A Conversation with Paul Spiegel on the Afghan Healthcare System

J. Stephen Morrison: And welcome to this CSIS event, “A Conversation with Dr. Paul Spiegel on the Afghan Healthcare System.”

I’m J. Stephen Morrison, senior vice president here at the Center for Strategic and International Studies, CSIS, an independent, nonpartisan think tank based in Washington, D.C. I want to offer a special thanks to many of my colleagues who helped put this all together, especially Humzah Khan on the Global Health Policy Center staff, along with Michaela Simoneau. And on the production side, those who are putting this event together, a special thanks to Mary Wright, Dhanesh Mahtani and Alex Brunner.

Dr. Spiegel is our lead guest, and we’re joined also by another expert and close friend, Leonard Rubenstein. Paul is the director of the Center for Humanitarian Health at Johns Hopkins University Bloomberg School of Public Health. He’s a professor of the practice in the Department of International Health. He’s got decades of experience working in medicine in difficult settings, for MSF, for CDC, for UNHCR. He’s just returned from five weeks, which he will describe momentarily, in Kabul, working for the World Health Organization. He published on December 16th in The Washington Post a powerful opinion piece that many of you, I expect, have read, “Hospitals are collapsing in Afghanistan. At this rate sanctions will kill more people than the Taliban.”

Leon Rubenstein is faculty at the Center for Public Health and Human Rights and the Berman Institute for Bioethics at Johns Hopkins University School – Bloomberg School of Public Health. He is a lawyer by training and has had a career as an advocate on human rights with a special interest in health. (Phone rings.) Pardon me for that. He has just published recently a terrific volume called “Perilous Medicine: The Struggle to Protect Health Care from the Violence of War.” We did a book event on that. It’s really an authoritative and definitive book, and directly relevant to what we’ll be talking about today. Leon and I also co-published about six weeks ago a CSIS commentary on the health crisis within Afghanistan.

There’s been a surge of action and very loud proclamations around the crisis, the burgeoning crisis within Afghanistan in recent weeks. We’ve seen a very powerful, and very detailed and nuanced congressional letter come forward – 37-38 members of Congress led by Congressman Tom Malinowski. The International Crisis Group under Laurel Miller has published some very impressive work that tracks closely with that congressional action. Peter Maurer and his senior staff at the ICRC in Geneva have become very loud and vocal on the nature of the crisis and things that need to be done. We had several U.S. combatant commanders, three- and four-star commanders, along with senior rank diplomats who’ve all served in Afghanistan come out with an appeal for easing of sanctions.

All of this is creating quite a debate. And the timing of this session here today could not be more propitious. We’re on the edge, as we’ll hear, of a very, very large international appeal for the emergency in Afghanistan, the largest of the kind anywhere in the world expected in the course of 2022. We’ll be covering a number of issues. There’s a great debate around sanctions relief, what form of sanctions, how to avoid the economy collapsing. We’ll have a debate today, how close are we to that? We know that there’s a high risk of mass flight.

We know that we – the conundrum of how do you deal – how can you respond to this and not engage the Taliban as the government in power, and how do you avoid enabling it in ways that we certainly don’t want to see? And there are issues around capacity of the U.N., of the NGO community, and the like. And we know and we’ll hear more the politics surrounding this issue here in Washington, D.C. is particularly poisonous and requires a special – a special strategy if trying to strengthen the will within the Biden administration to take some of the actions we’ll be talking about today.

For those in the audience, feel free to pose questions in the chat. And we will monitor those and try to bring those into our conversation today. We’ll be going for one hour. I’m going to – this is going to be an interactive and lively conversation among the three of us, with input from you in the audience. And we’ll be hearing the opinions on all of these subjects from both of our expert guests – from Dr. Spiegel and Leon Rubenstein. I’m going to start off here by just asking Paul to take 10 or 12 minutes, longer if you need, Paul, to detail for us the basics. Where did you go? What were you doing? What were you observing? How do these pieces come together? You have fresh eyes on this problem of the health and humanitarian and economic crises that are interlocking within Afghanistan, just back. And we’re very honored and delighted that you would take time today to do this. So I’m going to ask you if you could kick things off, please. Thank you.

Paul B. Spiegel: Great. Well, thank you. Thank you very much, Steve and Leon, for joining me today and for the opportunity to speak. I mean, the situation, as you’ve said and as, I think, many people now have been writing and commenting upon, is really untenable. There needs to be some immediate change or many, many tens of thousands of people, I believe, are going to die. I was in Afghanistan for five weeks. I was a consultant through GOARN, which is the global alert response network. And for three of those weeks I was the acting incident manager for WHO, which means I was responsible for the emergency operations there. Besides being in Kabul, I had the opportunity to visit Sarawbi, which is a district outside of Kabul, as well as spending some time in Kandahar, which really is the stronghold of the Taliban.

