That Sheep May Safely Graze: Rebuilding Animal Health Care in War-Torn Afghanistan

Abbreviations

The world of development aid is rife with acronyms. People involved in the work use them constantly. To reflect the reality on the ground, it is not possible to write this story without the use of acronyms. I hope this alphabet soup will not cause too much distraction for the reader.

Map of Afghanistan

1.

Go See the Warlord

December 1993

I had been working in Quetta, Pakistan, with the United Nations Development Program (UNDP) as a program veterinarian for southwestern Afghanistan for only a couple of months when my project officer in Islamabad, Bob Eaton, instructed me to fly to the city of Herat in western Afghanistan. He wanted me to find out if it was feasible to set up a veterinary training facility there for the Dutch Committee for Afghanistan, a humanitarian agency that had been working to provide veterinary services for Afghan herders and farmers following the Soviet invasion in 1979.

If you want anything done in Herat, Eaton said, you have to clear it personally with Ismail Khan. Ismail Khan was the former mujahideen warlord who had now officially become the governor of Herat Province. I had never met a warlord before, let alone negotiated with one, but if that’s what it took, then that’s what it took.

Ismail Khan possessed the aura of legend. He had been an educated career army officer in the Afghan National Army (ANA) prior to the Soviet invasion of Afghanistan. Then, in March of 1979, while serving in the ANA in Herat under the Communist government, a citizen revolt took place against the government in the city. Instead of assisting in putting down the insurrection as ordered, he and other officers joined it, distributing military weapons to the insurgents who subsequently killed Soviet advisors to the government garrisoned in Herat.¹ The central government in Kabul brought swift and severe retribution against the Heratis, but Khan avoided capture and reemerged as a powerful and effective mujahideen resistance leader. When the Soviet-backed government of Dr. Mohammad Najibullah finally fell in 1992, Ismail Khan quickly assumed leadership in Herat. Drawing on his intelligence, discipline, authority, and apparent flair for civil administration, he brought a semblance of normal life to Herat while other former mujahideen commanders plunged the rest of Afghanistan into further chaos and untold suffering as they battled for control of the country in a bloody civil war.

From the moment our small United Nations plane landed at Herat Airport, where the burned-out hulks of fighter planes littered the shoulders of the runway, the cult of personality that surrounded Ismail Khan was evident. In the airport terminal and on storefronts and billboards along the airport road there were large posters of the man, designed to celebrate his bravery and leadership skills. The most popular poster showed him close up, in the field, in full battle regalia. He had on a flowing turban and an army fatigue jacket, and was barking orders into a walkie-talkie held up to his mouth. One gleaming automatic rifle was tucked under his arm and another darker one was slung over his shoulder. He had a full, bushy black beard, authoritatively streaked with gray. Here, the posters proclaimed, was a decisive man of action and a force to be reckoned with.

It took me and my UN colleagues four days to get the chance to reckon with him. For three days, we went daily to the Foreign Office only to be told that the governor was not available. Finally, on the fourth day, we were told that Ismail Khan could see us, but at his military headquarters, not at the governor’s office. We climbed into our vehicle, headed to the outskirts of town, and came to a stop in front of some nondescript, low-lying, concrete buildings surrounded by barbed wire and with a large army tank displayed on a flagstone pedestal in front of the main gate.

One of my Afghan colleagues, Dr. Alemzada Qasem of the Dutch Committee for Afghanistan (DCA), went inside while the other three of us waited in the truck. After about thirty minutes, Qasem came out and signaled for us to come along. The driver started up the truck and we passed through the main gate, circled around the back of the buildings, and parked outside another sentry post. Beyond the sentry post, waiting on the veranda of the building, were numerous soldiers and a number of fierce-looking mujahideen-types seeking audience with the governor.

Up to this point, I hadn’t really given much thought to my actual meeting with Ismail Khan. Despite the widespread evidence of his authority and power, the fact that this man might be fearsome, threatening, or even dangerous had not really crossed my mind, and I had not adopted a strategy for our deliberation. Now, entering the building under the cold stares of the heavily armed men on the veranda, I began to regret my lack of forethought. Suddenly, the situation seemed unexpectedly menacing.

