[House Hearing, 112 Congress]
[From the U.S. Government Publishing Office]

[H.A.S.C. No. 112-138]
ACCOUNTABILITY AND REFORM EFFORTS AT THE AFGHAN NATIONAL MILITARY
HOSPITAL

__________

HEARING

BEFORE THE

SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS

OF THE

COMMITTEE ON ARMED SERVICES

HOUSE OF REPRESENTATIVES

ONE HUNDRED TWELFTH CONGRESS

SECOND SESSION

__________

HEARING HELD

JULY 10, 2012

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SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS

ROB WITTMAN, Virginia, Chairman
K. MICHAEL CONAWAY, Texas JIM COOPER, Tennessee
MO BROOKS, Alabama ROBERT ANDREWS, New Jersey
TODD YOUNG, Indiana MARK S. CRITZ, Pennsylvania
TOM ROONEY, Florida COLLEEN HANABUSA, Hawaii
MIKE COFFMAN, Colorado
Michele Pearce, Professional Staff Member
Paul Lewis, Professional Staff Member
Arthur Milikh, Staff Assistant

C O N T E N T S

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CHRONOLOGICAL LIST OF HEARINGS
2012

Page

Hearing:

Tuesday, July 10, 2012, Accountability and Reform Efforts at the
Afghan National Military Hospital.............................. 1

Appendix:

Tuesday, July 10, 2012........................................... 27
----------

TUESDAY, JULY 10, 2012
ACCOUNTABILITY AND REFORM EFFORTS AT THE AFGHAN NATIONAL MILITARY
HOSPITAL
STATEMENTS PRESENTED BY MEMBERS OF CONGRESS

Wittman, Hon. Rob, a Representative from Virginia, Chairman,
Subcommittee on Oversight and Investigations................... 1

WITNESSES

Moorefield, Ambassador Kenneth P., Deputy Inspector General for
Special Plans and Operations, U.S. Department of Defense....... 5
Sedney, David S., Deputy Assistant Secretary of Defense for
Afghanistan, Pakistan, and Central Asia, U.S. Department of
Defense........................................................ 2

APPENDIX

Prepared Statements:

Moorefield, Ambassador Kenneth P............................. 38
Sedney, David S.............................................. 33
Wittman, Hon. Rob............................................ 31

Documents Submitted for the Record:

News article submitted by Ms. Speier......................... 51

Witness Responses to Questions Asked During the Hearing:

Ms. Speier................................................... 57
Mr. Young.................................................... 57

Questions Submitted by Members Post Hearing:

Mr. Cooper................................................... 61
ACCOUNTABILITY AND REFORM EFFORTS AT THE AFGHAN NATIONAL MILITARY
HOSPITAL

----------

House of Representatives,
Committee on Armed Services,
Subcommittee on Oversight and Investigations,
Washington, DC, Tuesday, July 10, 2012.
The subcommittee met, pursuant to call, at 3:04 p.m., in
room 2118, Rayburn House Office Building, Hon. Rob Wittman
(chairman of the subcommittee) presiding.

OPENING STATEMENT OF HON. ROB WITTMAN, A REPRESENTATIVE FROM
VIRGINIA, CHAIRMAN, SUBCOMMITTEE ON OVERSIGHT AND
INVESTIGATIONS

Mr. Wittman. Folks, welcome.
I want to call to order this Subcommittee on Oversight and
Investigations of the House Armed Services Committee for
today's hearing on Accountability and Reform Efforts at the
Afghan National Military Hospital.
I would like to welcome our witnesses here today: Mr. David
Sedney, Deputy Assistant Secretary of Defense for Afghanistan,
Pakistan, and Central Asia; Ambassador Kenneth Moorefield,
Deputy Inspector General for Special Plans and Operations; and
Major General Dr. Douglas Robb, the Joint Staff Surgeon, Office
of the Chairman of the Joint Chiefs.
Gentlemen, welcome today. We appreciate your taking your
time to join us.
We are looking forward to your testimony today, and
Ambassador Moorefield, in particular, I would like to thank you
for the work you have done on monitoring these issues. I hope
you will let your team know how much this committee appreciates
their noteworthy dedication to this challenging mission.
Recently, I have traveled to Afghanistan and on a number of
times over the past several years and have seen, particularly
during my last trip in June, the great progress that has taken
place since the surge has begun, a ways to go, but certainly
significant progress to this point.
And the key to sustaining this progress is building a
capable Afghan National Security Force and, of course, the
support systems to maintain it, including a medical care system
responsible for the health and well-being of those who have
served and sacrificed. Taking care of these troops is
absolutely critical to this mission and must be a continued
area of focus as we move forward.
I am both disheartened and disgusted when I saw the
pictures showing patient abuse and neglect at the military
hospital, an institution where coalition forces serve as
advisers and mentors. We can and must do better to ensure that
these troops receive adequate medical care. Anything less is
detrimental to our mission and compromises our efforts to
secure Afghanistan's future.
As I understand it, no one to date has been held criminally
responsible for what happened. Moreover, there has been no
accounting of the millions of dollars of funds and medical
supplies that disappeared since these issues came to light. I
hope you will provide us with explanations and detail the
systemic reforms aimed at preventing this from happening again.
As an administrative note, I recognize that members of
other subcommittees will join us today. Pursuant to the
committee rules, I ask unanimous consent to allow their
participation. And absent objection, I will recognize them
after all O&I Subcommittee members have had an opportunity to
question the witnesses.
Gentlemen, thank you again. We look forward to your
testimony and taking our questions.
And with that, I will turn it over to our ranking member,
Mr. Cooper.
[The prepared statement of Mr. Wittman can be found in the
Appendix on page 31.]
Mr. Cooper. Thank you, Mr. Chairman.
I have no opening statement. I look forward to hearing the
testimony of the witnesses.
Mr. Wittman. Thank you.
Mr. Sedney, we will begin with you.

STATEMENT OF DAVID S. SEDNEY, DEPUTY ASSISTANT SECRETARY OF
DEFENSE FOR AFGHANISTAN, PAKISTAN, AND CENTRAL ASIA, U.S.
DEPARTMENT OF DEFENSE

Mr. Sedney. Thank you very much, Mr. Chairman and members
of the subcommittee.
And I particularly thank you, Mr. Chairman, for your
attention to this very important issue and for the continuing
interest and effort that you have put into this area, which you
have very aptly described the importance of.
I appreciate the opportunity to be before you and the
members of the subcommittee to discuss Afghanistan and
particularly the efforts towards accountability and reform at
the Dawood National Military Hospital in Kabul, Afghanistan.
I want to start off by going back to basic principles here,
which is why are we there? Why are we concerned about
Afghanistan and the Afghan National Security Forces and,
therefore, the hospital?
The United States, together with our coalition allies and
our Afghan partners, is dedicated to our core objectives in
Afghanistan of disrupting, dismantling, and defeating Al Qaeda
and its extremist affiliates, to deny them safe haven from
which they can launch attacks against the United States and our
allies and partners, and to deny the Taliban the ability to
overthrow the Afghan government and re-create such safe havens.
Thanks to more than 10 years of dedication and sacrifices
by our forces, our coalition partners, and the Afghan people
themselves, we have taken enormous strides towards achieving
those objectives, particularly over the last 3 years.
A key objective, the key objective to achieving this
strategy is the development of the Afghan National Security
Forces into a sustainable and capable force. Their growth and
confidence and demonstrated capability to provide suitable
security against internal and external threats are essential
for the responsible transition of security in Afghanistan to
the Afghans themselves by the end of 2014, as agreed to by NATO
[North Atlantic Treaty Organization] heads of state at Lisbon
in 2010 and reinforced by NATO heads of state at Chicago last
month.
To this end, with coalition support, the Afghan security
forces have made great progress, both in terms of size and
capability. Both the Afghan National Army and the Afghan
National Police are on schedule to meet their surge end-
strength goals of 352,000 by or before October of this year.
Their continued performance and ability has allowed them to
move increasingly into the lead for operations, including in
operations in recent days and weeks in countering major attacks
in Kabul, in Kandahar, Helmand, and elsewhere. Currently, the
Afghan security forces participate in over 90 percent of all
coalition operations, and more than 50 percent of these
partnered operations are led by the Afghan security forces.
In addition to the success of the Afghan security forces
that I mentioned, I want to stress to the committee the
importance of two signal achievements that have sent an
important signal to the Taliban, the Afghan people, and to
countries in the region.
The first is the strategic partnership agreement that
President Karzai and President Obama signed in May that shows
the United States and Afghanistan are committed to a mutually
beneficial relationship beyond 2014.
Second, as I mentioned before, the Chicago summit was a
great success and demonstrated the continued dedication of over
50 NATO and other partner nations to supporting security and
stability in Afghanistan. They reaffirmed their commitment to
the Lisbon timeline but, very importantly, agreed to continue
their commitment after 2014.
Despite these achievements, there are still many areas that
need improvement. Many, many areas. Particularly, in the Afghan
security forces, it is important to have improvements for them
to be the independent force that they need to be in 2014 to
protect Afghan security.
One of the key areas, as you have said, Mr. Chairman, is
the development of a medical system capable of sustaining the
health and well-being of the Afghan security forces. The
allegation raised in the past years, particularly in 2010, of
mismanagement at the Dawood National Military Hospital
highlighted gross deficiencies in the system and the critical
need for serious reforms.
Coalition medical mentors and advisers reported inexcusable
mismanagement and, at times, neglect in the operation and
provision of basic medical care, resulting in substandard
patient care, disturbing sanitation conditions, poor facilities
management, and a dysfunctional medical logistical system.
These concerns were elevated to senior leaders in the NATO
Training Mission-Afghanistan [NTM-A] and to its commander at
that time, Lieutenant General William Caldwell.
Recognizing the enormity of the situation, General Caldwell
took action. He requested the involvement of the Department of
Defense Inspector General [IG] Office of Special Plans and
Operations to assess the nationwide medical logistics system in
Afghanistan.
With regard to the substandard patient care concerns,
Lieutenant General Caldwell's staff alerted the IG and his
staff to those concerns, and the IG expanded the scope of its
oversight activities to include reports on this matter.
Thanks to the response and effort in reforming the
healthcare and medical systems, we are now helping to turn
around what had been a broken system, introducing
accountability, standards, and stewardship at all levels.
The senior leadership of ISAF [International Security
Assistance Force] NTM-A and the medical advisory group
recognized the critical importance of enabling a system that
could provide adequate healthcare to the Afghan security forces
now and for a transition to take place in 2014. Improvements in
the accountability of the changes in and improvements in the
hospital leadership and staff, the general sanitation
standards, the standard of patient care, and the logistics
systems are underway.
Following the removal of General Ahmad Zia Yaftali from his
position as hospital commander, new leadership established more
stringent planning and oversight to advance the professional
conduct and accountability of the medical staff, with special
attention towards combating staff absenteeism.
By last summer, NTM-A mentors reported that a new hospital
commander, chief of surgery, and chief nurse routinely
intervened in every case of possible neglect. And by August of
last year, there were no known cases of neglect.
Follow-up inspections in 2011 showed marked improvement in
cleanliness, dressing, and sterilization. The transfer of
medical logistics from the Office of Surgeon General to the
Logistics Command allowed the Ministry of Defense to enforce
its own standard controls over receipt, storage,
accountability, and distribution of pharmaceuticals and other
supplies.
Newly implemented medical inventory and tracking systems at
Dawood have introduced greater transparency and efficiency in
the supply chain management. The Logistics Training Advisory
Group and Medical Training Advisory Group conduct continuous
battlefield circulations throughout the hospital to provide
daily follow-up and ensure compliance.
These are just a few of the examples that I have been made
aware of. If you have further questions regarding these recent
improvements, we look forward to addressing them in Q&A.
NTM-A, the coalition forces, and the leadership, starting
with General Allen, remain committed to continuing this
progress and supporting our Afghan counterparts as they display
increasing capability and growing responsibility and
improvement. The conditions which existed before have changed.
A lot more remains to be done, but we are committed to the
sustained improvement necessary for Afghanistan to have that
enduring capability that you described, Mr. Chairman.
Again, I would like to thank you and the members of the
subcommittee for the opportunity to appear before you and look
forward to your questions.
[The prepared statement of Mr. Sedney can be found in the
Appendix on page 33.]
Mr. Wittman. Thank you, Mr. Sedney.
I appreciate your comments to begin with, but I would like
to recognize Representative Mike Coffman from Colorado for his
tireless advocacy to make sure that this issue with Dawood
Hospital would be addressed. So, Mr. Coffman, I appreciate your
efforts here.
And with that, Ambassador Moorefield, we will turn to you
for your opening comments.
I want to remind, too, the witnesses that as much as we
can, we like to try to stick to the 5-minute timeframe. Your
comments will certainly be entered for the record in their full
content.

