The Role of Medical Diplomacy in Stabilizing Afghanistan, DECLASSIFIED BOOKS
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Number
63
A publication of the
Center for Technology and National Security Policy
National Defense University
May 2008
The Role of Medical Diplomacy in
Stabilizing Afghanistan
by Donald F. Thompson
Overview
Comprehensive stabilization and reconstruction of Afghanistan
are not possible given the current fragmentation of responsibili-
ties, narrow lines of authorities, and archaic funding mechanisms.
Afghans are supportive of U.S. and international efforts, and there
are occasional signs of progress, but the insurgent threat grows as
U.S. military and civilian agencies and the international community
struggle to bring stability to this volatile region. Integrated security,
stabilization, and reconstruction activities must be implemented
quickly and efficiently if failure is to be averted. Much more than a
course correction is needed to provide tangible benefits to the popu-
lation, develop effective leadership capacity in the government, and
invest wisely in reconstruction that leads to sustainable economic
growth. A proactive, comprehensive reconstruction and stabilization
plan for Afghanistan is crucial to counter the regional terrorist
insurgency, much as the Marshall Plan was necessary to combat
the communist threat from the Soviet Union.
1
This paper examines
the health sector as a microcosm of the larger problems facing the
United States and its allies in efforts to stabilize Afghanistan.
and global application and should be adapted as part of our enduring
national security strategy.
Medical interventions are an important component of a diplomatic
strategy to regain moral authority for U.S. actions, regain the trust of
moderate Muslims, and deny terrorists and religious extremists unen-
cumbered access to safe harbor in ungoverned spaces. Such efforts in
Afghanistan will be intensely interagency driven and must be tightly
integrated and closely coordinated with offensive military operations,
defensive security actions, and other reconstruction activities so that
military actions are supported and resulting advantages are solidified.
Our security architecture must integrate these medical activities into an
appropriately time-phased campaign across the spectrum of conflict.
Nationbuilding in Afghanistan will be more difficult and time-
consuming than it was in post–World War II Europe. Afghanistan has
a long history of tribal allegiance rather than nationalist loyalty, and it
has endured an almost total destruction of its infrastructure, a process
that began with the Soviet invasion almost 30 years ago. The threat to
Afghanistan from diffuse insurgent networks is much more difficult
to localize than was the threat of communism in Europe. Walling off
terrorists is not possible in Afghanistan, where high value is placed
on the free movement of people and goods across and within national
boundaries. Furthermore, as our national strategy for stabilization and
reconstruction is reappraised, senior leaders must carefully consider
how to integrate effectively all elements of national power and create
the appropriate policy framework—coordinated interagency strategy,
doctrine, authorities, and resources—in which each instrument may
be applied.
A detailed RAND Corporation study cites the absence of an over-
arching, nationally driven plan, poor coordination, and the lack of a
lead actor as major barriers to successful health sector reconstruction
and stabilization.
2
Three obstacles identified in the RAND study are
at the root of our failing efforts in Afghanistan: poor planning and co-
ordination within and between U.S. Government military and civilian
agencies; lack of an overall health sector reconstruction game plan and
the resources required for implementation; and misunderstanding of
and failure to adjust for the complex counterinsurgency challenges of
security, stabilization, and reconstruction. Focusing on health provides
opportunities to overcome Taliban influence, strengthen the young
Afghan government, and set the conditions for long-term economic
growth. The lessons and principles from Afghanistan have broad regional
Strategic Goals
An effective counterinsurgency campaign against the Taliban re-
quires a combination of offensive, defensive, and stability operations,
where stability operations include civil security, civil control, essential
Defense
Horizons
1
May 2008
services, good governance, economic development, and infrastructure
development.
3
Essential services include water, electricity, health care,
and education—all of which support economic growth and progress to-
ward self-sufficiency. These services are unavailable to most Afghans,
adding to discontent and societal
tension and fueling the insur-
gency. Providing access to these
services is the crucial counter-
insurgency step that goes hand
in hand with security. Strategic
civil-military partnerships must
be developed that create unity
of effort where offensive militar y
operations, defensive security
operations, and the correct as-
pects of stabilization are applied
across the spectrum from con-
flict to peace.
