Abstract
Funding and defunding decisions in global health are often not subject to ethical scrutiny although they carry the potential for iatrogenic violence. The funding and defunding of a maternal health project in Kabul, Afghanistan during the 2000s reveals the post 9/11 science-politics dynamics that resulted in the emergence of maternal mortality in Afghanistan as a humanitarian object. Despite concerns raised by the Afghan Ministry of Public Health, U.S. Department of Health and Human Services subcontractors renovated one of four public maternity hospitals in Kabul, doubling the number of births per year and increasing the rate of caesarean sections. Project defunding in 2011 was due to a confluence of primarily political factors. Project actors–Afghan and internationals–expressed ethical concerns about the abrupt defunding and the particular risks to women undergoing emergency caesarean sections at the hospital. The analysis presented here has wider relevance for the global surgery movement and concerns about fluctuations in donor funding in global health. There is a need for an ethics of global health funding and defunding decisions that encompasses policies, relationships, stronger local public health systems and civic participation. Global health (de)funding must be made more of an object of ethical deliberation and negotiation.
| Original language | English (US) |
|---|---|
| Pages (from-to) | 1136-1151 |
| Number of pages | 16 |
| Journal | Global Public Health |
| Volume | 17 |
| Issue number | 7 |
| DOIs | |
| State | Published - 2022 |
Keywords
- Afghanistan
- ethics
- funding
- global health
- surgery
ASJC Scopus subject areas
- Public Health, Environmental and Occupational Health
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In: Global Public Health, Vol. 17, No. 7, 2022, p. 1136-1151.
Research output: Contribution to journal › Article › peer-review
}
TY - JOUR
T1 - Toward an ethics of global health (de)funding
T2 - Thoughts from a maternity hospital project in Kabul, Afghanistan
AU - Parsons, Michelle Anne
N1 - Funding Information: Northern Arizona University supported part of this research through faculty development funds. Maternal mortality in Afghanistan emerged as an object of humanitarian intervention through the entanglements of science and politics. The rise of maternal mortality as a global health issue is well documented (AbouZahr, 2001; Shiffman & Smith, 2007; Smith & Rodriguez, 2016). The first World Health Organization interregional meeting on maternal mortality was held in 1985. That same year Rosenfield and Maine’s (1985) seminal Lancet article, ‘Maternal mortality–a neglected tragedy: Where is the M in MCH?’ was published. Two years later the first international Safe Motherhood Conference was held, heralding the Safe Motherhood Initiative, an Inter-Agency group, and national committees and strategies. The Safe Motherhood Initiative had a goal of reducing maternal mortality by 50% in one decade. It was the beginning of an era when global health would stake numerous time-bound statistical goals. United Nations Millennium Development Goals included reducing maternal mortality by three quarters by 2015. The 2005 World Health Report focused on maternal, newborn and child health and the Partnership for Maternal, Newborn and Child Health was formed. Community-based and facility-based maternal care have a complex relation in global health, sometimes competing for resources. During the 2000s facility-based emergency obstetric care was ascendant. In part to monitor the progress toward the two maternal and child Millennium Development Goals (MDGs), the Lancet published a number of series related to maternal and child survival in the 2000s: child survival (Black et al., 2003), newborn survival (Lawn et al., 2005), maternal survival (Ronsmans & Graham, 2006) and stillbirths (Frøen et al., 2011). In 2015, the Lancet Commission on Global Surgery identified caesarean sections among three ‘must do’ global surgeries (Meara et al., 2015). This foment around global emergency obstetric care in the 2000s occurred during the years of the project. After 9/11, the U.S. launched retaliatory military strikes in Afghanistan in October 2001, overthrowing the Taliban and installing President Karzai in December; massive global humanitarian aid followed. Maternal mortality in Afghanistan emerged as a humanitarian object par excellence. Women have long served as a justification for global intervention in its various guises; in Spivak’s evocative phrasing, ‘white men saving brown women from brown men’ (Spivak, 1988). This is perhaps especially true of Muslim women (Abu-Lughod, 2002; Lazreg, 1994). In a November radio address, Laura Bush justified military intervention in Afghanistan: Fighting brutality against women and children is not the expression of a specific culture; it’s the acceptance of our common humanity–a commitment shared by people of good will on every continent. Because of our recent military gains in much of Afghanistan, women