STATEMENT OF AMBASSADOR KENNETH P. MOOREFIELD, DEPUTY INSPECTOR
GENERAL FOR SPECIAL PLANS AND OPERATIONS, U.S. DEPARTMENT OF
DEFENSE

Ambassador Moorefield. Thank you, Mr. Chairman and Ranking
Member Cooper and distinguished members of the committee and
subcommittee.
Thank you for this opportunity today to discuss OIG
oversight of the Department's efforts to develop the Afghan
National Security Forces [ANSF] healthcare system and also the
developments at the National Military Hospital.
The development of the Afghan National Security Forces has
included, as Dr. Sedney said, building an effective healthcare
system to support field-level combat casualty care, evacuation
of wounded casualties, restorative surgery, and long-term care
for disabled personnel.
Meeting this challenge has understandably proven difficult.
When the ANSF medical care system development efforts began,
the country's public healthcare system was rated among the
worst in the world by international experts. The remnants of
the Soviet era military medical facilities and services left by
the Taliban had further deteriorated this limited capability.
But given the importance of the medical care issue,
therefore, as it relates to the Afghan security forces, DOD IG
[Department of Defense Inspector General] has undertaken a
succession of oversight initiatives since 2008 and up to the
present.
Our assessments in 2008 and 2009 determined that the
complex set of issues related to medical stabilization and
reconstruction challenges in Afghanistan called for a robust
U.S. and international effort to develop and implement a
multiyear planning strategy.
Many U.S. military medical mentoring teams at that time
with whom our teams met were not appropriately staffed. The
development of ANSF medical personnel was seriously hampered
also by inadequate guidance to U.S. medical mentors,
particularly regarding standards objectives.
Our 2009 assessment recommended that the U.S. Training and
Advisory Command develop a clearly defined plan for building
the ANSF healthcare system in coordination with the relevant
Afghan ministries and security forces. In 2010, at the request
of the Commander, NTM-A CSTC-A [Combined Security Transition
Command-Afghanistan], we assessed the Afghan army medical
logistics system, which included the National Military
Hospital.
We made recommendations for strengthening the system,
including improved accountability and control of medical
supplies. We also determined that ANSF healthcare system
planning did not include a defined end-state goal, and the
mentoring effort was impeded by only having half the authorized
medical mentor personnel.
In February 2011, we conducted an inspection of just the
National Military Hospital. This mission was precipitated by a
report received by our IG who was on a tour of Afghanistan and
in Kabul in November 2010.
During this mission, our team identified issues related to
inadequate Afghan medical personnel staffing at the hospital,
failure of the logistics system to reliably deliver
pharmaceuticals to the hospital and the hospital to its
patients, significant quantities of unused medical equipment
and supplies, inadequate patient nutrition, and a lack of
clearly defined medical standards, among other issues.
We subsequently carried out an audit of the pharmaceutical
distribution system. The team found that although the process
had made progress in the previous year, the delivery and
inventory control processes for pharmaceuticals in particular
at ANA [Afghan National Army] medical facilities and depots
required further improvement.
Just 2 weeks ago, in this past June, a DOD IG team returned
to the NMH [National Military Hospital] to review the status of
efforts to improve its management, healthcare services, and
logistical support. As is customary, our team outbriefed our
military command and the National Military Hospital leadership
and staff prior to its departure.
There were 15 U.S. military mentors present at the NMH
during this inspection. The team noted that since our February
2011 inspection of the NMH, progress had been made in a number
of areas. This is further detailed in my written testimony.
Key among these areas were no complaints or evidence of
patient maltreatment; new processes and procedures to improve
personnel accountability and patient care, including for
nutrition; clearly defined medical standards; improvements in
the medical logistics system; and improved leadership by the
ANA medical command and at the NMH itself.
Also, ISAF, the International Security Assistance Force,
and NTM-A have now published an ANSF healthcare development
plan, identifying the readiness performance criteria for the
NMH to be able to meet the NTM-A transition objective of Afghan
assumption of lead responsibility for their functioning by the
third quarter of 2013.
Our team observed substantial NMH progress towards
achieving this objective. Once achieved, the NTM-A intends to
continue to provide mentor monitoring of the NMH performance
and the rest of the healthcare system through 2014.
There is still some NMH development challenges remaining.
These include personnel shortages, specifically at the pharmacy
and nursing departments, the transfer of ANA patients from
coalition medical facilities to the NMH. NMH requires better
coordination. Inventory control procedures have improved in the
bulk storage area but need to be implemented in the dispensary,
and the NMH staff needs additional training.
Finally, NTM-A is still working to identify the scope of
its support for a post-2014 ANSF healthcare development mission
intended to enable its enduring sustainability.
In closing, let me emphasize the DOD IG remains committed
to providing oversight of U.S. and coalition efforts to develop
further the Afghan military healthcare system, including at
NMH. And we thank you for this opportunity to speak to you
today, look forward to any questions you may have.
[The prepared statement of Ambassador Moorefield can be
found in the Appendix on page 38.]
Mr. Wittman. Thank you, Ambassador Moorefield. We
appreciate your opening testimony.
Major General Robb, I understand that you do not have
opening testimony, but that you will be available to answer
questions from committee members.
Thank you so much for joining us today.
With that, Mr. Sedney, I will begin with you. I want to
focus on the former surgeon general there in Afghanistan, Ahmad
Yaftali. And as you know, allegedly, he profited from missing
medical supplies there at the hospital and failed to address
some fairly serious neglect issues there at the hospital, in
some cases leading to people dying at the hospital.
And based on that, my question is, is he still under
investigation by our folks there in theater? Is he still
wearing a uniform? And are U.S. or coalition force dollars
still being expended to pay his salary?
Mr. Sedney. Mr. Chairman, we are very much aware of the
serious allegations against General Yaftali, and there is
currently an ongoing investigation. It is an Afghan
investigation under Afghan law, carried out by Afghan
authorities.
However, the U.S. Department of Defense, particularly
through Task Force Shafafiyat (Transparency) at ISAF, are
giving support to that investigation. We are conveying
accurately to the Afghan authorities all the information that
we have, working with them to develop additional information
where it may be needed for the possible--or for any possible
charges that may be brought.
Well, you are correct. No charges have been brought against
General Yaftali or anyone or others involved in this. I can
assure you that this is a very serious effort. It is supported
and monitored at the top levels of our leadership structure in
Afghanistan and here in Washington and that we believe that
this investigation will result in--that it will result in a
very close look at all the allegations.
We can't prejudge whether there will be charges, whether
there will be convictions, and what the fate of any individual,
including General Yaftali, will be. In fact, we have to be
careful not to try and make statements that will presuppose a
particular outcome in the Afghan judicial system.
But as I said, I can assure you that the investigation is
ongoing. It is serious and receiving a lot of assistance from
the U.S. authorities.
Mr. Wittman. Just to reiterate the question, is he still
wearing a military uniform, and are any U.S. or coalition funds
being expended to pay his salary currently?
Mr. Sedney. General Yaftali was removed from the leadership
of the hospital. To our knowledge, he does not have another
position inside the Afghan forces.
Whether he is receiving his salary or not is a question
that we will ask the Afghans, but we don't have any information
to say that he is not. However, any disciplinary action that
would be taken against him would come out of this ongoing
investigation. So I am going to be careful not to say anything
that will prejudge what that investigation might or might not
result in.
Mr. Wittman. Thank you, Mr. Sedney.
Ambassador Moorefield, your June 2011 report outlined a
number of significant shortcomings that continue to exist in
areas of planning and execution of a medical logistics system
there within the Afghan medical system. And you said there that
the current system could not be maintained without continued
U.S. and international support.
How long do you think this condition will continue to
exist, and what other areas of medical care system pose similar
challenges there in Afghanistan as we speak?
Ambassador Moorefield. Okay. I think I got it this time.
Thank you, Mr. Chairman.
The planning that is currently going on, and this is
according to our team's report--and they just came back a few
days ago and spent extensive amount of time with the command--
is that beginning at the end of 2013, after the third quarter
of the calendar year, they are going to transition to lead
responsibility to the Afghan medical personnel at all the
hospitals and the depots with the intention of monitoring their
performance through 2014.
And where intervention and support and additional mentoring
is required, be able to provide that. But essentially, transfer
the burden of that responsibility and, therefore, the need for
them to take appropriate action on their own hook. So that is
the intention through 2014.
Now I believe that the healthcare system has been
identified as an ongoing responsibility, support responsibility
of our command, along with several other key enabling function
areas. I understand that even though we don't have the
specifics of the plan, which I mention in my remarks and we
hope to get soon--they are still working on it--but in any
event, after 2014, we think the emphasis is going to be
primarily on training and education. And this is where they
seriously need additional assistance to help build a base,
basically, for an enduring and sustainable Afghan military
medical system.
And this could include a whole range of activities. There
is medical training that is going on right now, but that base
will be, we understand, expanded up to and include even
fellowships and residencies for doctors in specialty care areas
that would be undertaken in the country.
Mr. Wittman. Thank you, Ambassador.
With that, we will go to our ranking member, Mr. Cooper.
Mr. Cooper. Thank you, Mr. Chairman.
I am worried that the interface between U.S. personnel and
the Afghan so-called health system puts U.S. personnel in an
impossible situation. Because to read one of the documents
here, the MTAG [Medical Training Advisory Group] staff mentors
and advises the Afghans, but they do not treat patients,
prescribe, or otherwise administer vaccines or pharmaceuticals.
Their purpose is ``to help the Afghans perform and to
increase their capability, not by doing for them but rather by
advising them and stepping back. They perform not as a
clinician, not as a nurse, not as a technician, but as a
trainer. When they come here, it is advising.''
But this is an interface between the most advanced society
on the planet and Fourth World medicine. How on earth do you
advise when doctors and nurses so-called in Afghanistan don't
show up, don't feel an ethical duty to treat the patient? Let
them, in some cases, starve to death or steal their medicines
or let bedsores kill them.
These are unspeakable conditions, but then this is a
country without reliable power, without so many of the things
that we take for granted in this country. How on earth could
anybody advise in that situation? It is a guaranteed nightmare.
So I am not excusing any of the, by our standards, bad
behavior in Afghanistan, but we can't change the whole country.
And you wonder if we are fighting side by side with ANSF forces
and our folks get first-rate, First World medicine, the most
advanced battlefield medicine in the world, and some of these
folks go to their so-called hospital, you would almost rather
take a bullet than die of sepsis in one of these places.
But furthermore, in addition to putting U.S. personnel who
are tasked with this impossible job of advising this hospital,
I am worried that this puts you gentlemen in an impossible
situation. Because you don't want to upset the Afghan
relationship, and we know that it is a deeply corrupt country.
We know that their culture in so many ways jars with ours.
And in terms of standards of care, to my knowledge, they
haven't defined hospital services. So when we apply a Western
lens to this, aren't we kind of fooling ourselves? And I am,
again, not excusing any of the bad behavior over there, but how
on earth do you drain this swamp?
We have no ability to compel the Afghan doctors to show up,
to make them do right when they are there, to even sterilize
their hands or instruments. So how do you administer care or
how do you advise on administering care in that situation? This
is the worst nightmare a health provider could ever possibly
imagine to even be associated with that, without any control.
How do you fix it? All you do is get tainted by whatever
you are associated with. So, again, I am not excusing any bad
behavior. I wish they would do right. And when you wonder about
if somebody is being paid, the entire Afghan economy is
subsisting off of the U.S. and Western taxpayers.
So whether it is directly or indirectly, unless it is their
feeble internal production or the opium poppies, where else
does their money come from unless it is from the West? This is
why this is the second-poorest country in the world.
So I want to get to the bottom of this, and I am not making
any apologies for General Yaftali, but for U.S. personnel to
come in or alliance personnel to come in and try to fix this,
how do you go about that without any control in a purely
advisory capacity? What is the answer here, other than to put
good U.S. personnel in an impossible situation?
I have 49 seconds left if anyone wants to respond to that.
Mr. Sedney. I will say a quick word, Representative Cooper.
You have laid out the challenges. Those challenges existed when
we went into Afghanistan 11 years ago. And as Ambassador
Moorefield pointed out, Afghanistan had about the worst
healthcare system in the world.
There has been a lot of progress. A week ago today, I was
in Kabul. I met with a number of students from the American
