USAID: Remarks by USAID Administrator Andrew S. Natsios, 05/29/02

This is an archived USAID document retained on this web site as a matter of public record.

Remarks by Andrew S. Natsios
Administrator, U.S. Agency for International Development

Global Health Council
May 29, 2002
Text as Prepared

Thank you. I would like to devote my remarks today to the dire health situation facing the Afghan people.

The good news is that the wide-scale famine many feared has been averted and humanitarian food and relief extended to millions of Afghan homes. There remain pockets of desperate need, however, that must be reached. There is no question that the international community will have to continue supplying essential foodstuffs to much of the population until the Afghans can rebuild their agriculture. That will take at least a year, and probably considerably more.

If the drought that is now entering its fourth year continues, however, the consequences could be devastating.

In the meantime, we are doing our utmost to help farmers get a decent crop in this year and build up livestock herds, repair irrigation systems and replant orchards. All of these systems are broken. So, too, is the infrastructure - the roads and markets -- on which farmers and herders depend. War, drought, and the Taliban have each exacted a heavy toll.

The fact that most Afghans are now getting enough food has obscured the fact that millions of people are suffering from the long-term effects of malnutrition and undernourishment. We are now trying to determine the extent of the damage and the precise nature of people's health problems. This is very complex undertaking, and it may be many months before we have enough data to put together a solid picture.

Several factors complicate our efforts. Many of the health statistics the international community is using date from around the time the Taliban seized power. We simply cannot know how accurate they are today.

We are just beginning to gather new data. Travel is still difficult in most parts of the country and virtually impossible in others. So most of our data is preliminary. What nation-wide statistics as do exist tend to mask local conditions. Even within districts there are great variations. There are major regional differences in the health conditions people face. And whatever capability Afghanistan's Ministry of Public Health had to assess health conditions has been wiped out by years of warfare and destruction.

In addition, an estimated 10,000 Afghans a day are returning to their homes and villages from Pakistan and Iran, internally displaced persons camps, or wherever people have managed to find shelter. The fact that they are on the move makes them even more vulnerable to disease, food shortages, landmines, and the insecurity that still plagues the country. It also makes it extremely hard to monitor their health.

Still, we have some facts to go by. Life expectancy for women was about 47.2 years in 1999. For men it was even worse - 45.3. Other estimates put these figures even lower. To put this in perspective, these are roughly the same rates as in southern Africa, where a third of the population has HIV/AIDS.

Children's Health

According to UNICEF, in 1998 Afghanistan's mortality rate for children under age five was 257 out of 1,000. More than half of them - 165 out of that 257 - will die within their first year. These are among the worst rates in the world, unlike anything seen in Asia in many years and comparable only to countries like the Congo or Sierra Leone.

Twenty percent of the babies born in the country had low birth weight, obviously a reflection of food supply and maternal health, both major factors in infant mortality.

In the decade ending in 1998 - a period of great violence and destruction in Afghanistan -UNICEF reported that 48 percent of the children under five were moderately to severely underweight. A large percentage of them were chronically malnourished and thus highly vulnerable to diseases like diarrhea, malaria and respiratory infections, which often lead to further malnutrition and weight loss.

Not surprisingly Afghans suffer from a high incidence of infectious disease. Measles remains a problem. Malaria affects two to three million people a year. Tuberculosis is a serious problem, with 555 cases estimated per 100,000 people. Leishmaniasis, a disfiguring disease, is endemic in the country.

While very low, immunization rates are improving considerably. Less than half the children have been immunized for measles, but the figure is rising thanks to recent emergency vaccination efforts. More than eighty percent have now received some polio vaccine.

In addition, Afghanistan is probably the most heavily mined country in the world. An estimated 210,000 people have been disabled by landmines.

Women's and Maternal Health

Afghanistan's maternal mortality rate is one of the highest in the world - 1,700 per 100,000 live births. This is 140 times the rate in the United States. Altogether one out of every 15 Afghan women will die in childbirth or from complications related to it. About 16,000 do every year. Only about a third of the country's 330 districts has a maternal or child health clinic.

Only eight percent of Afghan women had the benefit of a skilled attendant during delivery, according to a U.N. report. That same number - eight percent - received prenatal care. Most of this occurred in urban settings, meaning that women in the countryside are desperately short of services. Well over 90 percent of deliveries take place at home. Hospitals that do offer obstetric care are crowded with women who have had complications, many of whom delayed seeking care until they were near death. As a result, even some of those who seek care die.

More than half the women in the country suffer from anemia, with some estimates suggesting a much higher figure.

The Consequences of the Drought

Over the past four years, Afghanistan has suffered from a drought of unprecedented length and severity. The situation is particularly acute in the central Hazarajat -- where the snowfall was minimal this year - but its effects continue to be felt in every region of the country.

Unfortunately, the drought is not over, as Sue Lautze of the Feinstein International Famine Center at Tufts University notes in her most recent report from Afghanistan. "Irrigation and drinking water problems will return to the north and west by this summer, while persisting at alarming levels elsewhere in Afghanistan until at least next spring."

In addition to its obvious effects on food supply and caloric intake, the drought has limited people's access to clean water, with all the attendant health problems that creates. Only 19 percent of the Afghan people have access to clean water in urban areas. In rural areas, the figure is less than that - 11 percent. Again, if the drought continues, these numbers can only decline.

The lack of water also means that things we take for granted like bathing and washing clothes have become too expensive for many people, with obvious consequences for their health and hygiene.

The drought also killed many fruit trees and destroyed household vegetable gardens. As Lautze notes: "The orchards provided an important source of vitamins in the household diet, and the loss of fruit increases vulnerability to micronutrient deficiencies… Nutritional vulnerability has been compounded by a loss of access to vegetables. Kitchen gardens, once ubiquitous throughout Afghanistan, largely have been abandoned because of the drought."

