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Gains In Afghan Health: Too Good To Be True?

Jan 17, 2012
Originally published on January 17, 2012 7:19 pm

A U.S.-sponsored mortality survey released last year announced huge improvements in health across Afghanistan. But the gains are so great that experts are still arguing about whether it's correct.

During three decades of war, Afghanistan remained a black hole of health information. The few mortality studies looked at a small slice of the population and then extrapolated.

The numbers were horrific. Life expectancy in 2004 was measured at just 42 years; 25 percent of children did not survive until the age of 5. For every 100,000 deliveries, a staggering 1,600 women died in childbirth, the second-worst rate in the world.

Enter last year's $5 million Afghanistan Mortality Survey, which was funded by the U.S. Agency for International Development with a contribution from the U.N. Children's Fund. Officials say the new survey provides the most accurate snapshot ever of health in Afghanistan — and it delivered shockingly good news.

Afghan surveyors in all 34 provinces brought back data suggesting that life expectancy at birth is now 62 years. Child mortality under age 5 dropped to 10 percent. Of 100,000 live births, the maternal mortality number was down to 327.

"We were all surprised," says Susan Brock, health adviser with USAID in Kabul. "That's what led to additional review and much more analysis."

Brock says it was such an improvement compared with previous surveys that USAID delayed the release to crunch the numbers again. Last November, after months of re-examining results and meetings of technical experts in Dubai and in Washington, the agency confirmed the findings and released the survey with great fanfare.

But believing the new numbers are accurate probably means accepting that the old numbers were way off, which makes it impossible to say exactly how much health has really improved. It's unlikely that both the old life expectancy of 42 years and the new estimate of 62 years are correct.

'Huge Question Marks'

Some experts who worked on the survey still think it shows too much of a leap forward to be credible. Dr. Kenneth Hill, a Harvard University demographer and technical adviser on the survey, says there are too many anomalies.

"If the results had come out closer to expectations, they would have been hugely valuable, I think," Hill says. "But because there are still huge question marks hanging over the estimates, I'm not sure there is an enormous value in the data."

The survey divided Afghanistan into three regions: north, center and south. In many findings, the southern zone is excluded, because security made it impossible to conduct polling. Cultural taboos about discussing female family members meant that the birthrate of female children was underreported, and that's also likely true of infant mortality.

The survey clearly and honestly explains these facts, and USAID says that statisticians accounted for many such factors. But Hill says he suspects the raw data is off.

"Conditions for data collection are desperately difficult," he says. "Knocking on someone's door and asking them details about their children and their household is not something most people would want to do."

Three of the six experts on the survey's technical advisory group told NPR they still have doubts, even after the extra analysis. That includes Julia Hussein, of Aberdeen University.

"You've got to match what you know in terms of evidence with what you see with your eyes," says Hussein, who has worked on maternal mortality in Afghanistan since the 1990s.

"My instinctive reaction to figures reported in the survey — I just find them unbelievable, knowing what sort of care is available in Afghanistan," she says.

Undeniable Progress

But defenders of the study say people can't believe the numbers because they've become accustomed to thinking of Afghanistan as hopeless.

Dr. Mohammad Rasooly, with the Afghan Ministry of Public Health, was the lead technician from the Afghan side of the survey. He says health care in his country is improving dramatically, and in many different ways.

"If we consider only the example of midwives, 10 years back we had only 400 midwives at the national level. So, today we have more than 3,000. This is very important for maternal care," Rasooly says.

Now, new paved roads mean that a journey to one of the thousands of newly built clinics takes hours instead of days in rural areas, says Rasooly. Widespread mobile phones have helped save the lives of people who in the past had no way to call for help. And there is little doubt that women have much more access to health care.

Maternal mortality is notoriously hard to measure, and the new figure of 327 maternal deaths per 100,000 births has a margin of error that could make it much higher. It could be nearer 500, says Rasooly, but it's certainly not 1,600, which is progress.

Need For Aid Still Acute

It's not about knowing the exact number, says Ken Yamashita, USAID mission director in Afghanistan.

"We're quite confident of the numbers. In the end, it's a survey, so any survey has an error margin," he says.

Yamashita says the new mortality survey is the best ever done in Afghanistan.

"What it represents is a more representative survey on the one hand, and two, a very real improvement in health," he says.

