Global Mental Health

The history and future of mental health around the world.

NATO’s Double Standard on Treating and Protecting Stabilization Forces in Afghanistan

US should change its medical policy towards allied Afghan casualties

The charred remains of cars and motorcycles, from a recent suicide bomb, litters the parking lot adjacent to the heavily fortified Canadian military base in Kandehar—a graphic warning that the Taliban are at the Coalition’s gates.  A wave of recent attacks and assassinations targeting NATO allies has presented a serious challenge to the ongoing operations in Kandahar and to the consolidation of gains in neighboring Helmand province, even as Afghanistan’s President, Hamid Karzai, sets milestones for Afghan security during this week’s international conference in Kabul.  While media pundits and policymakers in Washington are focused on the military dimensions of this conflict, a far less dramatic battle is being fought daily by an army of civilian relief workers and development specialists struggling to win hearts and minds of a skeptical Pashtun population.  In the words of one development officer and former U.S. Army infantryman: “We are the frontline warriors in an asymmetrical war.”

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In contrast to the recent offensive in Marja, which has had lackluster results in dampening the Taliban insurgency, the battle for Kandahar has been relatively light on firepower.  It has instead focused on garnering goodwill among Kandahar’s population by supporting improved governance, infrastructure development, economic growth and employment.  As a result, the much vaunted thrust of the campaign has been principally a civilian effort, led by the United States Agency for International Development (USAID) and its partners.  The use of development-focused “soft-power” elements to enhance security is not new to U.S. Central Command strategists.  It has been a core component of General David Peterus’ successful counterinsurgency doctrine in Iraq and there can be no doubt that the Taliban are aware of the blurred line between civilian stabilization efforts and military engagements.  For this reason, the past several months have seen a surge in insurgent attacks against USAID-contracted partners who work on implementing development projects throughout southern Afghanistan.  The most dramatic of these attacks occurred in April in Kandahar city, when explosions devastated compounds used by employees of several USAID funded non-governmental organizations (NGOs), causing over a dozen casualties, a number likely to increase with time as the psychological impact of the blasts takes it toll on the survivors.  Throughout the development community in Kandahar fear of explosive devices has been coupled with stories of Afghan staff resignations due to a campaign of intimidation by the Taliban.  One Afghan NGO employee reported that he had received a call telling him to “stop working with the Americans” or his family will be killed. Another Afghan talked of a coworker being gunned down by men on motorcycles, a preferred means of transport by Taliban assassins.  Not surprisingly, the rising trend of targeted violence has led to an exodus of NGOs and compelled a number of nonaligned humanitarian and international organizations, including the United Nations, to leave Kandahar altogether.  In addition, numerous thwarted attacks and near misses have had a devastating effect on the moral of civilians engaged in stabilization projects in this part of Afghanistan. 

Although the situation appears bleak, the ongoing military and political strategy of stabilizing Afghanistan’s Pashtun belt can still be successful, provided the Coalition takes concrete steps to bolster the position of its non governmental partners.  To begin with, ISAF forces and the private security firms protecting NGOs in southern Afghanistan need to have a formal and more integrated operational relationship to enhance the current level of security for development contractors until a more effective Afghan National Police force is established to ensure their security.  While formalizing the contractor-ISAF security liaison might not immediately diminish the rates and severity of attacks, it will enhance the general sense of safety amongst NGOs working in a volatile environment and extend their range of activities to more distant and less secure districts that might otherwise be avoided by private security contractors.

On the medical front, steps should be taken to ensure that civilian contractors, both Afghan and international, obtain the same treatment, in terms of quality and length of care, that is offered to ISAF troops and USAID employees.  While USAID and ISAF might loath to be in the business of providing health care to their NGO partners, the current system of emergency medical stabilization in military clinics and discharge to civilian care is unacceptable.  Treatment of “stabilized” casualties in local hospitals often lead to disastrous outcomes in a country that faces a dearth of specialized medical manpower and lacks a formal medical licensure system.  Even if the patient is lucky enough to survive an invasive procedure, he/she will have to grapple with lethal nosocomial infections that abound Afghan hospitals.  This was demonstrated in the case of a young and dynamic Afghan woman who was shot during a recent Taliban attack on an NGO compound where she worked.  What should have been a routine surgical procedure in a civilian hospital turned into an unnecessary exploratory surgery that can best be described as an abdominal safari expedition..  As if that was not enough, she developed a severe infection which would have taken her life had it not been for the foresight of her employers who arranged for her rapid transfer to a European hospital that managed to save her life after a long period of convalescence.  It is absurd for Brussels and Foggy Bottom to ignore the medical welfare of NGO contractors injured in the line of duty while at the same time acknowledge their vital role in the ongoing military effort.  Reassuring development specialists that they will be fully cared for will improve moral and slow the hemorrhage of qualified individuals, especially Afghans, by showing them that they will not be abandoned in the face of injury caused by an enemy who sees them as being equal targets to the men and women in uniform.  These steps would strengthen the work of USAID partnered NGOs and allow them to be more effective agents of stabilization, without which any victory in southern Afghanistan will be short-lived, an outcome which the United States and its international partners cannot afford.

 

Amir A. Afkhami, M.D., Ph.D., is an Assistant Professor of Psychiatry and Behavioral Sciences and of Global Health at the George Washington University.

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