Good afternoon, everyone. My name is Leonard Rubenstein. I'm the coordinator of the USIP Working Group on Peace, Building, and Health. And I'd also like to welcome everyone who is watching by webcast. This is a new working group here at USIP established to look at key issues around the intersection of health programs and health policy and peacemaking and peace building. This is the second of our meetings. And the interest in this topic was so great that it doesn't feel too much like a working group today, more like a formal presentation. We will, in the future, have more around the table kind of discussions. And the next discussion will be on the role of the health sector in addressing gender-based violence. And that should be in February. Today, of course, we're talking about health programs and health policy in Afghanistan. And in a very appropriate kind of introduction to this topic, Secretary of State this week gave a speech on development. And in her speech, Secretary Clinton had this to say, we are working to elevate development and integrate it more closely with defense and diplomacy in the field. Development must become an equal pillar of our foreign policy alongside defense and diplomacy led by a robust and reinvigorated AID. She went on to say, quote, now I know the word integration sets off alarm bells in some people's heads. There is a concern that integrating development means diluting it or politicizing it, giving up our long-term development goals to achieve short-term objectives or handing over more of the work of development to our diplomats or defense experts. That is not what we mean, nor what we will do. What we will do is leverage the expertise of our diplomats and our military on behalf of development and vice versa. The 3Ds must be mutually reinforcing, close quote. Though Secretary Clinton was seeking to reassure, her answer really raises as many questions as it solves. What does mutual reinforcement mean in policy and in practical programmatic terms? And what does it mean to leverage the military on behalf of development? And what does it mean to leverage development on behalf of military goals? Nowhere are these questions more acutely posed than in Afghanistan. On the one hand, the US has invested heavily and with some success in the development of a national primary health care system with Afghan leadership. At the same time, the military has been engaged in many health-related activities. And now the USAID director has stated that the goal of the program in Afghanistan is to support the building of capacity locally. At the same time, USAID projects must, quote, demonstrate how the proposed activity contributes to US counterinsurgency goals, close quote. These are the questions our wonderful panel will answer. All of them have great experience in this field and in Afghanistan. In USIP tradition, I won't give full biographies, but I'll just briefly discuss who they are and the order in which they'll speak. We'll start with Dr. Bill Newbrander, who has spent years as a senior advisor to the Ministry of Public Health in Afghanistan, and he's off for another two-month stint next week. So we appreciate him being here. Then we'll hear from Dr. Warner Anderson, who has had a distinguished career in civilian and military medicine, has served in Iraq and is now Director of International Health in the Office of the Assistant Secretary of Defense for Health Affairs. Then we'll hear from Dr. Ann Peterson, who in a previous life was Assistant Administrator of USAID at the very time that global health spending was expanding dramatically, and she was, of course, in charge of global health. And she has also spent a great deal of time doing evaluations of health programs in Afghanistan. And finally, we're privileged to have Zepideh Khabanshad, who is a career foreign service officer with many years of experience in Afghanistan, and was brought by Ambassador Holbrook to work as a senior development advisor on his staff. So each of the speakers will speak for 15 or 20 minutes, and then we'll have plenty of time for discussion. So we'll start with Bill. I guess I'm going to do a little bit of the retrospective of just trying to talk a little bit of where we were and where we are at this point. So and then talking a little bit about what would be some of the reasons for the success that we've seen in the health sector in Afghanistan, some of the really remarkable successes that there have been, and then looking to what are some of the challenges for the future, both directly for MOPH in terms of the continued development and extension of its health system, as well as some of the challenges under the current situation with the need for the counterinsurgency with the concerning the Taliban. So those will be the things I hope to cover here very quickly. Just for making a comparison between 2002 when USAID initiated some activities in health in Afghanistan in early 2002 and compared to 2009, WHO has come up with what they call six building blocks for a good health system. And these range from, which you might expect, certainly a good health service delivery to the workforce, a good information system so you know what you're doing or what you aren't doing, good drugs for delivering of services and then financing and then effective leadership and governance. And just put this up in terms of why are those the six building blocks, the fuller model that WHO has is that with those six building blocks, that helps to increase access and coverage, hopefully with improved quality and safety of the health services and the ultimate results and outcomes that hopefully you're getting from that are improved health, a health system that's responsive to the population, better efficiency, and really reducing any financial or social risk that different elements or ethnic groups of the population might have. Just looking quickly at 2002, I'll just cover this quickly and then go into these shortly to say what have been some of the achievements and gaps. I guess it would have been easy probably to just say F for everything, because there wasn't much there in early 2002 when we got started. But I guess health service delivery, I said D minus, it was pretty bleak. We think only about 5% of the population had any access to health care, mainly those in some of the urban areas, but probably was not available for women. You did have a few of the NGOs that have been there through all those years of war and were still delivering some health services. So there was a bit that was there, but really not much related to child health interventions or maternal interventions, which were a real need there. As far as the workforce, many of the professionals, as far as the physicians and top people in the health sector had left over the years to Europe, North America, other countries during those years of war. You still had some, as I said, the NGOs doing some training of health workers, but there were no standards, no standard treatment protocols. What one NGO called a community health worker, another called a community health worker, but it was more of maybe just a health educator or that. So there wasn't much there as far as the workforce. The information system, again, I gave it a D minus. They were reporting. They had everything down on one sheet, but it really didn't cover some of the critical areas. Only about 5% of the known facilities were even reporting. And it really missed the MCH issues. Then hardly any drugs, the few they had coming across from Pakistan or Iran, no real system of health financing. And certainly, even though there was a ministry of health during the Taliban times, there was really no leadership or governance. It was more of a still part of the political establishment of who was complying and who wasn't, as opposed to actually getting health services out there. So I'll just cover each of those six building blocks quickly, as far as what we've seen. Ryan, it's not advanced in form of done. You need to do something else, right? There we go, got it. OK, so these I'm not going to cover in detail. You've seen that, and I have a couple slides. But certainly, you've heard about the nearly 25% reduction in infant and under five child mortality. There's been certainly increased access to health services. If you've heard Dr. Fatimi, the ministry, says that it's about 83%, 84%, 85% have access to services now. And there's certainly been a large improvement in maternal care. We've not been able to get a maternal mortality rate, another fix on it. But that was what was done by CDC and UNICEF in, I believe, it was 2002 or 2003. That really gave us the baseline of how bad it was as far as maternal mortality. But that's really been improved, as we'll cover some of the other in terms of the services available and the midwives that have been trained. Some of the gaps that are still there, so I'm covering a little bit of what we still see right now as far as some of the gaps. The ministry still really needs to focus a whole lot more on community-based health components. And this was somewhat of a push. Certainly, USAID has certainly been emphasizing it. A bit less by some of the other donors, but a real need. And it certainly has come up as a big item in counterinsurgency. But even if you didn't have that as an issue, you really needed a much stronger community-based element because that's how you're really going to extend access to that last 15% where it's extremely difficult, as well as trying to start improving some of the quality. Most of that access problem is due to geography or certainly now security has been an issue too. Just gonna show two quick ones here as far as access. This first graph is from 2003 and it shows by district the population per health facility, whether that be a basic health center, comprehensive health center, or a district hospital. The darker shades of red are bad, meaning that it's a much higher population per facility and the lighter colors or shades of red or pink are good. So this is 2003 and if you contrast that with 2008, you see that we're going to a lot more light shading. The number of dark areas are much less. So the overall access has increased. You have a lot fewer districts that don't have the required number of health facilities given their population. And these tend to be, as I said earlier, mainly in the insecure and the areas as well as very difficult geographical areas. Wanted to just show a little bit in terms of people making use of those services. The one in the upper left corner is talking about total patient visits at per month average over a year starting with 2004, going up to 2007. And this is for all the clinics and hospitals in USAID-funded provinces. The 13 provinces that USAID had undertaken a commitment for, European Commission and World Bank had taken responsibility for the others. They had worked together quite well in taking different responsibilities. The upper right-hand one is the number of monthly deliveries at health facilities. And then the bottom one is talks of family planning services that have been provided. In the upper left and the lower graph, the, it's very hard to see, there's a yellow line here which is basically adding up what you have in terms of the dark blue bean services provided at health facilities, those being clinics and the pink being at health posts which are out in the communities and services provided by community health workers. And the yellow is just simply additive. What I wanted to highlight, you can see that it's been a significant trend from 2004, it goes all the way up to 2007. I'm sure it's difficult to read back there. I wasn't clever enough with, I didn't have the background spreadsheet but I do have the 2008 figures and there's been even a further huge increase. As far as clinic health services, this is actually our services at both health posts and clinics. That's jumped up to over 1.3 million per month which is just phenomenal. It's hard to see this grid but we started at about 150,000 by 2007. We thought we were doing, it was pretty good with up to about 750,000 per month but now it's, it really ramped up in 2008. Part of that might've been the ministry took a policy that there would no longer be any user fees and so there was a great deal of increased demand as well. I think the other significant thing is that if you look at the number of deliveries, really that's very significant as far as impact on maternal mortality. Again, we started with about 800 per month in 2004 which equates to about 30 deliveries a day in health facilities in these 13 USA funded provinces. By, in this graph here by 2007 I've been up to a little over 5,000 a month. In 2008 it's up to 13,774 per month. That's the average over those 12 months. So you're going, so we went from about 30 deliveries per day in these USA funded provinces to over 460 a day. So that's really significant and that's why I say when we do have an MMR, all of what USAID and the others have put into the health sector, we will see a significant drop in that. Just trying to go back here, Ryan. On the health, again, the women health issues and thus the children as well were the real target starting in 2002 of not just USAID but the other donors as well because that was where the need was. Just showing a couple of the things here that as I said, access, even if you have increased the number of clinics as we saw in one of the earlier slides, if you don't have female health workers at those clinics, most of the women, especially in the rural areas and the more conservative areas are not going to be able to have access. Their husbands or families just will not let them be seen by male health workers.  