Public Health

One of the main areas where we can see the continuing effects of conflict in Afghanistan both in terms of environmental damage and human suffering is in the field of public health. As conflict has resulted in further deforestation, soil degradation, lack of access to water, and other environmental catastrophes, these catastrophes have contributed greatly to Afghanistan's continuing public health struggles. After all, it is rather difficult to fight off a bout of the flu if one is already dehydrated from lack of access to water. Looser soil contributes to more respiratory issues and less food production. Malnourished women are much more likely to die in childbirth. These are not the only ways that conflict over the last 100 years has contributed to the current public health situation, though. It would also gut the public health infrastructure that did exist, greatly exacerbating the effects mentioned above. Ultimately, these twin effects would result in the situation Afghan public health being much the same as it was 70 years ago. In a world where where the polio vaccine had existed for 58 years, there have been three infections by April 12, 2019. How did Afghan public health reach this point, and what is being done currently to address these issues in Afghanistan?

Public Health challenges and Strategies under the Royal Government

The first period about which reliable information can be found regarding public health issues in Afghanistan is in those first years immediately After WWII. Though very few internal Royal Ministry of Public Health documents can be found in the West describing their work, we do have some record of correspondences between this Ministry and other, foreign governments. For example, in correspondences dated 1946-49, the Afghan Public Health minister describes the issues as he sees them to a US State Department official, and asks for certain types of developmental aid. As the Public Health Minister sees it, the largest issues facing Afghanistan at this point were communicable diseases such as malaria, tuberculosis, cholera, and syphilis, with secondary focuses on women's and children's health.

To address these issues, both the Afghan Public Health Minister and the US official with whom he was corresponding recommend a few important steps. First of all, both advocate for expanded foreign aid in everything. The American, for example, makes mention of the fact that he knows that US public health interests are being played off of those of the French, for example. Though the US official urges an increase in US involvement in public health issues, he also states that he welcomes the involvement of the French, as they can only bring further good to the health system.

Secondly, both recommend the use of American doctors to establish medical training schools in Kabul. One would be set up by a male doctor, and one by a female, a husband and wife team. These schools would train their respective sexes in the practice of medicine before teaching them how to teach others. In this way, it was hoped that these schools would lead to an exponential increase in the number of trained medical practitioners in Afghanistan. Though the Afghan government was in favor of the establishment of the school for men, initial feelings were cool towards the school for women.

Finally, the treatment of communicable diseases was to be focused largely on disease control and containment, rather than on prevention. This is most likely a product of the very limited resources of the Afghan Royal Government at the time. While the focus of medicine in much of the rest of the world was beginning to shift its focus towards disease prevention, Afghanistan simply did not have the resources required to take such an active stance in regard to communicable disease. They mention many times the lack of access to proper medications and vaccinations, and how this limited their stands against communicable disease.

Implementation Under the royal Government And Coup Government

Under the Royal Government and the Daoud Khan coup government, Afghanistan saw by far its largest expansion in its health sector from the 50's to the 70's. Training hospitals were established throughout the country to develop new young doctors. As we saw in the picture above, the Royal Government did eventually invest in a program to develop new female practitioners to address the issues of women's health and infant mortality. Many new hospitals were built with foreign money, such as the Mirwais Hospital or 'Chinese Hospital' pictured above, or Indira Gandhi Hospital in Kabul. Though these projects would result in a large expansion of the public health system, they would not come without their limitations.

Though many of the training schools in Afghanistan would produce good, quality practitioners who did much good in the country throughout these decades, most if not all of them were located in Afghanistan's urban centers, such as Kabul, Kandahar, and Mazar-i-Sharif. As a result, many of the practitioners produced through these programs would end up serving many of Afghanistan's urban centers, but rarely branching out into rural areas, some of those areas worst affected by disease, and especially women's and children's health issues. In addition, though policies of disease containment may have had some initial success in reducing the numbers of cases of infectious disease, they did little to reduce the possibility of infectious disease as a whole.

Responses such as these would continue throughout the 50's-70's, continued both under the Royals and under the coup government that succeeded them. Though they were successful in many of their smaller aims, these efforts fell far short in their efforts to address larger issues. For example, the failure to introduce any real connection between the cities and rural areas lead to the continuation of highly elevated infant mortality rates. As late as 1975, the average woman experienced 6 live births in her lifetime and lost 1.5 children on average. Communicable disease remained a rampant problem and would continue to be so. Many of those children who would die in infancy would often do so to the various diseases rampant in the community. Though adults may be able to contract these diseases and survive, their effects among the young and elderly cannot be understated.

The largest problem, however, would be the continuous decline in foreign funding to the Afghani health system. Throughout many early years after World War Two, quite a few of Afghanistan's medical facilities would be primarily founded and funded by foreign governments. As the 1970's began, though, many governments began to see that the Cold War was beginning to come to Afghanistan. As tensions began to rise after the coup, many governments began to pull more and more of their funding from Afghanistan. By the Soviet invasion in 1979, things were really beginning to turn down hill, and many governments were beginning to focus the entirety of their influence operations in Afghanistan toward a potential future war.