We passed into a long, narrow, dimly lit, low-ceilinged, seemingly endless corridor, punctuated by a series of successive anterooms, each packed with unsmiling armed guards. With a growing sense of claustrophobia, I realized that we were moving progressively through downward sloping tunnels into what amounted to Ismail Khan’s underground bunker, or inner sanctum. My throat went dry and my knees weakened. Into my fevered mind came the image of Dorothy, the Tin Man, the Cowardly Lion, and the Scarecrow quaking timorously in front of the spectral apparition and booming voice of the Wizard of Oz in the moments before Toto pulls back the curtain on the control room to expose the Wizard as a charlatan. But Ismail Khan was no charlatan. He was a man of considerable stature, power, and control and very real. How was this meeting going to end? The clanking of the Tin Man’s trembling knees reverberated in my ears.

Then, thankfully, I remembered that during my high school days, when acting in the school play or performing with the choir, this same sense of terror always seized me just before walking on stage and that it was, in fact, a good sign, for as soon as I went on stage, the panic always passed and was replaced by a sense of calm and self-assurance. Sure enough, to my great relief, the same thing happened as we walked through the final door, past the last two guards into the governor’s subterranean office. It was show time.

Ismail Khan sat on a long velvet couch at the far corner of the room. He was smaller than expected, and appeared older than in his posters. He was without his military gear and though there was clearly a toughness about him, he appeared more the city manager than the militant firebrand. We were introduced and he invited me to sit next to him on the couch. Dr. Sayed Gul Safi, an Afghan veterinarian and colleague who accompanied me from the UNDP office in Quetta, served as translator. The governor proceeded in Dari to welcome us. Then I stated our business in Herat, described the UNDP veterinary programs, and sought his cooperation and approval for the establishment of a training center for veterinary paraprofessionals in his city to be operated by the Dutch Committee for Afghanistan.

Khan listened attentively and then said nothing for what seemed a long time. My unease started to return, but after another few moments, he began his reply. He started with a small historical lecture, emphasizing how it was clear that the Afghans had done the dirty work for the West in a horrific proxy war to destroy the Soviet empire and that the West owed it to Afghanistan, after using the nation as a game board for its global strategy, to continue to help to pick up the pieces now that the Soviets had withdrawn. His skepticism concerning the questionable depth and duration of the West’s commitment was palpable and prescient.

He thanked us for the UN’s ongoing commitment to Afghan rehabilitation and made it clear that he would help in any way to facilitate the successful establishment of the training program, including the use of government veterinary facilities and veterinarians. We thanked him, exchanged a few more pleasantries, consumed the customary cup of green tea that had been offered, and exited back out through the long sloping tunnel, as if coming up a mine shaft. I breathed an audible sigh of relief as we opened the last set of doors and returned to the sunshine and fresh air of a cold, bright December day. The Dutch Committee was to have its training center in Herat.

2.

Unexpected Destination

That same evening, back in my sparsely furnished room in the cinder block annex of the UN Guest House in Herat, seated on the edge of my narrow bed under a dim, bare lightbulb and huddled next to the blue flame of the portable gas heater for warmth, the day’s events ran through my mind. It seemed as if I was in some parallel universe, living a life other than my own. I had grown up in the safe and secure bubble of suburban New York, and yet here I was, in a war zone half a world away, negotiating with a formidable warlord whose brave act of defiance against the Soviets in Herat was said to have catalyzed the mujahideen resistance in Afghanistan.

Borscht Belt cliché though it was, I had to ask myself the question: How did a nice Jewish boy like you end up in the underground bunker of a Muslim warlord in Afghanistan talking about veterinary training? How, indeed? It had been a circuitous journey, but the dots could be connected.

I was born in Brooklyn. My parents were raised there during the Great Depression, the children of Jewish immigrants who arrived in New York from Eastern Europe in the 1920s. When I was three, my parents left Brooklyn for suburban Long Island. Growing up, I never cared for life in the suburbs, so by the end of high school in 1967, I was keen to be somewhere else and planned on going to college out of state.

