Afghanistan versus Western Perspective?

I haven't blogged in a while. My analysis is that the lack of blogging is the simple result of multiple causes: partly because I've caught a mid-winter cold, partly because I've been working to ready myself for an upcoming study on Afghanistan, and partly because I'm in an Army school on the weekends. Today, however, I am going to write down my thoughts about:

Afghanistan.

In spite of the unfortunate confluence of events and the resulting lack of blogging, I have been thinking about the intersection between health, politics and society in Afghanistan, in particular. I will be working on a 90-day USAID sponsored assessment of the US Government's health reconstruction efforts in Afghanistan. This work promises to be informative on a number of levels. I will try to blog about it as appropriate, without giving away the results and getting myself into trouble.

But first, by way of context, it strikes me that there are several fundamental ideas that should be considered in any assessment and framework for the way ahead. Here are some of my initial thoughts, culled from reading and talking with colleagues:

1. Top-down, bottom-up is the best strategy for the way ahead (I stole this from a USIP report on Afghanistan published by Seth Jones and Chris Fair who are both at RAND). Afghanistan has never had a strong central government, and from my reading, the Karzai government's efforts (as would any central government's efforts) are often viewed suspiciously. Therefore, the goal of any health reconstruction efforts must be to promote local and regional ties to the central government and demote the advancement of regional rulers who have further regionalism on their agenda. Not an easy undertaking, but one that apparently USAID and the Special Forces are using now at the provincial level. (For some good reading on this, see Sloan Mann's article on the small wars journal: http://smallwarsjournal.com/documents/79-mann.pdf. Perhaps this approach can be rolled in to a regional strategy.

2. Health care and health attitudes are somewhere pre-civil war US, I'm guessing...tho I'm not a medical historian. Basically, there is no health care system. So, a whole system has to be built. Without a strong central government. This makes me wonder about the viability of the central government's Basic Package of Health Services. The problem here is that the US Government likes to legitimize the central state, because we view the world (and desperately want the world to be) a state-based system. So, we ask the central government what needs to be done. Then we roll up our sleeves and help deliver. Unfortunately, the central government has little control outside Kabul, so this approach is problematic.

3. NGOs provide and have provided most of the care. Therefore, the public probably does not view health care as a legitimate governmental responsibility. It's something that outsiders provide.

4. The Afghan public was recently reported by an ABC poll to have turned away from a positive view of the U.S. Frankly, I'm a bit suspicious about the utility of these polls, but taking the findings in gross, it may be that the US has allied itself too strongly with the Karzai government in the public sentiment. Not sure.

Health people like to think that providing health care makes the US look good in the eyes of the populace. This is a bit naive, I'm afraid. People's sentiments are changeable, though the more stable views are pretty much driven by cultural norms. Hence application of health activities to improve public perception would necessarily have to play along cultural norms. Very tricky. But this supports the argument for bottom-up approaches. If the goal is to be well thought of in order to win the insurgency war, then we need to use current cultural norms (clientelistic, "corrupt" --in our eyes-- patrimonial systems). That implies, by logical extension, that we use health care development in these give-and-take situations to develop some amount of loyalty among the tribal divisions.

5. Everybody is in Afghanistan. (All kinds of nations, that is). Makes things complicated. Afghanistan is not divided up by ethnicity. It's divided by geography, apparently. Local power-leaders rule in geographical areas (valleys). That makes things complex, too.

6. The world economy just tanked, hence the lack of donor contributions should get worse. That means fewer resources. But this is OK, in my mind, since there is no health system, basically. Rather than focusing on hospitals and clinics, perhaps the whole of government effort could be more cheaply focused on hand washing, nutrition and basic sanitation practices. Sometimes fewer resources means more efficient expenditure.

With these points in mind, assessing the construction activities and creating a framework for the way ahead in Afghanistan should be a snap.

Law, Culture and Health

One of my newest and therefore most cherished hypotheses is that different cultures view governance differently than we do, and cultures also view health services provision differently. The idea that everyone all around the world expects (or SHOULD expect) their government to provide health care is bizarre. One of my subset favorite ideas du jour is that in countries like Afghanistan, where NGOs have been providing health care forever, and where there has never been a strong central government, it doesn't make sense to try to "legitimize" the central government by assisting it with providing health services. However, I'm just formulating this theory, you heard it here first, and I'm sure I'll be back to mull this over quite a bit in the future.

Anyhow, while I was poking around on the web, I came across Georgetown Law's Oneil Institute that has a global public health and law center. Here's the URL: http://www.law.georgetown.edu/oneillinstitute/index.html.

I was thinking about human rights law this weekend (doesn't everyone?), and about war. I have recently read an interesting piece by an Air Force Colonel that described the liberalization of International Law and how that affected war. So, I was thinking about how "the West" also considers war, pondering the idea that cultures also don't think of war the same way we do. It's probably not always an extension of policy by other means, to misquote Clauswitz, in everyone else's mind.

