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In an ongoing effort to work in a united fashion with other government agencies and international organizations to improve the health care sector of Afghanistan, the MHS convened an important conference in mid-May called, "Building Health Security in Contemporary Afghanistan." Co-hosted by the National Defense University's Near East South Asia Center for Strategic Studies, the conference brought together leaders from Afghanistan, DoD, the U.S. Agency for International Development (USAID), Department of Health and Human Services (HHS), Department of State (DoS), international and academic organizations, and such coalition partners as the United Kingdom and Spain to discuss the important role health plays in establishing and sustaining security, and the U.S. military''s developing function in support of the overall U.S. government effort to help build health systems of conflict-stressed areas like Afghanistan.

"Improving health and health care independence in other nations is just as critical to enhancing stability and preventing conflict as our other missions around the globe," said Ellen Embrey, Performing the Duties of Assistant Secretary of Defense for Health Affairs. Since the U.S. became involved in health development work in Afghanistan there have been dramatic improvements. In 2002, after the collapse of the Taliban regime, only 9 percent of Afghans had access to basic health services; 25 percent of children died before age five; 42 percent of child deaths were due to preventable causes; and the country had only 460 low-functioning health facilities. Today, about 67 percent of Afghans have access within two hours walking distance to primary health care services; child mortality has been reduced by a quarter; there are 1,710 quality health care facilities; more than 90 percent of Afghan children have been immunized against polio; TB cases are down 60 percent; and Afghanistan has more attendants for birthing mothers. Gloria Steele, USAID's Acting Administrator for Global Health, called these improvements "tremendous." "More than three decades of war has put Afghanistan near the bottom of development indicators," Steele said. "Much needs to be done. Afghanistan still has the highest fertility and infant and under five mortality in Asia. Maternal mortality in Afghanistan is the second highest in the world, and it remains one of only four polio endemic countries and one of 22 TB high burden countries." Dr. S. M. Amin Fatimie, Afghanistan''s Minister of Public Health, expressed much gratitude to the U.S. government, as well as the World Bank and the European Commission for supporting Afghanistan's health and nutrition sector. "I strongly believe that development and security are two sides of the same kind," he said. "I believe that we have to work on even greater engagement with each other in order to have many more achievements. The time has come to combine compassion with efficiency for the health and dignity of all Afghans. When people know that their clinic has not run out of medicine and they have care, they are more likely to resist the Taliban. Our dream is to provide more support for the people of Afghanistan, health care for all. A peaceful, stable Afghanistan will make a peaceful, stable world."

DoD's role in health capacity building in Afghanistan through U.S. Central Command has been principally to develop the health care systems of the Afghan National Army and Police. The U.S. military has embedded medical professionals that mentor Afghan military teams, and also has medical personnel on civil-military Provincial Reconstruction Teams that build sustainable capacity at the community level. DoD has further helped develop a standardized, competitive program in the Afghan Military Medical School. There have also been efforts over the last several years to develop centralized logistics techniques and abilities, and to develop infrastructure, clinics and hospitals. Central Command Surgeon Brig. Gen. W. Bryan Gamble said the training and mentoring of the Afghan army and police has gone very well. "There is still a long way to go, but I think it's started to progress to where they're training individuals in such techniques as combat lifesaving, sanitation, helping to start early in intensive care units," he said. "That's still a great leap forward for them and gives us a foundation on which to grow." With the average lifespan in the early 40s, infectious disease is an issue. "Trying to address the basics of health care and address basic needs I think will go a long way to significantly helping advance their medical system," said Brig. Gen. Gamble. "I think it's really progressed significantly because now we have examples of where they're able to take care of their own individuals in a field of battle, to take care of some fairly significantly complicated cases in their hospitals by themselves." Although USAID has the lead for developing the health care infrastructure in the civilian sector, Brig. Gen. Gamble said he wants to ensure both the military and civilian health care systems are raised at relatively the same level at the same time. "That way you don't have big discrepancies in standards of care, quality of care, or have and have-nots, so I think that it's really worked well," he said.