are no longer imprisoned in their homes. […] The fight against terrorism is also a fight for the rights and dignity of women. (Bush, 2001) Bush’s voice joined many others that used Afghan women to justify interventions–military and humanitarian–in Afghanistan. In an October congressional joint hearing on Afghanistan’s humanitarian crisis, an ‘acute-on-chronic’ (Farmer, 2011) event precipitated by U.S. military strikes, maternal mortality figured. Senator Boxer, co-chairing the hearing, stated that Afghan women ‘die in tremendous numbers giving birth’ (United States Senate, 2001, p. 4). Eleanor Smeal, president of Feminist Majority, a nonprofit organisation dedicated to women’s equality testified: This is a near holocaust situation, and as far as health care, please, it is so minimal that one woman every 30 minutes, somebody calculated, is dying from childbirth […] we should be thinking in terms of billions of dollars, and we must be thinking in terms of really reconstructing this country, and at the center of it must be women. (United States Senate, 2001, p. 47) Maternal mortality statistics began to proliferate and mutate. Representative Carolyn Maloney, Chairman of the Women’s Caucus, wore an Afghan burka (chaddari) at the podium (Congressional Record, 107th Congress, 2001, p. 139: H6893): ‘An Afghan woman dies in childbirth every 30 seconds.’. The source of Smeal’s original statistic–one woman every 30 minutes–is unclear but the figure is plausible; Maloney increased the rate many times in what was certainly a slip. Representative Janice Schakowsky stated that ‘more than 1 in every 100 women dies in childbirth … Women give birth to their children on hospital floors and then watch them die due to minor complications’ (Congressional Record, 107th Congress, 2001, p. 139: H687). At a time when most Afghan women gave birth at home, hospitals, clinics and doctors emerged in the political rhetoric as intervention targets. Rhetoric on Afghan women’s health also reverberated in the media in the last months of 2001, coalescing around maternal health. In a November 13 Vancouver Sun (2001) article: ‘Women do not have access to health care; as a result, an estimated 45 women die every day from pregnancy-related causes’. In another article: ‘The average Afghan life expectancy is 45.8 years for men, lower for women because so many die in childbirth’ (DiManno & de Castro, 2001). Maternal mortality was reported as the highest in the world (Hull, 2001; Manuel, 2001). Cherie Booth, lawyer and first lady in the UK, chimed in with an opinion piece in the London Daily Mirror in November: ‘Afghanistan has the world’s worst record on maternal mortality partly because there are no female doctors and women have to be hidden from the sight of men’ (2001). And more rates drifted to the very top of the global rankings: ‘Infant, child and maternal mortality rates are now the highest in the world because there is no medical care for women. Life expectancy is virtually the lowest’ (Swain, 2001). Afghanistan had ‘the world's lowest life expectancy and literacy rates and the highest rates of infant, child and maternal mortality’ (Hume, 2001). The use of these statistics was part of a larger arrangement coalescing around Afghan women’s health. As part of this arrangement, the statistical claims made sense even if they were not always accurate. At the time, estimates of infant and maternal mortality in Afghanistan were unreliable and ranged between 820 and 1700 per 100,000 live births (UNFPA, 2001; WHO, 1999); Afghanistan often did not appear in the appendices of UN reports. Save the Children’s flagship publication, State of the World’s Mothers, was first published in 2000, introducing the Mother’s Index. In the 2000 and 2001 State of the World’s Mothers reports, Afghanistan is not mentioned and not included in the appendices (State of the World’s Mothers, 2000; State of the World’s Mothers, 2001 : A report by Save the Children, 2001). The 2002 report, published in May, focused on women and children in war and conflict (State of the World’s Mothers, 2002 : Mothers & Children in War & Conflict, 2002). The 42-page report includes 43 mentions of Afghanistan. An Afghan woman’s lifetime risk of dying in childbirth was estimated as one in seven–the worst risk statistic shared by only three other sub-Saharan African countries. Afghanistan began to be known as ‘the worst country in which to be a mom’ (Rahmani & Brekke, 2013). A group of epidemiologists from the CDC and UNICEF teamed with the Afghan Ministry of Public Health in 2002 to produce more reliable estimates of maternal mortality in four provinces in Afghanistan. They estimated overall maternal mortality in Afghanistan between the years 1999 and 2002 at 1600 per 100,000 births. In Kabul, the maternal mortality was estimated at 400, but the other provinces were estimated at 800, 2200 and an astonishing 6500 in Badakshan–‘the highest ever reported globally, highlighting not only the importance of this health issue in