This is a rare situation where you have an incredible amount of emergencies, which I’ll discuss in a second, but also you have the collapse – almost immediate abrupt halt – of the health as well as education and economic situation. So this was very, very complicated for everyone to respond because there is insufficient capacity right now, from the international and the national community, to be able to actually respond to trying to reset or restart the health system, the education, the financial system, amongst others, and at the same time to respond to so many different emergencies that are occurring. So I’m going to concentrate on health, but clearly this is one sector. And if we don’t address the education, if we don’t address the financial system, the health system no matter what we do will not be able to function.

I want to talk about SEHAT Mundi, which is a program that has been around for nearly 20 years now. And what it is, is it’s a program that addresses the basic healthcare of Afghanistan. There are approximately 2,300 health facilities that have been set up that deal from the community health centers, basic health centers, comprehensive health centers, all the way to district provincial hospitals. This has been funded by World Bank, from USAID, EU, et cetera, for many years. And this money previously – before August 15th when the Taliban took over – the money was provided to the Ministry of Public Health, who then through a competitive process gave these funds to NGOs. This was restarted as of – with CERF funding, the Central Emergency Response Fund, in November – November 1st, for three months.

So this will continue to January 1st. And the funding was given to WHO and UNICEF, and then they have been providing funds to the NGOs. And this, as I said, started in November. We were able to visit many of these health centers. And due to this funding, the health centers have now – are up and running, salaries are getting paid, medications are now there. So that’s an excellent and very, very important component and a very important response. The next phase, as of February 1st, World Bank, through the Afghan Reconstruction Trust Fund, will give approximately $100 million to UNICEF, who will then be working together with WHO. And this will, again, go to the NGOs. None of this money will be going to the Taliban, the de facto authorities, whatsoever.

So this component is very important, and it’s essential. The problem is that it’s only half a health system. Meaning that none of this money is able to, as I mentioned, to government services, to the Ministry of Public Health. So if we think about the non-SEHAT Mundi health system, this consists of approximately 67 hospitals throughout the country at the provincial level – which are still pretty basic but they’re essential, the workhorses of hospitalization. You then have regional hospitals in each of the provinces. You have the hospitals in Kabul, that are not – are also part of this. And you also have approximately 39 COVID-19 hospitals. None of these – none of these hospitals are getting funding from – currently from the international community because in the previous pre-Taliban money was provided to the Ministry of Public Health, and the Ministry of Public Health funded these specific hospitals.

That being said, ICRC now – and thank goodness for that – they have started to support at least 18, I believe it’s now over 20, of these hospitals. But, again, the majority are unsupported. I was able to visit numerous hospitals, both in Kandahar and in Kabul. And, for example, the infectious disease hospital that I visited is the reference infectious disease hospital for the country. They haven’t received salary since April, yet everyone is still – nearly everyone is still coming, including female doctors, health care workers, cleaners, et cetera. There’s no medication for the patients. There’s no food for the patients.

There’s no fuel for heating – and it really is quite cold, and getting much colder now in Kabul as winter is approached. They’ve had to actually resort to cutting down trees in the courtyard to be able to actually just have heating for patients. The ICU that we visited is really not an ICU at all anymore, and all of their ventilators have been given to the nearby COVID hospital – the Afghan-Japan hospital. Yet, the Afghan-Japan hospital, again, has not received any funding for very – for months, and it’s actually, we could say, partially to nonfunctional at this point. Insufficient oxygen, insufficient ventilators.

So the situation is in crisis mode at this point. And despite – there are many workarounds that I believe, and many of us believe, could occur to arrange a situation to pay for these government health workers. And it could be from maybe they have to take a special leave without pay and then they start being hired by the NGOs, for example, to be able to have a system similar to what’s happening in SEHAT Mundi. None of this is being allowed at this point. And it’s been made – been made very clear by the donors and the World Bank that this cannot happen because in the past this money, these were government hospitals, and therefore they’re not included in SEHAT Mundi, and therefore no funds can go to these hospitals directly.

On top of that, you have a Ministry of Public Health that is receiving no funding whatsoever. And the ministry is responsible for surveillance throughout the country. It’s responsible for ensuring transport of laboratory specimens. It’s responsible for monitoring much of the whole health system. I mean, without a Ministry of Public Health, one should think of it as the glue or the blood throughout a system that oxygenates the system. It is not functioning. In fact, people are just hemorrhaging leaving the Ministry of Public Health looking for other jobs. So many people have left and so many people are planning to leave that I think it’s going to take a generation to rebuild the Ministry of Public Health if we don’t do something immediately. And it was quite a competent ministry that had been built up over the last 20 years.

