Ten years on in Afghanistan

Ten years on from sending troops to Afghanistan, it is time to draw breath, and reflect on the human and health costs of war. Both the Afghanistan and Iraq wars were supposed to make the world a safer place. Yet, as ASIO noted, the risk of terrorist attacks on Australians has increased. And the deaths and illness resulting from these conflicts go far beyond the terrible body counts.

The 29 Australians killed in Afghanistan and the more than 900 receiving compensation for injuries sustained in the war are but a small fraction of the costs of the war. The New York Times cites more than 100,000 civilians dead in Iraq, and the independent US-based Costs of War project estimates between 12,000 and 14,000 civilians dead in Afghanistan. Nearly 19,000 members of the Iraqi and Afghani security forces have been killed, and over 7,000 coalition troops have returned home in coffins. The human tragedy is enormous and obvious.

Depressing as this is, in fact the damage is potentially much greater. In choosing to spend money on warfare, we have foregone many other opportunities. Australia's war expenditure has been over $9 billion ($2.4 billion in Iraq, $7 billion in Afghanistan and counting). We have thus turned our back on many programmes that would have saved lives, rather than cost them. In stark contrast, Australia's international development assistance budget allocation for health in 2010 was $173 million over four years – less than $45 million a year.

So much could be done in health and education, where positive projects could be funded by the huge sums spent on the conflicts. The UN Millennium Development Goals, addressing issues such as extreme hunger, poverty, child mortality, primary education and environmental sustainability are a long way behind their targets due to lack of funding. UN figures estimate that $10 billion, not much more than Australia's war expenditure, would achieve the goal of universal primary school education. This would mean every child would have access to schooling, and education is known to be a major factor in improving later health.

Locally, Australian and New Zealand funded health prevention strategies have proven highly cost effective. For example, integrating Hepatitis B vaccine into the immunisation program in ten Pacific Island countries has reduced hepatitis B rates enormously, costing roughly $190 for each premature death prevented. Technical support and funding was provided for a five year period. After that time the Pacific Island countries took over funding the program themselves. In addition, the success of this project has markedly reduced transmission of hepatitis B in Australia and New Zealand, saving millions of dollars in local health expenditures.

In Papua New Guinea, AusAID helped pay for more than 900,000 children to be immunised against measles and other childhood illnesses in 2009. Immunisation is one of medicine's 'best buys,' especially when it comes to reducing childhood deaths.

But there is still so much more we could do. Currently AusAID's own website notes that worldwide 9 million children under five die each year and 360,000 women die from treatable complications of pregnancy and birth. In 2008 the Australian government spent just 0.038% of our gross national income on development assistance in health. This puts us at 13^th out of the 23 OECD countries – not a statistic to be proud of.

Yet another health aspect to war in any region is the loss of skilled workforce, which particularly affects health services. In a conflict zone, a large part of the local population will leave. Salam Ismael, a representative of Doctors for Iraq, visited Australia several years ago and described a health system in crisis across the country with most senior doctors having either fled or been killed. As a result there is no adequate training of junior doctors, and the overstretched hospitals are desperately lacking in medical and nursing staff. On top of all this all the civilian war related injuries create a massive increase in workload.

The International Crisis Group is very grim in its description of the outlook for Afghanistan. Like Iraq, the health infrastructure has been decimated. In 2015, when the troops have left, they say there is no way the Afghan state will be in a position to provide even basic services to its people. This too will result in further deaths and disease. What little stability exists will further undermined.

Currently in Afghanistan it is unclear what is being achieved in the long term. Locals are reported as liking Australia's efforts in clearing roads and improving security, yet fearful of the night raids and the controversial "capture and kill" missions that result in civilian casualties. Civil war looms on the horizon, as it has for decades. It is proving extremely difficult to build robust Afghani security forces with training from foreign troops who know little of the country's culture and its people.

So what conclusions can we draw from all this? Can we salvage those opportunities that have been wasted since 7 October 2001? What measures will build goodwill and trust and undermine the hatred that breeds terrorism? Greatly expanded military budgets do not seem to be the answer.

We know that Australia's health resources can be used effectively and efficiently to reduce death and disease in countries overseas. Using Australia's resources strategically to improve health outcomes internationally would not only save lives but also indirectly strengthen international security.

The lives lost directly in the conflict are only a small fraction of the enormous human and health costs. War needs to be recognised for what it really is - both a tragedy and often a preventable health disaster.