So you were really swimming upstream starting in 2002 but the number of health facilities with at least one female health worker has increased from 21% back five, six years ago to about 83% now. The other significant thing I said, we really have to focus on the community-based healthcare and the community health workers are the core part of that. Again, if you train a lot of community health workers but they're mainly males because they can travel a lot more and they're not paired up with a female relative whether that be a wife or a sister or something, again, you're not gonna be reaching a lot of the female population that need health services. And that with the number of CHWs that have been trained has gotten so that we actually have slightly more female CHWs than we do males. It's about a 51-49. The weaknesses as far as with health workers is really the supervision and what I also put there in terms of continuing education and really monitoring more closely the quality of care that they are providing. As far as a function management system, you really need that for being able to figure out what's going on or what's not going right. Again, in the USAID-funded provinces, it hasn't been quite as strong in the other provinces, but over 95% of the health facilities are reporting. So when I give you those figures that I just gave you as far as increased health services, those are really good figures. They'd have very strong confidence intervals in terms of being able to report. They're not just 10 facilities and we're extrapolating. One other part that I didn't mention here is that as far as human resources and really figuring out what do they have available to them, that's part of the HMIS, we now have that the human resource database that USAID with its health work there helped us to get going about 2004. It now contains about 90% of all the health workers are listed on this database. We know where they're at, what their skills are, how recently they've been trained, and we're including all of the CHWs now, so it's gonna be quite a comprehensive one. But I think one of the issues with that information that's mainly at the central level, more may just be done to really push it down more at the provincial and community levels, not just so they have the information, but they use it and as I'll tell you later about I think one of the needs is really a much stronger decentralization, so there's more planning and taking of action at the local level based on local needs. Pharmaceuticals, this has been a very strong point. Wasn't part of anybody's plan back in 2003 as the different donors took responsibility for these different provinces and provided grants to NGOs to provide services. And it was USAID that just said, oh, there's nothing there for drugs. So we started in the USAID funded provinces a very sound system for getting drugs out there to these facilities. And at this point it's over $5 million a year that's going out there. And it's been so good and strong and a key part of raising care that the ministry is really pushing very hard for the World Bank and EC so that this is a national way of doing it as opposed to only for the USAID funded provinces. Again, really a need for standard treatment guidelines that can help make sure that we not only have drugs out there but they're used appropriately that there's good compliance. And so that's one of the needs for the future. As far as financing, it's been great mainly because the donors have been providing it. The donors have really stepped forward over these years as far as providing the money so services can be expanded. And the ministry has seen the need but as I mentioned in some of the weaknesses they've often talked about sustainability and what they can do as far as health financing but they're really only starting to do some real significant planning in that area now. It's only been recently that they've been doing it and maybe part of that's because there hasn't been a critical need in the sense that they've had a good amount of resources for what needed to be done. Last building block as far as leadership and governance just once again, I think the real achievements the ministry having the basic package of health services this tells what health services are critical for maternal health, child health, infectious diseases communicable diseases and as well as mental health and rehabilitation services it describes what you need to have at each level of the health system basic health center, comprehensive health center district hospitals, what kind of people you need what drugs you need there which ones are appropriate from the essential drug list and so it's really pretty much about how to and with them establishing this in 2003 it really set the priorities that they had focusing especially on women and children but also on mortality reduction and it also helped them to as other background noise or static came as far as you should be doing this you should be doing that it really helped them to stay focused and so that as well as then the companion one that came out a little later the essential package of hospital services have really been kind of very important for guiding. One other key part about governance is that the US signed an agreement with the Afghan government over a year ago in 2008 of committing to provide funding for the basic package of health services over the next three to five years and having that channel through the Afghan government with the appropriate monitoring in that so instead of passing through one of the US entities it is going directly to the government and so that's quite significant I think it might even be the first time possibly in the world that that has been done in a country where USAID is working as far as the gaps of that I think with a lot of the success that there's been some loss of focus on mortality reduction we've reduced the number of infant and under five child deaths and that's good, that's gratifying but you still have close to 600 kids a day that are dying from causes that really can be prevented or that they're with appropriate recognition and early treatment there's no need for them to be dying so as far as just then for 2009 I won't go in detail on this I think you can see and again this is Bill Neubrander's report card it's not an official report card so it's my assessment having been there over both those periods but I think you can see that there's been some real significant gains there's still some areas such as health financing that really need some strengthening there let me just talk a little bit of why do I think that there's been some of these successes that have happened with the ministry due to USAID support and being a partner with the Ministry of Health first of all is certainly they had those clear priorities and the basic package did that certainly saving lives as a priority and having those that basic package really has made all the difference in terms of getting the right things done at the right time over these years I think the second thing I would like to just mention certainly and I think it's actually the untold story about Afghanistan and what USAID has done there and that's capacity building the Ambassador's letter in August of 2009 that he sent out to everybody that said we're gonna do Afghanization and he was talking about everything that the US is involved with whether it be certainly from the military but certainly in the aid sector and I think I'd have to say at least my assessment would be that USAID could actually say been there done that because in the health sector because they've done a significant amount and the capacity development has been across the board there's been clinical as I say there's been this huge increase because of USAID helping them to establish these midwifery schools and then later a new cadre because of this gap in education of community midwives which allowed a greater number to be trained out in more of the rural areas for providing attended bursts in these villages but it's also been in management and in certainly financial management as well in terms of the ministry being the grants and contracts management unit of the ministry now being certified by the US government to receive funds. Why, what made the difference in capacity building? I think there's three or four things one in those early years experienced people were put on the ground these are people that had experience in other developing countries that had significant expertise in those areas of building a developing country health system they were there for extended periods it wasn't just two week visits and then they'd be back six months later that they were living there and on the ground to make it happen these were people that rolled up their sleeves and were working and mentoring the Afghans working in their offices and really making a difference in terms of that. Okay, I think one other factor is they work not only on the public sector but the private sector and finally the donors certainly USAID and EC and World Banks aligned with the ministry's priorities. The challenges for the future I'm not gonna go over them again I think they came out in some of the gaps and challenges that I covered earlier the one I just point out looks like Dr. Fatimi who's been the minister for the past five years he was the second minister was not approved by parliament last week and so a new slate of proposed ministers is going to be proposed I believe by President Karzai tomorrow and so and that's true for any developing country whenever there's a change of leadership it's always we adjust we work with whoever's there and so and working with them. Let me just cover the last two things as far as challenges with the counter insurgency I think the first point in case there's any doubt of anybody the military is necessary if the Taliban were allowed to be there without basically I guess you'd say terrorists running around you really wouldn't have any sort of development in the country you'd have chaos and anarchy and so the military is necessary for health development to go forward as well as other sectors. Second thing USAID just these are again my thoughts on going forward with USAID certainly and they've been doing this so I'm not saying that this is contrary to what they're doing but where we've had good results which in many of the provinces that have been for the most part secure to maintain that and continuing to do that and USAID is doing that they're not turning away from them and saying well we'll shift to the east and south. Secondly is further capacity building because that's where you're gonna have the long term results to so continue to do that and finally really looking for the effective ways that we can work in these insecure provinces in an effective way but an appropriate way. The last thing that I have on this slide is just mentioning that at times we only talk about financial resources are we diverting finances away from these areas to another. I think more of a concern isn't the finances which hasn't been an issue so far but is a concern about whether that could be the case in the future but I think it's the attention that's given that if we divert attention and energy to other areas and not continue the work that's been started in the more secure areas then we run a real risk of sliding backwards somewhat. Last thing as far as certainly some views in terms of for the military I guess for the PRTs and that that are involved may be involved in health development. I guess I basically said that they have a role where we can take advantage of their comparative advantage. The military is very good. I was a medical company commander. We're very good on systems and so one of the things I've indicated there is that as things such as medical maintenance that's always an issue in developing countries and the military has a very good system for that for maintaining medical equipment, repairing it, having parts, having a training facility for making those so that the goods work because as we often hear not just in Afghanistan donors come in, give equipment and after the first time it breaks or there's a part that goes or a bulb that goes or you don't have the reagents suddenly it's in the hallway and not used anymore. So that they do have resources and so for capital projects that need to be done clinics, elements to that or rehabilitation and Herat I think they bought a fair number of ambulances so those can be quite good. I think where there's real issues and we've seen some of this at times of the past not just in the most recent with the counterinsurgency is when the involvement with the military in terms of health affairs are not coordinated adequately with the ministry of health or they're not public health or not fully aligned with their priorities or just taking unilateral action. I think probably the worst example we remember was that this is a number years ago probably about four or five of where one of the units really well intention but they got a bunch of vaccine and went out and provided immunizations to a bunch of kids in that without any knowing if there had been any done before they had not coordinated with the provincial health officer they didn't know what had been gone on before so they just went out to undertake that. Now that's an extreme example, that's not the norm so I'm not trying to portray that as it, but and I think the last thing that I've mentioned here there is a real risk as far as the NGOs that and this is one of the real challenges of how providing aid and yet the NGOs that are out there day to day running those clinics and providing the services how can they not be have the appearance or certainly the perception that they're closely aligned with the military because they, there can be revenge to them and their staff as well as communities if there is that concern in those areas that are not fully held at this point. So I guess I'll conclude, thanks. Thank you Bill, we'll hold questions and comments until the end before the civilian perspective now the military perspective. Thanks a lot, I'm bringing my water here because I'm in the middle of a sore throat and a cold right now so Murphy's law says that any exacerbation of my illness will occur while I'm at the podium so I learned that in medical school. First of all it's a great honor but it's also a humbling experience to be here among people that I have a lot of respect for in this field. I actually was carrying around with me a picture with a paper which might look familiar to you. This is by Len Rivenstein and I have read it and made lots of writings in it in my internal dialogue with it many of which I can't read. So but it's very provocative and although I don't agree with everything in it that's not the purpose is to stimulate discussion and thought and also gene bond ventures in the back are my greetings to Gene and I have here the draft which I've also written all over and I need to deliver this to you later but I've learned a lot from Gene too and I've learned a lot from lots of folks in the room and I'm really happy to see you here today and I'm gonna try to finish this in about 15 minutes if I can. And just