4
Increasing the effectiveness of Afghan government institutions
and redressing popular grievances regarding essential services and
corruption should shift the support of the population from the Taliban
insurgency to the government of President Hamid Karzai. Improvements
in the health sector are especially important. U.S. military forces are
quite successful with conventional combat operations, but they struggle
with engagement of crucial civilian components of the government of
Afghanistan. While more resources are necessary, they will be wasted
if not applied more effectively.
Taliban have maimed Afghans who work at the PRT compound, cutting
off noses and ears to send a threatening message to others. When the
PRT commander sought assistance for reconstructive surgery to coun-
ter the insurgents, a specialty hospital in Kabul operated by the CURE
International nongovernmental
organization (NGO) designed
a plastic surgery training pro-
gram that would train 2 Afghan
surgeons a year while provid-
ing reconstructive surger y
to 30 patients each year. The
$430,000 project cost of build-
ing sustainable capacity within
the Afghan system was denied
by the U.S. Central Command
Humanitarian Assistance coor-
dinator. Funding this initiative
would have been a relatively in-
expensive way to show U.S. support for local populations, would have
helped to boost local morale, and would have built needed, sustainable
capacity in the Afghan health sector.
U.S. military forces are explicitly trained, equipped, and organized
for short, decisive wars against massed enemy forces. However, they
come up woefully short when the enemy instead seeks to discredit the
development of a competent government and demoralize and terrorize
civilians while using them for cover. Civilian U.S. Government depart-
ments and agencies have shifted their focus from operational capacity
to policy setting and are generally hampered by lack of specific con-
gressional authorization to operate internationally and to obligate their
funds outside their domestic domain. The complexity of the Federal
Acquisition Regulations and the risk-averse nature of contracting officers
often result in missed opportunities to act quickly in restoring essential
services.
8
Civilian personnel rules generally are not designed to support
deploy ment of U.S. civil servants when it comes to matters of compensa-
tion, life insurance, medical evacuation, and long-term rehabilitation.
Many capabilities within the military, civilian agencies, and NGOs have
become so specialized as they seek increased efficiency that they have
lost their ability to adapt and respond to a changing reconstruction and
stabilization environment.
In one case, over 18 months of negotiation were required to assign
two technical experts from the U.S. Public Health Service Commissioned
Corps, part of the Department of Health and Human Services (DHHS), to
the office of the Combined Security Transition Command–Afghanistan
(CSTC–A) Command Surgeon to help with civil-military health sector
development. These Commissioned Corps officers have outstanding
expertise in maternal and child care, development of basic health ser-
vices across cultural barriers, communicable disease control, and food
and drug safety, and they work widely throughout U.S. Federal medi-
cine in the Indian Health Services, Centers for Disease Control and
Prevention, Food and Drug Administration, and other Federal depart-
ments and agencies. DOD ultimately was required to fund not only travel,
deployment, and hazardous duty pay, but also baseline salary, benefits,
retirement, medical evacuation, and even death benefits because DHHS
is not funded for international stabilization and reconstruction work.
Twenty Commissioned Corps officers volunteered for the two CSTC–A
positions that were created; these experts could be more widely used if
DHHS were resourced for these international developmental tasks.
many capabilities within the
military, civilian agencies, and
NGOs have become so specialized
that they have lost their ability
to adapt and respond to a
changing reconstruction and
stabilization environment
Available Tools Unused
North Atlantic Treat y Organization (NATO) Prov incial
Reconstruction Teams (PRTs), originally conceived as the model for
reconstruction and stabilization in postconflict settings,
5
have been
criticized for their concentration on short-term, unsustainable construc-
tion projects that crowd out local initiatives and fail to stem the rising
violence in Afghanistan.
6
NATO and the international community have
been faulted for the lack of a well-crafted, publicly articulated compre-
hensive master plan for reconstruction that applies lessons learned to
enhance economic development.
7
These problems stem from American
inexperience with small counterinsurgency wars; the attempt to reap a
peace dividend from the end of the Cold War by reducing defense budgets;
and the focus on efficiency, technolog y, and specialization in many of our
domestic and national security agencies. The Department of Defense
(DOD) must now rapidly realign civil-military authorities and resources
for counterinsurgency and stability operations.
