Early last week, President Obama put forward his Afghanistan endgame. For those few readers living in a hole, the new strategy will deploy 30,000-37,000 additional NATO troops to the country. The hope is that the influx of ground forces will give the Afghan government time to build the legitimacy and capacity needed to continue fighting after international forces withdraw, optimistically scheduled for 2011. This is a markedly different strategy from the previous administration, which readily accepted the possibility of a semi-permanent, strong American presence in the country. Does health have a place in Obama’s new strategy? Absolutely. Enhancing Afghanistan’s local healthcare capacity offers a means to establish the political legitimacy of the central government.
Currently, most Afghanis have little relationship with Kabul. Outside the capital, the government has little role the lives of citizens, providing minimal services or public goods. The dubious reelection of Karzai only reinforced the disconnect between the general population and the political machinations in Kabul. Obama’s plan is contingent on closing this divide, building (note: not rebuilding) Afghanistan’s social contract. Increasing the capacity of Afghanistan’s local health system would be an important move towards increasing the interaction between the population and the Afghan government. In other words, hospitals and health clinics are “points of sale” for selling the value of the central government. The more citizens percieve interacting with the central government as beneficial to their lives and livelihoods, the more they will support that government when threatened. Whether Obama’s strategy includes such a goal is unclear.
But, I must end with a note of caution. As pointed out eloquently by Maj. Gail Fisher, the concept of political legitimacy might be inappropriate in Afghanistan:
Ideas of legitimacy are most likely created by cultures as shared meanings and understandings about governance and the relationship between the government and the individual in that culture. So I am looking for an understanding of “legitimacy” of systems outside our own Western view. For example, Afghanistan is a clientelistic society– what does that mean for governance? What does that mean for the health of their people? I doubt that the people of Afghanistan have the same understanding and ideation of governance as I and my neighbors. Their expectations are different, meaning that development must fit in to their schema, rather than mine. Do the people of Afghanistan expect the central government to supply a health system? I would suspect they do not. We, in America, have the same debate at this very time over the lack of coverage of nearly 50 million people and what should be done. Most people do not expect the government to provide health care to the population. Working with the Minister of Public Health in Afghanistan to build the health system is admirable work, but is it legitimizing the government? Does it delegitimize the coalition efforts to be involved? Should only NGOs do this work? All these questions depend upon the cultural ideation of legitimacy and health institutions, I think.
Food for thought for sure.
Christopher Albon is a Ph.D. candidate specializing in armed conflict, public health, human security, and health diplomacy.
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Democratization meets cultural relativism. Counterinsurgency and stability operation must necessarily adopt an approach of cultural relativism. That’s the US and Europe’s biggest weakness, and maybe China’s biggest strength (extraterritorially, at least).
Good point. Another way to put it is bottom-up approaches to health. The military has a decent amount of variation in applying cultural relativism to MEDCAP operations. Sometimes they hold firmly to the top-down approach to develop that fails so miserably in the 1960s, other times they blow NGOs out of the water with their willingness, even eagerness, adopt creative bottom-up approaches to development projects.
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