Photo: Bazaar In Afghanistan. Credit: CIA World Factbook.FROM: U.S. DEPARTMENT OF DEFENSE
Caldwell: Troubled Afghan Hospital Got Transparent Review
by Gerry J. Gilmore
American Forces Press Service
WASHINGTON, Sept. 13, 2012 - A three-star general who commanded the NATO and U.S. training missions in Afghanistan told a House subcommittee yesterday that his command conducted a transparent investigation into alleged patient neglect, mismanagement, theft and corruption at the Afghan-run Dawood National Military Hospital in Kabul.
Appearing before the House Oversight and Government Reform Committee's national security, homeland defense and foreign operations subcommittee, Army Lt. Gen. William B. Caldwell IV testified that he became the first commander of the NATO Training Mission in Afghanistan and commander of the U.S. Combined Security Transition Command Afghanistan on Nov. 21, 2009.
The NATO command was established to coordinate and synchronize the multinational efforts to raise, equip, train and sustain an Afghan national security force, the general said, and the U.S. command was responsible for the oversight of U.S. funding, training and ministerial development.
Caldwell told the panel that he recognized early on that his command faced immediate challenges, including issues within the Afghan medical system.
"This was a unique challenge, as we had three simultaneous tasks," Caldwell said. "First, we had to establish a new multinational command; second, we had to train, generate and sustain an enduring Afghan national security force that included the Afghan army, police and air force and all of their associated support systems; and third, we had to develop, advise and mentor at all levels of the Ministry of Defense and the Ministry of Interior."
The Dawood Hospital treats wounded Afghan soldiers. It is largely U.S. funded but staffed by Afghan medical personnel who are mentored by U.S. military doctors.
"Allegations began to surface regarding widespread theft, mismanagement and patient neglect at the hospital" during the summer of 2010 and as early as 2006, subcommittee chairman Rep. Jason Chaffetz of Utah said at the hearing. Evidence, he said, indicates that wounded Afghan soldiers endured starvation, bedsores and gangrene. Some patients, he added, were "extorted for medical care, while others were abused, neglected and made to suffer."
Caldwell recalled the state of Afghan medical care at the time of his assumption of command in November 2009.
"Afghanistan is a sovereign nation where their medical care was ranked in the bottom 10 percent globally by the World Health Organization," Caldwell said. "This poor medical care presented issues that were complex and required a high degree of coordination with our Afghan partners, coordination that was necessary and critical in order to have any chance of this care being established and enduring beyond our presence there."
By the summer of 2010, Caldwell said, "it was becoming apparent to us that there was corruption in the [Afghan medical] system, and we were then trying to establish whether, is it just going into warehouses? Is it corruption where people are making a profit off it? And so we internally started looking very hard at the whole corruption issue."
Caldwell testified that he'd also recognized early on that there were problems at the hospital.
"Part of our challenge was we didn't have the number of people in the hospital really providing the oversight inside the hospital until about August of 2010, when we really put our first two mentors in on the wards and started giving us some real day-to-day look at what was going on in that, because we just didn't have the depth," the general said.
Caldwell also told the subcommittee that he'd "supported all investigations, audits and assessments into any aspect" of his command in Afghanistan.
"At one time during my tenure, we had in excess of 27 simultaneous audits or assessments by multiple government agencies external to our command, ongoing," Caldwell said. "We embraced these so we could remain transparent as possible and to demonstrate sound stewardship of the resources that had been entrusted to us by the American people and the U.S. Congress."
At all times, he added, he and his command team addressed issues aggressively and immediately as they were presented to them.
Caldwell now commands U.S. Army North and 5th Army, and he's senior commander of Fort Sam Houston and Camp Bullis in San Antonio. He was accompanied at the hearing by Army Maj. Gen. Gary S. Patton, who served with Caldwell in Afghanistan as the NATO mission's deputy commander for army training and as commander of the U.S. transition command, and Ambassador Kenneth P. Moorefield, the Defense Department's deputy inspector general for special plans and operations. Patton is now the director of DOD's Sexual Assault Prevention and Response Office.
