Martin misleading on Afghan healthcare and the Canadian mission

I read an op-ed by Member of Parliament Dr. Keith Martin yesterday, and shook my head. He seems to have a basic grip on his facts, but no context for them whatsoever:

If you wanted to win the hearts and minds of a people, what would you do? Clearly, enabling them to access health care when they are sick and at their most vulnerable must rank near the top. Therefore it makes it utterly mystifying why Canada, with our hundreds of millions of dollars of aid money pouring into Afghanistan, have neglected this most obvious initiative. Nowhere is this need more acute than in Kandahar's Mirwais Hospital, a modern hell on Earth.

Look, I have no desire to be treated at Mir Weis, and I have no doubt that it is as scary a medical destination as Dr. Martin asserts. But to extrapolate from that one hospital's condition that Canada is "neglecting" health care is unfair in at least two different ways: it ignores significant progress made, and it ignores the fact that Canada is working within an alliance of nations all contributing to the rebuilding of Afghanistan in various ways.

Dr. Martin should concede that Mir Weis itself is improving. I'm not in a position to know if it's "enough" or not, since I don't know how fast a pace of improvement the Afghans can handle, but work is being done by Canadians or with Canadian funds at that hospital (from an e-mail with a DND source):

Canada is a strong supporter of the International Committee of the Red Cross, which is playing a lead role in improving public health care delivery at Mirwais Hospital. Canada's most recent contribution to the International Committee of the Red Cross totalled $3 million. With Canadian assistance, UNICEF is also helping establish a Maternal Waiting Home at the hospital; once it is once fully operational, it is estimated that the facility will benefit more than 1000 female patients each year.

Furthermore, while healthcare in Afghanistan is nowhere near Western standards, it's miles ahead of where it was under Taliban rule in late 2001. Some stats:

• 4,000 new medical facilities opened


• 83% of Afghans now have access to basic healthcare (as of early 2007), compared to 8% in 2001


• 7.2 million children vaccinated against polio


• 4.3 million children vaccinated against other childhood diseases


• 4 million women vaccinated against Tetanus


• 3.4 million people provided with hygiene education


• Village Medical Outreach (VMO) missions had provided basic medical care to more than 2000 Afghans in the remotest areas of Kandahar when I wrote this post in November of last year

And that's not counting any of the more low-key donations various CF bodies have put into Afghan hands - like wheelchairs, like stuffed animals, like medicine, like diagnostic kits for nurses, like baby formula and bottles, like a solid waste disposal truck for the infamous Mir Weis. It also doesn't include indirect measures taken by Canadians to improve the health of Afghans, like digging wells to provide clean water, or building roads that allow them to seek timely medical care, or helping repair irrigation canals that improve crop yields and thus improve nutrition among the general population. But don't for a minute forget that those projects also help Afghans lead longer and healthier lives.

Note also that the World Bank put out a report in April of this year that applauded the fact that "almost 6 million people in rural areas of Afghanistan now have access to primary health care, many for the first time." I'd encourage anyone interested in the improving health of Afghans to at least read the abstract provided here:

• The number of people visiting a health center in rural areas has increased four-fold since 2004. In most low income countries the average is 0.3 visits per person per year, whereas in Afghanistan it is approaching 1.0 in areas covered by the project.


• The Ministry of Public Health has contracted with NGO service providers in districts where 80% of the population are living - boosting access to health care in rural areas.


• An independent assessment shows a 40 percent increase in patient satisfaction.


• 60 percent increase in the number of functional health centers in the 11 provinces financed by the project during Phase I. Third party evaluations show that the centers are fully supplied, equipped, and staffed. There is almost no absenteeism, which compares well with up to 40 percent absenteeism among public sector doctors elsewhere in South Asia.


• The number of pregnant women receiving prenatal care per year has increased from 8,500 in 2003 (5 percent of pregnant women, based on the baseline household survey) to 123,000 in 2006 (63 percent, based on health management information system data). An ongoing household survey should confirm these numbers soon.


• NGOs maintained and even expanded services in unstable areas. In Helmand, one of the more insecure provinces, the number of patients seen more than doubled, from 157,000 in 2004 to 338,000 in 2006, despite the assassination of four health workers and the destruction of 15 percent of health centers.


• The number of patients diagnosed as a proportion of the expected number of TB cases has increased from less than 10 percent to almost 50 percent in less than 2 years (still short of the international standard of 70 percent).


• 8,000 patients have been diagnosed and are receiving effective TB treatment.


• More than 10,000 community health workers–half of them women–have been trained and deployed. They have helped increase family planning and childhood vaccination.


• The number of facilities with trained female health workers has increased from 25 percent before the project to 85 percent today.


• By providing virtually free health services, the project has helped increase access to preventive and curative care. It has, thereby, reduced the health-induced financial shocks that frequently push poor families deeper into poverty.

Again, I'm not trying to paint a misleadingly rosy picture of healthcare in Afghanistan, since the country has a long way to go:

After 30 years of civil strife, Afghanistan had almost no national health system in place. This meant that the country faced a serious development challenge, and the international community had to build the public health and health care delivery systems virtually from scratch. Most of the health problems in Afghanistan are not amenable to quick fixes, requiring long-term investment in nutrition programs, the creation of sanitation systems, and the development of a new generation of health care professionals.

No, I'm just trying to provide some context by letting you know where the country started in 2001, and what progress has been made up to this point.

Nothing is more indicative of the lack of context in Dr. Martin's piece more than this line, though, as he cites the shortcomings of Afghan medical care:

Afghanistan has an infant mortality rate of 140 per 1,000 births; and the under-five mortality rate of 230 of 1,000 children.

Prior to the fall of the Taliban, Afghanistan had an infant mortality rate of 165 per 1,000 births:

Infant mortality has dropped by 18 percent in Afghanistan since 2001, in one of the first real signs of recovery for the country five years after the ouster of the Taliban regime, health officials said Thursday.

"Despite many challenges, there are clear signs of health sector recovery and progress throughout the country," said Muhammad Amin Fatimi, the minister of health.

The infant mortality rate - the number of children who die before their first birthday - has dropped to 135 per 1,000 live births in 2006 from 165 per 1,000 in 2001, according to a countrywide survey by Johns Hopkins University, he said. By comparison, the infant mortality rate in France in 2005 was 5 per 1,000, according to Unicef.

That represents a drop of 18 percent and means that 40,000 to 50,000 infants who were dying annually during the Taliban era, are alive today, Fatimi said. [Babbler's bold]

I'd guess there are at least 40,000 sets of Afghan parents who would disagree with Dr. Martin's assessment that Canada is failing them in the area of improving healthcare, cradling a live baby in their arms as proof.

Healthcare in Afghanistan has improved in leaps and bounds over the past five years. It's not improved to the point where any of us, including the Afghans themselves, would want it in the long term, but it's miles ahead of where it was before the Taliban were overthrown. Canada has contributed, and should continue to contribute to developing the Afghan healthcare system - both with quick impact projects like distribution of humanitarian aid, and with long-term capacity-building projects like hygiene education and vaccination programs.

Dr. Martin's piece mischaracterizes that effort, and unfairly minimizes its impact. Canadians need a more well-rounded picture than what he provides them if they're to hold an informed position about Canada's contribution in this regard.

Update: A good discussion of the pros and cons of Dr. Martin's article, including opinions from some folks who have actually seen Mir Weis hospital with their own eyes, can be found in this thread at the indispensable Army.ca.

Upperdate: Bev Oda replies to Martin in the National Post.