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This is a guest blog by Seiji Yamada, MD.
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. 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.[1]
The Ministry of Public Health defined a basic package of health services, including 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.[2]
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.[3] 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.”[4]
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.[5]
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.[6] 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.[7] 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.
In Iraq, McChrystal’s role was as commander of Joint Special Operations, ie.e, overseeing Delta Force and Navy SEALs in covert ops such as the killing the leader of al Qai’da in Iraq, al-Zarqawi, by bomb strike. In Afghanistan, however, 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 these counterinsurgency principles on display in the Frontline episode “Obama’s War”,[8] in which 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 though they may be, it is nevertheless painful to watch Marines try to be goodwill ambassadors. As noted by retired Marine John Bernard, who 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, Marines are not trained to be police officers and nation-builders, but rather to “kill people and break things.”[9] Indeed, a July 2006 survey, 3 years into the U.S. invasion of Iraq, estimated 655,000 Iraqi deaths as a consequence of war.[10] 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.[11] In conjunction 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,[12] Pakistani sources report that of 701 people killed in 60 attacks between January 2008 and April 2009, only 14 were suspected militants.[13] 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.[14]
Why are such air attacks on civilians not considered war crimes? Air attacks are not as accurate as they are portrayed on TV. They often kill non-combatants, including women and children. Homes and neighborhoods, shelter, water and sanitation, people’s sources of livelihood, are destroyed. In military parlance, this is called merely “collateral damage”, but it is the lives of people and the infrastructure of society. We should also recognize that this bombing from the air turns people against those that they (correctly) hold responsible – the US military.[15] In the wake of the drone attacks on the 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 India and 11% the Taliban.[16] The Pakistani newspaper Dawn reports that Peshawar residents hold the U.S. responsible for bombings that the Pakistani government attributes to the Taliban.[17]
Finally, because we still often resist realizing that we live in an empire, we miss the implications of that fact. I was taken by the title of Seth Jones’ book In the Graveyard of Empires.[18] Jones urges caution in Afghanistan, where attempts at conquest from Alexander the Great to the British and Soviet Empires met ignominious fates. But, a number of chapters into the book, I realized that Jones himself 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.
Is it incorrect, then, to consider the US an empire? 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."[19] . 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] Rubenstein LS, Newbrander W. Undermining Afghan health care. Washington Post, Nov 29, 2009. Accessed Dec. 12, 2009 http://www.washingtonpost.com/wp-dyn/content/article/2009/11/27/AR2009112702454_pf.html
[2] Loevinsohn B, Sayed GD. Lessons from the health sector in Afghanistan. JAMA 2008;300:724-726.
[3] Gates R, Clinton H. Interview. CNN, Oct 5, 2009. Accessed Dec 12, 2009 http://transcripts.cnn.com/TRANSCRIPTS/0910/06/ampr.01.html
[4] 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. Accessed Dec 12, 2009 http://www.usglc.org/USGLCdocs/Shah_Responses_to_Kerry_QFR.pdf
[5] Rubenstein & Newbrander.
[6] Bristol N. Military incursions into aid work anger humanitarian groups. Lancet 2006;367:384- 386.
[7] Filkins D. Stanley McChrystal’s Long War. New York Times Magazine, Oct 18, 2009.
[8] Gaviria M, Smith M. Obama’s War. Accessed Nov 2, 2009 http://www.pbs.org/wgbh/pages/frontline/obamaswar/
[9] Sharp D. Marine’s dad speaks out. Honolulu Advertiser, Oct 18, 2009.
[10] 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.
[11] Mayer J. The predator war. New Yorker, Oct 26, 2009. Accessed Nov 8, 2009 http://www.newyorker.com/reporting/2009/10/26/091026fa_fact_mayer
[12] Shane S. C.I.A. to expand use of drones in Pakistan. New York Times. Dec. 4, 2009. Accessed Dec 12, 2009 http://www.nytimes.com/2009/12/04/world/asia/04drones.html?hp
[13] Ahmad MI. Pakistan creates its own enemy. Le Monde Diplomatique. Nov 2009. Accessed Nov 5, 2009 http://mondediplo.com/2009/11/02pakistan
[14] Mayer J.
[15] Young M, Sprey P. (Interview). Bill Moyers Journal. Accessed Nov 2, 2009. http://www.pbs.org/moyers/journal/01302009/watch.html
[16] Ahmad MI.