Afghani Health Policy Under the Soviets

When the Soviet troops rolled into Afghanistan in 1979, it was with the goal of propping up what was viewed as a failing Soviet satellite state. As such, The Soviets attempted to present themselves in many ways as continuing the public health policies of their predecessors. Upon the successful Soviet seizure of many cities in Afghanistan, they would attempt to implement Soviet structured public health plans, where access to good, quality healthcare was a fundamental human right. Unfortunately, in many rural areas, the Soviets failed to live up to their rhetoric. While the Soviets may have been promoting ever more investment into city-based public health schema, their policy towards those hinterlands that remained resistant to their rule was much different.

Under the Soviets, medical facilities controlled by the Mujaheddin resistance, like water sources, were frequent targets for bombing and destruction. As a result, for many rural people, whatever access they had to local healthcare was destroyed. Those facilities that remained were often under the direct control of whatever Mujaheddin commander was able to successfully defend them, and access to them was strictly limited to those on the good side of whoever happened to be in charge locally. As a result, there developed two nearly entirely separate public health networks: those in the cities, funded and supported by the central government and foreign intervention, and those in rural areas whose access to healthcare is limited by what is available in the area surrounding them and who is in charge locally. Ultimately, when the Soviets withdrew in 1989, the resulting void would result in the destruction of anything that could be said to resemble an Afghan public health system.

Civil War and Mujaheddin

Following the Soviet withdrawal in 1989, the Afghan state descended into a period of civil war. For the first 3 years of this period, the Najibullah government maintained at least nominal control over the city centers and at least some control of municipal public health services. However, for the vast majority of the country, the public health ministry had functionally ceased to exist, and whatever healthcare accommodations there were were made available based on one's own personal relationship to whoever held power locally. By the year 1992, there is functionally no more government in Kabul, and things begin to fully break down.

It is during this period that NGOs really begin to play a prominent role in the Afghan health sector. For example, Medecins Sans Frontiers, or Doctors Without Borders in English, have been an absolutely critical factor in the Afghan health system since they first began operations in the country in 1980. To many rural and Pashtun southwestern areas of the country, Doctors Without Borders can often be the only provider of medical care and has been for many decades. In certain parts of the country, for example, an MSF clinic may be the only medically safe place to deliver a baby within 100 miles. While many of the foreign funded and private hospitals may have remained for the city dwellers, it was often NGOs who provided on the ground care to rural people.

Taliban Rule

Under the Taliban, public health once more became a national crisis. Although previous national governments had at least attempted to appear interested in public health, when the Taliban came to power, there was basically no point. Unfortunately, 4 years before the Taliban took power, one of the main NGO coordinating bodies in charge of Afghanistan "Suspended operations until such time as further progress shall be possible". By the time of the Taliban takeover, many doctors had fled the country, and what medical facilities remained fell into one of three categories: either they were foreign-run and funded, and thus subject to scrutiny; or they were run by NGOs at the whim of the Taliban, whose orders must be obeyed lest the NGO be kicked out; or they were run by whoever happened to hold local power, and who might selectively distribute medical treatment to his partisans or away from his enemies.

Under the Taliban, fewer and fewer women gave birth in approved medical facilities, with more and more choosing to give birth at home. This, combined with higher rates of soil degradation and crop failure, leads to more and more malnourished women and children suffering from respiratory issues. As water became more scarce, forests disappeared, and the soil loosened, people's health naturally began to deteriorate and left things in almost a worse situation than they had been in before the war.

2001 Until now: What's changed and what will change?

Since the US invasion in 2001, there has been an attempt to re-establish a coherent Ministry of Public Health in Kabul. Founded in 2004, this ministry aims to coordinate the many disparate arms of the Afghan health sector into one solid cohesive unit. To do so, it has introduced a number of reforms, many of which have actually had a fair bit of success. As mentioned at the very beginning of this article, there are still cases of polio in Afghanistan. However, the situation has been much improved from just a few short years ago. Where there used to be dozens of cases a year in a country largely believed to have been the endemic home of polio, there are now only a few cases a year due to vaccination efforts, and The Doctors Without Borders run maternity ward in Khost is among one of the busiest private maternity wards in the world. Fewer and fewer infants are dying in childbirth.

This is not to say that the country remains without challenging medical issues to face. Life expectancy in Afghanistan is among the lowest in the world. Childbirth and infant mortality rates remain among the highest. Communicable diseases still run rampant in many areas of the country. However, there remains hope for Afghanistan. For the first time in many decades, some of the underlying causes of poor health outcomes, like environmental degradation, are being addressed, and the introduction of the Afghan Balanced Score Card for Health was a major step in the right direction in terms of establishing a baseline of medical care which all Afghans must receive. Ultimately, things still remain undetermined. In many ways, the situation is quite similar to that of 70 years ago. But in many other important ways, such as our understanding of and preventative treatment of communicable disease, I think Afghanistan finds itself primed for a much better public health future.