University of Afghanistan. They are well aware of the
challenges that their country faces, and they are taking them
on and moving forward.
Our advisers--and if we had time later, maybe General Robb
can talk about the ethical quandaries that you mentioned. But
the advice and assistance that we have been providing over the
last 10 years is resulting in the kind of improvements that
Ambassador Moorefield mentioned.
Is it a daunting challenge, as you have described it? Yes.
Is it an impossible challenge? We don't believe so. Will it
require continued effort even after 2014? Yes, and that is why
we are committed and our NATO allies and partners are committed
to continuing that effort.
But you have laid out very clearly the challenges. But I
think the Afghan people working with us see a way forward
despite those difficulties.
Mr. Wittman. Thank you, Mr. Cooper.
We are going to go now to Mr. Young.
Mr. Young. Thank you, Mr. Chairman.
And I thank all our panelists for being here today. Thank
you for your testimony.
Ambassador Moorefield, you had discussed at some length the
adviser/mentor program, and you talked about that. I would like
to dig a little deeper on that. Before I do, cite Lieutenant
General Caldwell, who mentioned underresourcing and staffing as
significant barriers to any further success we would see at the
hospital there and, thus, I would say by extension barriers to
achieving an independent force, as we look into the future.
Since Lieutenant General Caldwell made that statement, what
improvements, if any, have we seen in an adviser/mentoring
program trying to train more personnel in medicine? And is this
adviser and mentor role, is it sustainable as we consider
pulling forces out after 2014? With the understanding there
will still be some support role for our forces, but will that
in any way undermine our capability to strengthen the
capabilities at this hospital and other medical facilities?
Ambassador Moorefield. Thank you, Congressman Young.
The challenge is going to be ever-present for the immediate
future as to whether or not they are going to be able to pick
up the ball and run with it. I think that the command has a
good game plan, and that is that they are not going to just
give them the ball and walk away off the playing field.
They are going to be there to continue to monitor their
performance and intervene as appropriate and necessary along
the way. So there is a reasonable degree of confidence, and let
me just talk about the National Military Hospital.
There are standards now. One of the big problems that we
had identified in our work previously was in the absence of
standards, it was very hard for our mentors to know what to do
and for the hospital personnel either there or in the regional
hospitals to know exactly what is it that we are trying to
create here. What is the standard? What is the capability?
Considerable work has been invested in the last few years
in developing Tier 1, Tier 2, and Tier 3 standards, and there
is every expectation they will erase the Tier 1 standard, which
is the objective by the third quarter of 2013. That standard
has a whole series of requirements that are inspected on a
quarterly basis now by our command and by the Afghan command.
And they have made substantial progress.
Let me just quickly if I can say something about the
regional hospitals. I realize the focus has, more often than
not, been on NMH of late. But our work, which has included all
of the hospital system in the Afghan security forces, including
the ANP [Afghan National Police] hospital, has indicated the
regional hospitals have actually--had actually made
considerable progress that was not so visible because it is out
there in the regional commands.
And indeed, I think have been very impressively moving
forward, although even with greater speed and efficiency now
that they have defined standards. The NMH was a lagging issue,
and considerable progress has been made.
You mentioned, Congressman Cooper, that there were issues
related to not showing up at work. That is absolutely the case.
This is my own personal opinion, but I think leadership was a
major factor. And now that the leadership has dramatically
shifted in the right direction at the NMH, they are enforcing
the standards of showing up for work and doing your job.
And those individuals--and there have been recent cases--
who did not do their jobs have found themselves at the wrong
end of administrative sanctions. So going back to your original
question, I think there is a reasonable chance that if we
continue there with them, shoulder to shoulder, so to speak,
they will get to where they need to get to.
Mr. Young. I have got 30 seconds left, Mr. Ambassador. But
you indicated that there was progress, measurable progress
based on the standards that have been set and the measurements
as compared to those standards. Seeing as you have had access
to these reports and what-not, could Congress get access to
these progress, quarterly progress reports?
Mr. Sedney. I think that is certainly a very reasonable
request, and we will get back to you on that with a definite
answer.
Mr. Young. Thank you.
Mr. Wittman. Thank you, Mr. Young. We appreciate it.
Mr. Sedney, if you could follow back up with that and let
the committee know when and how those reports would be
available, we would like to have them for the committee
members.
Thank you.
[The information referred to can be found in the Appendix
on page 57.]
Mr. Wittman. Thank you, Mr. Young. We will now go to Mr.
Brooks.
Mr. Brooks. Thank you, Mr. Chairman.
Just a quick background information. How much of the
funding for the Afghan National Military Hospital comes from
the United States? Do you have a judgment as to the percentage
or the quantity, any of the three of you?
Mr. Sedney. What I can tell you, Representative Brooks, is
we have spent about $185 million over the past 9-plus years on
the Afghan military medical system, and to the best of my
knowledge, that has been virtually the only source of funding
for it during that period of time.
There have been occasional efforts by other countries that
have resulted in small amounts of--much smaller amounts of
money. So I can't say with certainty that all of the support
for the National Military Hospital come from the United States,
but the vast majority of it has.
Mr. Brooks. So that, I am sorry?
Mr. Sedney. That $185 million is for the entire military
medical system, of which the military hospital is only part of.
Ambassador Moorefield. I would just add that, of course,
there have been international donations, notably by Japan, in
terms of equipment and supplies. In addition, the training and
education has been very significantly impacted by coalition
forces. And for example, next to the National Military Hospital
is the medical university, and the program there has between 20
and 30 Canadian personnel that are responsible for training
physician's assistants and medics and medical technicians.
That is true also up in the north, where the German command
is located. So if you look at the overall effort, it is not
just our funding. But I think specifically related to funding
for equipment and supplies, that has been largely a U.S.
contribution.
Mr. Brooks. As America shifts more of the fight
responsibility from American troops and allies to the Afghans,
do you anticipate that the medical facility costs will go up?
Mr. Sedney. Trends right now are that the Afghan security
forces are suffering casualties in their last 2 months at a
somewhat increased level, at an increased level than we would
expect. As they move more and more into the lead, there will be
more Afghans who are wounded and require medical care in their
facilities.
So, yes, we would expect those costs to go up and the need
for care to increase.
Mr. Brooks. Do you have a judgment as to how long it will
be before the Afghan economy is strong enough to take over the
responsibility of funding the cost of the Afghan National
Military Hospital?
Mr. Sedney. For the Afghan security forces as a whole, the
NATO heads of state meeting in Chicago last month committed
that with $500 million of Afghan government support for
security forces, the international community would be
contributing about $3.6 billion, for a total of $4.1 billion
over the long term out through 2017 and beyond.
That was coupled with a commitment on the part of
Afghanistan that Afghanistan expected to be able to fund its
own security forces by 2024. So we look at continuing large
international contributions, but at a declining rate with a
goal of Afghanistan being able to support its entire security
establishment, including the military medical establishment, by
2024.
Mr. Brooks. So if my math is correct, roughly a dozen years
from now is when the hope is that Afghanistan will be able to
carry their own load?
Mr. Sedney. That is the goal that the international
community is working with Afghanistan to support. In a meeting
a couple of days ago in Tokyo on economic development
assistance, the countries of the world agreed to continue
funding for Afghan development and economic assistance that
supplements that commitment to security assistance that was
made in Chicago by the NATO countries and the partners.
So, yes, there will be a continuing very large need on the
part of Afghanistan, but our allies have stepped forward to
contribute even more. The relative weight of the United States
contribution, if I can just give you some numbers, sir. In the
current fiscal year, we will be spending about $11.2 billion to
support the Afghan security forces.
Our budget request for next year is $5.75 billion, a very
large reduction. For the longer term, we are looking at that
$4.1 billion, a larger portion of which, a significant portion
of which has been committed to by other countries.
So, yes, it is a large amount of money. But it is going to
be decreasingly a burden on U.S. taxpayers, more and more
shared by other countries. And eventually, yes, Afghanistan
is--Afghanistan's goal is to be able to support itself, but it
is a long time away.
Mr. Brooks. Thank you, Mr. Chairman.
Mr. Wittman. Thank you, Mr. Brooks. We appreciate your
questions.
And we will move now to Mr. Coffman.
Mr. Coffman. Thank you, Mr. Chairman.
Ambassador, let me start with you. So in your investigation
of the problems at the hospital, you concluded that there were
a lack of standards that were set in place, and that was part
of the problem? Am I correct in that?
Ambassador Moorefield. Yes, Congressman. I would agree with
you that that was a very significant part of the problem
because I think even part of the ethical issue that our medical
mentoring personnel were having had to do with not knowing
exactly what it was their role was supposed to accomplish in
terms of mentoring their personnel. So it was very hard to see
where the line was in terms of what they should be helping them
do to accomplish.
I think the introduction of standards is absolutely
critical. It was something we identified at least 3 or 4 years
ago. I think, as I recall, there was a visit by the Surgeons
General of our Army, Air Force, Navy, and they also pointed out
several years ago that without standards, how could you have a
focused mentoring mission and how could you hope to possibly
achieve an appropriate end-state objective?
Mr. Coffman. And that was a function of training? Isn't
that a part, the establishment of standards is a part of the
training mission?
Ambassador Moorefield. It is part of the NTM-A CSTC-A
responsibility. Is that----
Mr. Coffman. That is correct. And that was General
Caldwell's responsibility, was it not?
Ambassador Moorefield. Well, it was during the time that he
was there. And of course, it was a responsibility that preceded
him and succeeded him.
Mr. Coffman. And I think, in my view, he displayed a
fundamental lack of leadership in the performance of those
duties, and there will be a further investigation of this. I
think a hearing in 2 weeks in the Oversight and Government
Reform Subcommittee that will go into much greater depth.
And I have talked to some of his staff, or my office has
talked to some of his staff. I have talked to one member of his
staff directly, and my office has talked to another. And I
think that the problem really rose to the top, in my view. And
it is stunning that he is still serving today in the United
States Army after all that has occurred here.
Let me say that I think that, Mr. Sedney, your description
of events is fairly sanitized. Is it not true that there were
Afghan security forces dying in the hospital from suffering
malnutrition, suffering from untreated wounds because, in fact,
their families couldn't come up with the necessary bribes for
the hospital personnel?
Isn't that, in fact, true?
Mr. Sedney. Representative Coffman, as I said in my
statement, there was a wide range of abuses and problems in the
National Military Hospital for a number of times. As we
increased the number of our advisers there and as those abuses
were brought to our attention, we began to take action to try
and address them. And that action has been difficult because of
the level of medical care, as Representative Cooper pointed out
there.
But also because of individual--because of problems with
the way individuals were acting. Getting the change in the
leadership in the hospital was essential and getting in place
the standards that the ambassador mentioned. So where we are
today is a great deal farther forward than we were 2 and 3
years ago when the conditions that you described existed.
I would say that the biggest problem that looking back at
it is that when we began this effort, it was underfunded,
underresourced. And it was only after we increased our number
of advisers in the post 2009 period that we were able to take
the effective action that we have. So the situation today is so
much better than it was during the period you are describing.
Mr. Coffman. Well, I should say how slow the command was to
respond and how slow you were to respond to this issue as it
filtered up in terms of talking to some of the people that were
mentors on the ground. And at the point in time where they knew
that there was a problem to the point in time that action was
taken, there was a tremendous gap that doesn't, in my view,
reflect a competence in leadership.
With that, Mr. Chairman, I will yield back. Hope that there
will be a second round.
Mr. Wittman. Yes, Mr. Coffman, there will be. And I thank
you for your questions.
And we will move on now to Mr. Conaway.
Mr. Conaway. Thank you, Mr. Chairman.
Gentlemen, thanks for being here.
Ambassador Moorefield, you used the phrase ``intervene'' a
while ago in reference to what might be occurring in the future
with things that would be going on there, either post 2014 or
whatever. Does that represent a change in mission for our
advisers that are there?
Because, previously, when Mr. Cooper read the mission
statement for our folks, it was to watch what they are doing,
advise, but we don't do any clinical work. We don't change
dressings. We don't do the things that I know that our folks
who watched these bad things go on, which they are itching to
do. Is that a different word for them today than what would
have been in place during the time in question?