Poor resource support and central coordination for local efforts are
hampering the local and regional counterinsurgency impact of the PRT
in the restive Kunar Province bordering Pakistan. As an example, the
Dr. Donald F. Thompson is Special Assistant for Biological Defense in the
Office of the Secretary of Defense for Policy. He is a Colonel and a Senior
Flight Surgeon in the U.S. Air Force and specializes in Family Medicine and
Preventive Medicine. Dr. Thompson was Command Surgeon for Combined
Forces Command–Afghanistan and Combined Security Transition Command–
Afghanistan from March 2006 to April 2007.
2
Defense
Horizons
May 2008
Who Is Responsible for What?
Efforts to rehabilitate the health sector in A fghanistan suffer from
many of the interagency coordination defects that have plagued the
United States in its broader approach to postconflict stabilization efforts.
The Federal Government is largely organized such that one department
is in the lead in preconflict, conflict, or postconflict settings, while
the others assume secondary
importance. In theory, at least,
the State Department handles
preconflict negotiations; DOD
handles the conflict and rapidly
exits when the conflict ends; and
someone other than DOD han-
dles all the postconflict work.
This scheme fails in a counter-
insurgency because it does not
provide for successful postconflict reconstruction, nor does it account
for dealing with nonstate actors, terrorists, or insurgents. Insurgents
blend in with and terrorize the population, undermine the government,
and seek to perpetuate discontent, disorder, and instability. The key
step in a counterinsurgency is to separate these insurgents from the
support of the population. Mao Tse-tung described insurgents as fish
swimming in the water of the population. Counterinsurgency is much
more than simply attacking the fish, though sometimes this is the right
approach. The goal is to separate the fish from the water by providing
economic and political changes that undercut popular support for the
insurgents.
9
Insurgents have provided medical services to win over the
rural population; Taliban-owned hospitals operate in Pakistan along the
Afghanistan-Pakistan border and provide medical services to Afghans
in the region. Focused health sector development within Afghanistan
will draw the support of the population from the Taliban insurgents to
the Afghan government.
Counterinsurgency stability operations may require offensive mili-
tary actions at one time, while at another time security may be provided
merely by the threat of military action, by covert military action, or by
host-nation army or police forces. Essential services of clean water, emer-
gency food, or basic health care may be provided by military personnel
in a highly unstable setting or while active conflict is taking place but
should be provided by NGOs, international organizations, or the host-
nation government as soon as conditions permit. Developing government
capacity to provide health care services or confirming the quality of
existing government services may initially be achieved by military-run
PRTs but should quickly transition to U.S. civilian agencies assisting the
host-nation governmental authorities. The common theme is that as the
counterinsurgency operation evolves and stability and security increase,
the host-nation government becomes stronger and takes over actions.
Implementers of each specific task may change, but all offensive mili-
tary operations, defensive security operations, and reconstruction and
government capacity-building activities must be tightly integrated by all
military and civilian participants across all phases of conflict.
Required unity of effort has not been achieved even within the U.S.
military in Afghanistan today—one command structure controls offen-
sive counterterrorist actions, and another one handles defensive security
actions, security sector reform actions, and reconstruction actions. When
the need for other sources of technical expertise from civilian agencies
and other sources is considered, it is clear that the current organizational
structure is inadequate.
New DOD policy elevates stability operations to a core competency
akin to combat operations and states that while actions may best be per-
formed by indigenous, foreign, or U.S. civilian personnel, U.S. military
forces shall be prepared to perform all tasks necessary to maintain order
when civilians cannot do so.
10
The Government Accountability Office
notes that DOD lacks interagency coordination mechanisms for planning
and information-sharing and has
not identified the full range of
capabilities needed for stability
operations or the measures of ef-
fectiveness essential to evaluate
progress. Performance measures
must consider the crucial soci-
etal elements of civil security,
civil control, essential services,
governance, economic develop-
ment, and infrastructure development, and are doubly important when
taking on a new mission—stabilization and reconstruction—in a new
environment—postconflict—against a new enemy—an extremist
insurgency.
as the counterinsurgency
operation evolves and stability and
security increase, the host-nation
government becomes stronger and
takes over actions
Opportunities Lost, Lessons Not Learned
Nowhere is this disorganization more apparent, nor have more op-
portunities been lost, than in the areas of health and medical care in
Afghanistan. Too much effort is wasted on poorly coordinated Medical
Civic Action Programs (MEDCAPs), where U.S. and NATO International
Security Assistance Force (ISAF) military medical personnel deliver
health care directly to Afghan civilians, undercutting the confidence of
the local population in their own government’s ability to provide essential
services.