I chose Antioch College in Yellow Springs, Ohio, and the choice was life-changing. I was smitten by the agricultural landscape of southwestern Ohio and was especially charmed by the farm animals there. On a single country road, one could pass in succession a dairy cattle farm, a hog facility, a beef cattle operation, a horse breeding stable, and a sheep grazing enterprise, the pastures and paddocks teeming with livestock. I wanted to know more about domestic livestock and the people who kept them. Taking advantage of Antioch’s work-study program, I found work on beef and dairy farms and with a feed company. These experiences convinced me that I wanted to work with farmers and livestock, but how to do so? My suburban upbringing had not exactly prepared me to be a farmer or a shepherd, and my parents were surely thinking more along the lines of lawyer or doctor. Doctor? Livestock? Livestock doctor? Thus, the idea to become a farm animal veterinarian took root.

Entering veterinary school at the Ohio State University in the fall of 1974, I studied hard and graduated four years later. In addition to a veterinary diploma, Ohio State also provided me with the opportunity to meet my future wife, Laurie, who had come to Columbus to start medical school. Laurie was a lovely, smart, wonderful, and caring person with a great sense of humor. We fell in love and eventually married. After graduation, Laurie and I headed to the University of Minnesota to do our internships and residencies, and subsequently joined the faculties there, at the medical and veterinary schools, respectively.

Teaching clinical large animal medicine was my job at the veterinary school in St. Paul. The caseload was mainly dairy cattle, but there was also an unexpected number of goats. I developed a keen clinical interest in these curious animals, which ultimately led to becoming coauthor of a veterinary textbook dealing exclusively with the diseases of that species. The book, Goat Medicine, was the first comprehensive and definitive veterinary text to address the diseases of goats from a global perspective. It apparently met an unfulfilled need as it quickly led to international consulting opportunities for me on matters of goat health and production in Africa, Asia, and elsewhere.

Since it was most often the rural poor who kept goats, this international consulting work sensitized me to the problem of rural poverty in developing countries. My eyes told me that poor, rural people worked incredibly hard, but got little in return for their efforts. The notion that poverty is a result of laziness was simply not true. Rather, the problem was that hardworking people lacked access to the resources and opportunities they needed to get ahead. As a veterinarian, it was clear to me that one resource that poor people very often lacked was access to basic animal health care. This was especially disturbing, as livestock often represented the only valuable asset that poor people might possess. In some cases, their very own survival depends on having healthy animals, and yet the rural poor are frequently unable to access even the most basic veterinary service to preserve the health and productivity of their livestock. This was dramatically brought home to me during a trip I made to Bangladesh for the Food and Agriculture Organization of the United Nations to assess the situation there concerning a recent outbreak of the devastating disease, peste des petits ruminants (PPR), or sheep and goat plague, and make recommendations for its control.

On the third day in Bangladesh, I traveled from the capital Dhaka with a government veterinarian from the Ministry of Agriculture to the rural district of Jessore to see firsthand the effects of the PPR outbreak that was sweeping through the country. In a village not far from the district center, we encountered a young woman, recently widowed with two small daughters, whose entire wealth was wrapped up in five goats. Four of these goats had died of the disease in the days preceding our arrival and the young woman was devastated. Her last goat was in dire straits, but I thought it could be saved with the proper treatment. PPR is a nasty viral disease with a very high death toll. However, many affected animals die not from the virus infection itself, but from the dehydration that results from the diarrhea it causes or from the secondary bacterial pneumonia that commonly occurs. If the pneumonia is controlled with antibiotics and the animal’s hydration maintained by administration of oral electrolyte solutions, then affected animals may survive the PPR infection itself.

We had been joined in the village by the government district veterinarian, so I asked him if he had antibiotics and rehydration solutions at his clinic. Clearly embarrassed, he told me that he had nothing at his clinic. Bangladesh had free government veterinary service, but the government did not reliably stock or resupply the government clinics with the needed vaccines and medicines. So, I asked what people do when they need veterinary service. He told me that, if they have money, they can go to the bazaar where there are drug shops, but the drug shop owners often have no training and do not know the proper use of the medicines they have.