click the mouse to make the slides go. Okay, the reason I'm here today first of all thanks for inviting me. The reason I accepted the invitation is not so I could come and tell you what I think but so that when I'm done telling you what I think and what my division thinks I can hear what you think because that's much more important to me. As I've alluded you are the experts you are the interested parties many of you have more time in Iraq than I do many of you have more time everybody's got as much or more time in Afghanistan than I have a week there. So I don't come to you as an expert on Afghanistan. The International Health Division was stood up to look at policy for how the DOD uses health instability operations and it's working. This is some excerpts from DOD Directive 3000.05 which was issued in 2005. Now the DOD has been doing or the military I should say technically has been doing a lot of health interventions both in the United States. I worked for the Indian Health Service before the 1950s Bruno. Indian Health Service was the War Department wasn't it? So in some ways the Indians think it still is the War Department but we won't go down that road. I won't wander off the reservation on that. If you look at the kinds of things here that need to be done I won't read all this stuff to you but what I would like to talk about is the common thread for the military health system that is separate from the rest of the military and also is different from I think the other agencies. There's a common thread here in what we used to call STRO which was stability security, transition reconstruction operations. Now it's all been lumped together under the rubric of stability operations which for some reason the military has decided to call STAB ops and as an emergency physician I'm not entirely comfortable with that term but I have to live with the glossary to give me but if you look at stability operations or STAB ops, if you look at stability operations and you look at humanitarian assistance which we define as emergency kinds of stuff it's not the Oslo kind of stuff and then you look at counterinsurgency there's a common thread there for the military health system and in order to understand the importance of this you need to understand that the military health system was not set up to take care of host nation civilians. The military health system was set up to take care of military personnel and then oh by the way we've got Geneva conventions so we also have to take care of host nation civilians that wander into the line of fire or happen to be in that compound when we drop a predator on it or something like that so we wind up with them and in fact when I was a patient of a combat support hospital there were two Americans in the ward that I was in and there were I think if I remember right about nine Iraqis this is in 2003 during the invasion and of those nine Iraqis two were enemy prisoners of war and three were children toddlers really young children so that's what the patient makes turned out to be and we're required by law to take care of those people and ethically I might add. The other place where we run into this is that if we're in occupying power we as a government now I'm talking the US we US government and other governments who are occupying powers are required to provide essential services the life and death services so there are places where we being the US government are going to have to do that and sometimes the DOD especially when the bullets are flying is the only agency that can do that. But if you look at stability operations humanitarian assistance and counterinsurgency you find that the common thread with the military health system is that by design by nature we then interact with the host nation civilians on purpose not because they wanted into the line of fire not because we broke the country and now all of a sudden we own it for a little while till we can get out of there but because by on purpose we're going there to do this stuff and we don't have a good doctrine on that. We don't have the doctrine right now that's sort of what my job is to put together division that can do that and I think we're making some progress there. So any conceptions that you have about what the military was doing a year ago are pretty much obsolete now and indeed any assumptions that you or I have about what we're doing now will be obsolete at the end of this talk because I guarantee you that based on the feedback we're going to change where we're going with policy. So these things are important. On the next slide, do I go backwards using this one?  So where it says medical use your word finder and please put in health in your own minds but the military tends to use medical and health interchangeably. There are a number of different kinds of things that the military health system does with regards to health in interacting with host nation infrastructure, health infrastructure and host nation civilians. So I won't belabor that slide and I also won't belabor this slide except to say that we sort of we've been there we've done that we got the t-shirt for it but all the guys that been there done that got the t-shirt or retired or dead and so we have to learn this all over again. Every time we go someplace and do these kinds of things we have to learn it all over again and the conventional warfighting military has never when you're worried about the Soviet Union coming through the fold of gap you're not really worrying about the guerrilla warfighting that's going on in El Salvador for example and so we tend to ignore those lessons that we've been learning and they just drop off to the side so hopefully with some doctrine we'll be able to stop reinventing this stuff and I think the other thing that's important there is that there's a much greater recognition just as the DOD has recognized that the Army Air Force Navy have to blend together to fight and reestablish combat. Now three months ago this would have been very difficult to do because three months ago let's face it, we didn't have clear leadership we didn't have clear direction from our leadership on what we were doing but within a period of about six months in Afghanistan we went from development to counter-terrorism, to counter-insurgency. Now we're doing counter-insurgency, okay? So when you talk about development I'm not really hearing what you have to say I don't really care so much about development because the guys that I'm interested in the men and women that I'm interested in right now are the men and women that have to wear body armor because the places they are are so hostile and what I'm interested in is how do we use health and how do we use healthcare infrastructure to decrease the threat to them and to increase their ability to accomplish their mission and their mission is probably, if you think about it is probably stability and security and the stability and security permits what? Those are the permissive circumstances for development, right? So in a way you've heard talk about jeez what if we lose in Afghanistan? It's an evolving, the theater is evolving and some places it's devolving and so there are going to be areas where you have development occurring in one place other places you're going to have counter-insurgency indeed as the guerrilla war matures if we're not winning you're going to see conventional land forces Taliban conventional land forces so we need to think ahead we need to think about what we're doing and the situation is going to be changing all over the country in different places we'll be doing different kinds of things but if you look at the differences between development and counter-insurgency at least the principles of development the principles of counter-insurgency the principles on the right of counter-insurgency come from the army and marine FM3-24 counter-insurgency manual and if you look at the principles of development I'm sorry on the left, on the right you look at USAID principles of development they're not that different they're not that different the way they're stated I think tells you something about the culture but what we're looking for in counter-insurgency is the opportunity to extend the reach of the government primarily at least in Afghanistan and we can debate about whether the government is a functional government or a dysfunctional government but that's for other people to debate and I can talk to you about that offline as an anthropologist but what I'd like for you to do is compare and contrast the world view and the mindset that are evident in this now where DOD is doing counter-insurgency who's the lead? not DOD exactly Bruno it's Department of State is the lead the embassy the country team is the lead and USAID falls under the country team DOD falls under the country team so the State Department has to lead us in the counter-insurgency and the reason for that is that a counter-insurgency is described as being primarily political I think that's because we're used to political process I would say that I would say that counter-insurgency is primarily a sociocultural issue it's a matter of establishing trust building mutual trust building bonds of trust between the government and the people building bonds of trust between this tribe and that tribe building bonds of trust between this person and that person who had disputes that the rule of law can solve these things and the rule of law can although it doesn't work in everybody's absolute favor every time it averages out and it keeps us from going out shooting each other over property disputes things like that the US has some military capabilities in counter-insurgency right here are the medical units anybody know how many medical personnel we have? I don't but I think it's like a hundred and fourteen thousand, isn't it Patrick? it's like a lot it's too many, yeah accounting reservists we have a huge medical capacity one of the problems is we don't have training these folks are trained to provide care to soldiers and sailors and and airmen and marines that are shot or that you know drive into a ditch or something but they're not trained to take care of host nation civilians they're not trained very well to interact with host nation health infrastructure and we're moving to change that through the medical stability operations course that we're developing curriculum for hopefully all the eventually all medical personnel from DOD who go down range whether it's to Afghanistan or elsewhere we'll be getting some instruction on those kinds of things we're not there yet we understand that the army and marine field manual has the preferred division of labor and if you look at this it says it's always preferred for civilians to perform civilian tasks there are many US agencies and civilian IGOs with more expertise etc etc etc hence the preferred or ideal division of labor is frequently unattainable that's the bottom line on the preferred division of labor we want to be led in counterinsurgency we want state department to lead us in that when it comes to development we want USAID to lead us in that but sometimes when you're like like I was and I think probably even like Bruno was when you're out there in the middle of of the streets and and and the bullets are flying the reason you're there is because only DOD will be there although ironically we're both public health service nevertheless speaking for DOD now I put a note to myself here uh... I don't want I don't want this next thing I'm going to say to get out to al-qaeda or Taliban so if there are any Taliban or al-qaeda in the room please leave for a moment and then you can come back in if you want to cripple the United States government I think all you have to do is ask this question what agency in the U.S. government is responsible for blank and the U.S. government will be incapable of performing that function for the next you know ungodly amount of time because there'll be acrimony and recriminations and all kinds of discussion about that and I suppose unless it worked out real well and then there'll be a lot of people arguing over taking the credit uh... I think we're coming to the point where we're getting over that and the reason I can say that is because I have so many friends here in the room from the other agencies so the realistic division of labor is that if if I'm the guy who's out there in body armor wearing a colonels insignia and uh... and there are kids with swords all over their faces or there's an outbreak of malaria or something like that but I'm the guy who has to decide whether to spray the malaria or give everybody neosporin or basatracin or whatever we're going to do for those problems and later on somebody else is going to come along and say you made the government look bad when you did that I'm going to say yeah that sucks that's life and so there's a we have to live in the real world we have to live not just in the real world of D.C. but we have to live in the real world of operations that's one of my take home messages the transition is always difficult and people soldiers always ask me how do we know when to make the transition to the other agencies and my my answer is fairly simple it's it's when they're there when they're when they're there and you've got like three months to do the handoff now then you make that transition right then but you can't transition to somebody who's not there you can't transition to somebody who's loggered up at FOB if you're out in the field transition your your operation in Helmand or or Harrod or somewhere you can't transition that to somebody who doesn't leave Kabul so the transition is going to require some I think some culture change I want to say that one of the as an anthropologist I'll say this is no surprise to any of the bureaucrats here that the US government has been criticized for trying to solve problems by throwing money so whenever we have a problem what we do we throw money we got a health care problem we throw money god forbid we should get people quit smoking now we're gonna throw money at the health care problem if we and I'm this is not believe me this is not a partisan talk this is a cultural talk if we if we have a you know a problem with gangs we throw money at it but I'm not sure we have effective interventions for those things and we've been criticized in in Iraq for throwing you know fifty billion dollars worth of money at problems that never got solved now secretary gates and this is