Ambassador Moorefield. Thank you, Congressman Conaway.
Our concept, our understanding of their concept of the
command's goal here is to transition not just with respect to
mentoring of the Afghan National Security Force's hospital
system, but for the Afghan security forces as a whole, to their
taking the lead.
And when I say ``intervene,'' I meant that if they needed
mentoring because it was clearly something their mission, their
function, they were not fully prepared to carry out and it
became evident, then we would intervene and provide that.
Mr. Conaway. So if somebody in an operating room were
starting to bleed out and we had a surgeon there watching and
can save their life, he would have the authority to step in and
help save that life?
Ambassador Moorefield. I do not believe that their current
mission includes directly intervening.
Mr. Conaway. Okay. So the word ``intervene'' has a
different definition?
Ambassador Moorefield. Yes.
Mr. Conaway. Leon got a letter. Panetta got a letter from
Jay, from Chafetz and the committee that Michael was
referencing to. Dr. Kem directed, I think, a Colonel Mark Fassl
to send you an email October 28, 2010. And then, apparently,
there was a bit of a dustup in Kabul with Caldwell and others,
and they attempted to retract that.
As Inspector General, does that give you a red flag that
gives you a chance to wade in? Or given the fact that the
three-star withdrew the request blocked you from being able to
try to get at these issues a little quicker than might have
otherwise happened under the actual timeframe that actually
happened.
In other words, how much time was lost by you getting your
team in there to see for yourself what was going on?
Ambassador Moorefield. Let me recall exactly what happened
from our vantage point and my vantage point. Yes, I did receive
an email from the CSTC-A IG, Colonel Fassl, whom I knew well,
and had several phone conversations with him about the
command's interest in having DOD IG provide a mission, an
oversight mission.
And this was, as you said, towards the end of October. What
I told him at the time is we were absolutely committed to
supporting that, and we would begin preparing to do so right
away, which we did, because they were talking about a mission.
He was talking about a mission that would have a very short
fuse, given the normal lead time that CENTCOM [U.S. Central
Command] and the command requires.
So we were already well along when I finally received a
letter, I think it was the 10th of November, from General
Caldwell saying please come out and perform this logistical
system oversight mission. So, in fact, I had a team on the
ground the day after Thanksgiving, which, I have to say, given
that I had to mobilize subject matter experts in addition to
our own personnel was probably some sort of record response to
any request we have ever received.
Mr. Conaway. How long did it take you to get the work done?
When did they finish up the field work, so to speak?
Ambassador Moorefield. On that particular mission, the
report was issued in May or June of the following year.
Mr. Conaway. Again, we are operating through a lens of----
Ambassador Moorefield. Yes, I was just going to say--excuse
me for interrupting. But of course, they got a full outbriefing
from our team before we left. So they knew what the issues were
by the time our people left Afghanistan.
Mr. Conaway. And based on what you know, since then did
they actually take action ahead of your report in May, or did
they let the conditions continue to----
Ambassador Moorefield. They took action in a number of
respects, but I should point out that there were two follow-up
missions that we implemented. One was that February following
that mission that came back just before Christmas in December
of 2010.
By February, we were on the ground inspecting the National
Military Hospital in a very specific way.
Mr. Conaway. How is that different from what you did in
November and December?
Ambassador Moorefield. Well, what we did in November and
December was a countrywide review of the entire logistical
system and whether or not it had accountability and controls
over U.S.-supplied equipment and pharmaceuticals.
Mr. Conaway. So patient mistreatment wasn't your focus
until February?
Ambassador Moorefield. It was not what was requested. And
even though we took note of conditions, it wasn't until we got
a specific report, in fact, our IG received a specific report
in, I think, November of 2010 when he was on the ground in
Kabul from the command, indicating that there were patient care
issues at the hospital that we deployed the team very soon
thereafter. I think almost a week from the time we found out
about this mission, we had a team on the ground there
inspecting the hospital.
And then, in addition, we sent an audit team out to take a
look at the pharmaceutical accountability and control
countrywide and then specifically also at the NMH. So there
were a succession of oversight missions that ensued during that
period.
Mr. Conaway. I am over my time. But you said a team that
went to look for the patient mistreatment was November 2010 or
November 2011?
Ambassador Moorefield. If you are referring to the National
Military Hospital, that was February 2011.
Mr. Conaway. All right. That is the first time you had
anybody looking at the patient mistreatment?
Ambassador Moorefield. In detail, yes.
Mr. Conaway. Okay.
Thank you, Mr. Chairman.
Mr. Wittman. Thank you, Mr. Conaway.
We have been joined by Ms. Speier, who is a member of the
full committee. And at this point, we will go to her, and then
we will return to the subcommittee members for a second round
of questioning.
Ms. Speier.
Ms. Speier. Thank you, Mr. Chairman and Ranking Member
Cooper, for holding this important hearing.
I am deeply troubled by the reports that we have heard, and
I think this hearing underscores a very important question,
which is, is the Department of Defense living up to its
responsibilities to root out waste and fraud of taxpayer
dollars?
I would like to express disappointment, however, that
Colonel Geller is not before the committee to discuss his
concerns about the significant level of corruption in the
Afghan military medical organization. If his allegations are
true, we can only conclude that the Army was complicit in
wasting millions of dollars and the horrendous neglect and
abuse of patients that had a reasonable expectation of quality
care.
It is clear that a follow-up hearing on this issue is
needed, and it is my hope that Colonel Geller will be the first
to testify so that the facilitators of wrongdoing can respond
to his concerns.
With the chair and ranking member's permission, I would
like to submit into the record a news article that lays out
Colonel Geller's concerns.
Mr. Wittman. Without objection.
[The information referred to can be found in the Appendix
on page 51.]
Ms. Speier. Most troubling to me, however, is Major General
Gary Patton's alleged role in covering up this corruption.
According to press reports, he urged the suppression of an
investigation into this wrongdoing by urging Lieutenant General
Caldwell to defer an investigation until after the 2010
congressional elections.
It also appears that when he learned that an external
review was not supported by his commander, he backed off of his
recommendation for an external investigation of the wrongdoing.
I have also learned that once the Pentagon Inspector
General investigation was underway, Major General Patton may
have attempted to obstruct the investigation by intimidating
witnesses. Now those are very serious charges.
As the newly appointed head of the Sexual Assault
Prevention and Response Office, or SAPRO, Major General Patton
will have primary responsibility for cases that are not
politically popular, particularly by his senior commanders. I
worry that instead of enforcing justice, he will only enforce
what advances his career, making his interests almost
diametrically opposed to getting justice for victims.
These allegations imply that he has used his leadership to
create a chilling effect against reporting wrongdoing, instead
of facilitating the command environment necessary to maintain
zero tolerance for these abuses.
If any of these allegations are true, I have very serious
concerns about Major General Patton's capacity to be an
effective advocate for victims of rape in the military. I
believe that it is this committee's duty to investigate the
veracity of these claims and to take up the question of whether
Major General Patton is the appropriate choice to head SAPRO.
I look forward to working with my colleagues on this issue,
and I yield back.
Mr. Wittman. Thank you, Ms. Speier.
We are going to begin a second round of questioning. And
with that, I am going to go to Mr. Coffman.
Mr. Coffman. Thank you, Mr. Chairman.
What is stunning in this whole situation is the fact that
we have U.S. taxpayer dollars flowing into Afghanistan,
obviously, in addition to the contributions of our allies. But
predominantly, U.S. tax dollars are funding much of the Afghan
security forces, certainly to include the Afghan medical
component of that. And that we have all these dollars flowing
in, but yet a real lack of oversight over them.
And as we draw down, obviously, we are going to have fewer,
a lighter footprint there. And so, I am very concerned that,
first of all, obviously, we haven't dealt with the situation
that has occurred, I think. But we will in time, hopefully,
whether both with General Yaftali on the Afghan side and
General Caldwell on our side.
But also I think the fact that we are going to have a
lighter footprint, one of the concerns expressed was that we
didn't have enough personnel to monitor the situation. And now
how are we going to monitor it in the future?
How are we going to make sure that we deal with this
culture of corruption in terms of how U.S. tax dollars are
handled prospectively? And I am real concerned about that.
Mr. Sedney, why don't you try and address that?
Mr. Sedney. Thank you, Congressman.
You have raised some very important questions. I do want to
just comment for the record that because there is an ongoing
investigation regarding the individuals that were mentioned
earlier that we are not allowed to comment on that. We, of
course, have heard allegations, but once this ongoing
investigation is completed, then we will be able to respond to
some of the allegations and various stories that appear to have
been in the press.
The questions about the ability to account for U.S.
taxpayers' dollars, to account for whether we have achieved the
goals that we have set, as you mentioned, Representative
Coffman, is very important.
Certainly up until 2008, our advising effort in Afghanistan
was underresourced and underfunded. This was recognized by this
administration, and the surge into Afghanistan included a surge
in advisers, mentors, and trainers, both from the United States
and from our allies, that enabled us in a host of areas,
including in the national military area, to put in place high-
quality mentors who had the ability to take a look behind the
scenes what was happening.
That is why we were able to discover the problems that you
have laid out and why we were able to work with the Afghans to
put in place systems that they just didn't have before for
monitoring. In Ambassador Moorefield's testimony, he lays out
some of the improvements that have begun to be made.
Those improvements are ongoing. One of the major tasks that
we have right now out in the field is to help the Afghans build
those systems, work those systems, including the investigatory
efforts that are going on that I mentioned earlier, and then to
monitor to see if they are working.
And then, this is where the intervention comes in, sir, we
have to try and intervene on a policy way to try and get the
policies and procedures that the Afghans are using up to the
level so that we can get the level of certainty that we need.
Mr. Coffman. Are we serious about this now? Because,
obviously, we weren't serious about this in the past. But all
of a sudden, now we are serious about the----
Mr. Sedney. I would say that certainly since we have put
more resources into this, we are very serious. It has not just
the attention of the highest levels. It has the attention of
the Department, but also of our leaders in the field.
Mr. Coffman. Why weren't we serious in the past?
Mr. Sedney. I don't say it wasn't serious. I say it was
underfunded and underresourced before 2008.
Mr. Coffman. You don't think there was a lack of leadership
there?
Mr. Sedney. I think before 2008, we just didn't have--
before 2008, we just didn't have the resources to follow
through with doing it.
Mr. Coffman. You don't think it was lack of leadership?
That the fact that the leadership couldn't even tell that there
was a, couldn't even say, ``Hey, I don't have enough resources
here. Because we don't have the resources here, we have got
some problems with corruption.''
Or do you think the leadership just wasn't even paying
attention because how could you miss something so big?
Mr. Sedney. I think that the leadership on the ground
before 2008, going back to 2004, 2005, 2006, and 2007,
recognized that there were problems that they weren't able to
address because they didn't have the resources and made the
request for additional resources in terms of mentors and
oversight ability. But we were not--we, the United States, were
not in a position to provide the level of resources----
Mr. Coffman. So what we did instead of that was we just
allowed corruption to occur. We didn't care about accounting
for U.S. taxpayer dollars. I guess that was okay then because
we didn't have enough people there, and we just didn't know
what was going on. Is that what you are trying to say?
Mr. Sedney. No. I am saying that the people who were there,
who tried very hard to do sometimes the jobs of two, three,
four, and five people, were overwhelmed by the level--by the
amount of the challenges and the amount of effort that they
have in that period of 2004, 2005, 2006, 2007, and 2008.
The situation, as Representative Cooper described it, it
was very accurate in terms of the challenges that were faced.
And so, we had a lot of good people doing their very best, but
they were overwhelmed by the magnitude of the problems.
Mr. Coffman. I think we disagree with this, and I think the
truth will come out.
Mr. Chairman, I yield back.
Mr. Wittman. Thank you, Mr. Coffman.
And we are going to go now to Mr. Cooper.
Mr. Cooper. Thank you, Mr. Chairman.
I am a little worried that with all this talk of standards
for the Afghan healthcare system and monitoring and resources
and all that good stuff, that sounds like we are talking about
it in a nice, air-conditioned hearing room in Washington. And I
am no expert on Afghanistan, but the reality on the ground,
when they have intermittent hot water, intermittent
electricity, all kinds of personnel and quality problems that
we can't even imagine, that without enforcement, without some
ability for U.S. personnel to step in and, as my colleague Mr.
Conaway was saying, stop somebody from bleeding to death
because the bribe wasn't big enough to save the life.
Or to give a starving man a candy bar that might tide him
over until the next day until the family can come up with the