[17] Bombings, drone attacks fuel anti-US sentiment in Pakistan. Dawn. Dec 7, 2009. Accessed Dec 12, 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
[18] Jones S. In the graveyard of empires. New York: W.W. Norton, 2009.
[19] Perry T. Afghan women lead protest against government corruption. LA Times. Dec 10, 2009. Accessed Dec 12, 2009
http://www.latimes.com/news/nation-and-world/la-fg-afghanistan-protest11-2009dec11,0,320839.story
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Showing posts with label Afghanistan. Show all posts
Showing posts with label Afghanistan. Show all posts
Monday, January 11, 2010
Sunday, November 22, 2009
Health Workers and Our Wars
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This guest column is by Seiji Yamada, MD, a family physician, Associate Professor of Complementary and Alternative Medicine at the University of Hawai’i John A. Burns School of Medicine, and one of my mentors. This essay is an expansion of the one that was published in the AAMC journal Academic Medicine, chosen as one of the five best responses to the question put forth by editor Steven Kanter “How can academic medicine respond to peace-building efforts worldwide?”. Dr. Yamada’s original essay, “Academic medicine should start at home”, is at http://journals.lww.com/academicmedicine/Fulltext/2009/11000/Academic_Medicine_Should_Start_at_Home.18.aspx
Health Workers and Our Wars
What is the responsibility of American health workers with regard to our nation’s wars in Iraq, Afghanistan, and Pakistan? As Americans, our primary responsibility should be to influence the actions of our own government. As health workers, our expertise is in the realm of morbidity and mortality, encompassing the direct effects of violence as well as the indirect effects arising from the collapse of health services, poor access to water and food, and damage to infrastructure, economies, and societies. Thus, we should monitor our government’s actions, apply the scientific methods at our disposal, apply the moral and ethical principles to which we subscribe, formulate and recommend policy, and disseminate our findings to the people. In a democracy, the citizenry would then determine the course of action.
During this decade, our nation has been responsible for invading and occupying two countries halfway around the globe—Afghanistan since 2001 and Iraq since 2003. In the case of Iraq, the invasion of 2003 was preceded by comprehensive economic sanctions, which hampered the rebuilding of its infrastructure after the Gulf War of 1991. The consequences included childhood deaths, mental illness, juvenile delinquency, begging and prostitution, as well as cultural and scientific impoverishment.[1]
In 2002-03, the American people were not convinced by the Bush administration that war on Iraq was justified. However, despite massive demonstrations against the war prior to its launch, the intellectual classes, the corporate media, and our elected representatives went along with the administration. Democracy failed us in this respect. Prior to the war, we health workers should have been recounting the health toll of the First Gulf War and the sanctions regime. With its onset, we should have been disseminating the images and recounting the narratives of casualties of the war.[2] As it progressed, we should have been acutely interested in the number of casualties caused by the war. The best estimates for deaths among Iraqis are those of the July 2006 epidemiological survey that reported 655,000 deaths as a consequence of war.[3] This study did not distinguish among civilians, military, and irregular combatants. While its authors have been criticized for breaches in the non-identification of participants, the study is nevertheless considered the most accurate estimate.[4]
Insofar as we have failed to pay attention to such findings, American health workers have failed its constituents.
At the mention of history or political economy, many health workers groan. We are not interested in politics, they say. But unreflective citizens repeat the blather that they are fed by the corporate media. We need advocate for the cause of health—in particular for the health of those whose voices are otherwise unheard, whose deaths are otherwise uncounted, unmourned, unopposed, and unorganized against. In order to do so, our analysis must be geographically broad and historically deep, as Paul Farmer urges us.