So now moving to some of the emergency components beyond the basic health care system. There are six ongoing epidemics. There’s measles, malaria, dengue, COVID-19, polio, and there’s acute watery diarrhea that the authorities are not allowing to be called cholera, but it is cholera. It’s been – it’s been diagnosed and cultured as cholera. Looking at COVID-19, the data are extremely poor because the system – surveillance system is not functioning well. It really is impossible to understand what the COVID situation is in Afghanistan for a variety of reasons. There are very few COVID tests that are occurring. On average – we have the data – between 2,300 to 2,800 out of a country of 38-40 million people. Very few COVID tests are occurring. And when they are, it’s mostly people who are – who are sick. There’s really no community-based surveillance in the country right now. So it’s mostly facility based, and therefore we’re seeing just the tip of the iceberg.

Another way to look at it would be to say, well, let’s look at the bed occupancy rate. Let’s look at the ICU occupancy rate. But it’s very difficult to look at that and understand what is happening because many of the COVID hospitals have closed. Only three out of the 39, 8 percent, are actually fully functional. And on top of that, people can’t afford to actually go to get health care. And so is the bed occupancy relatively low compared to previous waves because people can’t go there or is it because currently COVID – the transmission is not as high as it was before? I don’t think we can answer that very clearly. There’s been no genotyping for Omicron. We really do not know what will happen, but certainly in the winter we can expect an increasing number.

I have one minute and 48 seconds left, Steve. I’m going to continue to just talk about measles. There’s been a largescale measles outbreak. Depending on the data that is being reported, over 65,000 suspected cases in the existing HMIS, which is limping along. We did manage to do a measles campaign. WHO, and I’m speaking in my personal capacity not as WHO or Hopkins. But when I was there we were able to do a measles campaign in the six hardest-hit provinces. And we just finished that last week. That affected about 1.4 million children between nine to 59 months, which is great. But it’s not – it’s clearly not enough at all. And the measles is still ongoing in many, many other provinces beyond the six.

And because we now have access, because there’s so much more security in the country right now, we have access to many other parts of the country that we didn’t previously. And the level of childhood immunization is extremely low. There is an urgent need – probably in January/February – to do a multiantigen campaign across the whole country. It would not be surprising if we see diphtheria, pertussis. And given – and measles will continue. And given the high rate of acute malnutrition, the numbers of deaths will be very, very high.

I’d like to just end by talking about cholera. There was a widespread cholera outbreak starting in September in five provinces. Luckily, the transmission was reduced in many of these provinces. Winter will help with that. There’s still cholera occurring in Sarawbi district, where we visited, and in Kabul. Very poor response at this point because of the – most of these hospitals, as we mentioned, are not going to be – are not receiving any funding.

And one of the big concerns is going to be in the winter, as winter stops – sorry, we got rid of my – as winter stops, what’s going to happen in terms of cholera in particular, and a lot of other diseases that do – that transmit during the spring and summer months? I’m particularly concerned about cholera, to avoid a Yemen-like situation, given that the water infrastructure is so poor, and many people are – most of the people are relying on wells. And the leakage and the hygiene is questionable. So while we have to deal with the current emergency, we also need to really consider the future emergencies, and particularly some of the epidemics.

What needs to be done is, I think, recognize that the available funding for SEHAT Mundi is only part of the health system, and we need to be able to provide funds to these hospitals. And there can be, and must be, ways and workarounds to be able to do this while not providing funds directly to the government, but that requires that the sanctions – the U.S. government is very clear that this can be done and how it can be done. We need to, also, really restart and consider what’s happening in COVID-19. About 12 percent of the population has been vaccinated, most with J&J. And there will be some very serious concerns in winter if we don’t restart these COVID hospitals now.

Much more to say, but I’m going to hand it over back to you, Steve.

Dr. Morrison: Thanks very much, Paul. I’m going to Leon to share some of his observations. I know, Leon, you’ve had a chance to speak with many people on the ground and you’ve been watching this very carefully. What do you want – what do you have to add in terms of observations?

Leonard Rubenstein: Thanks so much, Steve, for having me to participate in this really important discussion. And thanks to Paul for the dire, but important, report. And that, of course, reinforces that we have to address the possible, frightening, consequences of the collapse of the health system for this population that’s already suffered through the war. And as Paul said, there are workarounds that are possible. And we can discuss them later. But I want to talk about another dimension, because for obvious reasons there’s such enormous distrust of the Taliban, not only in withholding the money but in their – in the administration of the health care system in any form, whether they’re formally running it or not, whether they will interfere, whether they will so disturb good health care that it will make the system fail regardless.

I think that the picture’s really much more complicated. In recent years, the Taliban saw health services as necessary to achieve their political goals. And so Ashley Jackson, the terrific Afghan political – analyst of Afghan social services, said their strategy was to co-opt them rather than attack them. So there were rare instances – so not – it was not completely so – that they did not destroy clinics or attack them directly. But they did coerce them. They imposed their will on health programs to the extent they could in the areas they controlled. And they appointed general health officials in the provinces, and they made demands on hiring services and operations. Sometimes they used threats of violence, and that resulted in largescale shutdowns or temporarily or long-time closures of facilities. Kidnapping of staff was a tactic used.