probably where I and we're being webcast thank you very much this is probably where I lose my job but it's been fun secretary gates has been very very forthcoming and pointing out that USAID is under under resourced under financed and under staffed and uh... so state department and I think there's little to argue with about that the question I have as an anthropologist is that can those things be solved by throwing money at them or does it require a culture change do we have to go back to our Vietnam era where we had USAID in the field with us working alongside us so that as it was with public health service one time I told a guy wearing a uniform to get his burrata and cover that sector of fire and he said on public health service and I said well we'll talk about that when we get back to the team house for right now you cover that sector of fire and that's the kind of presence we need downrange with state department and with uh... with USAID and dare I say it with uh... public health service and health and human services uh... until we get that uh... all of the interagency talk a lot of it's going to be moot running out of time let me just run through a couple topics really quickly um... this is where this this is the mess that is command and control in afghanistan right now this is the mess that is command and control most of you can not everybody can see it in case you're not familiar with it who's the boss who's the boss who's the final arbiter what's going to be done and this is what late late last night when I was reviewing my slides I came up with the anderson complexity index take the number of nations involved in an effort and you multiply it by the number of agencies that are involved in that effort and you wind up with problems in languages interpreters national systems of reporting and accounting international systems like the united nations world bank when it comes to reporting and accounting organizational systems ethical and cultural norms variations and assumptions it really this organization is is is set up for failure and i think that as a you know d-o-d is all about unity of command and i think that we need to get some unity of command out of this um... this is another slide this was put together by an air force colonel and as an anthropologist i'll tell you this is typical of air force colonels and and if don thompson disagrees with me i'll show you one of his slides i saw about a year ago but this is c-stick it these are all things that joe anderson over there now told me that c-stick is involved in and and if you look at them ministry of public health world health organization the p-r-t's national police national army isaac ministry of higher education with the cobalt medical university curriculum unfortunately u-s-a-d has pretty little ellipse right there and i think that should be a lot bigger but that's just what c-stick is involved in and that's their that's too complex too many moving parts just not going to work let's just let's just be honest about the stuff it's just not going to work we need a top-down and a bottom-up revision of how we're doing this however fighting this counterinsurgency uh... i think i'm just going to go to my last slide now which is to show you in anthropological terms but they're only a planet away from each other neither one of them actually touches the earth though i'd like to point out that a lot of folks from our international health division are here and i'd like for you to please try to take the opportunity to get to know them uh... some really outstanding people and i would like for them to get to know you as well because we do have to work hard on this policy and uh... i think it's this is life and death stuff thank you very much thank you butch uh... now we'll have uh... an outside perspective uh... someone who has looked at the programs great deal of experience thank you so much uh... it is an honor to be here i don't know if i actually qualify as an outside perspective because in fact certainly have a i d background i've worked with d o d and h h s so you know perhaps it's the cross-cutting and that's actually what i'm hoping to bring to you today i was privileged to be able to go to afghanistan and try and get a broad look at what it was going on from the u s government perspective not from the afghan government perspective alone not from a single agency perspective alone but to look very broadly it was commissioned by u s a i d thank you u s a i d but it was very very important in what we were doing that we had a steering committee that included h h s u s a i d department of defense and department of state so we were answerable to everybody we really tried to stay objective goal no there we go was to be able to go nowhere thank you to look at what the u s government writ large was doing in afghanistan to look for how the the different agencies were coordinating with one another the programmatic coordination as well as communication around it and how they were aligned with the afghan priorities both of our previous speaker talked about the importance of supporting the afghan government and legitimizing the afghan government and we were to look at is that really happening or is it not really happening as we went there we go it is clear that every agency that's involved in a country has their own specific mandates u s a i d is a development agency d u d has security as its main focus and we have department of state for diplomacy in uh... h h s for health and communicable disease control as we were going it was also the time that uh... afghanistan was rising again in importance and whole bricks white paper was coming out so beginning to look at what are the overarching u s government policies and how would specific agency mandates fall into that so as we went forward and i know sapida is going to talk lots more about the policy things it really became clear to us that what we needed to look at was not just what was u s government doing to promote improvements in health and having a health goal but also where were we relative to coin was it possible to have smart power the picture here on the left or on the right was actually from a visit i made in two thousand in four out into hurrah district and we were with a group of muslim men and they gave the story about the programs even then that were happening in afghanistan saying their women were no longer dying in childbirth their children were no longer sick and they saw it as part of the peace dividend so this was their words that because there was peace they were able to have these health programs that were changing the lives of their family so for our team this idea that you could have dual goals at least seemed possible the question is were we as a u.s government really promoting it or was that not happening it was just wishful thinking uh... bill did a lovely job talking about the health situation i will only pick out some of the highlights situation was bad when the taliban i think in all my years of working in public health that development of the basic package of health service and the e p h s the focus that afghanistan took in the reconstruction is really key it's not singularly unique but it's not very usual and i think it was really really important and while u s a i d was instrumental in this it was also very strongly part of the ministry of health ministry of public health and the minister of health this is what we want to do in rebuilding our country i think that's a strong part of why there has been so much success in rebuilding afghanistan in ways that i haven't seen in many many other bill showed you most of that i just want to say yes when we went we truly not only saw the data that shows that the health is improving but in fact the stories from people everyone is acknowledging that in fact there is huge progress in the health of the people so of our dual goals we know we're making some progress we still have to measure maternal mortality but we know we're making progress the other i can get myself back one slide go back up for me thank you one more right there this was the other very fascinating and i mean how does one measure contribution to coin i don't know i think we need to work on indicators but this was a quote that we heard from an afghan as we were going around and then we tested it with a number of different audiences the ministry of public health is the only ministry that does not have a shadow taliban counterpart isn't that interesting what does that mean both about the functioning of the ministry of public health why do other ministries shadow counterparts there's a justice system that the taliban runs education systems what does it mean that the ministry of health doesn't have that equivalent shadow taliban counterpart and is that part of a contribution to a coin strategy and is it just happenstance or is it something that we can think about learn maybe move forward in the future the key on the health progress is that when i talk to the minister of health that she may who is now gone the deputy minister and many others they will acknowledge that in fact it's the three donor agencies u s a i d world bank in e c that have worked through the b p h s who have made this possible for them so the combined focus and then the agencies that have allowed them to uh... implement that progress uh... i won't go very deep into what we found for each of the different agencies but we did specifically look at each one of the major agencies did this absolutely massive uh... table of all the different programs they had how those programs contributed to health goals contributed to afghan national priorities and how it contributed to the u s government priorities and just did a cross tabulation are we going where we should be going uh... it was interesting and important to outline exactly what each of the agencies did and who they are because in fact one of the key findings was the agencies didn't know one another so we had folks from d o d who said ten months into their twelve-month time they actually found out a i d was there and they began to learn what a i d did and realize there was a resource they did not know about now that's a year old and i'm sure it's getting better the description of who the different agencies are is in fact a transforming piece of information for them in afghanistan u s a i d has been one of the big players since two thousand two has been instrumental in much of the b p h s and e p h i will add a special note on the health systems that bill pointed out and that is as i looked at it from a very high level and especially keeping the two goals in mind it is clear that having a really vibrant health management information system doesn't sound boring data numbers you know reporting people getting sick in fact what it is done is set up a trend an objective and transparent way of doing business in the health sector so there were clear jobs and clear criteria for skills clear hiring firing criteria you knew what was happening in different places so it it led to good governance that wasn't otherwise possible that then helped legitimize the uh... ministry of public health did not get rid of all of the problems that people could say well you know it's an awful lot better the places that are a little slippery they're really small now this h m i s system while it looks very systems oriented and uninteresting has probably been enormously important for good governance which i believe contributes to coin h h s uh... has a specific initiative the african health initiative afghanistan health initiative which is in the maternal material maternal hospital in cabal rabbi about uh... in it has involved very nicely many of the different agencies so your complexity slide uh... you could add to that any one of the agencies has its own bundle of internal things and this particular initiative is a good example so in the in health services there and cdc and i mean h h s itself there's been a host of things in addition u s a i d has funded h h s mainly cdc but also nyosh is there uh... to do specific things and as we were evaluating the agencies we were looking for can we define a comparative advantage when is something really within a i d's realm or h h s's realm or d o d's realm this is that question with the line that that which brought up for us uh... but tried to define what they're doing now and what are they really good at for each of the agencies department of state has the congressional mandate to coordinate what was a little interesting and disturbing was great excitement and willingness to do that here in dc but we saw much less of that interest or willingness to coordinate uh... at least the health activities in afghanistan and get the engagement there was a huge clamor and call for that coordination just like you heard department of defense again i will go very very quickly i will summarize if you possibly do that for something as complex as d o d the main missions that we heard expressed from d o d itself that number one is force health for the troops they're there to keep their own guys healthy number two force health training the afghan national forces how to take care of their soldiers third was quote health sector development but within health sector development working with afghan leadership it included the service to civilians as you heard earlier both casualty and other and it included going out into the villages in other places and some assessment and reconstruction one of the huge advantages obviously that was alluded to earlier is the large footprint that d o d and with many personnel lots of contractors lots of funds so the serf funds are large designated for dealing with civilian issues not military personnel not very much of it goes to health right now but it is rapidly mobile and they are large dollars just a really quick overview so it's the elephant in the room some things aren't going so very well in afghanistan in the health realm we don't know what's happening in maternal health we think it's going better but we don't know yet and the fact that we can't yet find out is a problem in and of itself and we certainly know that in the south and in the east some of the very conservative areas we are still struggling to find women who will be allowed to be trained to care for the other Pashtun women in those areas uh... the economic crisis and then the food crisis began to underpin so it isn't just the health sector it is