Afghanistan is not a hopeless quagmire

The choice now is to risk abandoning a decade of military and civilian investment, or to capitalise on it.

NATO’s leaders have set out a roadmap for long term political and economic support for Afghanistan, but the headline-grabbing component is that the NATO-led combat mission will cease in 2014.

Despite repeated assurances that the alliance will provide support and training to the Afghan National Security Forces well beyond 2014, the strategy is frequently portrayed as a "rush to the exit". This perception threatens to undermine our armed forces’ remarkable achievements in Afghanistan. After more than a decade of their sacrifices, the Afghan National Security Forces are increasingly able to take the lead in maintaining security. This is essential in order to build a functioning Afghan state.  But it is only one part of the task.  There are still daunting challenges to strengthen civilian services and the economy.

A decade of development assistance has transformed many lives. 5.8 million Afghan children, including 2.2 million girls, are now in school – up from 1 million boys and no girls under the Taleban.  More than half the population now have access to health facilities within an hour’s journey, compared to less than 10 per cent in 2002.

The situation in Afghanistan is far from rosy, but it is not the hopeless quagmire sometimes portrayed in the media which, understandably, gives more space to dreadful events like "green-on-blue" attacks, rather than the slow but steady progress with Afghanistan’s ability to stand on its own feet.

I have recently returned from my fifth visit to Afghanistan where I had the opportunity to take stock of the situation as seen by NATO military and civilian personnel and Afghan parliamentary and provincial leaders. One measure of progress is the truly remarkable growth in the Afghan National Security Forces (ANSF).  A few years ago – and not before time – efforts began to recruit and train the over 350,000 soldiers and police men and women judged necessary to maintain security in Afghanistan.  With well over 300,000 now in place, Afghan forces are now taking the lead in a growing number of districts and provinces.  By the end of next year, they will be in the lead throughout Afghanistan although ISAF – and its successor – will continue to provide support and training well beyond 2014.  Some capabilities such as air support, medical evacuation and other key “enablers” take time to build from scratch.  Highly-skilled pilots and engineers cannot be produced quickly in a nation whose education system has been woefully neglected for decades.

This leads me to my key point: NATO-led forces have enabled Afghanistan to increasingly take responsibility for its own security.  We must now do more to assist Afghanistan to bring about a similar step change in governance and the economy.

President Karzai is due to step down, and a new president to be elected, in April 2014. The election will not run like clockwork but it must be free and fair enough to reassure voters that the victor really is the people’s choice.  Afghanistan’s large, well trained and well equipped security forces are accountable to the Head of State.  If the new President were to lack legitimacy their loyalty and accountability could be compromised.

The challenges are formidable. The relationship between central government and the provinces is sometimes dysfunctional, corruption is rife, skilled labour is in critically short supply, and the economy has been devastated by decades of war.  But the investments needed to address these problems are much smaller than those that have been made in security.  The choice now is to risk abandoning a decade of military and civilian investment, or to capitalise on it.

During my recent visit, I saw how leaders in Herat have begun to take advantage of the relatively stable security environment there to create new economic opportunities.  They greatly appreciate the transformation that the international community has made possible, but they are also aware that they still have an enormous mountain to climb, and the climb could be made faster and easier with more outside help.

So what can we do?

First, launch specific assistance programmes to mitigate the economic effects of reducing force numbers and closing military bases.  The force drawdown will hurt local communities which have benefited economically from providing goods and services to many of our military facilities.  We must avoid delivering a harsh economic blow to an already impoverished people.

Second, help Afghanistan to register voters and create a trusted and independent electoral commission to supervise the elections.

Third, emphasise and re-emphasise that 2014 marks a transition to a new form of engagement and not a withdrawal.  The Afghan people remember being abandoned by the international community before and naturally fear the prospect of a repeat performance.  There is already evidence that uncertainty about “post-2014” is leading to the flight of capital and educated Afghans whom the country can ill afford to lose.

NATO and its partners should announce as soon as possible the details of the forces that will deliver support and assistance beyond 2014.  At the same time, the national and international organizations delivering civil and economic assistance should demonstrate a visible expansion of their activities.

Fourth, as the budget for "military operations" reduces, governments should allocate a proportion of their peace dividend to development assistance in Afghanistan.  The ratio certainly doesn’t need to be one-to-one.