So the question is, what’s going to happen now? And I think, as Paul can illuminate better than I can, since he was recently there, that – the leadership of the Taliban seems committed to a functioning well-administered health care system. And right now I think what’s happening is that the record on the ground is mixed. In places – at higher levels, I think that that commitment has been shown. And, paradoxically, in places where the Taliban controlled territories and NGOs operating services there, or hospital officials, have gotten used to negotiating with them, dealing with them, keeping services running. And that has good potential.

In other places, including at hospitals in Kabul where mullahs have – in some hospitals, mullahs have been replacing health officials to run services, there are serious issues. There are serious issues about gender, about patient care, about threats to surgeons and doctors and nurses. One surgeon told me that medical staff are assaulted almost daily, and extraordinary events. Like, one person told me about an unmarried woman who was – had just given – had just given birth. And when the staff learned that, they realized that they she had to get out of the hospital because when the Taliban returned and learned this, who knows what would happen to her. She probably would be arrested and beaten, and who knows what else.

So there are serious issues about the conduct of Taliban, especially the uneducated ones or the mullahs, in health services. But I think the prior record also suggests that when there is funding and support by other agencies for the health system, that provides a point of leverage, because the Taliban want those services continued. So the funding could not only provide an opportunity for them to continue, but could be at least a partial break on the kind of hospital-based violence and coercion that we’ve seen in some places. So I think it’s almost like a double benefit if there is engagement, both on funding and support for administering these services.

So I’ll stop there, and happy to talk more, Steve.

Dr. Morrison: Thank you. I do want to speak just quickly about polio, because I think this is an important dimension of the story, that is complex and disturbing in many, many respects, as Paul has outlined. Six outbreaks simultaneously, most of them barely addressed. In the case of polio, what’s interesting is that there was the ability to move forward with the first-round national campaign of vaccination in the country in November.

The second round, the second campaign, is underway right now. In that first campaign, they were able to reach 8 ½ million, which is – this population had not been reached in three and a half years. And within that eight and a half were two and a half who hadn’t been seen ever, predominantly in southern Taliban-dominated areas. They deployed 53,000 workers, of which 10 percent were women. That’s lower than the normal, I believe, proportionalities. They had no security incidents of any significance.

In half of the country, they were able to negotiate permission at the provincial level for house-to-house administration of vaccines, which was the desired and enormously important step. And half of the provinces, they were not able to do that, and it was mosque-to-mosque. And so you did have some women providers, not as many as perhaps would be – would have been the case before. You had no security incidents. And the campaign went forward in a fairly significant and dramatic way.

Now, the polio effort, in some ways, is its own operation. It oftentimes finds itself in tension with other health objectives, other vaccination efforts, and the like. So I wanted, Paul, can you just put this context? What are we to make of this? Is this something that should raise our confidence about finding solutions in other areas? What does this tell us?

Dr. Spiegel: Yeah. Thank you, Steve.

Well, while I was there, actually, there were two confirmed polio cases as well, which is very concerning. The Taliban so far have been very supportive of health and health services throughout the country. And polio is one example, absolutely. Also it’s not – the Taliban, as we know, is not homogenous. And so some provinces agreed to, as you mentioned, to do house to house. Others said, no, we must do mosque to mosque. But when we also said, OK, we need to do a measles campaign as well, given the situation, and on top of that, after negotiations with the polio team from UNICEF and WHO, we were able to do a joint integrated measles and polio campaign as well, in between the two national immunization days.

There is a tremendous – in my view, there’s a tremendous amount of opportunity right now because the country is more secure in terms of access and reach. And the Taliban are allowing the international community and the NGOs to actually go to areas that we couldn’t go before, because of the fighting. But I will say, one of the problems that came out in the polio campaign, in the measles campaign, is payment of workers. They’re just – the liquidity, which maybe we will get to – is massive. And so there was a lot of difficulty in paying these people and making sure that some had to be paid in liquid, in cash. It’s very difficult to transfer funding. And so we need to address this issue, because that’s one of many that needs to be addressed – one of many problems will be these outreach, and these epidemics, and these campaigns. But there is no the liquidity or the financial system to allow this to occur.

Dr. Morrison: Leon, did you have any thoughts?

Mr. Rubenstein: Well, I think the polio work, actually, of the Taliban is long and fairly good. If you go back 10 years, Mullah Omar wrote a letter to all his local commanders saying, please cooperate. And just like in the mosque versus house to house, there was a lot of variation among how they participated, or whether they did participate. But I think it does – it is an indication that the Taliban, if they have the resources and if resources exist – not if they have the resources – but if resources exist, they can go forward. And the fact that areas that were too insecure to reach can be reached now, is great news. And it would be tragic if it ends because there’s no money to pay for them.