bribe money or whatever other nightmarish scenario is out there
that without enforcement, we are still putting good U.S.
personnel in an impossible situation.
Like why do that? Because even being associated with this
mess can ruin a career. And standards sound fine, and they
sound good for us, but that just assumes that there is going to
be some sort of accountability or enforcement or people want to
do right.
We are worried here about green on blue violence. Well,
this is green on green violence, and it seems to be, sadly, a
part of the culture. Well, maybe that is why they are the
second-poorest country in the world.
So I worry about good, clean U.S. personnel like it is the
worst assignment in the world. So whoever is associated with it
must have drawn the short straw to get this. I always thought
that the Aleutian Islands was the worst posting you could get.
This has got to be the worst of the worst.
So I am not making excuses for any of this bad behavior,
but to apply Western standards to this is like completely
unrealistic. If our guys are just tasked with the job of
standing there and looking at evil, looking at Afghan people
destroying the lives of their own Afghan military, and
presumably with Western aid or even minimal local resources
they could have done something about that, at least let their
own family members nurse the poor invalid.
So standards, monitoring ain't going to do it. It is going
to take some sort of ability to intervene or enforce or do
something. Otherwise, we are putting our folks in a bad place.
Would anyone like to comment on that?
General Robb. Yes, sir. The feedback we are getting from
the surgeon over there for the National Training Mission-
Afghanistan, as was also evidenced by the IG report, is
subsequent to three major events that occurred in the fall of
2010. One was increased mentors on the ground. And the early
fall, mid fall was, of course, when they transferred the
medical logistics from the National Military Hospital system to
the ANSF Logistical Command.
And then, but more importantly, late fall/early winter was
the subsequent relief of about 25 senior medical leaders. And I
think that was the key to include, as you know, their surgeon
general and also dual-hatted as the hospital commander.
So fast forward 1 year plus about 6 months later, you get a
report, again as recent as June 2012, that addresses many of
those issues, sir, that rightly we have concerns and you have
concerns. So the key that has happened, and again in direct
discussions with the leadership on the ground, the mentors, is
that the approach that they have taken is you have heard that
they have standards now.
In other words, we are not using Mayo Clinic standards. We
are using the standards that are appropriate for the level of
care that would be delivered in Afghanistan. We are using what
we call the Tier 1 or the cure standards. So now they have a
definitive end-state of which they know that they must
accomplish.
And so, what the new leadership, again expressly through
the leadership of the new hospital commander there, he
personally takes interest in any cases of abuse, of which there
have been none reported, you know, in the recent 6 months. And
the way they did that was because of a leadership change.
So what our mentors did was when they saw during last year,
as they were cultivating a culture of accountability in the new
leadership, they got those to chief nurse, the chief of
surgery, and the hospital commander also demanded to be
involved in those cases of suspected either undertreatment or
maltreatment. And so, they were involved.
And so, that is why you see now, with accountability
through their leadership, there is no shortage of people that
want to do good things in Afghanistan, and I have experienced
that. You know, they are underresourced, okay, and they may be
undereducated, but there is no shortage of, again, good people
with the desire to do the right thing over there.
And I have been impressed with the Afghan, again, medical
professionals. That doesn't mean there weren't bad actors over
there, but I have met many of them that are good.
So I am encouraged, sir, again. And it is going to take
time. And that leadership, that culture change began, again,
with what I would call weeding out of the 25 poor leaders and
have been replaced with leaders that our mentors now and our
medical leadership over the training mission believe they have
the right stuff to help turn the tide there not only in the
National Military Hospital, but also within the whole Afghan
healthcare system.
As was mentioned before by my colleagues here, there are a
lot of success stories out there. I mean, when you look at
Kandahar, you look at Herat, Mazar-e-Sharif, Gardez, these are
the regional hospitals that we share with the Ministry of
Public Health. And they are, again, by Afghan capability,
standards, training, and by the resourcing, they are doing an
incredible job.
And quite frankly, I am proud of them. I am proud of them,
again considering where they have started. Four decades of
really neglect because they weren't allowed to, again, train to
what was appropriate for Afghan standards because of four
decades of war and, again, back and forth with the different
folks that have occupied their country.
So I am encouraged by the direction that has taken place in
this last year.
Thank you very much.
Mr. Wittman. Thank you, Mr. Cooper.
We are going to go to Mr. Conaway.
Mr. Conaway. Just real quickly, this may sound pretty
frivolous, but in terms of where they are right now, do they--
Mr. Sedney or General Robb, do our advisers run customer
satisfaction surveys of folks coming out of the hospital to see
if there are lingering or ongoing issues that aren't obvious,
or do you actually use that tool? Or does it make sense to use
that tool in that society?
General Robb. Sir, I will have to get back to you on that.
I am not sure. I know that we have validation teams that are
going through now to match against the standards. And then
Ambassador Moorefield may have more detail on that.
Ambassador Moorefield. Yes, thank you.
They do. They do run customer surveys. And our team, while
they were there, by the way, inspecting the hospital, spoke
with many patients. They have a bill of rights. It was not well
understood and shared with the patients previously.
It is now explained to them when they enter the hospital.
And when we discussed what their rights were with the patients,
they knew what their fundamental rights were, to get three
square meals a day, to have a doctor see them every day and a
nurse every 8 hours. So I would say that there is certainly an
enhanced consciousness about the obligations of the hospital to
the patients and the patients' understanding of those
obligations.
Mr. Conaway. The customer satisfaction surveys that we run,
are they controlled in a way that the folks who are being
evaluated don't have the ability to skew the results?
Ambassador Moorefield. As part of the standard that is
applied now, they have to conduct regular customer satisfaction
surveys and put it in writing.
Mr. Conaway. The Afghans do?
Ambassador Moorefield. So we are not aware that they are
anything but objective.
Mr. Conaway. Best you can tell.
Ambassador Moorefield. But we will--we are going to
continue to provide oversight. So that is one of the things we
will be looking for.
Mr. Conaway. In the agreement that was made for the $4.1
billion, Mr. Sedney, does it have enough teeth in it to allow
the proper oversight of these functions as the dollars flow,
continue to flow to the system during those timeframes?
Mr. Sedney. Yes. We have some very good accounting systems
that we are putting in place. And the continuation of the
funding obviously will be based on the Afghan military and
police's performance. But they are going to be tested this
year, as I have mentioned before.
Mr. Conaway. Thank you, Mr. Chairman.
Mr. Wittman. Thank you, Mr. Conaway.
We will now go to Ms. Speier.
Ms. Speier. Thank you, Mr. Chairman.
I just have one question for Major General Robb. You
indicated that there is a change of leadership there, and over
the last 6 months, things look like they are much better.
Who would someone report a problem to in the existing
system if there was denial of care or denial of service? Who
would they report that to, and how would they be informed of
that as a patient?
[Pause.]
General Robb. Yes, ma'am. As I stated before, the
leadership--and again, as have been pointed out to us,
specifically, the chief of surgery, the chief nurse, and also
the hospital commander have taken this personally under their
role to, again, address each one of these cases where folks
feel that they were either underserved or not treated properly.
The first directors of the hospital have also been instructed
that if they discover something to pass that up again to the
senior leadership for them to personally address that.
Ms. Speier. But if I am a patient there----
General Robb. Yes.
Ms. Speier [continuing]. And I am seeking care and I am
told, ``Well, unless you give me $10,000, I am not going to
give you care,'' how would I know who to report that to? When
they walk in, are they given some patient bill of rights to say
at no point should you be subject to any kind of bribe?
Healthcare here is provided without additional remuneration
or----
General Robb. Yes, ma'am. That is part of the bill of
rights. That is what they are instructed on when they are
actually admitted to the hospital.
Ms. Speier. Would you make a copy of that bill of rights
available to the committee?
General Robb. Yes, ma'am. Yes, ma'am.
Ms. Speier. Thank you. I yield back.
[The information referred to can be found in the Appendix
on page 58.]
Mr. Wittman. Thank you, Ms. Speier.
We will now go to Mr. Coffman.
Mr. Coffman. Thank you, Mr. Chairman.
Let us talk about, going forward now, that here is my
concern that not only going to be reducing our footprint, but
as we get to 2014, to the end of 2014 when we are expected to
give operational control or switch operational control to
Afghan security forces. And at that point in time, our
expectation is that they will have the internal capability,
logistically, administratively, to take U.S. military aid in
whatever form, U.S. military medical aid and other forms, and
to be able to disseminate it to their subordinate commands.
That actually increases the potential for corruption. So
how are we going to be able to monitor that going forward?
Mr. Sedney. The procedures for monitoring--for the Afghans
to be able to monitor, first of all, that they have to build up
their own ability to have an inspector general capability,
which NTM-A is working on to build, so that they can
investigate problems and issues and come up with ways both to
fix problems and also to recommend problems to the law
enforcement bodies is a capability we are developing.
That capability is one that we are only more recently
starting to work on because the original part of building the
Afghan security forces was focused on the fighting forces.
Building the supporting structure, such as you are describing,
is what we are doing now.
We are going to have to examine that progress as we go
along, and that will go into the determination of what kind and
level of presence we need after 2014 either from the United
States or from our coalition allies as we continue that train,
advise, and assist mission after 2014.
But really, it is going to depend upon the performance of
the Afghans themselves and the determination of the commander
in the field as to what is necessary. It is a great question,
and we don't really have the full answer yet, but we will be
developing it over the next 12 to 24 months.
Mr. Coffman. Ambassador Moorefield, do you have anything?
Ambassador Moorefield. Yes, sir. I think that one of the
commitments that we have made in this post 2014 through 2024
era in terms of the continuing development of the Afghan
National Security Forces is their logistical system. And
essentially, aside from getting bullets and food and medical
care to the troops in the field or the police forces wherever
they may be deployed, there has been a very serious ongoing
effort, and this will continue post 2014 to build up their
logistical capability, to provide accountability and control
for their resources because we will be providing fewer
resources. They will be paying for more of the resources. So
this isn't just about taking care of congressional and U.S.
taxpayer and other coalition-supported resources.
So building those accountability and control mechanisms is
a top priority. I would mention one of the reasons why I think
I personally believe this is going to be an ongoing
responsibility and challenge is building a logistical system is
a lot more complex than turning out fighting forces or
policemen on the beat.
And it is the case that we prioritize creating their--
generating their security forces and only in the last few years
have put our shoulder to the wheel on building up their
logistical system. But it is complex challenges, and it is
going to be an ongoing assistance effort.
Mr. Coffman. Well, thank you, Ambassador, Mr. Sedney,
General. I hope we don't learn that the hard way, as we have
obviously seemed to be learning things in Afghanistan up to
this point.
Mr. Chairman, I yield back.
Mr. Wittman. Thank you, Mr. Coffman.
We will now go to Mr. Cooper.
Mr. Cooper. Thank you, Mr. Chairman.
I don't want to prolong this unduly, but it is my
understanding that the life expectancy in Afghanistan is among
the shortest in the world. And an adult male lives to maybe his
late 40s, something like that?
So just allowing them to revert to the previous standard is
half the life that a U.S. citizen would expect to live. I don't
know what it would be if you were denied the state-of-the-art
U.S. battlefield medicine. That would have to increase your
chance of death from a bullet wound, from 1 percent to 50
percent, 70 percent, something like that.
So, again, in my opinion, it is very difficult for us to
even understand a Fourth World medical system, and I hope we
don't continue to put good U.S. folks in jeopardy by putting
them in an impossible management situation.
Thank you, Mr. Chairman.
Mr. Wittman. Thank you, Mr. Cooper. We appreciate that.
Are there any other questions of the committee members?
Panelists, we thank you so much for joining us today. We
appreciate you giving us your perspective on the challenges
that we face there in Afghanistan. This is one of many,
obviously, the medical system there itself and the efforts of
providing care to the Afghans, as well as the issues of
corruption there, things that are very much at the foremost of
folks' minds here on the committee. So we appreciate you
shedding some light on that.
We did have a few requests for some information. We would
appreciate it if you would be timely in getting that back to
the committee for our consideration.
And I want to remind committee members, too, if you have
any additional questions, please let us submit those in writing
to the panel members.
And if there is no further questions, we appreciate the
panelists' time, and this hearing is adjourned.
[Whereupon, at 4:23 p.m., the subcommittee was adjourned.]
?