According to one estimate, each American serviceman costs about a million dollars per year.  To put that in perspective, Afghanistan receives about 220 million Euros per year in aid from the European Union’s central budget and about five times that figure from the EU nations themselves.  That is a lot of money, but less than $2 billion, so less than the cost of 2,000 soldiers when we are bringing tens of thousands home.  We shouldn’t just throw money at Afghanistan, but we must make sure that development programmes are sufficiently resourced.

We should do this because we have succeeded in raising hopes in Afghanistan, and we have a responsibility to help those hopes to be fulfilled.  And if that is not reason enough, we should remember that it is in our own interest to ensure that Afghanistan does not fail. We have witnessed the terrible consequences of the world turning its back on Afghanistan. Through literally heroic efforts and sacrifices, Afghanistan is almost ready to take the lead in dealing with its own security problems.  We should now rise to the civil and economic challenges to make sure that our military sacrifices have not been in vain.

An elderly Afghan man walks past a US Army infantryman in the Panjwai district in Afghanistan. Photograph: Getty Images.

Hugh Bayley is Labour MP for York Central

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Want to know how you really behave as a doctor? Watch yourself on video

There is nothing quite like watching oneself at work to spur development – and videos can help us understand patients, too.

One of the most useful tools I have as a GP trainer is my video camera. Periodically, and always with patients’ permission, I place it in the corner of my registrar’s room. We then look through their consultations together during a tutorial.

There is nothing quite like watching oneself at work to spur development. One of my trainees – a lovely guy called Nick – was appalled to find that he wheeled his chair closer and closer to the patient as he narrowed down the diagnosis with a series of questions. It was entirely unconscious, but somewhat intimidating, and he never repeated it once he’d seen the recording. Whether it’s spending half the consultation staring at the computer screen, or slipping into baffling technospeak, or parroting “OK” after every comment a patient makes, we all have unhelpful mannerisms of which we are blithely unaware.

Videos are a great way of understanding how patients communicate, too. Another registrar, Anthony, had spent several years as a rheumatologist before switching to general practice, so when consulted by Yvette he felt on familiar ground. She began by saying she thought she had carpal tunnel syndrome. Anthony confirmed the diagnosis with some clinical tests, then went on to establish the impact it was having on Yvette’s life. Her sleep was disturbed every night, and she was no longer able to pick up and carry her young children. Her desperation for a swift cure came across loud and clear.

The consultation then ran into difficulty. There are three things that can help CTS: wrist splints, steroid injections and surgery to release the nerve. Splints are usually the preferred first option because they carry no risk of complications, and are inexpensive to the NHS. We watched as Anthony tried to explain this. Yvette kept raising objections, and even though Anthony did his best to address her concerns, it was clear she remained unconvinced.

The problem for Anthony, as for many doctors, is that much medical training still reflects an era when patients relied heavily on professionals for health information. Today, most will have consulted with Dr Google before presenting to their GP. Sometimes this will have stoked unfounded fears – pretty much any symptom just might be an indication of cancer – and our task then is to put things in proper context. But frequently, as with Yvette, patients have not only worked out what is wrong, they also have firm ideas what to do about it.

We played the video through again, and I highlighted the numerous subtle cues that Yvette had offered. Like many patients, she was reticent about stating outright what she wanted, but the information was there in what she did and didn’t say, and in how she responded to Anthony’s suggestions. By the time we’d finished analysing their exchanges, Anthony could see that Yvette had already decided against splints as being too cumbersome and taking too long to work. For her, a steroid injection was the quickest and surest way to obtain relief.

Competing considerations must be weighed in any “shared” decision between a doctor and patient. Autonomy – the ability for a patient to determine their own care – is of prime importance, but it isn’t unrestricted. The balance between doing good and doing harm, of which doctors sometimes have a far clearer appreciation, has to be factored in. Then there are questions of equity and fairness: within a finite NHS budget, doctors have a duty to prioritise the most cost-effective treatments. For the NHS and for Yvette, going straight for surgery wouldn’t have been right – nor did she want it – but a steroid injection is both low-cost and low-risk, and Anthony could see he’d missed the chance to maximise her autonomy.

The lessons he learned from the video had a powerful impact on him, and from that day on he became much more adept at achieving truly shared decisions with his patients.

This article first appeared in the 01 October 2015 issue of the New Statesman, The Tory tide