Dr. Morrison: Yeah. Now let’s shift to the bigger picture, which is if you read across all of these different publications and editorials and analyses, there’s one theme that comes out loud and clear, is that this is a race against time. Yes, we may see progress, 280 million (dollars) released by the World Bank Afghan Trust Fund, to go 100 million (dollars) towards health, 180 (million dollars) towards the humanitarian demands. But that’s a fraction of what is truly needed.

And the bigger picture is one of an economy with a severe liquidity crisis that is at risk of complete collapse, in which case the game is over, in a sense, that this is going to trigger mass out-migration. It’s going to trigger massive suffering and death. And I think that’s dominating a lot of the thinking of people about the urgency and extraordinary risk that exists today nationwide for the country, for the 38 million Afghan citizens.

How close are we? I mean, what is the – paint the picture here, Paul. As we think about entering the first quarter of next year, paint the picture. When do things begin to really fully break down if actions are not taken? And how much is this – how does this race against time unfold, in your view?

Dr. Spiegel: I hate to be pessimistic, but I’m worried that it’s already – well, I know it’s unfolding now. But I’m worried that it may be too late. There needs to be – there needs to be clarity, particularly from the U.S. government, on what can and cannot be done in provision of the humanitarian aid, number one. There’s a lack of clarity. But then the other big component is, beyond just the lack of clarity and what can be done from the humanitarian, if there’s not a way to have billions – not millions but billions of dollars – get into Afghanistan and to deal with the broad financial and economic system, there will be – there will be collapse very, very soon, particularly because winter is so harsh in Afghanistan.

And so there needs to be – it needs to be done immediately. And my concern right now is – and you’ve talked about this and I think you will shortly, Steve, in terms of the U.S. political situation right now. Will this be able to occur quickly? And then how quickly – once there is clarity and agreement – how quickly can this conspire so that there can be a tremendous amount of funding into various parts of the economy? So I’m – you know, one of the reasons I’m so thrilled to be here and one of the reasons I’ve been speaking out since coming back is because the situation is already very dire, and I’m very concerned that it may be too late already.

Dr. Morrison: What – let’s jump ahead here and talk – you mentioned that the U.S. position on sanctions is ambiguous and difficult to understand. And we – sanctions relief seems to be an essential step – not the only step, but an essential step. Can you be more specific about what is it that you’re arguing for?

Dr. Spiegel: Well, for the health there should be a way – if there is sufficient money and liquidity – there needs to be an immediate workaround. I’m not arguing that we should be giving money directly to the Taliban. But there should be innovative ways to ensure that all of the hospitals throughout the country can be funded, number one. Number two is that’s not enough. There needs to be transportation. There needs to be funding to every Afghan to be able to ensure that there’s sufficient transportation for them to get to the hospitals. There’s going to be a tremendous – there needs to be a serious examination of logical supply chain, because they’re – from everything from basic medications to more complicated medications, medical supplies, oxygen there is a massive shortage.

So there needs to be likely a lot of work with both India and Pakistan, but looking across – and Iran – to look across the borders, and the ‘stans, to be able to bring this in. And then I think there would need to be an examination of the actual glue, as I mentioned, the surveillance, the Ministry of Public Health, to make sure that these components are actually functioning because, as I said, without that glue the system will not be – will not work efficiently. This is just a minimum. But then I imagine we can look at what’s happening on education. It’s going to be the same thing. What’s happening in basic livelihoods. And so all of this needs to – there needs to be clarity, because the U.S. position isn’t just affecting the U.S. It’s affecting all of the other donors, because of these – particularly because of the Swiss system and the sanctions.

And so it’s affecting the EU. And while I was there, we had numerous discussions with the donors. And it was made very clear that these monies cannot go to the – what we have to call the de facto authorities. And they were very, very strict, understandably, about this. So we needed to make sure that was the case, which meant even some really basic things like fuel and food could not go to these hospitals.

Dr. Morrison: Thank you. Leon, what are your thoughts on what needs to happen in terms of U.S. policy?

Mr. Rubenstein: Well, I think the first principle is we have to find the workaround that Paul mentioned, that the implications of collapse in a country the size of Afghanistan, and with a food crisis we haven’t even talked about that is just stunning in scope, we’re looking at just a calamity for millions of people. And of course – although this shouldn’t be the only reason – an enormous refugee crisis which will affect Europe, it’ll affect the region.

And the other thing is that although the scale and the circumstances with the Taliban are different than in other countries, there have been workarounds before where the international community did not want to support a government, it was worried about health care. And that various methods were used in Zimbabwe under Mugabe. There have been various mechanisms used in Yemen. And although this will have to differ, there’s no perfect model, I think there is a possibility if officials put their mind to it. (Laughs.) The mechanism is a solvable problem. You don’t have to support the Taliban. You can find a workaround. But time is the enemy.