also health related to many other sectors and then of course the increasing insecurity my first trip to afghanistan as i was flying to hurrah one of the NGOs was flying out one of their american staff people who'd had a stab wound to the chest uh... in his own compound the afghan NGOs the previous week had lost too we know that there is increasing an active targeting of civilian aid workers uh... including health personnel so the NGOs who are out there are doing it at some risk to themselves for every complex problem there is a simple solution and it's usually wrong every one of the organizations agencies is doing really good stuff absolutely well-intentioned and they all have their limitations you've actually already heard most of USAID's limitations they are understaffed uh... and underfunded for the work that they are being asked to do as we talk with DOD and i heard exactly what dr anderson said we want aiding to guide us in the development programs but frankly there's not enough people there's a huge footprint for DOD and now they know aiding exists and they're asking for exactly the kind of information USAID has and there are not enough people to be rapidly responsive especially with a huge number of very fast-moving flexible serp funds so that's the major limitation that and being locked down on the basis the contractors could get out when i was there with three other women we were going from place to place because no one could come to see us in fact we had to go visit the military guys on the base because they weren't allowed to come to our hotel but for women we're allowed to go traveling around probably i think dr anderson pointed out most of these i will say that the overwhelming message as we interview dozens and dozens of people in the end over two hundred fifty the great desire to do more most of the DOD personnel in the health realm are activated you know docs nurses people that are do regular practice here in the u.s. they come to afghanistan whole new world whole new task and they see a world of hurt they've never seen before and the desire to do something and make a difference is huge and they start doing their very very best in about half way into their time realize it's not going very well so the level of distress that we heard from especially the d o d personnel who are wanting to do the right thing and don't know what it is or how to do it better was actually uh... quite overwhelming to at least for my own stereotypes i never expected to be in a room with thirty macho military guys and have them in tears because of the the distress that they were feeling in the disconnect between what they were asked to do in the skills that they had to bring to bear to it walk down again it really wants to stay on that slide again the throwing money at a rack we heard this uh... a number of times but i think more important wasn't just the throwing money at a problem it was the short time frames for action there was a desire to do something visible and immediate there were overarching goals but not strategic long-term goal wasn't any follow-up a serp funds were the commander's emergency response and he needed to spend it while he was there and then he was gone so there wasn't a mechanism for looking that money that was spent this year what was the impact the next year the next year the next year and we uh... as we went around certainly the NGOs would talk about huge military presence we traveled in the military vehicle in god's name armed and uniformed uh... soldiers going to the hospitals where afghan women are lying in beds the cultural issues of that interface is very difficult donations uh... these examples of wells are the uh... we saw a number of times and you'll hear many of these kinds of stories great intentions we know they need safe drinking water they dig a well they give a generator only they give such a large wonderful huge generator there is no petrol no gasoline to keep it running so that uh... a few months later it is dysfunctional people are back to where they were before but there's an important in the work that people are doing afghanistan started in very very bad shape in two thousand and two and we've all been working very hard to do better and improve what's going on and so there has been huge gain and in many of the parts of the world that i work in people will go yes we're making great progress and you heard that today i saw and i was not expecting it in afghanistan was that that gain is real but in our uh... promises and in the things that we are doing we have actually led them to believe in the communities at the highest level and also at the small village level that they were going to get something more than this more than actually got delivered and so what you have them is a gap between what was delivered and what they were expecting and so instead of having the rejoicing of the gains which are real you actually have the dissatisfaction unmet expectations and this has happened when clinics have been overbuilt when the technology that's been brought in isn't appropriate and can't be sustained the underestimates of the population that sounds like a minor thing but in fact if you look at afghanistan the parts of afghanistan that are growing the fast highest reproductive rate are in the south in the east the bphs and the e p h s are based on population estimates that happened previously map out the amount of services the amount of drugs based on the population and then when you deliver it across the country now a number of years later you have too little going to the south you have gore province with stock loads in pharmaceuticals in their back covered in the south where we are most concerned about the conflict and the insurgency is exactly where people have been promised services staff medicines and it's in short supply and part of it is we just don't have accurate estimates of population in a flexible enough system to say a ha we need to rejigger and supply the places based on the population this is in itself a simple and easy thing to flex and begin to address it on a population basis now is it possible that's actually going to take some systems issues or a census which again like maternal mortality has been planned and hasn't happened because of conflict so uh... small issues can in fact be both difficult and transforming unrealized expectations can cause harm not only in the u.s. government to afghanistan relationships but also on the legitimizing the government of afghanistan just a few notable quotes from all of the people that we talked to we didn't really know what u.s. a i d the complexity is an obstacle made worse by turnover there should be some kind of mapping to guide new staff turnover kept coming up because people were learning actively then they were gone or they built a relationship then they were gone the d o d wants u s a and civilian agencies to tell them what to do but they're too few too slow oh and the ministry of health please give us just one u.s. government person to talk to one committee somebody just not everybody so with some really interesting pieces then we realized that in fact some simple frames would help the different agencies begin to think about what can they do in different parts of afghanistan because the other elephant in the room of course is the conflict zones what you can do in hurrah is not the same as what you can do in helman but how do you know what you can do and as dr anderson said how do you make the transitions how do you know when to do the transition so we began to talk with the afghans themselves about what kinds of triggers would let you know you could move to the next stage how do you begin the work in the conflict zone so they are planned to opportunistically you know find an opportunity to do training and take that so that you have the staff and the people during those small moments when something allows you to do it sort of the final pieces is the time is really now distress is high compared to a couple years ago where the agencies both culturally and by policy we're not working together the agencies now want to work together they are ready they're willing they're actually chomping at the bit to find ways to to do that and to coordinate both programmatically communications they need to know each other are i love the slide that essentially laid out the same kind of principles but in the different languages of the agencies because that is very very real that they speak sometimes exactly the same thing but in different words and they don't even realize they're saying the same thing to one another turnover is a huge issue definitely needs to be addressed and we need some balance between the agencies if we're really going to do coordination then we have to have enough people to do it to be there it's a manpower issue for each of them and there needs to be a lead u.s. government coordinating mechanism and an agency on the programming front clear goals uh... one of the things that not just for afghanistan but in many many places we've seen is that you just need to be able to annunciate shared goals and that overcomes many of the differences between the agencies and then you have to measure the contributions to those agencies so a i d has a long tradition of measuring outcomes as hhs has started on their afghanistan health initiative they've been tracking things and in fact it's been very eye-opening and instrumental when they started to look at what was happening with outcomes and allowed them to go back and do some quick reconstruction on their programs to improve them but you've got to look or you won't do it right move it forward there's lots of controversy on uh... what lane d-o-d should be in and what it should be doing but if d-o-d is going to continue to do the kind of development they need the capacity for their own people there's a very strong ethos i won't say perfection isn't the right word but you know if you're going to do it well you need or you're going to do something for d-o-d you should be doing it really really well and yet in this particular area people are out there without capacity to do what they really need and do no harm we talk about that all the time in public health but in the case of afghanistan i think it's really important to think about don't create expectation gaps that you cannot fill that's a different twist on it but seems to have been very very instrumental in afghanistan in having some of our well-intentioned pretty good programs actually probably cause harm to the overall legitimization of the of the government of afghanistan in our relationship with them okay one more where are we on the dual goals of health and coin is it conflict of interest or creative tension the big footprint has big potential d-o-d is here to stay sometimes when i say that before we hear from separate he's going to give us all the answers about with the these have been terrific presentations and i'm sure you have questions so i'd like to find out if we could if we can have the room for another fifteen minutes thank you if you could all stay good afternoon everyone it's really great to be here although i have to say i feel at it disadvantage speaking after all these great presentations and as i'm sure you can see from the two little letters at the behind my behind my name i'm not a health expert so what i'll be talking about is not specifically about health but as they said just about what are the u.s. government policies when it comes to health uh... i also have to apologize i don't have a powerpoint presentations when i was over at the u.s.a. id i learned how to do them and i would have probably done all sorts of animations for you but sitting over at the state they're not as enamored with powerpoints and as was described before you know they they talk about d-o-d's from mars and u.s.a.d.'s from venus i'm not quite sure state department falls into that uh... but you know i'm learning i'm managing lence started with a couple of quotes from the secretary speech a couple of days ago and i would like to follow up on that and talk about another quote that she gave during that day because apparently they were a lot of really great quotes of uh... part of her presentation uh... one of the things she said is whether it's to improve long-term security in places torn apart by conflict like afghanistan or to further progress in countries that are on their way to becoming regional anchors of stability we pursue development for the same reasons to improve lives fight poverty expand rights and opportunities strengthen communities and secure democratic institutions and governance and in doing so advanced global stability improve our own security and project our values and leadership in the world and i think this is really a perfect time to be having this discussion given that it is two days after that the secretary spoke about um... you know what she saw excuse me as development in the twenty-first century and the day after the new uh... u.s. anti-administrator right doctor as you've shot was sworn in because the speech that he gave also really touched upon a lot of these uh... a lot of these issues you know what are we doing in terms of development why are we doing it what is our role and and there's a lot of uh... you know there's a lot of principles that they've talked about which then takes me to the question that was asked of this panel and as the invitation went out which was what are the goals for an implications of u.s. health initiatives in afghanistan is it to address health needs of a suffering population for state capacity building or to support counterinsurgency and as and said uh... for every complex problem there's a simple solution uh... i'm here to provide you with a simple solution and my answer to that is yes uh... it is all of those uh... and of course there is a longer answer which i'm going to talk about a little bit and and i won't speak very long because you know you've heard a lot and i know you all have a lot of questions that you've been holding for the past hour and a half and i know you want to get those out the way uh... i want to present that to you what are the goals of our health programs in afghanistan frankly are not just the goals of our just our health programs these are the goals of a lot of our for of our development assistance of a civilian assistance in afghanistan i've put them under four categories and a lot of these you've heard before but i try