As the United States pulls its troops out of Iraq and sends them to Afghanistan, as our military wields drones called Predator and Reaper in Pakistan, we should concern ourselves with whether the cause of peace is thereby served by such acts. Our commander-in-chief is apparently now reflecting upon whether to double down (again) in Afghanistan and pursue counterinsurgency, as urged upon him by his general in the theater.[5]
Apparently, “counterinsurgency” no longer connotes Vietnam or Central America.[6] But the “clear and hold” strategy utilized late in the Vietnam War was characterized by indiscriminate shelling and bombing of villages[7] and ran concurrently with the Phoenix program of torture and assassination.[8] Extrajudicial killings in the Federally Administered Tribal Areas of Pakistan are now being carried out by the CIA by missile attacks by drones, with the deaths of many innocents.[9] Of 701 people killed in 60 attacks in FATA between January 2008 and April 2009, fourteen were suspected militants.[10]
The British and the Soviets failed in their attempts to militarily control Afghanistan, while inflicting untold casualties on the populace. The Soviet Union’s invasion of Afghanistan proved to be its Vietnam. One would think that our own country would not repeat its mistakes in Vietnam, but our wars in Iraq and Afghanistan’s go on. As American health workers, we must concern ourselves with the morbidity and mortality caused by our own government’s actions. Let us get to work.
References
[1] Save the Children UK. Iraq sanctions: humanitarian implications and options for the future. Available at: (http://www.globalpolicy.org/component/content/article/170/41947.html). Accessed July 21, 2009
[2] Yamada S, Fawzi MC, Maskarinec GG, Farmer PE. Casualties: narrative and images of the war on Iraq. Int J Health Serv. 2006; 36(2):401-15
[3] Burnham G, Lafta R, Doocey S, Roberts L. Mortality after the 2003 invasion of Iraq: a cross-sectional cluster sample survey. Lancet 2006; 368: 1421–28.
[4] Tapp C, Burkle FM, Wilson K, et al. Iraq War mortality estimates. Conflict & Health 2008;2:1-13.
[5] Filkins D. Stanley McChrystal’s long war. New York Times Magazine, Oct 18, 2009.
[6] Parry R. Bush’s death squads. In These Times, Jan 17, 2005. Available at (http://www.inthesetimes.com/site/main/article/1872/). Accessed Jan 23, 2005.
[7] Steinglass M. Vietnam and victory. Boston Globe, Dec 18, 2005. Available at (http://www.boston.com/news/globe/ideas/articles/2005/12/18/vietnam_and_victory/). Accessed Sep 27, 2009.
[8] Chomsky N, Herman ES. The Washington connection and third world fascism. Boston, MA: South End Press, 1979.
[9] Mayer J. The predator war. New Yorker, Oct 26, 2009. Available at (http://www.newyorker.com/reporting/2009/10/26/091026fa_fact_mayer). Accessed Nov 15, 2009.
[10] Ahmad MI. Pakistan creates its own enemy. Le Monde Diplomatique. Nov 2009. Available at (http://mondediplo.com/2009/11/02pakistan). Accessed Nov 5, 2009.
This guest column is by Seiji Yamada, MD, a family physician, Associate Professor of Complementary and Alternative Medicine at the University of Hawai’i John A. Burns School of Medicine, and one of my mentors. This essay is an expansion of the one that was published in the AAMC journal Academic Medicine, chosen as one of the five best responses to the question put forth by editor Steven Kanter “How can academic medicine respond to peace-building efforts worldwide?”. Dr. Yamada’s original essay, “Academic medicine should start at home”, is at http://journals.lww.com/academicmedicine/Fulltext/2009/11000/Academic_Medicine_Should_Start_at_Home.18.aspx
Health Workers and Our Wars
What is the responsibility of American health workers with regard to our nation’s wars in Iraq, Afghanistan, and Pakistan? As Americans, our primary responsibility should be to influence the actions of our own government. As health workers, our expertise is in the realm of morbidity and mortality, encompassing the direct effects of violence as well as the indirect effects arising from the collapse of health services, poor access to water and food, and damage to infrastructure, economies, and societies. Thus, we should monitor our government’s actions, apply the scientific methods at our disposal, apply the moral and ethical principles to which we subscribe, formulate and recommend policy, and disseminate our findings to the people. In a democracy, the citizenry would then determine the course of action.