11
While reasonable people may disagree about the effectiveness
of MEDCAPs in nations where there is no functioning government to pro-
vide this health care, MEDCAPs in Afghanistan are largely inappropriate
because they fail to contribute to long-term capacity-building. These
teams are more appropriately used as tactical implementers of recon-
struction projects in conjunction with PRTs, as described below.
Other activities have mixed results. Training of skilled birth at-
tendants and midwives has turned out many graduates, but their poor
distribution around the country has left many areas underserved, so the
record-high maternal mortality rate remains extreme in most rural areas.
Much effort is wasted when medical and educational infrastructure is
built without assuring that trained Afghan personnel are available to
operate and sustain the facility. Such criticism has been leveled at PRTs
at the provincial and local level, at DOD in development of the Afghan
National Army (ANA) and A fghan National Police (ANP) health care sys-
tems, and at DHHS at the level of the Ministry of Public Health.
12
U.S. civilian government efforts have not focused on comprehen-
sive reconstruction of the civilian and military health sectors but rather
have largely been limited to U.S. Agency for International Development
(USAID) attempts to provide for NGO-delivered primary health care
services under the Ministry of Public Health’s Basic Package of Health
Services (BPHS). USAID, the European Community, and the World Bank
are the primary donors supporting development of the BPHS, and have
demonstrated considerable success in making this basic level of health
care available to 82 percent of the population (defined as the percentage
of the entire population within a 2-hour walk of a village health post or
Defense
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May 2008
better medical facility). Medical care is adequate, though minimal, for
most Afghans. The rest of the health sector remains largely untouched.
efforts to integrate health care services for the ANA and ANP into an
efficient, cost-effective, sustainable ANSF system, cultural antipathies
between the army and police are leading toward separate combat medic
training for the two systems and redundant hospitals in Kabul, despite
hundreds of empty hospital beds in the ANA hospital already renovated
with U.S. dollars.
U.S. and ISAF military medical resources are primarily used to
deliver health care to Afghan security forces and Afghan civilians, not
to treat U.S. and coalition casu-
alties. On any given day, 70 to 90
percent of patients hospitalized
in coalition medical facilities
are Afghans. Almost all Afghan
casualty movement must be by
U.S. and ISAF aircraft, since ci-
vilian ambulances are almost
nonexistent. These dramatic in-
equities were demonstrated by a
heroic medical evacuation mis-
sion that attempted to save four
Afghans critically burned in two separate mass casualty incidents. A U.S.
Air Force C–17 aircraft with two 3-member Critical Care Air Transport
Teams was launched from Al Udeid Air Base in Qatar and landed in
Kandahar to retrieve two A fghans who were being maintained on venti-
lators from ISAF facilities. From there it f lew to Tarin Kow t in Uruzghan
Province for two more Afghans on ventilators in the ISAF facility there,
and then it went to Kabul to transfer the patients to the Afghan system,
where ventilators are almost unknown. The patients were transferred
from the most modern of Western medicine—flying intensive care
units—to Afghan ambulances where each patient had to be manually
ventilated. Three of the four patients died of their burns within 24 hours;
the fourth was transferred to the U.S. facility at Bagram Air Base, where
he died the next day. Some may question the valiant extent to which ISAF
went in attempting to save these four civilians, but none will question
how much greater the lifesaving impact would have been for many more
Afghans if the costs of just the flight time for this 12-hour mission had
been invested in building capacity within the Afghan civilian health care
system. Not until such investment can be made will dependency on U.S.
and ISAF resources be reduced.
ISAF remains minimally involved in ANSF health sector reform,
despite positive movement in late 2006. NATO member nations could
have a major impact on ANSF capacity development by contributing 5- to
10-member medical or surgical teams to work along existing U.S. DOD
teams in the 400-bed National Militar y Hospital in Kabul and the 4 other
100-bed regional hospitals. All hospitals are within secure ANA garrisons,
so national caveats concerning hostile exposure need not apply.