Dr. Morrison: And the larger question is, how do you reanimate the economy, right, when you’ve got a banking system that has collapsed, and the sanctions are directly tied to that, right? So there’s been some relaxation of ability of the diaspora to transfer funds. There’s a debate around do you internationalize the central bank or do you go through private banks. There’s – so there are options that are under discussion right now in debate, but that seems to me to be very foundational to being able to carry forward with any of these health and humanitarian and education requirements, because if the economy continues to descend it becomes – it becomes impossible to move ahead on these other fronts.

Mr. Rubenstein: Absolutely. (Laughs.) I’m not an expert on this, but the banking system is –

Dr. Morrison: OK. Let’s assume for the moment that it does become possible to find some way to avert economic collapse and reanimate some form of finance and banking, commercial sector activity. One of the outstanding questions on these interlocking crises is how much can we rely on the U.N. to carry forward what is really a very, very ambitious set of tasks? And it’s currently – WHO and UNICEF are playing very important operational roles. We have NGOs that are partners. We have the possibility of private sector service providers being brought in. Paul, give us some idea. How – if it becomes possible, and this appeal comes forward and resources begin to flow and we can figure out a way to circumnavigate the political sensitivities around the Taliban, but also to address in an urgent and timely way, how are we going to manage the capacity issue here, Paul?

Dr. Spiegel: Yeah. It’s going to be very difficult. And I’ll just mention, I mean, for me to get there was extremely difficult. Getting visas both in Pakistan and then getting the Afghan, the Taliban, getting visas. And so sometimes we don’t discuss – we talk about the broader aspects and we don’t talk about some of the nuts and bolts. To get very experienced people there, to ensure that there’s enough space, for example, even the U.N. compound and then outside where the NGOs are staying, there are still very big security concerns. And so it will require a lot of perhaps mundane but hugely important capacity to increase.

We need to convince people to go there. A lot of people when we were trying to surge a lot of people just said I don’t really want to go to Afghanistan right now. So then we need to ensure that there’s enough housing. That was a major problem for all of the – many of the U.N. organizations was sufficient space in actually the U.N. compound. And there have been – and we have to be careful, because with ISIS-K and other groups there, the U.N. and others, the international community, certainly is and will be a target. So there’s a lot of basic things that we’re going to need to address. And that needs to be done immediately.

On the other hand, there are ways we can deal with this by doubling up and by, you know, just allowing people, if we can convince them to come in, to double up in terms of rooms and other things. So it’s doable, but it’s going to be – I’ll be a lot of convincing. And there are many concurrent emergencies going on that, of course, we all know about. So getting the right people who have the experience and maturity to be able to come in, and working – and I’ll just add also, in terms of capacity, one of the problems is that there are – the Afghans themselves are really – you know, many are well-trained, well-educated, and can address this issue.

But we have to be careful that we don’t hire every government employee that existed previously because, again, it drains the Afghan government and the capacity for the future. So it’s going to be a fine line. And I do believe that capacity is going to be a rate limiting problem for NGOs and the U.N. agencies as we move forward.

Dr. Morrison: Yeah. I mean, just recently, I mean, there was great concern about ISIS-K. They were able to carry out spectacular bombings at the major mosques in Kabul, in Kandahar and in the north, with relative impunity. But that seems to have – that seems to have subsided. You’re not coming back saying – I mean, when that was occurring and we were talking to international NGOs, they were saying, look, you know, we could be targeted next. I don’t – I hear a lot less of that. Why is that, Paul?

Dr. Spiegel: Well, so, I think it’s because, at least for the last few weeks, there haven’t been any major, spectacular, like, bombings. But with UNDS and the security service, when I was there, were getting text messages of what’s happening. And there’s been an increase in magnetic IEDs. So they’re now attaching to cars magnetically, hence the word. So they’re not necessarily, you know, at this point, thank goodness, not to my knowledge, international NGOs and national NGOs or the U.N. has not been targeted. But they are continuing. And there is a strong threat still.

And it is still, despite – you know, when I sent to Sarawbi, we have Taliban convoys with us to be able to – it’s ironic in many ways, but you have to – so you have the Taliban in the back and the front of your convoys to – for protection. And it’s the only way that any of us can actually move around there. And it is very difficult to move around, to get the permission to move around. Wherever you go, there needs to be UNDS or some security needs to go and understand what’s happening. And so security still remains a problem, not – ironically, not necessarily due to the Taliban, as it was in the past, but due to ISIS-K.