to change the wording a little bit because i think sometimes a little bit more nuanced than that what we talked about and this is really no particular order so don't think that i'm making one anymore important the other one uh... the first one is contribution to sustained stability uh... and and this is for example you know we've talked about military opalations you know where people are shooting at you and their bullets flying what do you do and that this is really what we're talking about and you and i did not say to provide stability but i said to to contribute to a sustained stability and i would really like to have a discussion about that actually at the question answer period because i think those are different things and the question that also uh... and the question i would actually propose to that in terms of uh... you know what what do you do when there's a lot of great need and there are bullets flying my question would be what actually really does need to get done in that situation there's a lot of needs there's a lot of things you could do but when there is this insecure unstable situation what does it that what is it that you actually have to get done as a first order of business and the second one is improving the capacity of the afghan government institutions and the afghan government and again i did not say capacity building what i said is improving the capacity because what we very often forget in many many countries but specifically in afghanistan because the level of capacity the base is solo we forget that there's actually something there and there is something to build upon and there are there's a culture there there is a way of doing things that you really do need to take into consideration and you work off of that and a great example of this is actually the minister of public health um... it is amazing that the ministry is already receiving funds directly from the afghan from the u.s. government and you know they're they're managing to hire and contract the NGOs themselves we were doing this through an implementer and now we're no longer doing that and that goes to show that actually really is a lot there i mean obviously takes leadership from the ministry it takes a lot of work it takes a lot of improving capacity that we've done in the past several years but again we were working off of some kind of a base and the third one that is very related to improving the capacity is building up governance and i think uh... you know several people talked about that because again the issue is you know if if the government institutions can actually do the work themselves that does improve governance and we always talk about connecting the people to their government and and i think to that some extent that leads into that and then finally is the long-term engagement and partnership with the afghan people what we've been hearing a lot lately uh... and this was not just in the secretary speech but also in the president's speech is we are here for the long-term in afghanistan and so what that means is a lot of these programs will continue in a different manner and and again that goes back to you know uh... why are we here for all of these reasons because there are the short-term reasons where we do health programs but also education programs and justice programs or other civil assistance program but there is the long-term of okay once you've achieved some kind of stability security then what uh... so that is a somewhat longer answer of you know what what are what are the reasons we're doing that so it really is a little bit of everything and i think it has to be time it has to be sequenced you have different objectives for your program in different places at different times obviously what you're doing in the south in helmand and in kandahar is very different from what you're doing in mazara sharif at this particular moment what you're doing in helmand today is going to be very different from what you're going to be doing in helmand maybe six months from now maybe a year from now maybe three months from now i don't know so so all of these uh... really have their own different timelines and the different objectives at these different times uh... and there are other thing i just wanted to talk about and and then i think i'll be done and you guys can ask all your questions i'm sure you've been holding is the other thing that we're doing is we actually are changing the way we're doing business and and i know this has created a lot of questions this has created a lot of concerns in the past several months within the different communities in which we work but that really also does go back to the reasons we're doing these programs we're trying to move away from having the type of implementers that we've had our programs doing the job to more increasing the capacity and really moving more towards the local implementers and the afghan government itself and as you've seen in the case of the minister of public health we've been able to do that that doesn't mean that the minister of health is able to do all the work on their own and they don't need any assistance any technical assistance or training from us what we've made a real effort to move in that direction and then focusing really on afghan government afghan institutions and local implementation and again i i know this has caused some concerns and i would be happy to discuss any of those if you have but and again if you're not just doing this in afghanistan we're going to be doing in all of our programs this does go back to the secretary's speech which is we are here to build a partnership with these countries to work with them to really build on what they can't do and what they have been able to do and i will just really end by saying that this really is an amazing sector because there is an amazing amount that has been done and has been achieved as you've heard from the other three presenters the maternal mortality has decreased i guess infant mortality has decreased you know that the amount of services that are available to people but there obviously is a lot to do and as we think about the next steps that we have to do to go and then the rest of what we have to do um... let's just keep in mind these principles that we've talked about why are we there why are we doing these health programs well thank you to all four of you for terrific and very illuminating presentations i have good news and bad news for everyone out here everyone here the bad news is i'm going to use the privilege of the chair to ask first question good news it's only going to be one question uh... and when you do ask a question please go to the microphone or do we have one to move around if not you'll have to line up at the microphone my question is is this also please identify yourself when you you ask a question my question for everyone on the panel is this we've heard a lot about how to harmonize counterinsurgency and development objectives and that you've all talked about that in one way or another the question i want to ask you is one of the questions that was in the in the notice which is are there tensions are there tensions between those goals for example in geographic areas of geographic investment and concern are there tensions in short term versus long term objectives are there any other tensions could you all or not all you don't have to answer this but whoever would like to answer this i think it would be helpful to to know what you think about this i think uh... yes there are tensions and there have been tensions i think what we have to do first of all not personalize any of any of these things and and it's too easy to personalize these problems the second thing is that we need clear leadership in terms of who's responsible for what issue but i think the third thing is that we have to realize that the past is the past and it's there to be learned from hopefully it's it's there to caution us against future mistakes and that as as these agencies are living bodies we need to learn and adapt based on our past mistakes and to go forward and to improve the way we do things and and i realize maybe that's being polyanna sure hopelessly optimistic but i think we're doing that again the short answer is of course there are tensions and i think it will continue to be tensions i mean we went back going back to the first slide there are different cultures of people who are working in afghanistan uh... you know there's a military there is the u.s. government civilian there are the NGOs there are the contractors i think we are all used to doing different things differently and we do have the tension when we actually are trying to figure out what we're doing and i actually will give an example the first time i went to afghanistan was in 2004 and i wasn't working on health i was actually working on justice sector and i had to work a lot with my military colleagues and i had done that before in Haiti but not to the extent where i was working with them in afghanistan and it was really really difficult until we said you know what let's just sit down around the same table and you explained to me what you're trying to do and what why you're doing what you're doing and i will explain to you the same thing and once that happened i mean honestly there will continue to be tensions but at least we knew where we were coming from and i will go back to you know what i was talking about there are different situations in afghanistan at different times and i think both from the civilian and from the military we need to recognize that if you are in a very insecure environment there are certain things that will take precedence and security will be that and i think people from the civilian side probably need to understand that now when you go to the more secure areas that shifts a little bit and so you need to you know work that through and i will only say that yes in the short term versus long term the same thing there are tensions i think we're becoming actually better than that better with that a little bit but that will probably continue also i can't really speak on behalf of the different governments we're an implementer and not part of government ourselves i think i would just share our experience has been that that we primarily deal with us aid the the mission in Kabul is the one that is doing the primary interface with the military and with prt's which are the provincial reconstruction teams which would be the ones that would be heavily involved in development we do provide a fair number of briefings for prt's in that but i think that what stands out in my mind and was pointed out a couple times is the time frame as development people we've been involved in other countries to development we know is a is a long process and so i guess you'd say we're in it for the long haul so to speak and often with the military as we speak with them in that it's not that you know we have different purposes or one wants to do good and the other one doesn't or something it's but their time frame was as mentioned is quite different with the rotation of personnel and that that it's it's a much it rolls over much more the ministry you have a pretty you have change over there but it's it's pretty constant this the new minister will only be the third one since the Taliban left in 2002 so so that's more of a perspective of a implementer that us aid has been very helpful to us we haven't felt pressures or tensions that and we haven't felt any as i mentioned in the speech we haven't been told to do a hundred eighty degree turn so it's not turning on dime and doing something totally different and and we think that's really critical keep doing what you're doing and then discussing how we can do it in the insecure areas and how we could ramp up there more in a reasonable way one that's not erratic nor stupid in terms of what you can actually do in these areas where it's more restricted i'd like to follow up on a little bit of that theme certainly as we talked to different people in afghanistan especially the ngos we're very concerned that having a coin focus above a health focus was going to change the decision making and in fact could make a difference in in the effectiveness and the prioritization of the health programs um one of the sort of insights as we went forward and bill talked about health or development is a long-term process that's every sector not just the health sector but takes a long time to change outcome indicators and a whole culture of how people deal with the health issues i will venture to say that coin in the counter insurgency has more of an emphasis on trust and relationship building and meeting people's immediate and perceived needs now in the health realm we actually deal with this all the time when you go into a new community and you're doing community health development you need to address not just the long-term infant mortality maternal mortality you need to address the the communities perceived need of i want a clinic right now when my child is sick and so this shouldn't be actually a new area of conflict or tension we've walked this path lots and lots of times we do need to address some of the visible needs the perceived needs and they need to you need to have some quick wins if you're going to have trust built people need to know that you've heard their needs and responding to it so i think it's not it is definitely tension and it will stay but it's also that balance of how do we do some very visible addressing of perceived needs that will build the trust that will contribute to coin while doing good development at the same time and i think we know how to do that i think we just need to put that into our mindset that we're going to have to do some of the visible things while we keep in mind and set our goals and our accountability also for impacting on the long term first question my name is ken dylan of sciencia press afghanistan has its own traditional medicine unani medicine and uh it has among other things an important economic dimension because it's largely in herbal herbal medicine based system and afghanistan was traditionally a major exporter of herbal medicines so that for the farmers in afghanistan it has some potential i'm wondering do we have a sense of how right now unani medicine is functioning in afghanistan and secondly has the united states or have other foreign organizations sought to reach out and interact with unani practitioners uh the