The only way to know will be to conduct more surveys a few years down the road, at the same comprehensive standard, says Yamashita. He adds that even the new, more encouraging numbers show that Afghanistan is still desperately in need of international aid to help improve the health of its people.

Copyright 2013 NPR. To see more, visit http://www.npr.org/.

Transcript

ROBERT SIEGEL, HOST:

From NPR News, this is ALL THINGS CONSIDERED. I'm Robert Siegel.

AUDIE CORNISH, HOST:

I'm Audie Cornish. And we begin this hour in Afghanistan. A U.S.-sponsored mortality survey released late last year announced huge improvements in health across the country. Among the headlines, life expectancy in Afghanistan has increased by 20 years, just since 2004. USAID funded the study with a contribution from the United Nations Children's Fund. Officials say it provides the most accurate snapshot ever of health in Afghanistan.

But the scale of improvement is so remarkable that experts, including several involved in the survey, worry the results are too good to be true. NPR's Quil Lawrence reports on the debate about the data.

QUIL LAWRENCE, BYLINE: During three decades of war, Afghanistan remained a black hole of health information. A few studies looked at a small slice of the population and then extrapolated. The numbers horrified the world. Life expectancy in 2004 was measured at just 42 years, 25 percent of children did not survive until the age of 5. For every 100,000 deliveries, a staggering 1,600 women died in childbirth, the second-worst rate in the world.

But last year's survey delivered shockingly good news. Afghan surveyors in all 34 provinces brought back data suggesting that life expectancy at birth is now 62 years. Child mortality under 5 dropped to 10 percent. Of 100,000 live births, the maternal mortality rate was down to 327.

SUSAN BROCK: We were all surprised. That's what led to additional review and much more analysis.

LAWRENCE: Susan Brock, health adviser with USAID in Kabul, says it was such an improvement that they delayed the release to crunch the numbers again. Last November, USAID confirmed the findings. But some experts who worked on the survey still think the data is too good to be true, like Dr. Kenneth Hill, a Harvard University demographer.

KENNETH HILL: Because there are question marks still hanging over the estimates, I'm not sure that there is an enormous value in the data.

LAWRENCE: Hill says many Afghans simply don't discuss family matters with strangers.

HILL: Conditions for data collection in Afghanistan is desperately difficult. Knocking on someone's door and asking them details about their children and their household is not something most people would want to do.

LAWRENCE: USAID says their statisticians adjusted the findings for many anomalies which are all explained honestly in the survey. But three of the six experts on the survey's technical advisory group told NPR they still have doubts, like Julia Hussein of Aberdeen University, who has worked on maternal mortality in Afghanistan since the 1990s.

JULIA HUSSEIN: You've got to match what you know in terms of evidence with what you see with your eyes, virtually. And I suppose - so my instinctive reaction to figures like this, that have been reported in the survey, is that I just find them unbelievable, knowing what sort of care is available in Afghanistan.

LAWRENCE: But defenders of the study say people can't believe the numbers because they've gotten used to thinking that Afghanistan is hopeless. Dr. Mohammad Rasooly says health is improving in many different ways. He was lead technician from the Afghan side on the survey.

MOHAMMAD RASOOLY: For instance, if we consider only the example of midwife, 10 years back we had only 400 midwife at the national level. So today, we have more than 3,000. So this is very important for maternal care.

LAWRENCE: Also, new paved roads mean a journey to the clinic takes hours instead of days, says Rasooly. Widespread mobile phones help people call for assistance. Dr. Rasooly says the survey's margin of error is pretty big, but he has no doubt health is much better now than 10 years ago. It's not about knowing the exact number, says Ken Yamashita, USAID mission director in Afghanistan.

KEN YAMASHITA: We're quite confident of the numbers. In the end, it's a survey, and so, any survey has an error margin.

LAWRENCE: Yamashita says the new mortality survey is the best ever done here, but it will take more studies like this one some years down the road to do a comparison and establish a trend.

YAMASHITA: What it represents is a more representative survey on the one hand, and two, a very real improvement in health.

LAWRENCE: So while the experts debate whether life expectancy could have really jumped 20 years since 2004, doctors now have a better baseline. And even the most optimistic numbers still show that Afghanistan will need help for many years to improve the health of its people. On that, at least, all the experts agree.

Quil Lawrence, NPR News. Transcript provided by NPR, Copyright NPR.