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A P P E N D I X

July 10, 2012

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July 10, 2012

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DOCUMENTS SUBMITTED FOR THE RECORD

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WITNESS RESPONSES TO QUESTIONS ASKED DURING

THE HEARING

July 10, 2012

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RESPONSE TO QUESTION SUBMITTED BY MR. YOUNG

Mr. Sedney. Response to Information Request for Quarterly
Assessment Reports of Dawood by NTM-A/CSTC-A Validation Team for NTM-A/
CSTC-A Surgeon's Office (CJSURG) assessing all ANA hospitals on a
quarterly basis, using their Healthcare Standards tool.
Quarterly Assessment Summary: The Afghan National Military Hospital
(NMH) is evaluated utilizing a healthcare standards tool to validate
Capability Milestones (CM). The goal is for the NMH to operate
autonomously. The NMH displayed significant improvement and received a
CM1B rating during its May 2012 assessment, up from a CM2A rating,
received during the February 2012 Quarterly Assessment.
The NMH demonstrated best practices (CM1A) for Blood Bank, Central
Sterile Service Department (CSSD), Dental, Human Resources, Intensive
Care Unit (ICU), Internal Medicine, Laboratory, Leadership Council,
Medical Logistics (MEDLOG), Nursing, Operating Theater, Outpatient
Clinic, Patient Administration, Pharmacy, and Surgery. The Biomedical
Repair, Facilities Management, Infection Prevention, Radiology, and
Ultrasound departments earned CM1B ratings.
The remaining departments are at a CM2A rating, which NATO Training
Mission-Afghanistan (NTMA-A) expects will improve with enhanced
mentoring, training, well-written standard operating procedures (SOPs),
and improved organizational structure. Emergency and Anesthesia have
been identified as functional areas requiring improved leadership. The
Emergency Department also requires improved written SOPs, improved
equipment/supply organization, more attention to cleanliness,
renovation, and space expansion. The Anesthesia Department requires
greater supervision and oversight, equipment management, and clerical
documentation.
The ANA Medical Command (MEDCOM) has established an Afghan
validation team that allows for direct reporting of hospital elements
and practices to the ANA Surgeon General. Through the ANA MEDCOM
validation team, the NMH should realize significant gains in its health
system. This process will be completely led by ANA leadership. [See
page 12.]
______

RESPONSE TO QUESTION SUBMITTED BY MS. SPEIER
General Robb. [The chart provided can be found on the following
page.] [See page 23.]

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QUESTIONS SUBMITTED BY MEMBERS POST HEARING

July 10, 2012

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QUESTIONS SUBMITTED BY MR. COOPER