Obstacles to Success
Resource restrictions reinforce and perpetuate poor performance
and lost opportunities. Authorities for spending U.S. taxpayer funds are
outdated, having been designed for small-scale humanitarian assistance
in emergency settings where
an effective government re-
sponse is lacking. DOD Overseas
Humanitarian, Disaster, and
Civic Aid (OHDACA) funding
is restricted to humanitarian
emergency assistance that ben-
efits only civilians and may not
be used to build sustainable ca-
pacity. Bureaucratic obstacles to
getting A fghan projects approved
made OHDACA essentially a use-
less funding mechanism. Congress created the Commander’s Emergency
Response Program to provide some flexibility to the local commander
for urgent humanitarian projects, but these funds are unavailable for
developing substantive capacity in the civilian health care system. Other
experts have recognized the deficiencies of such humanitarian assis-
tance programs and are attempting to develop measures of effectiveness
that will improve transparency, cost effectiveness, and interagency
collaboration.
13
the United States is developing a
disparate system in Afghanistan
by putting almost all of its health
sector reconstruction resources
into the security sector while
ignoring the civilian sector
Security Sector Health Care: Independent or
Integrated?
DOD has invested hundreds of millions of dollars in the ANA health
care system yet is unable to apply funds where needed to make the sys-
tem sustainable. Also in desperate need of rebuilding are the civilian
institutions that provide direct support to the A fghan National Security
Forces (ANSF), such as civilian medical and nursing schools, civilian al-
lied health professional training institutes, emergency medical services
systems, and clinical care for family members of the ANA and ANP.
In many nations, entitlement to use the superior military health
care system is extended to political dignitaries and dependents of mili-
tary personnel, leading to a multitiered system and discontent from the
masses destined to use the underfunded, underequipped, second-class
civilian system.
14
The United States is developing such a disparate system
in Afghanistan by putting almost all of its health sector reconstruction
resources into the security sector while ignoring the civilian sector.
Current resource restrictions stall the development of a sustainable
health care system with the correct central structure and relationship
within and between ministries.
Afghan National Security Forces funds could be used to build an
expensive military medical school for the ANA (despite a lack of profes-
sors to provide a quality medical education), but could not be legally
used in the existing civilian medical university. Less than 5 percent
of the amount required to build a military medical school could build
tremendous capacity and quality in the civilian medical university to pro-
vide a sustainable source for all the physicians needed for the army and
improved quality within the civilian health care sector. Despite strong
Not as Hard as It Seems
Detailed examination of health sector reconstruction in
Afghanistan demonstrates the interconnectedness of governance and
capacity-building. Many well-intentioned infrastructure projects have
been undertaken, including construction or renovation of hospitals,
clinics, schools, and dormitories. Hundreds of millions of dollars have
been spent on modern equipment and supplies to provide state-of-the-art
medical and educational facilities. Highly publicized opening ceremo-
nies are held where the facility or equipment is turned over, with much
4
Defense
Horizons
May 2008
fanfare, to the appropriate ministr y. Often, however, a visit to the facility
several months later reveals that it is not operating as intended, creating
the perception that the government has failed. This is frequently due to
the lack of skilled manpower and the difficulty of providing culturally
sensitive training that is understood and adopted by local workers. A
more appropriate alternative would include the purchase of basic medi-
cal equipment from India or Pakistan while simultaneously developing
training programs that provide education in literacy and basic sciences,
in addition to the technical skills required for the particular position.
Didactic training is not as effec-
tive in Afghanistan as hands-on
mentoring, so commitment to
longer-term training engage-
ment is essential.
A fter a female A fghan
National Army Air Corps pilot
bled to death during an emer-
gency Caesarean section at a
civilian women’s hospital in
Kabul, an obstetrics mobile
training team did a comprehensive assessment of labor and delivery
care. Findings included lack of rudimentary scientific knowledge and
decisionmaking abilities concerning the use of basic medical equipment,
such as blood pressure and heart rate monitors. A U.S. Army respiratory
therapist brought advanced adult and neonatal ventilators, yet Afghan
physicians preferred a 2-hour, hands-on workshop in using oxygen masks
and hoods rather than learning to use the advanced ventilators. Basic
decisionmaking needs included distinguishing between low-risk and
high-risk patients, and managing life-threatening emergencies.