Afghanistan, but also that great variation in health exists within Afghanistan’ (Bartlett et al., 2002, p. 4). In the conclusion of their report, the authors write, ‘Most women did not access a doctor or physician to help with the birth, an important way to prevent maternal deaths’ (6). A press release on the report was headlined, ‘Afghanistan is among worst places on globe to be pregnant’ (UNICEF, 2002). The issue of maternal mortality in Afghanistan was entangled with a rapidly expanding statistics of global and maternal health in the 2000s. Claims about maternal mortality both reflected a crisis and enacted a crisis amenable to intervention. These claims were increasingly tied to the provision of emergency obstetric care by doctors in hospitals and clinics even though, at the time, most Afghan women gave birth at home. Rottenburg writes of the staging and performance of the power of science. ‘Humanitarian interventions into zones of disaster are nearly as excellent opportunities for this exercise in stagecraft as astronautics or military interventions’ (Rottenburg, 2009, p. 433). The staging of this power necessarily makes invisible all those other failures related to more mundane medical problems such as fatal dehydration in young children due to diarrhea and all those even more mundane failures lying behind the medical emergencies, such as the provision of healthy drinking water, urban sewerage systems, healthy and sufficient food, healthy environment, fresh air and basic health care for all. (433) Afghan maternal mortality was a product of extremely challenging political, economic and social conditions, but the issue was often framed as a problem of clinical care. The day of the UNICEF press release U.S. Department of Health and Human Services (DHHS) Secretary Tommy Thompson announced that the DHHS would build a new women’s health clinic in Kabul, which would provide training for Afghan health workers. Just reading the CDC/UNICEF report breaks your heart. In provinces outside Kabul, in places like Kandahar and Badakshan, most women die from the complications of childbirth. The vast majority of these deaths–not only from childbirth, but also from infection, disease, and trauma–are preventable. But they’re only preventable with the right equipment. They’re only preventable with the right personnel. They’re only preventable with the right education. And that’s where we come in. The DHHS, which includes the CDC, Indian Health Service, National Institutes of Health and Food and Drug Administration divisions, was one of a number of U.S. government agencies administering aid to Afghanistan during the 2000s. The Kabul project, funded through the Afghanistan Health Initiative, helped forge a greater role for the DHHS in U.S. global health diplomacy. The day after the UNICEF press release the DHHS received a cable from the new U.S. embassy in Kabul. The cable contains information, albeit secondhand, on Afghan perspectives on the project at this time. The Afghan Ministry of Public Health wanted to prioritise primary health care throughout the country and did not want a Kabul-based teaching facility. The cable listed a number of issues: The MOPH proposes that other areas of the country be chosen for the program as Kabul is relatively well served. MOPH would like consideration of where the greatest needs are as a factor in choosing other sites for these clinics. MOPH expects HHS to cover the operational costs of whatever facility(ies) are part of the proposed program. HHS proposes to establish a ‘model’ clinic, presumably to international standards. The Afghans are asking for a model clinic not set to meet unsustainable US standards, but to set high standards in the Afghan context. The MOPH requests that the proposed HHS training/mentoring by presumably HHS-funded Afghan-American doctors or volunteers should be turned into long term commitments. HHS proposes short-term assignments. The cable concluded: Embassy is concerned that the apparently good faith offer made by Secretary Thompson has not been coordinated sufficiently with the MOPH, that the MOPH has a different idea of what it wants … Until we understand what is on the table and can confirm the MOPH is on board, request any further planning for the initiative be delayed. The DHHS went ahead, renovating one of four public maternity hospitals in Kabul. Over the course of 9 years, the DHHS subcontracted with various U.S. and international state and non-state agencies, including a research university, the CDC, Veterans Affairs, Indian Health Services and CARE, investing over U.S. $50 million. The humanitarian crisis resulted in a context particularly conducive for international agencies to implement their projects without much coordination, either with representatives of the MOPH or with each other. Amina, who had worked at a maternity hospital before moving to a position in the MOPH, spoke of international agencies that quickly secured ministry signatures during the 2000s. The bad thing was, especially the UN organizations, they didn’t have very good coordination. For example, they just designed their programs. They were going to the minister and got the minister’s signature. They didn’t coordinate their activity with the director of reproductive health first before signing with the minister. […] Once they brought us the signed project and we didn’t have that capacity to work with them, they just pushed us to do that. The minister pushed us to do that. We didn’t have enough staff. We didn’t have enough time. All organizations rushed on us to coordinate with them whenever they wanted. […] They already have the signature. They say, ‘We already have our strategy. Why should we use your strategy?’ We said, ‘No. We know about our staff. We know about our country. We know about our facilities.’ They said, ‘No, no. Please come and open our workshop. Come to the closing workshop.’ […] We wanted a plan for the country. We made a plan. It took two or three months to put their [international organizations’] activity in our plan. We got that plan. We got the signature from the minister for our plan. Then they come with something else. We showed them. This was our plan and they already put their input into our plan. We couldn’t say anything. One U.S. midwife had also worked in post-conflict Kosovo spoke about post-conflict maternal and child health and ‘the proprietary mess of NGOs involved’ in Kabul. ‘Everybody had their own shtick, and they were very protective of it. They were very territorial and proprietary in their approach to what they wanted to do’. The author would like to thank all of the project actors who participated in interviews and provided information and data. In particular, MSS helped arrange my visit to Kabul. Publisher Copyright: © 2021 Informa UK Limited, trading as Taylor & Francis Group.
PY - 2022
Y1 - 2022
N2 - Funding and defunding decisions in global health are often not subject to ethical scrutiny although they carry the potential for iatrogenic violence. The funding and defunding of a maternal health project in Kabul, Afghanistan during the 2000s reveals the post 9/11 science-politics dynamics that resulted in the emergence of maternal mortality in Afghanistan as a humanitarian object. Despite concerns raised by the Afghan Ministry of Public Health, U.S. Department of Health and Human Services subcontractors renovated one of four public maternity hospitals in Kabul, doubling the number of births per year and increasing the rate of caesarean sections. Project defunding in 2011 was due to a confluence of primarily political factors. Project actors–Afghan and internationals–expressed ethical concerns about the abrupt defunding and the particular risks to women undergoing emergency caesarean sections at the hospital. The analysis presented here has wider relevance for the global surgery movement and concerns about fluctuations in donor funding in global health. There is a need for an ethics of global health funding and defunding decisions that encompasses policies, relationships, stronger local public health systems and civic participation. Global health (de)funding must be made more of an object of ethical deliberation and negotiation.
AB - Funding and defunding decisions in global health are often not subject to ethical scrutiny although they carry the potential for iatrogenic violence. The funding and defunding of a maternal health project in Kabul, Afghanistan during the 2000s reveals the post 9/11 science-politics dynamics that resulted in the emergence of maternal mortality in Afghanistan as a humanitarian object. Despite concerns raised by the Afghan Ministry of Public Health, U.S. Department of Health and Human Services subcontractors renovated one of four public maternity hospitals in Kabul, doubling the number of births per year and increasing the rate of caesarean sections. Project defunding in 2011 was due to a confluence of primarily political factors. Project actors–Afghan and internationals–expressed ethical concerns about the abrupt defunding and the particular risks to women undergoing emergency caesarean sections at the hospital. The analysis presented here has wider relevance for the global surgery movement and concerns about fluctuations in donor funding in global health. There is a need for an ethics of global health funding and defunding decisions that encompasses policies, relationships, stronger local public health systems and civic participation. Global health (de)funding must be made more of an object of ethical deliberation and negotiation.
KW - Afghanistan
KW - ethics
KW - funding
KW - global health
KW - surgery
UR - http://www.scopus.com/inward/record.url?scp=85106306180&partnerID=8YFLogxK
UR - http://www.scopus.com/inward/citedby.url?scp=85106306180&partnerID=8YFLogxK
U2 - 10.1080/17441692.2021.1924821
DO - 10.1080/17441692.2021.1924821
M3 - Article
C2 - 33977857
AN - SCOPUS:85106306180
SN - 1744-1692
VL - 17
SP - 1136
EP - 1151
JO - Global Public Health
JF - Global Public Health
IS - 7
ER -