Mr. Cooper. Please describe in detail the ``vast improvements''
made in the accountability of hospital leadership and staff, general
sanitation of facilities, the standard of patient care, and the
supporting logistics systems.
Mr. Sedney. Afghanistan's National Military Hospital (NMH) has made
improvements in the accountability and responsibility of its
leadership. Demand for training and education at the hospital has also
increased. The combination of these changes will result in improved and
sustained patient care.
Improvements in NMH leadership and staff accountability, general
sanitation standards, standard of patient care, and logistics systems
are underway. Following the removal of General Ahmed Zia Yaftali as
hospital commander, new leadership established more stringent planning
and oversight to advance the professional conduct and accountability of
the Afghan National Army (ANA) medical staff, with special attention
towards combating staff absenteeism. Major General (MG) Wardak, ANA
Surgeon General, established rules, regulations, and policies that
Brigadier General (BG) Sherzai, the NMH Hospital Commander, actively
enforces. Since MG Wardak's appointment in February 2012, twice-daily
attendance verification for all ANA NMH staff members has decreased
absenteeism. Absence, depending on frequency and length, has resulted
in pay deduction, transfers, or termination. Attendance verification is
ANA-led and sustainable.
Accountability for the general cleanliness of and sanitation for
the NMH is a routine discussion topic with the Hospital Leadership
Council (HLC). Hospital administration, facilities management, and
nursing staff personnel monitor each floor for cleanliness. Having
facilities sanitation and cleanliness as a routine HLC agenda item
brings heightened awareness to all NMH leaders, as well as to the
hospital commander. In 2011, the NATO Training Mission-Afghanistan
(NTM-A) Medical Training Advisory Group (MTAG) mentors reported that
the new hospital commander, chief of surgery, and chief nurse
intervened in every case of alleged patient neglect; by August 2011,
there were no substantiated cases of patient neglect. An ANA Nutrition
Task Force was created, which implemented processes and monitoring
systems to improve patient nutrition. MTAG mentors currently supply
liquid supplements from the United States, but are working to develop
an Afghan-led solution that is sustainable after 2014. The transfer of
medical logistics from the ANA Surgeon General to the ANA Logistics
Command (LOGCOM) allowed the Ministry of Defense to enforce standard
controls over receipt, storage, accountability, and distribution of
pharmaceuticals and other supplies. Newly implemented ANA medical
inventory and tracking systems have brought greater transparency and
efficiency to the supply chain management.
Mr. Cooper. What remains to be done with improving accountability
in the Afghan National Military Hospital?
Mr. Sedney. Overall, accountability in the Afghan National Military
Hospital (NMH) has improved greatly. Continued NATO Training Mission-
Afghanistan (NTM-A) mentorship will sustain the improvements in
accountability.
MG Wardak, ANA Surgeon General, established rules, regulations, and
policies that BG Sherzai, NMH Hospital Commander, actively enforces.
Since MG Wardak's appointment in February, twice-daily attendance
verification for all Afghan National Army (ANA) NMH staff members has
decreased absenteeism. Absence, depending on frequency and amount of
time, has resulted in pay deduction, transfers, or termination.
Attendance verification is ANA-led and sustainable. Personnel
accountability is further tracked through a Surgeon General-chaired
meeting, held twice each week, where the hospital commanders provide
daily reports on personnel accountability.
MG Wardak has placed logistics, supply, and equipment
accountability as a top priority. He has fined the Director of the
Outpatient Clinic for allowing pharmaceuticals to expire and has warned
BG Sherzai not to allow this waste to occur anywhere in the NMH.
Logistical practices have been implemented to ensure that
pharmaceuticals are rotated and not filled with items near expiration.
The logistics system continues to advance with greater scrutiny on
administrative oversight, personnel training, and maintenance of
authorized pharmaceuticals. Accountability is further tracked through a
Surgeon General-chaired weekly meeting that includes the ANA Logistics
Command (LOGCOM) Commander, who provides an account on medical
logistics.
NTM-A Medical Training Advisory Group (MTAG) mentors will continue
to advise ANSF medical leadership on the importance of continued
enforcement of personnel and logistics accountability, as well as the
importance of developing clear and concise standard operating
procedures (SOPs). Moreover, ANSF-developed training programs need to
be standardized and verified by Ministry of Defense (MoD), Ministry of
Interior (MoI), Ministry of Public Health (MoPH), and NTM-A Medical
Validation teams.
Mr. Cooper. Will the U.S. Medical Training Advisory Group continue
after the transition in Afghanistan? In what way?
Mr. Sedney. We are currently assessing all of our post-2014 train,
advise, and assist missions. Even though the Afghan National Security
Forces (ANSF) Health Care System is well on the way to autonomous
operations, we currently envision that the role of the Medical Training
Advisory Group (MTAG) will continue, in a limited role, after 2014 by:
Assisting the ANSF Health Care System leadership to
conduct self-assessment of internal processes to identify areas of
improvement via surveys, data analysis, and evidence-based best
practices. Following validation of Regional Military Hospital (RMH)
Herat, Afghan National Army Medical Command (ANA MEDCOM) and MTAG
mentors will develop and implement a survey process that continues to
improve the ANSF health care delivery;
Encouraging ANA MEDCOM in the continued evolution and
quality management of health care in Afghanistan to meet the changing
challenges, needs, and wants of the ANSF;
Mentoring greater cooperative health care efforts amongst
the Ministry of Defense, Ministry of the Interior, and Ministry of
Public Health.
Mr. Cooper. Is the Afghan government committed to improving the
ANSF healthcare system? If so, how and what actions have they taken and
demonstrated to show this to the U.S. government?
Mr. Sedney. The Afghan government has taken actions to improve the
healthcare system in the areas of fighting corruption and in
collaboration, capability, and accountability.
Corruption--Since January 2012, under the direction of President
Karzai, Afghanistan's High Office for Oversight and Anti-Corruption
(HOOAC) assessed crimes committed at National Military Hospital (NMH)
by both staff members and the former Surgeon General (Yaftali). As of
July 2012, the HOOAC's efforts had led to seven potential cases for
investigation and prosecution. Three cases were referred to the
Ministry of Defense (MoD) Legal Department for investigation and
prosecution. Two of these cases were referred to military courts. The
four remaining cases (including the case against Yaftali) have yet to
be referred by the HOOAC.
Collaboration--In July 2012, Afghan National Security Forces (ANSF)
hosted a two-day Healthcare Shura attended by medical leaders from the
Afghan National Army (ANA), including the ANA Surgeon General, Minister
of Defense (Health Affairs), and NMH and Regional Hospital Commanders;
the Afghan National Police (ANP), including the ANP Surgeon General and
Hospital Commanders; and the Ministry of Public Health (MoPH). U.S.
Department of Defense Inspector General representatives also attended
this event.
The participants in the Shura discussed the current state of the
ANSF healthcare system, the impact and challenges the ANSF faces as
Coalition forces complete transition in 2014, and actions required to
mitigate the impact of transition while enhancing Afghan stewardship of
the ANSF healthcare system. A constant theme emphasized by ISAF leaders
was that the responsible Afghan government entities must develop their
own plan for taking ownership of ANSF healthcare, and that coordination
and cooperation across the MoD, the MoPH, and the Ministry of Interior
is critical throughout this process.
Capability--The NMH demonstrated progress ahead of expectations in
meeting quality performance criteria for the first tier capability of
the ANSF Healthcare Standards, a key indicator of the NMH's readiness
to transition. Furthermore, an Afghan-led team (ANA Medical Command)
validated this effort with NATO Training Mission-Afghanistan (NTM-A)
oversight.
Accountability--Under the command of MG Wardak, the NMH has
implemented improved procedures to ensure its medical personnel act in
a professional and ethical manner and work their assigned hours. This
accountability is monitored at the command level, with NTM-A mentor
oversight, and verified in the Capability Milestone validation process.
NTM-A plans to continue its oversight of NMH progress and the continued
development of the Afghan healthcare system, which will be a key focus
of the 2013 assessment process.
Mr. Cooper. Does the U.S. government now have a way to account for
pharmaceuticals supplied to the Afghan government?
Mr. Sedney. Newly implemented medical inventory and tracking
systems have introduced greater transparency and efficiency into
pharmaceutical supply chain management.
The transfer of medical logistics from the Surgeon General to the
Afghan National Army's Logistics Command (ANA LOGCOM) allowed the
Ministry of Defense (MoD) to enforce standard controls over receipt,
storage, accountability, and distribution of pharmaceuticals and other
supplies. These controls are embodied in Decree 4.0, described below.
Decree 4.0 addresses logistics within the Afghan National Army
system and specifically delineates logistics processing. The guidance
states:
All incoming supplies, including pharmaceuticals, are accounted for
via MoD Form 8. This form is the receipt document for orders. A
delegation of three members representing the ANA LOGCOM, Medical
Command (MEDCOM), and Acquisition, Technology, and Logistics (ATL)
initiates an MoD Form 8. The form details the number of supplies
ordered, who shipped the supplies, and identifies any systemic
deficiencies. A copy of the MoD Form 8 is sent to the following:
Materials Management Division. A copy of the MoD Form 8
is sent to the Minister of Finance and the Coalition comptroller, who
validate receipts, orders, and funding allocated.
Warehouse Manager. The Manager creates an MoD Form 1 to
annotate that purchased materials have been added to the warehouse
inventory.
The processes above are monitored by Coalition mentors resident in
the Medical Training Advisory Groups (MTAGs). The Coalition Comptroller
validates receipts, orders, and funding for pharmaceuticals and other
supplies. The MTAGs verify if hospitals have the pharmaceuticals and
other supplies on hand, while Coalition logistics mentors verify the
medical inventory in the warehouses.
Mr. Cooper. What remains to be done with improving accountability
in the Afghan National Military Hospital?
Ambassador Moorefield. The ANA Medical Command (MEDCOM) is now
under the command of Major General Mussa Warkak who has established
responsible expectations for the conduct and performance of ANA medical
personnel. Specifically, the National Military Hospital (NMH) has
implemented procedures to ensure their personnel act in a professional
and ethical manner and work their assigned hours. These procedures are
positively impacting on NMH personnel accountable performance.
Additionally, MEDCOM and NMH are taking action based on
recommendations made in the DOD IG report ``Additional Guidance and
Training Needed to Improve Afghan National Army Pharmaceutical
Distribution'' Report No. DODIG-2012-083, published May 7, 2012. This
report recommended that the ANA and MEDCOM develop a training program
and implementation guidance specific to the pharmaceutical distribution
process and the proper use of the Ministry of Defense (MoD) Decree 4.0
logistics forms to properly receive, account for, and distribute
pharmaceuticals. Additionally, it was recommended that MEDCOM undertake
the same initiatives for non-Ministry of Defense forms addressed in
Decree 4.0 that are used to collect and report pharmaceutical usage
data. Pharmaceutical usage data is necessary to properly identify
pharmaceutical resupply requirements for procurement. Furthermore,
continued refinement and use of pharmaceutical usage data will help to
prevent mismanagement, theft and waste of U.S. funded pharmaceuticals.
Continued oversight by NMH, MEDCOM, ANA GS Inspectors General, as
well as NTM-A and the DOD IG, is required to ensure that effective
internal control procedures are in place and implemented to ensure the
accountability of commands and their personnel with respect to medical
supplies. Additionally, a collaborative relationship and effective
communication between ANA Logistics Command and MEDCOM is critical to
ensuring continued improvement of pharmaceuticals accountability and
control throughout ANA, MEDCOM and at NMH specifically.
Mr. Cooper. Will the U.S. Medical Training Advisory Group continue
after the transition in Afghanistan? In what way?
Ambassador Moorefield. Based on our discussions with NTM-A
leadership and our assessment of the National Military Hospital
(conducted from 28 June-5 July), we understand that both NTM-A and ANA
medical leadership believe it is important to continue the medical
advisory mission beyond 2014. Accordingly, we will request a plan which
describes the medical advisory effort beyond the transition to Afghan-
lead of the National Military Hospital, which is estimated for the 3rd
quarter of Calendar Year 2013, and then in the post-2014 transition
era.
Mr. Cooper. Is the Afghan government committed to improving the
ANSF healthcare system? If so, how and what actions have they taken and
demonstrated to show this to the U.S. government?
Ambassador Moorefield. We have observed and reported on progress in
the capability and performance of the ANSF healthcare system over time
and believe this is an indication of the Ministry of Defense and ANA
General Staff's commitment to continued reform and improvements.
Specifically, ISAF continues to mentor the MoD/ANA and MoI/ANP to work
together to further develop and improve the ANSF healthcare system.
ISAF's efforts to improve ANSF healthcare also includes a collaborate
effort with both the Ministry of Public Health (MoPH) and Ministry of
Education (MoE). For example, in July 2012, ISAF together with the ANSF
hosted a 2 day ANSF Healthcare Shura attended by medical leaders from
the ANA (including ANA Surgeon General, MoD Health Affairs and NMH and
Regional Hospital Commanders), ANP (ANP Surgeon General and ANP
Hospital Commanders) and MoPH. DOD IG representatives attended this
event.
The purpose of the Shura was to discuss the current state of the
ANSF healthcare system, the impact and challenges the ANSF faces as
Coalition forces transition in 2014 and to initiate action to mitigate
the impact of transition while enhancing Afghan stewardship of the ANSF
healthcare system. A constant theme emphasized by ISAF leaders was that
the responsible Afghan government entities must develop their own plan
for taking ownership of ANSF healthcare from Coalition Forces and that
coordination and cooperation across MoD/MoI/MoPH is critical throughout
this process.
We have observed additional indicators of Afghanistan's commitment
to improving their healthcare system at NMH during our recent
assessment. Specifically, NMH demonstrated progress in meeting the
performance criteria to qualify for the first tier capability of the
ANSF Healthcare Standards, a key indicator of their readiness to
transition. Furthermore, it was an Afghan-led team who worked shoulder-
to-shoulder with NTM-A's validation team in determining this level of
effort.
We plan to continue our oversight of the NMH and the continued
development of the Afghan healthcare system will be a focus of a future
assessment planned for 2013.
Mr. Cooper. Does the U.S. government now have a way to account for
pharmaceuticals supplied to the Afghan government?
Ambassador Moorefield. Under the new Afghan pharmaceutical
distribution system developed by CSTC-A, U.S. officials provide funding
and Afghan Acquisition, Technology and Logistics (AT&L) officials
procure pharmaceuticals. The pharmaceuticals ordered should be based on
requirements identified by Afghan Medical Command officials. The USG
have both the CSTC-A Medical Training Advisory Group and Logistics
Training Advisory Group providing guidance to these Afghan entities.
During our audit, CSTC-A personnel were able to obtain and provide
documentation of the items Afghan AT&L officials procured as well as
documentation with the total funds spent to acquire the items.
According to CSTC-A personnel, the USG is still responsible for
managing vaccines for the Afghans separately from other pharmaceuticals
because they require cold storage and transportation costs are higher
and easily diverted.
Mr. Cooper. Please describe in detail who the DOD IG team met with
during the recent visit to Afghanistan.
Ambassador Moorefield.
ISAF