Dr. Morrison: Both of you, I mean, you’ve got a set of quandaries here. One is, we talked about, the race against time and is it too late or is there still time? There is also the reality that at some point those who are able to leave will get up and leave. And so we could have a situation where things begin to stabilize, but there’s still – it’s still awfully dangerous. And those that can flee, do so. And what does that – how does that change the complexion of this – of this situation? We also know that money is escaping the country in fairly significant volumes, which of course then begs the question, if you’re going to ease the restrictions on baking and commercial transfer, and reanimate the economy, do those resources simply flow in and out? And how do you guard against that? So, Leon, why don’t you say a few words, and then Paul, on those quandaries that we face.

Mr. Rubenstein: Well, on the first one, certainly I know people, health providers, who have left. And I’m in touch with them. And they left for very good reasons. But this goes back to the timing problem. The more time that goes by without funding going through to kind of reestablish some kind of system, the more likely people are going to leave. So time is an enemy, not just for people’s health but for the survival of the workforce. So that’s a real – that’s yet another form of the urgency of acting here. There’s no way it’s going to have the same workforce it had a year ago. But it’s going to get worse and worse and worse, I think. As to the banking, that is beyond my competence. (Laughs.)

Dr. Morrison: Paul, how do you structure the reopening of the economy in order to be able to raise confidence – external confidence – that the resources are moving forward in a way that they’re serving their objectives?

Dr. Spiegel: Like Leon, I think I’m not a – you know, an expert in that area, in terms of the banking side. I’m going to punt on that one. But if I may, I wanted to – I see there’s a question in the chat that perhaps I could respond to.

Dr. Morrison: Yeah.

Dr. Spiegel: But and there’s – I’d like to respond to that, and then I’d like to make an issue in terms of the urgency. Actually, maybe I’ll start with that.

The other big problem is currently the Taliban are working constructively with the international community. The longer this goes one, at one point they – and, as we know, the Taliban is not homogenous. And they – we may – they may just decide, enough. This is not working. And they may not allow us to – the international community and the national communities within Afghanistan – to actually continue this way. Maybe they’re going to stop and say that we’re no longer going to give access to polio and others. Maybe they’re going to stop even SEHAT Mundi and say, we’re not going to allow money to go to the NGOs.

So there are a lot of unknowns that we really do not know at this point. And I certainly believe that the posture of the Taliban right now will not stay this way it continues to be – we continue not to allow funding to come in. And I met with many of the – many senior Taliban officials that were in health. And they’re very – they’re, for the moment, very clear. None of them said, we want money to come to us. What they said is, we want money to be able to – not “we,” as the Taliban – meaning we need money to be able to go to these hospitals. We need to go into these now remote areas that we never access – that never had access. How can this money come? And so they were very clear. They knew it was not going to come to them, at least for now. But that’s not even happening. So they’re going to become more and more frustrated.

And in terms of Jamie from IRC, yes, the humanitarian principles, as always, are essential. And neutrality is one of them. But I think at this point, given the gravity of the situation, the principle of humanity needs to be number one right now. And I’m sure there are ways to – I’m sure there are ways to address the neutrality and the independence, but this is humanity first and foremost right now. And so I think that has to take precedence over neutrality at this point. Over.

Dr. Morrison: Let’s – we got a few minutes – 10 minutes left here. Let’s talk about how to make the best case, how to – you know, we know that the politics surrounding all of these issues here in Washington, D.C. are very toxic, and very, very complicated, and difficult. And I’m encouraged that former commanders, three- and four-star flag officers, retired, have stepped forward, senior diplomatic figures who invested enormous amounts of their career in Afghanistan are stepping forward and making the case. That’s terribly important. But there’s many other players here that can be quite important. The U.N. Secretary-General Guterres, the EU leadership, the major leadership of the major powers within Europe that have been deeply invested in Afghanistan as well. Then you’ve got the neighboring countries, Afghanistan’s neighbors, who fear an unraveling as well.

What kind – and we will have this appeal come forward, which will bring people together. But in your view, what can be done both here and broader on an international front to make the case in the most effective way, that will make it easier potentially for the Biden administration to step forward and take some of these steps that we’ve discussed? Paul, you want to offer your thoughts, and then Leon?

Dr. Spiegel: Sure. I think some aspects, it’s clear in terms of the sanctions that we’re not – it’s not going to be possible just to say stop the sanctions, even if people wanted to, for a variety of reasons, particularly some of the terrorism component. And so there needs to be, in my view, very clear guidance on what the humanitarian exceptions are going to be, and it needs to be because of the hold on the overall – the sanctions and the Swiss system, and the control over the economy regarding potential sanctions, if people do provide funding to – or seem to provide them to the Taliban, there needs to be very strong clarity from the U.S. government on what can and cannot be done.