Patton said the problems associated with the Dawood Hospital "were highly complex ones, complicated by elements of Afghan corruption, failed Afghan leadership and hospital staff apathy, worsened by the inherent problems of national illiteracy and the historic inadequacy of Afghan health care."
The hospital's operations also were burdened by the consistent flow of wartime casualties, he added.
Patton said the NATO training command stepped up to the challenge and devoted considerable time and energy to improving the medical care and management of the hospital while simultaneously manning, building, training, developing and equipping the Afghan army while at war.
"We took very seriously our role as advisors to drive positive change at the hospital through active, persistent and firm engagement with our Afghan partners," he added.
It was important to conduct a partnered effort, Patton said, "because in our experiences working with other Afghan systems, although a coalition solution to a problem would usually yield an immediate fix, only a partnered or Afghan-led solution would produce an enduring result."
Moorefield told the subcommittee that in late October 2010, the Combined Security Transition Command Afghanistan inspector general requested DOD IG assistance in addressing possible discrepancies concerning the distribution of and accounting for pharmaceuticals distributed to the Afghan National Army.
On November 10, 2010, Moorefield said, Caldwell sent him a message reconfirming his command's request for DOD IG medical logistics mission assessment, adding that with the assistance of a recent increase in personnel, he had become increasingly concerned about "possible illicit activities and inadequate accountability measures concerning pharmaceuticals supplied.".
His team deployed to Afghanistan on Nov. 28, Moorefield said. After visiting the Dawood National Military Hospital and three of four regional hospitals and associated medical depots, he told the panel, the IG team briefed the command on deficiencies related to dysfunctional medical logistics that negatively affected hospital management and patient care at Afghan National Army hospitals. The team also found and reported a lack of strategic planning to better focus joint efforts by the NATO and U.S. commands and the Afghan army to make effective use of scarce resources and noted that hospital mentoring teams were staffed at only 50 percent of authorized personnel, among other issues.
In February 2011, as a result of the November assessment mission, Moorefield said, his team "held an inspection of just the [Dawood facility] focused on unacceptable conditions reported by the command concerning hospital management, medical personnel conduct, sanitation, and patient care, and supply and inventory issues." This inspection, he added, also resulted from a joint series of inspections by the NATO training command and the U.S. transition command of the national military hospital.
Although the state of general sanitation and medical supplies had improved at Dawood, Moorefield said, "a number of the other concerns were confirmed, and we made recommendations to the command for corrective actions."
This June, the DOD IG again inspected the Dawood military hospital and the Afghan national security forces medical care system and a number of key areas necessary to create an independent, sustainable system, Moorefield said.
"We found that development had advanced in the areas of planning and mentoring, leadership and management, and logistics, and patient care," he said. And there is "evident commitment" by the new Afghan army surgeon general and the Dawood hospital commander to continue work on improving whatever needs improvement, he added.
Significant challenges still remain with respect to the development of the Afghan national security forces medical system and Dawood's capacity-building initiative, Moorefield said, noting that as U.S. and coalition forces draw down, the decreasing numbers of medical mentors will focus on priority medical areas requiring improvement.
At Dawood, he said, these areas include emergency room, anesthesia, physical therapy, preventive medicine and radiology. "And improving medical logistic support for the [Afghan forces] and its medical care system is critical and is expected to require attention through 2014 and perhaps beyond.
Reinforcing the Afghan security forces' commitment to the enduring stewardship of the health care system "will need to remain a priority of both the command and the Afghan government," Moorefield said.
Moorefield emphasized the DOD IG is committed to continued oversight of the development of Afghan national security forces health care, including at the national military hospital.
Chaffetz said he was "encouraged by more recent reports of progress at Dawood hospital and the Afghan medical system."
"Our men and women in uniform have an exceptionally difficult task [in Afghanistan] and should be commended for their efforts," he added.