Moved by the plight of the young woman who had lost four goats to a disease that was readily preventable by vaccination and whose one last goat was barely hanging on to life, I felt compelled to intervene. At the risk of further embarrassing my Bangladeshi veterinary colleagues, I pulled some local currency from my pocket and asked the local government vet to go to the bazaar and get a small bottle of oxytetracycline, a syringe and needle, and some oral rehydration salts. He returned about thirty minutes later with the drugs. I injected the goat with tetracycline and had the vet explain to the woman how to repeat the injections over the next four days. Then I showed her how to mix up the proper amount of rehydration salts with water and offered it to the goat. Fortunately, the goat still had the will to drink, so I had the vet instruct the woman on how much to offer to the goat each day.

On the car ride back to Dhaka, there was ample time to reflect on the events of the day. This was not an isolated situation. Throughout the developing world, particularly in Africa and Asia, veterinary services were ostensibly provided by government free of charge to the citizenry. But you get what you pay for. Most of these governments neither had nor allocated the budgets necessary to support their government veterinary services. Provincial and district veterinarians were without equipment and supplies to conduct diagnostic investigations or lab tests, vehicles or fuel to make farm visits, vaccines to prevent disease, or medicines to treat disease. The service might be free, but there was little or no service to be had. Clearly, there had to be a better way than a government veterinary service that did not serve, and my mind stayed occupied thinking about alternative approaches on the long, bumpy journey back to the capital city.

In 1987, Laurie and I left the Twin Cities for faculty positions at Tufts University in Boston. Not long after arriving at Tufts veterinary school, the opportunity arose for me to transition from teaching clinical medicine to joining the International Veterinary Medicine program, which at the time was the only such program of its kind at a veterinary school in the United States. The aim of the program was to provide a global perspective on the veterinary profession for young American veterinary students and to identify innovative ways to broaden the impact of veterinary medicine on society in an international context.

Shifting to the International Veterinary Medicine program provided me with the chance for a long-term assignment in Quetta, Pakistan, seconded from Tufts University to the American charitable organization Mercy Corps International. MCI was conducting humanitarian aid projects across the border in Afghanistan with funding from the United States Agency for International Development (USAID), focusing on human health and agricultural projects involving horticulture, crop production, and irrigation. But following discussions with the head of the International Veterinary Medicine program, MCI had agreed to incorporate livestock activities into their agriculture program, and I agreed to be the Tufts faculty member in the field. So, a few days before Christmas in 1991, I found myself at Logan International Airport in Boston bound for Quetta, Pakistan, via London and Karachi.

This opportunity in Quetta, Pakistan, existed because of the hot war going on next door in Afghanistan. The Soviets had invaded Afghanistan in December 1979, and the Afghan mujahideen resistance to Soviet occupation quickly emerged. By 1989, the mujahideen fighters, with support from the United States and others, had forced the Soviets to withdraw from the country. Yet the Soviet-backed government of Dr. Najibullah showed an unexpected tenacity and had remained in power in Kabul after the Soviets departed. When I arrived in Quetta in 1991, the mujahideen were still actively engaged in trying to dislodge the Najibullah government, and so Afghanistan remained at war.

Millions of Afghan refugees had flooded across the Afghanistan borders into Pakistan and Iran over the preceding decade and most remained in UN-operated camps. In Pakistan, many humanitarian aid agencies had set up shop to provide assistance to the refugees living in camps and to Afghans still living in their own country, but whose lives were severely disrupted by the seemingly endless conflict. While most of these aid agencies were located in Peshawar, Pakistan, and served the needs of northern Afghanistan, a smaller number, including MCI, were present in Quetta, Pakistan, to serve a somewhat smaller refugee population from the more rural provinces of southwestern Afghanistan and the city of Kandahar.

The MCI/Tufts project, The Private Sector Animal Health Initiative, embodied a community-based approach to animal health care, and it served as the foundation for all my future veterinary work in Afghanistan. In this project, farmers and herders were recruited from the provinces of Kandahar, Helmand, Zabul, and Urozgan where MCI was already working on agricultural projects. The recruits were trained by MCI and Tufts to provide animal health care in their own villages and districts. This community-based approach to health care delivery first gained acceptance in human medicine in the late 1960s in China through the training of so-called barefoot doctors. The barefoot doctors were local farmers trained for short periods to serve their communities by promoting basic hygiene, preventive health care, and family planning as well as treating common illnesses. The program grew out of recognition that rural populations were being underserved by the professional medical community who were largely unwilling to move to remote rural areas to practice medicine. By the 1980s, the notion that people with basic training could provide competent services to solve common problems in underserved areas was being applied to other professions in other countries as well, and barefoot veterinarians were being trained and fielded in India, Nepal, Niger, and elsewhere.