ministry does have um i'm not sure if it's a full department of that they do recognize and um and i i don't remember whether it's under the pharmaceutical or separate it be quite small on traditional medicine so the minister and his staff have recognized it it's not a large component not a large emphasis so i'm not sure if i can precisely answer you other to say i it's not ignored um it's also not a huge element in terms of of um what's being provided and whether that would make a major part in the future that would really be up to the ministry leadership if they wanted to take it in that direction and certainly u.s.a and other donors you know certainly have those discussions with the ministry and are willing to you know follow as they have so i would say that what you see right now is is the ministry's actions and and direction that they have so they've recognized it but it's not a huge element in terms of treatment and and promotion i guess you would say okay and as far as you know the far no other foreign organizations are involved with the unani sector there could be some small NGOs i mean there's so many folks that are involved i guess uh they certainly would not be a major involved player thank you hi my name is john dunlop i'm a health officer in the office of military affairs at usa id um health programs uh tend to spring from and health strategy springs from the ministry of health at a central level rolls down to uh in many most cases district level health services um i finished a tour in iraq working on an eprt and even as a health officer found extraordinarily challenging for prts and eprts to play a positive role in in the health sector kind of at the local level i'm wondering about in the afghanistan context what is the role of the prt um for being a positive force in um kind of improving the overall health situation and not kind of diverting health towards local tactical uh issues and that sort of thing if you could if you could comment on that okay i'll do a stab at that um the prts have both security forces and they have the reconstruction teams which will include a usa id person to help guide the kinds of decisions that they are doing in many of the provinces where usa id had somebody posted um in the last couple years so the kinds of examples we saw they were building very close relationship between the health officers for the prt from from the dod perspective and the provincial medical teams so that as there were CERC funds available from dod and there were needs at the provincial level those two were coming together and they were no longer being allowed to just go out and do things it was being linked into the kind of reconstruction that the province was doing itself now there were guidelines coming down from on top from the central government on where facilities could be placed and staffing in that you know so the provincial medical team themselves not the the afghan rather than the the prt had their own strictures but if they had needs they could define them send them up centrally and then if there was funding or expertise available from the prt it was being linked so while it was partially top down there was ability to do local tailoring and there was beginning to be i'll say stronger than that in some of the places there was very good cooperation so that in fact our prts were facilitating what was happening with within the provincial strategy now that's simultaneously with u.s government mainly u.s a id's programs that have been doing essentially management training of the provincial medical officers the provincial health officers so that and you know they said we're learning how we're supposed to manage a team and hire and fire and design programs and set priorities so they themselves were as a management unit becoming very much stronger and then we're pulling from the prt some of the funding options so it's headed the right direction but again it's nascent there you've got really good people who care and you've got some places where there's more capacity and somewhere there's less capacity and it's being built with both the od us a id and the provincial health the teams now again there was clear evidence that us a id had fewer people than they could needed to guide those kinds of programs so in some of the prts we saw someone with us a id person who was the the go-to development person who had limited expertise and experience and would be guiding on health programs without having very much health expertise so there was a limited capacity for us a id to be able to man the prts in ways that they should have to guide the process that was starting to be put in place fairly functionally let me add to that a little bit though because um you've all heard i'm sure of the whole civilian increase and how they're dramatically increasing the number of people the number of civilians that we're sending to Afghanistan and a huge number of that increased number of civilians are going out outside of Kabul to the prts to district support teams to regional platforms and the idea for that is actually to send more experts out there including help including health experts because in the past what we would normally have is in a prt you would have one state department person one us a id person and maybe a us da person department of agriculture and we're dramatically increasing that number and the idea is to have several civilians in each of these prts or dst or at the higher levels so that you can actually provide that expertise and do more of a coordination now the other thing though to to talk to talk about and again this is not just in the health sector and it might be a little bit better in the health sector because of the way the health system is managed it has been very difficult for the afghan government to deliver services beyond and to the provincial and the district levels for a lot of different reasons because the money doesn't flow down because the people in the malign ministries don't necessarily want to go to a lot of these places now that's a different issue than the u.s. government sending its own its own civilians to provide advice and to coordinate you know between the civilians and the military but that does remain an issue and we are you know we have to work with the afghan government and nbr to try to figure out what to do with that hi uh surge dusts with international medical core i always thank all of you for coming and making presentations which are critical particularly at this time and my question is about coin and humanitarian space uh all the donor countries uh participating in the uh u.s. led coin strategy in afghanistan including the u.s. development agency uh aid and it is also requiring ngos that would like us aid money to contribute to the coin strategy and so my question is how can uh sustainability in health programs in the afghan population have any hope of success over the long term when these programs in many ways are being implemented for political and military reasons with a such a large department of defense footprint throughout the country and it's interesting that someone mentioned that the state department is in charge of counterinsurgency but i don't see any state department or a id personnel throughout the country and that we understand that it's the military and and the way this is perceived by the afghan population so at some point the u.s will leave and the military will leave but the ngos who've been operating there particularly i am seeing many others for the last 25 years we have no exit strategy and our credibility is increasingly hurt because of the population's perception that we are aligned with invading and occupying forces um i mean i can take a step at that um well i'd like after perhaps dr. aniston and dr. pierceen are able to answer that well all of you can answer i just basically wanted to start by saying this is a concern that we are hearing throughout the NGO community and um this is something obviously we've been trying to deal with and we are continuing to deal with um and i can tell you this was actually a topic of discussion with ambassador holbrook just a couple of days ago about how to be addressed this issue and the one thing the quick answer that would go back to again to my simple quick answers is that um in a lot of these areas where they are truly insecure and you know there there has to be military operations that are going on um i would go back to what we would expect from these programs and this is especially actually the first time i met someone we had um do our programs can we expect our programs to contribute to stability or what what i was trying to say is to sustain the stability because in many of these places unless you have the security in place it's very difficult for any a lot of these NGOs to actually even get in there and work when i was there they were trying to draw a map of some of these NGOs you know the whole red versus green and a lot of the NGOs were not even able to operate and these were NGOs that had been there before so again i would go back to um you know we're trying to create the space the security for one of the if there's some of these to operate and then hoping that our NGOs and other implementers can go in there and at that point do their programming okay well first of all let me ask you to get with with matt right there sitting behind cladette because he has cds of our new NGO handbook for the military and do you have enough to go around matt you have 10 okay so first count first served yeah no injuries no injuries in the rush but um we we uh we put together through the jackson foundation a handbook for the military on NGOs it's about a 400 page handbook actually on how to how to work with NGOs and it's been getting some pretty good press so i think that's a that's a kind of a good start and it may actually be helpful to other agencies as well um the the second thing is that NGOs can become kind of a cottage industry and you mentioned lack of an exit strategy and i'm a a huge fan of imc and i've never seen imc trying to feather its own nest through contracts and stuff but but i have seen others do it and uh anytime a host nation government is going to be working through NGOs then NGOs are going to be springing up like mushrooms in the rainforest to take the money and and i think we have to be careful about that because then the anderson complexity index you know goes up by another bazillion factor of a bazillion but um the NGOs have a um and an irreplaceable role in counterinsurgency the problem is the that that area where they overlap and i'll i'll never forget in iraq in 2003 when we went to the icrc headquarters and they got all nervous that we were there and uh we thought that was a little bit silly of them and then a a few days later some icrc guys started getting beheaded out there by the tegris river so it's a real issue that i think we're aware of on the other hand uh if you read the blog health and conflict and health uh there's a lot of talk there about how the NGOs no longer have a an immune position anyway the the enemies that we're fighting now have no more respect for the NGOs than they do for the red cross on a tent so um not addressing that directly but i was going to say what it reminded me of is um that one another one of the big success stories of afghanistan is the number of national NGOs and many of the international NGOs have been very instrumental in helping develop foster um partner with them but um you know initially in 2002 and three when we started contracting there were international and um some national now it's primarily national NGOs so and uh you know and they developed that capacity of that to um you know be accountable financially accountable um they have a reason for being there uh they're committed and that so um and that's also a role that many the NGO international NGOs have played as well of helping to foster that development so i just wanted to mention that that um i'm not sure if i touched on it but i think that's another one of the real success stories is that you have afghans looking after afghanistan in in many many different ways in that that doesn't mean there's no need for international NGOs we still have a strong role in terms of capacity development and that but that capacity is being developed and they're developing their own institutions and civil organizations i would have just three quick points and i'll start a follow on here when we um we're looking at what do we do in the conflict zones as we first went everyone said where the bullets are flying only the military can be there there isn't any other option and it's part of the way through our time we said okay let's question that premise is there anybody else or any other way of bringing health and health services to people who need it in the conflict zones and and started talking with people about that and and basically if you have people there who need health services that means you do have people there who could be providing health services maybe not easily but it brings you directly to afghan um NGOs or the private sector that is there and looking for and using the capacity that is on the ground building what there is up to the next level taking small moments of peace and moving it forward so i think being very creative in some of the relationships with the local NGOs could begin to move some of that forward on the international NGOs we gather a group of them together and very strongly got exactly the message that you were giving surge but as we pursued it longer basically they got to the same place that sepida just said and that is you know we can't go if there isn't security so we don't like it that there needs to be military but in fact oh yeah actually we acknowledge we do need to have some military presence there and then the discussion became more how do we get enough degrees of separation between the military presence and the NGOs so that the NGOs especially in doing aid work are able to go more freely and that's a slightly different concept then you could talk about could money from do d go through provincial um health teams could there there be a contracting from USAID to NGOs can there be presence in the DRTs in the surrounding areas but not right where the NGOs are doing their work so they began to look at ways that you could get enough degrees of separation between the military and the NGOs and let both do the jobs that they're good at so