Reasons for Hope in Afghanistan

Shortly after the U.S.-led coalition toppled Afghanistan's Taliban regime in the fall of 2001, the Bloomberg School's Gilbert Burnham went to Afghanistan as part of an effort to assess the country's health care needs. He and his team traveled the countryside freely, often sleeping in remote villages.

Six years later the security situation is worse. The Taliban insurgency is targeting soldiers, civilians and, increasingly, foreign aid workers. Today, the Johns Hopkins team and other Westerners tend to stay in a compound in Kabul, with most of the work outside the city done by Afghan nationals. But despite the security problems, the health care situation for Afghans has actually improved since the Taliban's defeat.

"Many of the indicators are very bad, representing many years of lack of access to health services. But there have been some dramatic changes over the four years we have been measuring," says Burnham, MD, MSc, PhD, professor of International Health and director of the Center for Refugee and Disaster Response. "Although numbers are fairly weak in some areas, the amount of change is impressive."

Burnham leads a research team from the Bloomberg School and the Indian Institute of Health Management Research that carries out research studies for Afghanistan's Ministry of Public Health. Their recent work documents health care and health system gains:

• The percentage of Afghan women receiving prenatal care from a skilled provider rose from 4.6 in 2003 to 32.2 in 2006.
   
• During that same time period, the number of women in rural Afghanistan who received help from a doctor, nurse or midwife during childbirth increased threefold from 6 percent to 18.9 percent.
   
• The number of children in rural Afghanistan receiving a vaccine against tuberculosis increased from 56 percent in 2003 to 70 percent in 2006, and those getting the oral polio vaccine jumped from 30 percent to 70 percent. (Burnham notes, however, that less than 30 percent of children have received all vaccines by age 5.)
   
• The infant mortality rate (measured as the number of deaths in the first year of life, per 1,000 live births) dropped dramatically. In 2002, it was estimated to be 163. By 2006, that number dropped to 129. (The comparative number in the United States is 8.)

Despite such improvements, Burnham notes that Afghanistan is still suffering the effects of decades of war. First there was the 1979 invasion by the Soviet Union, followed by 10 years of insurgency. After the 1989 Soviet pullout, fighting among Afghan factions continued until the Taliban took power.

In nearly three decades of conflict, the Taliban's rise to power had the most serious health consequences, especially for women, Burnham says. Female medical professionals were prevented from working, and female patients were discouraged from traveling for medical care. As a result, the vast majority of pregnant women continue to deliver at home, usually without skilled birth attendants.

Since the Taliban's collapse, the Afghan government has been working to bolster its health care system through community-level primary health care units—most of which are run by nongovernmental organizations. In 2003, the government began what it calls the Basic Package of Health Services initiative, designed to provide standard health services throughout the country.

Despite the successes, there is room for improvement. Treatment for tuberculosis is still not available at many clinics. Hospital laboratories cannot conduct many basic tests. Referral services from clinics to hospitals function poorly. And complete information is not available for five provinces in the south where the insurgency is at its strongest, and health status is likely to be poorer.

One of the biggest challenges: 30 percent of the country's population lives in areas so remote that they have no access to health care at all.

It's a rural population that Carl Taylor knows well. A professor emeritus in the Department of International Health (and the department's founding director), Taylor, MD, DrPH, MPH, went to Afghanistan shortly after the collapse of the Taliban as part of his work with a West Virginia NGO called Future Generations, which his son Daniel leads as president.

"It was the usual situation in relief situations around the world, where everybody gets in quickly and takes part of the action. We decided to find the gaps," recalls Taylor.

For two years, he and other volunteers did "shoe leather epidemiology"—traveling to remote villages and talking to the people, especially women. Their goal, he says: "to find innovative, community-based solutions."

Taylor and Future Generations developed a program that brought together women selected by community councils to be trained as community health care workers. After their five-day workshop, these women then returned home and trained other women in their villages. The organization also set up community-based literacy programs in mosques in 350 different communities over three provinces.

Taylor wants to return to Afghanistan soon, but fears that he might put the Afghan staff in danger, since Western aid workers are often targeted by insurgents.

Despite the obvious obstacles, Taylor says his work there has made him optimistic. "I always have great hope when I'm out there working with the women," he says. "It's this empowerment thing—this encouraging sense of seeing them begin to solve their own problems."