Randolph Augustin, the health officer overseeing USAID's Afghanistan health program based in Kabul, said USAID is assessing potential steps to improve coordination and synchronization of the different U.S. government interventions. He said it is important to try to take a step further to begin joint planning and to operationalize the whole of government approach in Afghanistan. "The challenges are that the different agencies are not structured to work in a coordinated fashion. Each agency has its own set of objectives and priorities, and ways of doing business," he advised. ¿Other challenges being staffing; it requires time to coordinate. It''s been very personality-dependent and driven. We've contracted a group of consultants to help us look at how do we create mechanisms to streamline these processes so that we are able to coordinate without overburdening our different agencies." In addition to this USAID-led 90-day assessment by independent consultants with experience in different U.S. government agencies that will result in recommendations for a way forward, an interagency steering committee has been established. Anne Cummings, Asia Pacific regional director in the HHS Office of Global Health Affairs, said HHS also chairs an interagency group that brings together USAID, DoD, DoS and other stakeholders and further sits on an Afghanistan/Pakistan task force chaired by USAID that examines ways to collaborate along the border. "When you look at the health sector and the investments the U.S. government has made in the health sector, it proves to the Afghan people the U.S. government''s interests goes beyond the sort of immediate war or counter-insurgency," said Augustin. "It really extends to the well-being of the Afghan population, which is why it is important for the U.S. government to continue to support the health sector."

The security situation in Afghanistan has impacted efforts, however. "It's definitely been a barrier to services," Augustin advised. "USAID supports service delivery in 13 of the 34 provinces. Out of those 13, seven are highly insecure provinces. What we've seen is while our contracts with NGOs have them running a certain number of clinics, because of insecurity we've had certain districts where clinics are not able to operate at all." While clinics have been forced to shut down after particular incidents in some districts, other clinics are unable to be staffed because Afghans do not want to work in insecure areas. Pharmaceutical supplies have also been taken by insurgents in some instances. "There is definitely a real challenge in these insecure areas. But we've also seen where, working through community members, we are able to overcome a lot of these challenges," Augustin added. Augustin said there have been cases where kidnapped health care workers or hijacked vehicles transporting pharmaceuticals were returned after community leaders negotiated with insurgents. Augustin said USAID is exploring ways with DoD and the other stakeholders about how they can work differently in the insecure areas. "Those are discussions we are encouraging to happen at the provincial community level to identify what localized solutions will work," he said. "Ideally, if DoD or others and hopefully the Afghan police and Afghan army are able to secure these provinces, then we would have the space to operate freely to deliver the services we intend to."

Cummings said HHS operates a program focused on the Rabia Balkhi Maternity Hospital in Kabul as a model and teaching tool for improving emergency cesarean sections, post-partum care, and services to women, children, and expectant mothers. "We''re very pleased with how that has gone," she advised. HHS also collaborates with WHO on polio eradication efforts and vaccinations, sending teams to Afghanistan to work on field epidemiology training to help Afghans build their capacity to monitor overall disease burden. Cummings called health sector development work in Afghanistan and Dr. Fatimie¿s leadership a ''bright spot''. "The across the board ability of women and children to go to a clinic near them within four hours walk (which is available to about 85 percent of the population) and be seen by a qualified medical professional has been night and day over the past six years. It''s been a real success story and is something that has made a huge difference. (But) there are still challenges about improving access to care," she advised.

"Afghanistan is a landlocked country," said Dr. Fatimie. "We are really dependent on our neighbors to have access to the international market. I hope that problems we have with our neighbors in our region will not create problems for the socioeconomic development of Afghanistan, particularly for health development in my country. However, I cannot ignore the fact that stability in Afghanistan really also is related to stability in Pakistan, so if activities of insurgents in Pakistan are going to be controlled, if our other neighbors also cooperate, then without doubt socioeconomic development in Afghanistan will be accelerated."

DoD health stability operations to develop indigenous medical capacity were given the same priority as combat operations, per a Nov. 28, 2005 directive that also requires the department to work closely with other U.S. government agencies, foreign governments and NGOs in an integrated way in order to carry out such operations successfully. DoD's International Health Division, which organized the conference and is tasked with developing this policy, has convened several forums over the past year that have focused on health stability collaborative efforts in various regions, including Iraq and Africa. "It's a whole of government approach that's going to make a difference in Afghanistan, and not just a whole of U.S. government, but a global approach," said Dr. Warner Anderson, Director of the International Health Division.