So, in the tradition of the barefoot concept, MCI would train basic veterinary workers (BVWs). Since most Afghan farmers and herders spent their whole lives tending animals, they possessed an abundance of accumulated experience and insight on health and disease in livestock. It was an indigenous knowledge, and by and large it was sound. Though a herder could not provide the Latin name of a particular parasite or describe its life cycle, he clearly could recognize and describe the clinical signs and patterns of occurrence for the most common forms of parasitism that affected his flocks. Though he would not know the names of the bacteria and viruses causing pneumonia, he could easily recognize pneumonia for what it was and describe the signs. Though he could not describe the pharmacological properties of a particular medicine, we would be able to teach him the purpose of a particular medicine, link it with the treatment of a specific disease, and show him how to choose and administer an appropriate dosage.

Before my arrival in Quetta, MCI had already recruited some veterinary staff, including two graduate veterinarians trained in the Soviet Union as well as seven paraveterinarians. These seven paravets were high school graduates who were recruited from the Afghan refugee camps around Quetta and who then received almost six months of intensive training in fundamentals of veterinary medicine, most of them at the Dutch Committee for Afghanistan training center in Peshawar. These paravets would prove to be ideal trainers for the BVW program.

Though we were from completely different worlds, the paravets and I quickly found camaraderie, collegiality, and common purpose. The paravets were ethnic Pashtuns and devout Muslims, raised in the traditional culture of southwestern Afghanistan. They had grown up in small rural villages without cars, televisions, or even electricity, and only a couple of them spoke any English. Five times each day, they stopped whatever we were doing in order to pray, they left their shoes at the door when they entered a building, ate sitting cross-legged on the floor, and wore turbans and the traditional shalwar kameez, consisting of baggy pantaloons and a long-tailed shirt that had beautifully detailed, silver-threaded, geometric designs embroidered across the chest. Even their names were exotic to me—Sayed Asamudin, Sayed Ali Mohammed, Mohammed Naeem, Usman Ghani, Gulam Hazrat, Gulam Farooq, and Din Mohammed.

All were proud of the knowledge and abilities they had acquired through their paraveterinary training in Peshawar and were keen to become effective teachers of BVWs. They all had seen firsthand how the Soviet invasion and its aftermath had shaken the foundations of village life and created profound insecurity in their homeland. They understood the importance of livestock to rural Afghans and recognized the value that BVWs could have in restoring basic animal health care to the provinces where they grew up. They were ready to travel to the villages of Kandahar, Helmand, Urozgan, and Zabul provinces to recruit young men like themselves and then train them as BVWs to serve their communities.

I worked feverishly on the training manual and course content with excellent support from my Afghan colleagues at MCI, who were able to produce original artwork to illustrate the training manual and translate it into Pashto. The task was complete by the end of January and we held a training of trainers workshop at the beginning of February for our seven paraveterinarians (Figure 1). With the trainers trained, we were able to launch the first two-week training course for our initial group of BVWs by mid-February.

Figure 1 Paraveterinarians working for Mercy Corps International as trainers of basic veterinary workers, along with other staff, observe a demonstration necropsy conducted by the author to review anatomy, gross pathology, and necropsy techniques as part of their training of trainers course in Quetta in 1992.

In addition to training and outfitting BVWs, MCI also monitored them. Over time, input from our field monitors indicated that for the most part, BVWs had been accepted by their communities, were actively working, and were providing valued services. About a year into the program, the monitors were reporting to us that the more ambitious BVWs we had trained were looking to increase their activity. They wanted to learn more skills, and they wanted some form of transportation so they could extend their reach and provide additional services to more farmers in their own and surrounding villages. In response, we decided to offer a refresher course for BVWs and to issue them a bicycle upon completion of the course.