So, where am I going with all this? Well, it seems to me that the Global War on Terror, which is apparently now over somehow...according to the Obama administration...., is being articulated as a war against those who fight against the State-ordered international system. That's kind of a no-brainer, and if you step back, it's a bit startling too. But to move on, it seems to me that rushing hither and thither about the globe helping people develop their own health systems or handing out aspirins in the hope of creating healthy and stable communities might be a bit premature without a better understanding of what THEY think of health, their government and so forth.

I'm speculating, here, really. But it's as fair to speculate in this way as it is to speculate in terms of the benefits of 'health diplomacy' if one were only to focus on benefit to the other guy. Don't forget that there is a lot of gratification in doing good deeds all about.

I have strayed away from my thoughts about law, but they follow along this same vein. Law is the venue by which cultural imperatives express themselves. It would be interesting to study the changes in international health law to better understand international priorities...or at least priorities of the dominant actors in the international arena. Ah ha. Another possibility for a dissertation.

Afghanistan

Soon I'll be off to Afghanistan to work on a USAID-sponsored assessment of the USG health-sector reconstruction activities. As part of this assessment, my office is also sponsoring a conference on the way ahead in health sector development. I have been coordinating this conference and will post the web announcement and registration page.

Meanwhile, I'm reading up on Afghanistan. Dave Kilkullen recently testified before Congress on "AFPAK" and a shortened version of his testimony can be found on the Small Wars Journal webiste here: http://smallwarsjournal.com/mag/docs-temp/177-kilcullen.pdf.

The interesting thing about all this is the growing (thankfully) recognition that there are geopolitical influences on health. Afghanistan cannot be treated as an entity in and of itself. USAID, apparently, has just sent out an assessment team to understand what can be done in the FATA region. It strikes me that repairing a hospital or training doctors is worthwhile, but probably not really the answer. It seems to me that there has to be structural change to the societies we are working in. And the way to understand this is to ascertain what their expectations and beliefs are. Normally, we do this through the Minister of Health in order to legitimize our actions. The problem with this is that while we gain approval and legitimacy for our actions, we don't understand whether our activities will actually prove viable or not. The normal answer for this problem is to hire NGOs. While NGOs provide part of the answer, I assume, they must be met with healthy skepticism as well since some NGOs are religiously-motivated, for example.

The effort in Afghanistan will continue to take time and patience. The American people will have to be reminded of 9/11 many times in the near future, I suspect. But as Kilkullen points out, there is no way to take short cuts here. Let's hope Charlie Wilson's War made its point.

Trying to find an interagency solution

In the newly released Quadrennial Roles and Responsibilities document, Walter Pincus from the Washington Post reports that DoD wants various USG agencies to share goals, budgets and understandings of the end state. Imagine that. Coming from DoD.

Here's the Pincus rundown: http://www.washingtonpost.com/wp-dyn/content/article/2009/02/01/AR2009020101964.html.

There are sooo many opportunities to leverage existing operations for institutionalizing practices. It nearly makes me want to cry.

"Health Diplomacy"--What is it? The NIC report "Strategic Implications of Global Health"

I went to an interesting round table last week and listened to a brief discussion about "health diplomacy" among other things. Most of the other people at the table were from DoD, State,NGOs and various academic-types. It was proposed that we take up the theme of "health diplomacy" at the next round table. Almost somehow in concert with this proposal, I see that the Chinese have revved up their hospital ship and are making some news. In fact, they even receive an honorable mention in the National Intelligence Council's assessment "Strategic Implications of Global Health" found here: http://www.dni.gov/nic/PDF_GIF_otherprod/ICA_Global_Health_2008.pdf.

Like most scary phrases, "health diplomacy" probably means something completely different to a DoD-person as compared to a USAID person, for example. And I wonder what an NGO person would think? The U.S. military's Mercy and Comfort ships are usually cited as "health diplomacy", whereas efforts in Iraq and Afghanistan and the Horn of Africa or even the Ukraine are not mentioned. While I'm not quibbling with the use of examples, I'm not comfortable letting it rest at merely the Mercy and the Comfort.

Although while "health diplomacy" is not defined in the NIC report, it is interesting to note that on page 7 of the report, the NIC assessment suggests that "More and better-publicized developed world medical diplomacy efforts -- for example, the U.S. Naval Ship Comfort's humanitarian tour of 12 Latin American countries in 2007 could mitigate such influence [of Cuba and Venezuela] while improving the health of citizens of poor countries. "

Using health as a commodity with which the U.S. (or other nations like Cuba, or even organizations with agendas like NGOs) can influence the world is not new. Much like Russia uses oil and the pipeline through the Caucasus as a commodity for manipulating the international order, the West is using health. I'm not sure that I have heard this discussed, since most of the people talking about the diplomacy-development and defense "health" triad are health people who really only want to make others happy and healthy members of the world. However there are some ethical implications, clearly, as well as "execution" and outcome implications. If the Mercy and the Comfort are merely symbols of the US' goodwill, for example, then I wonder if it would be better just to sail around with a bunch of pop stars--Britanny Spears and Bono maybe--making port calls giving free concers. Might be cheaper, and a better use of talent. Probably less ethically challenging anyhow.

In any case, "health diplomacy" is a topic of discussion in the NIC report, in spite of the lack of definition, or any evidence that using health as a diplomatic instrument is useful. But that's OK, it starts us all talking.