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Magazine
In the crossfire
SAMANTH SUBRAMANIAN
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It is becoming increasingly difficult for health staff to work in Afghanistan.
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Photo: AP
Not enough hospitals around: Medicare is a big casualty of the war.
In the summer of 2006, Aneesa Arur somehow slept through a loud rocket attack in Kabul. “Everyone else woke up, of course,” she says. “One rocket landed next door, and the other in a park close by. Neither had any ammunition, though
. I think it was more of an intimidation attempt by the Taliban, directed at Kabul in general and not us, and less of a real attempt to do any damage.”
“Us” was a Johns Hopkins Bloomberg School of Public Health team that has, over the last few years, been working with the Afghanistan Ministry of Health to rebuild the country’s primary healthcare sector. Along with other partner and donor agencies, the Ministry and the Bloomberg School — where Arur is a Ph.D. candidate — have painstakingly improved people’s health standards from their subterranean 2001 levels. Part of that effort has been one of the largest initiatives in contracting health service delivery out to NGOs, the worth of which Arur is studying for her thesis.
Successful
Even if Afghanistan has far to go, there are many signs that contracting out is working well, says Peter Hansen, the Afghanistan Country Director for the Johns Hopkins project. By 2007, NGOs had trained and deployed over 17,000 community health workers and 1,864 midwives. They had opened 667 basic health centres, 387 comprehensive health centres and 49 hospitals. In 2003, just 4.6 per cent of pregnant women in rural Afghanistan received any sort of skilled care before delivery; in 2006, that number stood taller at 32.3 per cent. “The gains that have been achieved in a short period of time in a difficult environment are impressive,” says Hansen. But all that progress is now threatened by the deteriorating security situation in many parts of the country.
Like droplets of mercury rushing to coalesce with each other, the Taliban have, over the last year and a half, pulled back into a semblance of their earlier selves. This spring, suicide attacks and roadside bombings rose by 25 per cent as fighters filtered back across the border from Pakistan. In 2006, when Arur was in Kabul, the Taliban killed 191 American and NATO troops, a fifth more than in 2005. “In Washington, officials lament that NATO nations are unwilling to take the kinds of risks and casualties necessary to confront the Taliban. Across Europe, officials complain the United States never focused on reconstruction, and they blame American forces for mounting air attacks on the Taliban that cause large civilian casualties, turning Afghans against the West,” the New York Times reported, observing strategy rifts between NATO and the United States over tackling this counter-insurgency.
Hansen first came to Afghanistan in the summer of 2004. At the time, he says, “I spent much of my time here travelling freely with survey teams in the field.” It was easy; every night, Hansen ate and slept in a different village, without the wearying logistics of arranging for food and lodging advance. But agencies are not able to do that any more. “We feel that we have had no choice but to reduce greatly our level of exposure in the field,” says Hansen. “We now conduct all of our work from Kabul or from regional centres like Herat, Kunduz or Mazaar-e-Sharif.”
Hansen lives in the Shar-e-Naw section of Kabul, in a compound with secure gates and high walls, unarmed guards, blast film on the windows, and emergency supplies. On a routine day, he meets technical staff or leaders at the Ministry to evaluate data, develop strategy, and pore over policy issues. When he does travel out of Kabul, he does so as inconspicuously as possible. “When we do get a chance to leave Kabul, for example to Panjshir or one of the major regional cities, it feels great — liberating, even.”
Feeling insecure
Kabul itself is no model of safety, and Arur, preparing for her trip last summer, began to hear that there were riots in the city. She was, naturally, apprehensive; the riots had been sparked by an incident with U.S. troops and then degenerated into general looting. “The mobs targeted NGO compounds first, and that left most of us who were living there feeling very vulnerable,” says Arur, a diminutive, bespectacled young woman whose eyes express every memory of that fear. “You know that if there are riots like that, there is very little help that can be expected from the police.”
Much of the insecurity is endemic to Afghanistan today, and health workers are often caught, quite literally, in the crossfire. “At one point one of my survey teams were in a health facility in Paktya, talking to the personnel there, when some wounded Taliban came in for treatment,” says Arur. “The Afghan National Army followed, and there was a fire fight. Luckily my team was able to run out from the back door and get out of there.”
The Taliban, says Arur, are also specifically targeting anybody who is seen as supporting or working with the government, and health workers fall heavily into that category. In areas outside Kabul, Hansen has heard of NGOS receiving “night letters” — anonymous written threats, left at night, promising violence if the agency does not move out of the region. Thirty-nine government medical workers have been killed over the last two years.
“In certain areas, health staff have paid a terrible price, and some health facilities have been burned down,” says Hansen. “One hospital in Wardak has served the local community with essential services for over 20 years. Last week the director of the hospital was found strangled in his car and his driver was stabbed to death. Under these conditions, it is extremely difficult for NGOs to recruit and retain staff, to keep drug stocks and supplies current, and to conduct supervision and training.”
No easy answers
Any progress that has been made, therefore, is on the verge of collapsing onto itself. Workers hesitate to venture into the Southern provinces, for example, and the districts of Helmand, Zabul, Uruzgan and Kandahar have not been surveyed since 2005 because of the serious risk involved. Personnel are either leaving or getting disheartened.
“I remember one of my colleagues telling me that he had been offered a position there to head one of the hospitals, but he was not willing to move because of the security problems,” says Arur. “It is getting increasingly harder to staff those health facilities.” There appear to be, Hansen says, no easy answers at all, except to hope that the health workers continue to do what they’re doing right now — plug away, ignoring as best as they can the intimidations, abductions, assassinations and burnings.
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