Despite these glaring limitations, most contributions to the health
sector consist of expensive medical equipment that is quickly broken be-
cause of inconsistent power supplies, runs out of reagents and becomes
useless, or is never set up at all. The biomedical equipment technician
on the obstetrics mobile training team quickly became the most sought-
after person in town, and he repaired patient monitors, sterilizers, infant
incubators, surgical lights, suction machines, defibrillators, fetal heart
rate monitors, infusion pumps, and laboratory equipment at multiple
military and civilian hospitals around Kabul, while training Afghans
twice his age to troubleshoot and repair such equipment after he left.
Such mismatches between technology and maintenance capacity can be
prevented by a proactive training effort in biomedical equipment repair.
A collaborative training institute between the Kabul Medical University,
the Ministry of Public Health, and the Ministry of Defense could train
biomedical equipment technicians and many other allied health workers,
such as radiolog y and ultrasound technicians and respirator y therapists.
Graduates from this institute could work in government, militar y, or pri-
vate hospitals and could be the foundation for economic development in
the private sector.
Infrastructure development in conflict-prone settings often must
include forgoing some efficiency in order to promote indigenous job cre-
ation and employment of host-nation contractors. For example, more
local workers will need to be hired and trained for particular tasks in the
initial years, leading some to question effectiveness of training programs.
In fact, this practice broadens the opportunities for economic develop-
ment to more A fghans and builds broad-based community support for the
project. Development of host-nation capacity to drive the strategic and
planning processes takes much time and patience but is essential in the
long run.
15
Afghans are best able to recommend what will and will not
work and must be involved in every aspect of planning and implement-
ing such development.
Achieving Success
The health sector has significant manpower, training, economic, re-
ferral, and geographic distribution factors that require a holistic systems
approach. A fghanistan lacked a strong health care deliver y system before
the Soviet invasion, and subse-
quent fighting devastated what
did exist. Women are highly rep-
resented in the health sector in
much of the world; their cultural
exclusion from much of Afghan
society makes effective recon-
struction more difficult. The
long history of ethnic and tribal
conf lict bet ween Pashtuns,
Tajiks, Uzbeks, and Hazaras,
with recent decades being marked by changing associations of militias,
warlords, and mujahideen, complicates any effort that requires working
cooperatively. Even with the Taliban extremists largely removed, work-
ing with others is anathema; consolidation of control is the standard.
Sustainable development of the health sector requires work against
these ingrained cultural tendencies, but it must be done on A fghan terms
and timelines, not those from the West. Engagement provides many
opportunities to improve governance, reduce corruption, and validate
the government’s ability to provide for the people. All projects must be
done in concert with Afghan priorities, which require building endur-
ing personal and professional relationships, making every attempt to
understand cultural issues, and adjusting timelines accordingly. As
reconstruction of the ANA medical system was under way, a senior
Afghan official said, “Don’t look at us in a U.S. DOD-sized mirror. We’re
very young compared to you.” The Afghan leadership recognizes that it
is very new at developing a national army and national pride, and while
they desire to move forward, it will take time, commitment, and much
hard work. Another official said, “It took you over two hundred years to
get where you are. Don’t expect us to change overnight.”
Every aspect of every project must emphasize collaboration.
Ministries must work together at the central level; internal components
within each ministry must work efficiently; and each central ministry
must work well with its regional and provincial components. Entry-level
positions must be created wherever possible, especially for women, and
basic education and literacy training must be incorporated. Projects
must include work at the provincial and district levels, so jobs can be cre-
ated at these levels rather than only in the capital, Kabul. Health-related
education and economic opportunities offer acceptable alternatives to
poppy cultivation and armed resistance. Facilitating sustainable devel-
opment of capacity in good, effective governance is the center of gravity
for all stability operations in Afghanistan.
A recent burn-prevention education initiative funded by a private
donor emphasizes these key governance issues. The initiative devel-
ops capacity in the Ministries of Public Health, Women’s Affairs, and
Education, both centrally and at the provincial levels. The Ministry of
Public Health lacks capacity to manage private sector funding, so the
project is managed by SOZO International, an NGO that specializes in
Afghans are best able to
recommend what will and will
not work and must be involved
in every aspect of planning and
implementing such development
Defense
Horizons
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May 2008
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