Indeed, most Afghans today are getting by almost exclusively based on starches - rice, gruels, bread and potatoes. Over an extended period of time, this takes an enormous toll on people's health.

"There is a national nutritional crisis in Afghanistan," Lautze reports. "These micronutrient deficiencies are contributing to stunting in children, poor concentration, reproductive health problems, blindness, growth failure and etc. and prohibit the proper utilization of consumed food resources by the body. While representing serious health concerns in the short term, micronutrient deficiences represent a challenge to the development of Afghanistan."

Recent Assessment of Women and Maternal Health Conditions

Recently, one of our technical advisors, an epidemiologist and public health nurse named Patricia Stephenson, returned from a month in the country, where she was part of a UNICEF team sent to assess maternal and newborn health needs.

Let me share with you some of her findings. First, there is a local NGO community in Afghanistan - women doctors, nurses, midwives, and health care workers. While the quality and services they provide varies considerably, they nevertheless represent an important resource that the international community should continue to be support.

One major problem in extending maternal and newborn health services is the lack of female health care providers. There is an urgent need to recruit and train midwives and auxiliary midwives. All training in this area ceased during the time of the Taliban.

Midwifery education is being reintroduced now, but it faces several obstacles. The Taliban's restrictions on women's education substantially reduced the number of women who have the necessary reading and writing skills. Only 22 percent of the women in the country are literate. Materials in Dari and Pushtu are limited, although a new curriculum is being developed. Further, schools lack the means to house women and pay them stipends while they study, making it particularly hard for those from the countryside - where the needs are the greatest -- to attend.

Somewhat to the surprise of our researchers, Afghans apparently are quite interested in family planning. Women are particularly eager to increase the time between children. Birth spacing and reducing the number of children women have will have a major impact on infant mortality and women's overall health.

Basic medicines are available at facilities supported by NGOs. Those who do not have access to these hospitals and clinics can find medicine in the markets, but it is often prohibitively expensive and of questionable quality.

Further complicating the situation is the lack of security. People, especially women, continue to have great difficulty getting to hospitals and clinics because of landmines, fighting among warlords, and general safety concerns.

Health Care as part of overall strategy

Addressing Afghanistan's health care crisis is an important part of our overall recovery strategy. Important though they are, however, health is just one piece of a large and very complex picture. For the present, food and security, remain our primary concerns.

Our overall goal is to help Afghans rebuild their lives and livelihoods. This means making sure people have enough to eat. It means supporting the Interim Authority and the new government that will come from the Loya Jirga. It means revitalizing agriculture, planting crops and rebuilding people's livestock herds so that people can begin to feed themselves or purchase what their families need. It means repairing roads and irrigation systems. It means supporting education, reopening schools, training teachers, and paying particular attention to the needs of women.

In the meantime, we are doing what we can - pooling our resources and expertise with the other donor nations, the U.N. specialized agencies, and the NGO community.

Within that context, let me outline five areas we are working on in the health field.

Emergency Nutrition. Working with our long-time partner in Afghanistan, the WFP, we have supplied $77.5 million in emergency food aid since last September. In fact, we have been the largest donor of such assistance to Afghanistan for many years. Now we are planning to fortify our donated wheat with iron to combat the widespread anemia and vitamins to address the country's need for micronutrients. We are supporting supplementary and therapeutic feeding centers and helping re-establish kitchen gardens. And we are continuing to monitor and assess people's nutritional needs, particularly in those areas hardest hit by the drought.

Immunizations and infectious disease control. We are providing vaccines and syringes to immunize 2, 260,000 children against measles and supporting polio eradication. We are confronting two of the biggest killers of children - treating acute respiratory infections and training health workers in safe water handling, sanitation and oral rehydration therapy to fight chronic diarrheal disease. And we are working with WHO to distribute impregnated bed nets that keep out the mosquitoes that cause malaria.

Primary Health Care and Maternal and Child Health. In order to get a better understanding of the conditions facing the country, we commissioned Management Sciences for Health (MSH) to survey the country's hospitals and clinics. This will be carried out summer and should give the donor community and the Ministry of Public Health a much better idea of what facilities exist, where they are located, what kind of shape they are in, the services they provide, whether they have female staff, and what kind of equipment, supplies and financial support they have. In addition, we are also funding MSH to work with local Afghan NGOs and health care institutions, and providing essential drugs and supplies. We are providing technical assistance to the Ministry of Public Health in management, pharmaceutical procurement and personnel systems, and doing spot rehabilitation of health clinics and establishing emergency obstetric care centers.

Water and sanitation. We are rehabilitating damaged wells and drilling new ones, helping people dig latrines and improve their sanitation facilities. We are working with communities to establish water resource management committees, and providing water and sanitation services for people still living in the country's IDP camps. At the same time, we are using Radio Kabul to inform people about a host of health issues, while using the private sector to distribute low-cost oral rehydration salts, safe water containers, and chlorine for water purification.

Services for war victims. Using Leahy War Victims Funds, we will be training orthopedic technicians and establish a new organization to promote technical standards for orthopedic and rehabilitation services. And we are contributing $1 million to help provide service for victims of torture.

No one can say with any certainty how long Afghanistan's desperate health care crisis will continue. There are many factors beyond our control - the drought, the unsettled security questions, the rivalries among the various ethnic groups and clans. But the Afghans are a people of amazing resiliency. There are hospitals and NGOs and local health care professionals that have managed to survive, and they are eager to forge ahead. They want to help their countrymen climb out of the abyss that circumstances have forced upon them. They want to be trained and taught new techniques. Much can be done with such people, and we are fully committed to doing it. That is the best news of all.

Thank you, and now I would be happy to take your questions.