Secondly, there needs to be ways to be able to address the liquidity and the amount of money that needs to get into Afghanistan. That’s well beyond my expertise, but at least speaking with various people there’s a lot of thought on this that needs to be done ASAP. And the other – and I’ll just end by saying the other – beyond the U.S., the EU, the U.N., who are very strong players, the U.K. now, they also, I think, need to be very clear on what their red lines are and how their red lines may be able to shift a bit in terms of either working with the Taliban and/or allowing certain monies to go to technocrats, to government employees that are not part of the Taliban regime, but are technocrats that allow – whether it be teachers, whether it be those in the Ministry of Health – to ensure that these systems can function. So again, I think there are ways to understand the limitations of sanctions, but also not cross the red lines in terms of terrorism and other components. But there are ways to make exceptions to make this happen. And it needs to be done immediately.

Dr. Morrison: You know, there’s been – there’s been talk, going back to the summer when – the August 15th takeover by the Taliban. There’s been a certain thread of sentiment that we’ve heard about, look the more time goes on, Americans aren’t going to really care that much about what happens in Afghanistan. The recent events suggest otherwise. Recent events suggest that a lot of people of different backgrounds, of different profiles, of different expertise are stepping forward and making very strong arguments. And that’s quite striking. The other thing that I think that looms out there as a factor is that if the worst happens in Afghanistan, wouldn’t you expect that the United States is going to be held to blame pretty widely, Leon?

Mr. Rubenstein: Absolutely. And I think the point you made just now about the welcoming of the refugees make a difference. I think as the reporting about what’s going on there now, particularly about the famine, increases I think people are aware and there is a sense of responsibility.

I want to make another point about what you’ve just been talking about, about red lines. I think having the perfect agreement and the perfect structure is not enough, because the other player here in the Taliban. And just setting up the rules about what you can do and what you can’t do and how you have to leave everybody alone is going to be problematic. There has to be the ability to have real ongoing nonfinancial relationships. You got to be able to work things out. And the scariest part of trying to make the perfect agreement so there’s no role for the Taliban is probably going to make it harder.

I learned this from Ambassador Jimmy Kolker, who talked about you can’t – you can’t accomplish things in these difficult environments without having a little bit wiggle room with the other party. So I think we have to be realistic. And that has a political cost, you know, because you can’t go to Congress and point to all the black and white language that is perfect. But you’re not going to be able to solve all the problems on an ongoing basis, not just today but in six months, without having some contact with the Taliban to solve problems, and to set conditions as needed, have a little wiggle room, though, to make this thing work.

Dr. Morrison: I do think, you know, if you read the ICG report, if you read the statements coming from Peter Maurer and others at the International Committee of the Red Cross, there’s a pretty blunt statement about we’re going to have to – we’re going to have to somehow come to terms with dealing with this state governed by the Taliban, if we’re going to – and the question then is, how do you do that smart? And how do you manage the blowback? Because it’s going to require being toughminded and taking some hits. And there’s no getting around that.

There’s no way to come up with a workaround that’s going to be – going to keep everybody feeling entirely comfortable. It’s going to be an uncomfortable set of compromises that are going to be essential to avoid the worst outcomes, and which are going to be controversial and difficult to defend against the worst critics that are out there right now. And that’s going to require simply taking this on and making the judgement that, yes, this is the right thing that has to happen, and take some of those hits.

Paul, I know you felt like maybe you needed to say a bit more about the issue of neutrality raised by Jamie in IRC. And then we’re going to circle back and ask you, Paul, for closing thoughts on the next steps.

Dr. Spiegel: Yeah. Thank you. I reread Jamie’s question. It’s an important one. And in terms of neutrality, I think what he or she was implying was – implying, which I would agree, is that neutrality requires us to be able to work on all sides, which requires us to be able to work with the Taliban, with any side of any situation. And right now, the rules are not allowing us, the donors in many ways, are not allowing us to work in some ways with the Taliban. But I think it’s really important to make it clear that we are – we, the international community – is meeting with the Taliban. We’re providing them no money whatsoever, but we are able to speak with them, get their views.

It’s not as if we’re ignoring them. I had numerous meetings with the heads of the hospitals, and even some of the shadow ministers and people under them who were working previously in Doha. And again, they really – I was impressed with what they knew about the system. And where they were very clear about the red lines, and yet they were still able to provide us very specifics about what they – what they would like. And, again, not for them, but for the health system itself. Even to the point of saying we need a complete blood count machine in this really far area.

So I found for the most part the people that I was meeting, which are a very biased group of people, of course, but I found them to be knowledgeable, very clear that they were not going to be receiving money, but willing to work with us for now. And as I mentioned, I’m worried that may change in the next few months.

Dr. Morrison: Thank you. Thank you, Paul. Thank you, Leon. We’re at the top of the hour here, and so we’re going to adjourn. I want to thank our online audience for joining us today. And I want to thank all of my colleagues at CSIS who worked so hard to pull this all together, and Paul and Leon for making so much time to be with us today. Thank you.

Mr. Rubenstein: Thank you, Steve.

Mr. Speigel: Thank you very much, everyone.