US Faulted on Efforts to Rebuild Nations
    By Bryan Bender
    The Boston Globe

    Wednesday 19 April 2006

Healthcare called too low a priority.

    Washington - The United States failed to make the health of ordinary citizens in Iraq and Afghanistan a top priority of reconstruction efforts, missing an opportunity to create substantial good will in the crucial days after the US-led invasions, according to a study to be issued today.

    The nearly 400-page report by the government-funded RAND Corporation compared the successful rebuilding of post-World War II Germany and Japan with more recent nation-building efforts in Iraq, Afghanistan, and the Balkans.

    It found that those earlier reconstruction efforts put healthcare - including nutrition, basic sanitation, and medical care - at the top of the rebuilding agenda. But those efforts have not been replicated in recent nation-building efforts.

    Even after failure to adequately address health concerns undermined nation-building in Somalia, Haiti, and the Balkans in the 1990s, the United States did not make sufficient efforts to provide basic services in Iraq or Afghanistan.

    "Of the many lessons about health and nation-building that the international community learned in the 1990s few have been applied in Afghanistan or Iraq," according to the report, a copy of which was obtained by the Globe.

    The study found that 40 percent of the water and sanitation network in Baghdad has been damaged during the last three years, and remains unrepaired, in part because of the ongoing insurgency.

    Moreover, a year after major combat ended in 2003 the three main sewage plants in the capital were inoperable, forcing sewage to be dumped into the Tigris River and placing the population at risk of communicable disease outbreaks, the study said.

    The sewage plants eventually were repaired, but surveys afterward indicated that most Iraqis were unhappy with the quality of the new sanitation services, according to the report.

    Meanwhile, the study found that too many early efforts in Iraq were focused on redesigning medical-training programs and disease-tracking systems - efforts that had little impact on citizens' daily lives. The lack of a meaningful connection between the occupiers and ordinary citizens may have led to support for the insurgency, the study said.

    "Counterinsurgency experts have long argued that winning hearts and minds is a key - if not the key - component in establishing peace," the report said. "Health can play an important role in the effort by, for example, offering tangible health programs to the local population and meeting basic health needs."

    There are some bright spots in the report. The researchers noted that serious outbreaks of malnutrition and disease were prevented in the immediate aftermath of the 2003 invasion and that many of Iraq's hospitals were reopened in the months after the toppling of Saddam Hussein.

    The report, "Securing Health: Lessons from Nation-Building Missions," was prepared by RAND's Center for Domestic and International Health Security in Santa Monica, Calif., and was funded by a donation from a California couple involved in international philanthropy.

    It highlights historical nation-building efforts in which early emphasis on public health paid off. In Japan after World War II, for example, a program to distribute powdered milk to undernourished schoolchildren created much good will, the eight-member research team found.

    Indeed, the study rated the rebuilding efforts in Japan and Germany as the most successful of those the researchers looked at, in part because of the heavy emphasis on basic public health.

    More recent efforts in Kosovo and Iraq were considered "mixed cases," while the report characterized as the least successful the recent efforts to provide basic healthcare in Afghanistan, Haiti, and Somalia, which have all been the subject of US-led relief and peacekeeping efforts.

    The report says that Afghanistan faces some of the most vexing healthcare challenges.

    After three decades of strife, the country still has no national health system, requiring the international community to build one from scratch. The country will require long-term investments in nutrition and sanitation. Afghanistan will also have to train a new generation of doctors, nurses, and other healthcare professionals, according to the report.

    Success in rebuilding the public health sectors was defined in the study as measurable improvement over time in life expectancy rates, birth rates, death rates, infant mortality rates, the rate of infectious disease, and malnutrition.

    The researchers acknowledged that making historical comparisons is difficult because different countries face different challenges. For example, Germany and Japan had far more advanced infrastructures in place when American troops arrived, while more recent targets of nation-building were considered failed states or nations with little semblance of a modern healthcare system.

    And, in the cases of Haiti and Somalia, the US government did not stay long enough to make a lasting difference, according to RAND.

    Germany and Japan did not suffer from the security problems posed by heavily armed insurgents, terrorists, or killing squads that have wreaked havoc for US nation-building efforts in Afghanistan and Iraq.

    "The healthcare sector is particularly sensitive to security in at least two ways: through direct effects, such as the inability of patients to visit doctors; and through indirect effects, such as the inability of healthcare facilities to function properly," the report says.

    Even in Germany, which was relatively stable following World War II, local authorities were unable to take responsibility for healthcare for nearly three years after the occupation, a testament to how difficult it will be to staff and sustain public health systems in less mature societies, RAND found.

    But improvements in the health of ordinary citizens soon after the US invasion of Iraq three years ago might have helped to head off some of the insurgency, the assessment asserted.

    "There is some evidence that poor health conditions - especially poor sanitation conditions - contributed to anti-Americanism and support for the insurgency," it said. "Most early reconstruction efforts in the Iraqi health sector went into activities that were not immediately visible to Iraqis."