i i think um if we can get beyond sort of gut reactions and philosophical approaches we could get to some compromises that could work out some good relationships thank you for your comments and let me just make one final note at the end of the 80s there was a humanitarian consensus that was negotiated by the UN in Afghanistan that allowed UN personnel and NGOs to be able to work within within Afghanistan and on border areas of neighboring neighboring countries two questions and then we'll get the uh the panelists will answer both questions thank you thank you for your short trip thank you to a very interesting panel um my name is Emily Lavitt i've been coming and going from afghanistan for about five years working on maternal and child nutrition work um so i'm not really here to speak so much about nutrition but um one thing that i learned on my last trip and i was working for the world bank this past year as a consultant on nutrition issues and what i learned when i was talking to different ministries about how one could integrate maternal child health nutrition into different sectors was that um in the ministry of labor social affairs martyrs and disabled the social safety net ministry what i learned in their policy document was that they said one of the top reasons for desertion and poor performance or showing not showing up for duty among the military and the police was that there wasn't a strong safety net for the families of the military and the police and that if something happened to them if they were disabled dismembered killed that because often women aren't working there'd be no way to provide for their families so that was an interesting link um that i hadn't thought about that occurred to me i've been trying to forget what to do with that information as we've been looking at a strategy for afghanistan in general and i just see that we have a lot of very able bodied motivated afghans who love their country who are willing to stay there and try to make something work in their country um for stability i think much more capable although we are an elephant a gorilla whatever we are militarily then afghans people have been comparing us to vietnam and i think the geography of afghanistan is spectacular and incredibly inspiring but it's complex maybe similar to vietnam and i think afghans know their geography and how to fight there maybe better than we do i'll venture i guess and i just wonder if we give them the incentives they need to show up and fight that could relate to health and social safety nets which yes is economics but maybe relates to health um might that be a counterinsurgency strategy that we could put more resources into because i hear we cost five hundred thousand dollars for every person that we put on the ground so just a thought last but come on my name is muhamad dowj from voice of america and by coincidence i'm also a public health expert from afghanistan years of experience there i first want to refer to the reconstruction of the health infrastructure in afghanistan which was mainly done through the last seven or eight years by contractors and mainly international contractors as we are talking about relating the the development projects in afghanistan to stability operation so my idea or my view is that ministry of health or the health sector beside the education sector are the two main potential sectors in afghanistan that the infrastructure development could have been used as a potential means for stability not not not as an end the reconstruction of the infrastructure in the health and education sectors which is a huge and it reaches out to the grassroots of the population in afghanistan these two sectors the infrastructure rehabilitation and building could have been used as a very great potential means of connecting the people and getting community participation and community empowerment through their involvement in the process of reconstruction and ownership of these buildings and as i don't know how it didn't you know take place and it was not a kind of you know opportunity that was not used for you know trust building or for community empowerment that was my point that i want to make and the second thing i refer to the imc colleagues point about the NGOs what is the main as and the afghan constitution the health services as part of the government responsibility to provide for the people what is the purpose and the criteria that is selected for giving out health services to the contractors or to the NGOs in afghanistan whether it is the incapability of the ministry of health that they are not able to provide health services in certain parts of the country or is it some kind of other you know a criteria that is considered that sometimes it it gives a kind of duplication and sometimes gives a kind of duality of of standards in the health services that the NGOs they are getting better in a support of getting better resources they can provide better health services and the government cannot and that's what that was a question that i had about having contracting the health services to the NGOs in afghanistan and whether it's going to be sustainable that's what i'd like to ask the panelists to do in in a minute each for each of you to answer both questions if you like uh or either question or neither and make whatever final remarks you would like to make and why don't we go in reverse order if we can so we'll start with step in it or don't you want to let me respond to the police one first i think great point and there's a lot of reasons the police are deserting part of it is because they don't get paid enough they're getting killed more than the a and a is and part of it is because also they're not getting services and and so there's a lot of discussion currently going on about what kind of training do you provide the police what kind of what do you provide them how much of a salary pay so quick answer it's an issue but health and that is one of the many reasons why they're deserting and those are some of the things we're looking at in terms of the second question i think i will let you to answer the NGO because you guys have dealt a lot with it but relating development to stability operations i i think again these are some of the things we're constantly struggling with and and this goes back to you have to be very specific where you're talking about and and you know usa id has actually done this study which we call it in t-calf which really focuses on what are the drivers of stability in different places and so you know is it health and education that is driving instability is it the lack of justice that's driving instability you can't necessarily go into every place and say well if you bring health you know these communities are going to become more stable maybe it's dispute resolution maybe it's just you know really lack of security and maybe it is health and education so i think you have to be very specific about that now we do talk a lot about again sustaining security and stability once you've actually reached some level of it and i think at that point it really does become important providing health providing education and the example that is constantly given is a national solidarity program because that is one that everyone talks about there is community involvement you know it's the community itself who chooses what kind of programs they want and they're very very involved and i think we are learning a lot from that and we're trying to apply a lot to those lessons that's fine thank you you were short before and okay i think we heard the the economic issue about getting sufficient pay to keep people in their jobs as an issue across the board not just for the police though it clearly was a much larger problem there the one of the other interesting pieces relative to that was the the police versus the army being a less trusted part of the security forces in afghanistan and at least a hint that not only economically but the issue of drug use in that population could be a factor again that could be a health issue that we could begin to deal with from the the drug abuse and the mental health perspective and assist the a and a and a and p to address some of those issues and the only other thing that i thought would be important at least on the the contracting out of the health services that was raised is while it may have been done out of expediency initially in afghanistan there are a number of places in the world where contracting out for the government to ngo's has been taken on later in the development cycle and it can be sustainable it can be the best way to do it or it can be a temporary interim step as you build the capacity of the government itself so i've been astonished actually at the flexibility and forward thinking of the government of afghanistan in rebuilding its health sector in ways that are focused thoughtful and creative and fairly functional and they're making great progress one of the fears i would be would have is that we let them go too soon before they are able to really continue it on their own and then we would be in exactly the same place as some of the findings that we had of we've created very high expectations of better health services and then if support gets withdrawn there will be a faltering in that you will have people expecting services they even even less get now and you increase the dissatisfaction and instability so i would say we have to very very firmly hold on to the progress that we've made in health it as part of the coin strategy in stabilization thank you bill you get the last word oh oh i didn't you know i was looking right past you doesn't reflect anything but i'm sure i'm sure um regarding uh first of all regarding the afghan national army anp um as as the anan and p ramp up their numbers every single soldier and every single police officer becomes important because training them is very difficult to recruit him it's very difficult to train him it's very difficult to retain him not unlike the american military and uh and uh beyond that what i want to say is i agree with you and if you get with dr mason mack moode sitting back there beside you we'll continue to work with you in the future and we look forward to it very much so thank you very much for your question um the uh the second issue um i'd like to say that um everybody in here probably has worked all their lives to get a's on all their report cards all their transcripts every one of you i know is has i mean yeah i went through premed so you know by his liberal arts guy first but so i know what premed people are like and you're out there um is it is it real important that we get an a for for all of our reconstruction efforts is it real important that our marks are all a's not to me um i want to do the best job i can but i know that if i'm taking calculus or quantitative chemistry quantitative analysis i'm not going to get an a it ain't going to happen but there are other things i'm going to get an a and i think it's the same way with do d there are certain things that if we're trying to build a hospital system somewhere i'm i'm okay with getting a b when usa id comes in and takes it over or on behalf of the host nation government usa id comes in and you know takes it over um if if if they tell us that we got a 84 percent i'm just going to be hilariously happy thank you okay i guess i get last crack um emily levitt's comments remind me of one thing uh not so much reminded me but an observation we've been talking about you know how do we coordinate amongst the u.s government agencies i'd say one gap is there's uh not much coordination among afghan ministries of themselves so there's some work to be done there as well so i was just going to say it's not just us that have a hard time getting this thing together and correct so uh in fact it's a nutrition is one of them at least within the ministry where we're starting to work with the agriculture and um the um some of the un agencies dealing with um uh food and that uh wfo and that so anyway so that's just one uh additional bonus comment um the second was what uh ann had mentioned the national solidarity fund has been tremendously successful this is a government of excuse me a program through the uh mr rd ministry where small grants are given to communities to do with they have to come up with a plan and it might be a uh a micro hydro uh electric uh one you know a little tiny dam or something to give some electricity in the evening hours for remote villagers of that but they figure it out and they can get a grant to provide that and then that money they use local contractors and that to do it um so that's been very successful and i know there's looking at how they can expand that or make that and i but it's recognized across um all countries uh and donors that this has been a very successful program of the afghan government third thing on as far as the delivery of services um i was in the meeting and i believe was april of 2002 when the ministry of health with the donors the decision was made that um the afghan government's ministry of public health would uh it's the um it oversees it's the steward of the health sector but there would not be the recreation of a huge bureaucracy in terms of the government providing the services actually delivering the services they would oversee set the standards establish what um what would happen what needed to happen um but using the uh mechanism of NGOs to deliver the services rather than creating basically a huge bureaucracy if you had to have all those as staff or um employees civil servants of the government so that was a conscious decision it's not something that's just stumbled across or that and the government was full and parcel part of that decision so um i think the i guess just for our final word i was just searching for um i guess a word and uh at least uh i think for me personally um maybe i'll use two words i guess uh and i'm not sure which one to use promising and hopeful you know we can talk about that we hear the news and that but there's so many other things going on little bits here and there uh with the different parts of government that are happening and not just in the health sector so it's not all dark clouds over afghanistan there's actually many good things here and there well i think we should thank our panelists not just for their terrific presentations but for the work they're all doing so let's give them a and thank you all