsible for bombings that the Pakistani government attributes to the Taliban. (18)
Finally, we still have not seem to have realized that we live in an empire. I was taken by the title: In the Graveyard of Empires. (19) The author urges caution in Afghanistan, where the Alexander the Great and the British and Soviet Empires met ignominious fates. But a number of chapters into the book, I realized that the author did not think of the U.S. as being an empire. The RAND political scientist has a plan for the U.S. to conduct counterinsurgency more effectively.
Politically, in some respects, the U.S. remains one nation among many, such as in the UN General Assembly. In the economic realm, it competes with Europe and Asia. In the military realm, however, it reigns supreme. The tendency is thus for the U.S. to “lead with its strength,” choosing to resolve conflicts by military threat or attack.
In the words of Afghan women leading a recent protest against government corruption, "The innocent and oppressed people will be the victims of American air and ground attacks." (20) This is a central problem for health workers in the U.S. As Americans, we are responsible for our nation’s actions around the globe. As health workers, we must uphold the cause of health worldwide. What should be our role be?
1. Substantial Improvements Achieved in Afghanistan’s Health Sector. http://www.jhsph.edu/publichealthnews/press_releases/2007/Burnham_afghanistan.html
2. Rubenstein LS, Newbrander W. Undermining Afghan health care. Washington Post, Nov 29, 2009. http://www.washingtonpost.com/wp-dyn/content/article/2009/11/27/AR2009112702454_pf.html
3. Loevinsohn B, Sayed GD. Lessons from the health sector in Afghanistan. JAMA 2008;300:724-726.
4. Gates R, Clinton H. Interview. CNN, Oct 5, 2009. http://transcripts.cnn.com/TRANSCRIPTS/0910/06/ampr.01.html
5. Questions for the Record Submitted for the Nomination of Rajiv Shah to be USAID Administrator by Senator John F. Kerry (#1) Senate Foreign Relations Committee. http://www.usglc.org/USGLCdocs/Shah_Responses_to_Kerry_QFR.pdf
6. Rubenstein & Newbrander.
7. Bristol N. Military incursions into aid work anger humanitarian groups. Lancet 2006;367:384- 386.
8. Filkins D. Stanley McChrystal’s Long War. New York Times Magazine, Oct 18, 2009.
9. Gaviria M, Smith M. Obama’s War. http://www.pbs.org/wgbh/pages/frontline/obamaswar/
10. Sharp D. Marine’s dad speaks out. Honolulu Advertiser, Oct 18, 2009.
11. Burnham G, Lafta R, Docey S, Roberts L. Mortality after the 2003 invasion of Iraq: a cross-sectional cluster sample survey. Lancet. 2006; 368: 1421–28.
12. Mayer J. The predator war. New Yorker, Oct 26, 2009. http://www.newyorker.com/reporting/2009/10/26/091026fa_fact_mayer
13. Shane S. C.I.A. to expand use of drones in Pakistan. New York Times. Dec. 4, 2009. http://www.nytimes.com/2009/12/04/world/asia/04drones.html?hp
14. Ahmad MI. Pakistan creates its own enemy. Le Monde Diplomatique. Nov 2009. http://mondediplo.com/2009/11/02pakistan
15. Mayer J.
16. Young M, Sprey P. (Interview). Bill Moyers Journal. http://www.pbs.org/moyers/journal/01302009/watch.html
17. Ahmad MI.
18. Bombings, drone attacks fuel anti-US sentiment in Pakistan. Dawn. Dec 7, 2009. http://www.dawn.com/wps/wcm/connect/dawn-content-library/dawn/news/pakistan/07-bombings-drone-attacks-fuel-anti-us-sentiment-in-pakistan-ha-02
19. Jones S. In the graveyard of empires. New York: W.W. Norton, 2009.
20. Perry T. Afghan women lead protest against government corruption. LA Times. Dec 10, 2009.