During this decade, our nation has been responsible for invading and occupying two countries halfway around the globe—Afghanistan since 2001 and Iraq since 2003. In the case of Iraq, the invasion of 2003 was preceded by comprehensive economic sanctions, which hampered the rebuilding of its infrastructure after the Gulf War of 1991. The consequences included childhood deaths, mental illness, juvenile delinquency, begging and prostitution, as well as cultural and scientific impoverishment.[1]
In 2002-03, the American people were not convinced by the Bush administration that war on Iraq was justified. However, despite massive demonstrations against the war prior to its launch, the intellectual classes, the corporate media, and our elected representatives went along with the administration. Democracy failed us in this respect. Prior to the war, we health workers should have been recounting the health toll of the First Gulf War and the sanctions regime. With its onset, we should have been disseminating the images and recounting the narratives of casualties of the war.[2] As it progressed, we should have been acutely interested in the number of casualties caused by the war. The best estimates for deaths among Iraqis are those of the July 2006 epidemiological survey that reported 655,000 deaths as a consequence of war.[3] This study did not distinguish among civilians, military, and irregular combatants. While its authors have been criticized for breaches in the non-identification of participants, the study is nevertheless considered the most accurate estimate.[4]
Insofar as we have failed to pay attention to such findings, American health workers have failed its constituents.
At the mention of history or political economy, many health workers groan. We are not interested in politics, they say. But unreflective citizens repeat the blather that they are fed by the corporate media. We need advocate for the cause of health—in particular for the health of those whose voices are otherwise unheard, whose deaths are otherwise uncounted, unmourned, unopposed, and unorganized against. In order to do so, our analysis must be geographically broad and historically deep, as Paul Farmer urges us.
As the United States pulls its troops out of Iraq and sends them to Afghanistan, as our military wields drones called Predator and Reaper in Pakistan, we should concern ourselves with whether the cause of peace is thereby served by such acts. Our commander-in-chief is apparently now reflecting upon whether to double down (again) in Afghanistan and pursue counterinsurgency, as urged upon him by his general in the theater.[5]
Apparently, “counterinsurgency” no longer connotes Vietnam or Central America.[6] But the “clear and hold” strategy utilized late in the Vietnam War was characterized by indiscriminate shelling and bombing of villages[7] and ran concurrently with the Phoenix program of torture and assassination.[8] Extrajudicial killings in the Federally Administered Tribal Areas of Pakistan are now being carried out by the CIA by missile attacks by drones, with the deaths of many innocents.[9] Of 701 people killed in 60 attacks in FATA between January 2008 and April 2009, fourteen were suspected militants.[10]
The British and the Soviets failed in their attempts to militarily control Afghanistan, while inflicting untold casualties on the populace. The Soviet Union’s invasion of Afghanistan proved to be its Vietnam. One would think that our own country would not repeat its mistakes in Vietnam, but our wars in Iraq and Afghanistan’s go on. As American health workers, we must concern ourselves with the morbidity and mortality caused by our own government’s actions. Let us get to work.
References
[1] Save the Children UK. Iraq sanctions: humanitarian implications and options for the future. Available at: (http://www.globalpolicy.org/component/content/article/170/41947.html). Accessed July 21, 2009
[2] Yamada S, Fawzi MC, Maskarinec GG, Farmer PE. Casualties: narrative and images of the war on Iraq. Int J Health Serv. 2006; 36(2):401-15
[3] Burnham G, Lafta R, Doocey S, Roberts L. Mortality after the 2003 invasion of Iraq: a cross-sectional cluster sample survey. Lancet 2006; 368: 1421–28.
[4] Tapp C, Burkle FM, Wilson K, et al. Iraq War mortality estimates. Conflict & Health 2008;2:1-13.
[5] Filkins D. Stanley McChrystal’s long war. New York Times Magazine, Oct 18, 2009.
[6] Parry R. Bush’s death squads. In These Times, Jan 17, 2005. Available at (http://www.inthesetimes.com/site/main/article/1872/). Accessed Jan 23, 2005.
[7] Steinglass M. Vietnam and victory. Boston Globe, Dec 18, 2005. Available at (http://www.boston.com/news/globe/ideas/articles/2005/12/18/vietnam_and_victory/). Accessed Sep 27, 2009.
[8] Chomsky N, Herman ES. The Washington connection and third world fascism. Boston, MA: South End Press, 1979.
[9] Mayer J. The predator war. New Yorker, Oct 26, 2009. Available at (http://www.newyorker.com/reporting/2009/10/26/091026fa_fact_mayer). Accessed Nov 15, 2009.
[10] Ahmad MI. Pakistan creates its own enemy. Le Monde Diplomatique. Nov 2009. Available at (http://mondediplo.com/2009/11/02pakistan). Accessed Nov 5, 2009.
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