Citations

• Central File: Decimal File 890H.01A, Internal Affairs Of States, Government. Mandates, Recognition., Afghanistan, Foreign Adviser. Other Advisers Are Classified Subjectively, Financial Adviser, Ect., July 31, 1945 - November 25, 1947. (n.d.). Retrieved April 20, 2019, from http://go.galegroup.com.proxy.lib.umich.edu/gdsc/retrieve.do?sgHitCountType=None&sort=DA-ASC-SORT&inPS=true&prodId=GDSC&userGroupName=umuser&tabID=T001&searchId=R1&resultListType=RESULT_LIST&contentSegment=&searchType=AdvancedSearchForm¤tPosition=3&contentSet=GALE|SC5101141273&&docId=GALE|SC5101141273&docType=GALE&viewtype=Manuscript

Records of the Department of State relating to Internal Affairs: Afghanistan, 1945-1949

• Central File: Decimal File 890H.01, Internal Affairs Of States, Afghanistan, Government. Mandates, Recognition., January 8, 1947 - February 2, 1948. (n.d.). Retrieved April 20, 2019, from http://go.galegroup.com.proxy.lib.umich.edu/gdsc/retrieve.do?sgHitCountType=None&sort=DA-ASC-SORT&inPS=true&prodId=GDSC&userGroupName=umuser&tabID=T001&searchId=R1&resultListType=RESULT_LIST&contentSegment=&searchType=AdvancedSearchForm¤tPosition=4&contentSet=GALE|SC5101141289&&docId=GALE|SC5101141289&docType=GALE&viewtype=Manuscript

Records of the Department of State relating to Internal Affairs: Afghanistan, 1945-1949

• UK aid to Afghanistan FCO 37/2279. (n.d.). Retrieved April 20, 2019, from http://www.archivesdirect.amdigital.co.uk.proxy.lib.umich.edu/Documents/Images/FCO_37_2279/11

Records of the Foreign Office of the United Kingdom, 1980

• Preliminary report: A village-level health survey in Afghanistan. (n.d.). Retrieved April 20, 2019, from http://www.afghandata.org:8080/xmlui/handle/azu/4438
• Pinto, N. (n.d.). Working manual : Shewaki Health Centre / prepared by Necker Pinto. Retrieved April 20, 2019, from http://www.afghandata.org:8080/xmlui/handle/azu/4419
• Enright, M. (n.d.). Health planning in Afghanistan. Retrieved April 20, 2019, from http://www.afghandata.org:8080/xmlui/handle/azu/4533
• In search of fulfilment : Three years of achievements, 96, 97, 98 / by Afghan Health & Development Services (AHDS) ; art & design Waheedullah Waissi ; photography AHDS Archive. (n.d.). Retrieved April 20, 2019, from http://www.afghandata.org:8080/xmlui/handle/azu/13947
• Afghanistan. (2014). Retrieved April 04, 2019, from https://www.doctorswithoutborders.org/what-we-do/countries/afghanistan
• Afghanistan. (n.d.). Retrieved April 20, 2019, from https://www.msf.org/afghanistan

Images

• Stegeman, K. (n.d.). [Afghan Doctor With Baby]. Retrieved April 20, 2019, from https://www.msf.org/afghanistan
• Quayoumi, M. (2014, January 22). [Afghan Women Being Taught Biology]. Retrieved April 20, 2019, from https://www.dailymail.co.uk/news/article-2543902/Photos-just-free-women-Afghanistan-Taliban-rule.html
• Zheng, S. (2015, January 28). [Entrance to Kandahar Chinese Hospital]. Retrieved April 20, 2019, from https://www.icrc.org/en/document/afghanistan-chinese-hospital
• [FILE: A column of Soviet military vehicles crosses the border in Termez, Uzbekistan as they return from Afghanistan (February 1989).]. (2019, January 04). Retrieved April 20, 2019, from https://gandhara.rferl.org/a/right-to-be-there-afghan-officials-observers-dispute-trump-s-view-of-soviet-occupation/29690235.html
• Sobahni, O. (2014, July 04). [Policemen gather around a shopping mall after a Taliban attack in January 2010]. Retrieved April 20, 2019, from https://www.cfr.org/backgrounder/taliban-afghanistan
• Khan, S. (2016, September 08). [Members of the Taliban militia ride in vehicles during Afghanistan's annual Independence Day parade in Kabul on Aug. 19, 2001. Afghanistan was largely cut off from the world during the Taliban's rule from 1996 to 2001. That changed dramatically after the Sept. 11 attacks.]. Retrieved April 20, 2019, from https://www.ksmu.org/post/view-kabul-sept-11-2001#stream/0
• Huylebrook, J. (2019, February 01). [Zalmay Khalilzad, the special representative for Afghanistan reconciliation, has been negotiating with the Taliban to find a way out for U.S. troops. (JIM HUYLEBROEK / NYT)]. Retrieved April 20, 2019, from https://www.thestar.com/opinion/editorials/2019/02/01/afghan-peace-talks-fall-short.html