By December of 1992, a year after my arrival, we started to develop a refresher course curriculum to provide some additional skills and activities, including vaccination techniques and pregnancy diagnosis in cattle. Though scheduled to leave Quetta and return to Tufts at the end of January 1993, I was there long enough to set up the refresher courses and welcome the first group of refresher trainees, which included some members of the first BVW training session held a year earlier. One returning BVW, Shahabuddin, had a remarkable personal success story to tell us.

After a long and dusty bus ride, Shahabuddin was walking back to his village on the final leg of his trip home from his original BVW training, his mind filled with new knowledge and his new kit bag full of medicines and supplies slung over his back. Then, up ahead, he saw a man standing by the side of the road with an obviously sick horse. The animal was thin, with its head hanging down and ropes of snot dangling from its nose. Fresh from his training, Shahabuddin recognized immediately that the horse most likely had pneumonia and that, in his backpack, he had the medicines that could most likely cure it.

Of course, we expected Shahabuddin was going to tell us how he convinced the man to accept his services to treat the horse, but he surprised us. His instincts were far more entrepreneurial and not as selfless as we anticipated. What he did in fact was offer to buy the horse, as is, on the spot. The man no doubt thought that this was indeed his lucky day. Here was a fool appearing out of nowhere and offering to pay cash for an animal on death’s doorstep. He quickly agreed to sell it for what Shahabuddin had offered.

Shahabuddin, in fact, had gotten the better of him. He led the horse home, treated it with antibiotics, offered it good quality feed, and soon restored it to full health. Then he used the horse as transportation to carry on his BVW activities well beyond the confines of his village, even visiting the encampments of nomadic herders at their summer pastures in the hills to market his veterinary services for the nomads’ large flocks of sheep and goats. Before long, he himself was training two assistants as BVWs to further expand his sphere of activity. He sold the horse, bought a motorcycle, and started to make regular trips back to Quetta to purchase drugs in bulk at better prices than he could get by resupplying through MCI at its health clinics in Afghanistan. He had quickly become a widely known, respected, and prosperous man, offering a needed and valuable service to livestock owners in Kandahar Province.

Shahabuddin’s story was an epiphany for me. It offered proof that sometimes the only thing holding a poor person back was a lack of opportunity—not laziness, not stupidity, not an absence of purpose or a flaw of character, not even war, but just a lack of opportunity. Shahabuddin had within him the spirit and determination to succeed. The training and equipment provided by our project was all that he needed to take off like a rocket. It was remarkably gratifying to be able to provide that opportunity, and I started to think of myself as not only as a veterinarian, but also as a development worker.

One of my responsibilities while at MCI was to coordinate our veterinary work with the veterinary activities of the United Nations Development Programme. As such, I met regularly with Dr. John Woodford, a British vet who was the program veterinarian for southwestern Afghanistan at the UNDP office in Quetta. UNDP provided funds to quite a few humanitarian aid agencies based in Quetta to conduct cross-border animal vaccination campaigns in Afghanistan.

UNDP also was engaged in a more far-reaching development effort to rebuild veterinary infrastructure in Afghanistan. Through UNDP contracts with nongovernmental organizations (NGOs) such as MCI, they were attempting to replace the old government veterinary clinics with private sector enterprises staffed by veterinarians, when available, or paraveterinarians, when not. The system would be structured on a hub and spoke model with the vet or paravet located at a facility in a provincial district center and a network of BVWs living and working in the villages beyond each district center. The BVWs would be under the supervision of the senior vet or paravet and would come to the district center to resupply medicines and vaccines and for advice and consultation.

John Woodford became a keen supporter of our BVW training approach. He arranged for other nongovernmental organizations working in the veterinary sector under UNDP contract to have their BVWs trained by MCI and also encouraged UNDP to adopt the MCI training program as its standard.

My assignment with MCI finished in January 1993, and I headed back to Boston. As it happened, John Woodford had given notice to UNDP that he would leave his job in July of that year and had recommended me to replace him. UNDP offered me the position, to start in August. Laurie was able to obtain a leave of absence from her job at Tufts and the veterinary school agreed to extend my leave of absence for another year as well, So, in August of 1993, with a signed one-year contract from UNDP in my pocket and Laurie by my side, we headed back to Quetta and new challenges.

One of the challenges for expanding UNDP’s private sector clinical veterinary program in southwest Afghanistan was the lack of trained personnel. NGOs complained that they could not find