Grp Cpt Steven Kilbey, UK, Deputy ISAF Surgeon

IJC

BG Norvell Van Coots, Surgeon General for USFOR-A, Medical Advisor to
COMIJC

NTM-A/CSTC-A

LTG Dan Bolger, USA, Commander NTM-A/CSTC-A
Cdre Mike Farrage, UK, Chief of Staff, NTM-A/CSTC-A
COL Kenneth Deal, USA, DCG-OPS, NTM-A/CSTC-A
COL Debra Daniels, USA, Director Content Management/Audit Oversight
NTM-A/CSTC-A
CAPT John Lamberton, USN, Chief of Staff CJSURG, NTM-A/CSTC-A
CAPT Fernando Moreno, USN, Deputy Command Surgeon, NTM-A/CSTC-A
CAPT Donald Worm, USN, Team Lead for Validation, NTM-A/CSTC-A
CDR Kathryn Mangion, USN, ANA Command Surgeon/Medical Command (MEDCOM)
Advisor, NTM-A/CSTC-A
CDR Joe Taylor, USN, MTAG Team Lead, NTM-A/CSTC-A
CDR Ethan Josiah, USN, MTAG Deputy Team Lead, NTM-A/CSTC-A
CDR Melissa Smith, USN, MTAG Nurse Advisor, NTM-A/CSTC-A
LCDR Steven Bailey, USN, MTAG Hospital Administrator Advisor, NTM-A/
CSTC-A
LCDR Kelly, USN, MTAG Pharmacy Advisor, NTM-A/CSTC-A
Capt Sarah Byron-Smith, USAF, MTAG MEDLOG Advisor, NTM-A/CSTC-A
MSgt Troy Inabinet, USAF, MTAG Physical Therapy Advisor, NTM-A/CSTC-A
Ibanez Cocrates, MTAG Radiology Advisor, NTM-A/CSTC-A
HM2 Joanna Castro, USN, MTAG Dental Advisor, NTM-A/CSTC-A
LT David Varney, USN, MTAG Facilities/Administrator Advisor, NTM-A/
CSTC-A
Dr. Susanna Cooper, MTAG Physician Advisor, NTM-A/CSTC-A
LCDR Gail Alexander, USN, MTAG Nurse Advisor, NTM-A/CSTC-A
Capt Kimberly Price, USAF, MTAG Nurse Advisor, NTM-A/CSTC-A
SSG Michael Lonak, USAF, MTAG Medical Logistics Advisor, NTM-A/CSTC-A
HM1 Alvaro Benitez, USN, MTAG Bio-Medical Repair Advisor, NTM-A/CSTC-A

ANA Medical Command

MG Mussa Wardak, ANA Surgeon General

ANA National Military Hospital (NMH)

BG Nazir Shirzai, ANA, NMH Commander
COL Jurhat, ANA, Chief of Administration
COL Hasan, ANA, Chief Pharmacist
COL Noorzai, ANA, Chief of the Medical Staff
COL Rahmani, ANA, Director of Medical Logistics
LtCol Latif, ANA, Chief Nurse
MAJ Ahmar, ANA, Plans Officer
MAJ Zia, ANA, Chief Quartermaster Pharmacy
MAJ Khalil, ANA, NMH Warehouse Manager
Lt Behroz, ANA, NMH Pharmacy Dispensary
Various Charge Nurses, Physicians and Patients at the NMH

Mr. Cooper. Describe the joint effort between ISAF and the Afghan
government to develop and implement an overarching ANSF healthcare
system plan.
Ambassador Moorefield. ISAF released the ANSF Healthcare System
Development Support Plan to the COMISAF OPLAN 38302 in December 2011.
This plan identifies the focus areas for the plan which are defined as
follows:
a) ANSF Medical System Organization--The organization of the ANS
medical system will be optimized in terms of core processes,
sustainable Tashkil \1\, clear and reliable command and control (C2),
and capability laydown, thereby ensuring maximal efficiency of health
care delivery.
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\1\ The Tashkil describes the authorized strength and structure of
an ANSF organization.
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b) Personnel--Effective operation of an ANSF-developed,
requirements-driven, personnel management system that continuously
adapts to meet the changing needs of the Afghan Health system and
results in optimal staffing, with appropriate geographic distribution.
c) Education and Training--A standards-based, ethics driven system
of education and training that produces professional and competent
healthcare providers, administrators, and technicians that is
responsive to enterprise requirements, adaptive to emerging demands,
and sustainable.
d) Evacuation--An efficient, sustainable ANSF ground casualty
evacuation capability, tailored to geographical region, with developing
en route care capability.
e) Quality Management--An enduring culture of quality will exist
within the ANSF health systems, manifest by continuously improving
metrics of clinical outcomes, independently fostered by ANSF quality
management experts and programs. Ideally, the ANSF culture of quality
will spur development of and be supported by a culture of quality
within the broader government health systems within Afghanistan, as
reflected in national quality and credentialing standards.
f) Logistics--A requirements-driven and accountable requisition,
receipt, reconciliation and distribution (R3D) process, embedded within
the MoD and MoI logistics systems and aligned to ANSF clinical needs.
The vision driving the planning efforts, and the Afghan Healthcare
System development effort overall is ``quality warrior care, from point
of injury through a professional, ethical, effective and efficieint
medical system, to recovery and discharge, for the nation's
defenders.''
The ANSF Healthcare System Development Support Plan will be one of
the foci of a DODIG Special Plans and Operations (SPO)-led assessment
planned for March 2013.
Mr. Cooper. Describe the new medical logistics plan for
accountability for medical supplies.
Ambassador Moorefield. In 2011, we observed a restructuring of ANSF
medical logistics whereby the functions of requisition, acquisition,
storage, transfer and disposition of medical logistics were transferred
from the ANA Surgeon's General office to the MoD/GS G4 and the ANA
Logistic Command. This action brought MEDCOM into compliance with MoD
Decree 4.0 and was intended to improve and promote accountability and
responsibility for medical supplies.
We saw several examples of improvements in the medical logistics
system during our recent visit to NMH. Specifically we observed that
the medical logistics staff participated in training to ensure they
were complying with directives in MoD Decree 4.0. Additionally, they
provided training to other NMH staff who also are required to utilize
the MoD logistic forms. Furthermore, we observed that U.S. mentors
assisted NMH medical logistics staff in developing an automated system
which helped the Afghans to properly account for medical supplies and
pharmaceuticals in their warehouse. Although recently implemented and
only 20 percent complete, the Afghans were excited and proud to display
this new technology and their intent to complete the data entry
allowing them to completely automate inventory control measures for
their medical supply inventory.
Mr. Cooper. Describe the personnel shortages of the NMH in more
detail.
Ambassador Moorefield. During our recent NMH assessment, we
observed personnel shortages in the pharmacy and on the patient care
wards.
The Pharmacy at NMH is authorized five pharmacists according to the
1391 Tashkil and they have five pharmacists onboard. However, we
observed that the pharmacy was extremely busy due to the high patient
volume. NMH is a facility with an average daily census of 260 patients
and has a bed capacity for 410 patients. We believe they could use 1-2
additional clinical pharmacists who would be dedicated to dispensing
pharmaceuticals to patients and providing pharmacy oversight of the
inpatient wards.
Additionally, we noted that several of the busiest inpatient wards
experienced nursing personnel shortages. Specifically, the Orthopedic
Ward (mostly war-related injuries) had 45 patients and only 6 nurses
assigned filling 13 positions that were authorized on the NMH 1391
Tashkil. However, at the time of our inspection visit, there were 126
Nursing positions at NMH with 97 filled and 28 vacant for a fill rate
of 77.6%, a significant improvement in staffing compared to our
assessment in 2010 in which we noted a nursing fill rate of 51.5%.
Nonetheless, the nursing staff shortages that still exist are in key
medical support areas which may affect the quality of care and safety
of patients.
Mr. Cooper. Describe the problems regarding security of controlled
pharmaceutical substances in more detail.
Ambassador Moorefield. DODIG conducted an audit of the ANA's
pharmaceutical distribution, which was published on May 7, 2012. One of
the discrepancies noted at NMH during this audit was that controlled
pharmaceuticals were not secured separately from uncontrolled
pharmaceuticals. NMH took corrective action based on the report's
findings and removed the controlled pharmaceuticals from the open
shelves in their pharmacy stock room where they were stored with
uncontrolled pharmaceuticals. Additionally, NMH obtained a storage
locker where they placed all the controlled pharmaceuticals and locked
the container per their regulations.
However, during our visit in July 2012, we noted that this storage
locker, although an improvement of the previous method of storing
controlled substances, was not properly secured to the floor to ensure
that it could not be easily removed. Our understanding is that NMH is
already working on fixing this problem based on the recommendations we
made during our out-brief to the command in July.
Mr. Cooper. Describe the problems regarding equipment transfer and
repair in more detail.
Ambassador Moorefield. During our July 2012 visit we noted that
some wards needed additional medical equipment such as patient monitors
and IV pumps. We observed that some wards had equipment that was not
used 100% of the time, and other wards did not have access to a
particular piece of equipment when it was periodically needed. It was
explained to us that accountability of medical equipment is taken very
seriously among the Afghans and wards are possessive of maintaining
control over the equipment they have assigned to them on their Tashkil.
Consequently, the wards do not easily share medical equipment that may
be needed for patient care on other wards. We will recommend in our
report that NMH reassess the accuracy of the amount and distribution of
medical equipment listed on the Tashkil and develop policy/procedure
which enable loaning of medical equipment among the different patient
wards. We also made this recommendation to the Hospital Commander, ANA
Surgeon General and Assistant Minister for Health Affairs.
Additionally, we noted that NMH continues to have challenges with
the maintenance and repair of their medical equipment. This was due, in
part, to a lack of qualified medical equipment repair technicians. NTM-
A initiated a contract to support NMH with medical equipment repair in
2011 due to a lack of qualified ANA medical equipment repair
technicians. However the Afghan company under contract did not perform
the work that was required. Due to the contractor's non-compliance,
work on this contract was discontinued in July 2012.
In 2011, the ANA Armed Forces Academy of Medical Sciences (AFAMS)
developed a 12 month curriculum, with U.S. and Coalition support, to
train ANA soldiers as bio-medical equipment repair technicians. The
first set of students have completed the didactic portion of the
training and are now involved in the 2nd phase of the training where
they participate in hands-on training maintaining and repairing
equipment at ANA medical facilities. 10 of the 21 ANA soldiers who
completed the first phase of training were assigned to work at NMH in
June 2012.
Mr. Cooper. Describe your concerns regarding the plan for medical
monitoring beyond 2013 in more detail.
Ambassador Moorefield. ISAF released the ``ANSF Healthcare System
Development Support Plan'' in response to the COMISAF OPLAN 38302 in
December 2011. Accordingly, NTM-A has developed a coordinated plan to
guide the efforts of medical mentors/advisors as they work with their
ANSF partners to transition to Afghan-led healthcare facilities. The
objective for transition is as follows: ``An interdependent,
professionally-led ANSF Health Function which generates and sustains
sufficient police and army medical personnel, infrastructure, services
and logistics capabilities, with accountable and effective health
system that support the ANSF''.
We have reviewed ISAF's plan and NTM-A's supporting plan, which
includes objectives and milestones for the development of the Afghan
healthcare system for 2012, 2013 and 2014. ANA hospitals, under the
mentorship of U.S. and Coalition forces, are beginning to achieve
success in demonstrating their readiness to transition.
According to an NTM-A assessment conducted in June 2012, NMH
received an overall rating which indicated that they are capable of
executing functions with coalition oversight only. Furthermore, the
NTM-A plan identified the third quarter of Calendar Year 2013 as the
window for the transition of NMH to an ``Afghan-led'' hospital.
Given the successes of NMH in working towards transition, we have
asked NTM-A/CSTC-A to define a plan for the medical mentoring mission
beyond the transition to NMH-lead to ensure the continued success of
NMH and the ANSF Healthcare system, in general.