The Battle for Access - Health Care in Afghanistan
by Brigg Reilley, Gloria Puertas, Anne-Sophie Coutin.
The New England Journal of Medicine. May 6, 2004.Vol350,Iss19;pg.1927
Recent rounds on the infectious disease ward in Mir Wais Hospital, in
Kandahar, Afghanistan, found a young farmhand recuperating from
meningitis sitting with the two friends who had accompanied him to
the hospital. He had survived the disease, but only barely, and the
episode had left him blind. In quiet tones, the man discussed with
the medical staff whether his condition was permanent. In another
room, a family of six was recovering from typhoid fever. The family
members were fortunate that they had sought care early, because
typhoid has a fatality rate of nearly 10 percent in Kandahar. The
most acutely ill patient was in the female wing - a comatose teenage
girl with suspected meningitis whose illness was not responding to
treatment. Her mother had brought the girl to the hospital three days
earlier and had remained at her bedside ever since.
Mir Wais is the referral hospital in Kandahar, and many patients with
the severest illnesses in the southern part of Afghanistan - at least
those who have the means - eventually find their way here. Overall,
nearly 6 percent of the patients who are admitted to Mir Wais do not
recover. More than half of the patients who die on the ward (57.8
percent) are children younger than five years of age, who usually die
from diarrheal diseases. Late presentation is an important
contributing factor to the risk of death, since most deaths occur
within 24 hours after admission to the ward. Many patients, such as
the blinded farmhand and the family with typhoid, have traveled
considerable distances to reach Mir Wais. Death records reveal that
less than a third (28.4 percent) of the patients who died were from
the city of Kandahar, whereas more than one in five (21.1 percent)
had traveled from another province altogether.
An hour west of Mir Wais Hospital and Kandahar is the community of
Zhare Dasht, or "Yellow Desert," which is home to about 40,000
people, most of whom are Pashtuns who have fled either drought in the
south or ethnic disputes in the north. The settlement lies in the
desert plain, and the last leg of the road is clearly marked with
warnings not to stray from the dirt track that has been cleared of
land mines. Here, Afghan doctors and other health workers, with the
support of Medecins sans Frontieres (MSF, or Doctors without
Borders), perform about 7500 consultations each month in a setting
that tests the limits of clinical skill, where there is a wide range
of endemic disease and no laboratory support. Most patients are
children with respiratory infections and diarrheal disease, but each
year, the clinicians also see cases of malaria, trachoma, and viral
hepatitis. Recently, Zhare Dasht was hit by a regional diphtheria
epidemic that sickened scores of people and is known to have killed
six. Unfortunately, because of violence and instability, including
the deliberate targeting of aid workers, MSF was forced to suspend
community-based service at the beginning of winter, the peak season
for acute respiratory infections.
Conflict and instability are not new to Afghanistan. The country has
struggled through decades of war and continues to rank among the
worst in the world in basic health indicators such as infant and
maternal mortality. Armed conflict and large displacements of the
population have made accurate data extremely sparse, but according to
the best estimates available, one in four Afghan children dies before
his or her fifth birthday. An estimated 85,000 children younger than
five years of age die each year from diarrheal disease, and 15,000
die from tuberculosis. Although important progress has been made in
measles vaccinations and other projects that have rapid effects, the
health care system faces chronic deficiencies, such as a poor
infrastructure and a lack of trained medical professionals.
The poor infrastructure is a substantial barrier to access to medical
care and one of the main reasons for late presentations by acutely
ill patients. Moving between villages or even cities generally
requires slow and laborious travel in four-wheel-drive vehicles. For
example, to cross Afghanistan (which is approximately the size of
Texas) from the provincial capital of Qala-I-Naw, in the west, to
Kabul takes at least three days. The recent repaying and reopening of
the Kabul-Kandahar road have reduced travel time, but the road is
still too unsafe for aid workers to use. With nearly 80 percent of
Afghans living in rural areas, the lack of roads, transportation, and
a referral system means that medical care, especially in emergencies,
is often out of reach. In the Mir Wais surgical ward, for instance,
extremely late presentations of women with complications of pregnancy
such as hemorrhage, obstructed labor, or retained placenta result in
interventions targeted primarily at saving the mother: more than half
the time, when such a woman reaches the ward, her fetus has already
died.
[Photograph]
Rounds at Mir Wais Hospital, Kandahar, Afghanistan.
Courtesy of Medecins sans Frontieres.
Even if a patient manages to travel to a government clinic, there is
no guarantee that he or she will find a doctor. With only 8
physicians per 100,000 people, many districts do not have a doctor at
all. Especially in rural areas, it is not atypical for the formal
training of a medical officer who serves as many as 25 villages to
consist of no more than a few months of medical education completed
decades ago. Poor salaries (about $32 a month for a physician),
sometimes paid months in arrears, push the doctors to pursue private
practice and to cater to patients who can afford to pay for service.
In practical terms, this means that doctors who subsist solely on a
government salary are generally on duty for only about five hours
each day, usually from 8 a.m. to 1 p.m., even in major urban
hospitals.
Many of the elements necessary for the rehabilitation of the health
care system are clear. Additional doctors and nurses need to be
trained and allocated, with special emphasis on rural postings and
female professionals (cultural norms necessitate that women see
female doctors regarding obstetrical and gynecologic matters). The
transportation infrastructure needs to be strengthened so that
patients can reach health care providers and so that outreach health
care services or badly needed programs, such as those for
tuberculosis control, can serve their communities. Access to clean
water and proper sanitation facilities must be improved in order to
reduce the risk of waterborne disease, one of the leading killers of
Afghan children. Yet in Zhare Dasht, as in much of the southern and
eastern regions of the country, where more than one third of the
country's population lives, the long process of reconstruction that
is necessary for addressing these problems is severely hindered by
ongoing insecurity and armed conflict.
Currently, the majority of health care in Afghanistan is provided
through nongovernmental organizations. It is estimated that more than
80 percent of functional health care facilities have some form of
support from such organizations, often including the supply of
medicines and other basic materials. In the south and east, these
groups must operate with extreme caution, if they can work at all,
because aid workers are perceived as supporters of the coalition's
political agenda and, as such, have become targets of anticoalition
forces. Members of a nongovernmental de-mining organization were
recently detained by gunmen near Zhare Dasht, although they escaped
with only minor wounds. Several other aid workers, both Afghan and
foreign, have been murdered in similar ambushes. The inability to
deliver aid means that millions of Afghan civilians are beyond the
reach of humanitarian assistance, including basic health care
services. Indeed, one of the main reasons that the staff of Mir Wais
Hospital sees so many patients who come from considerable distances
is that the reconstruction and rehabilitation of medical services in
the surrounding areas have been severely limited by the ongoing
conflict.
In the face of such daunting barriers, some efforts have been made to
focus aid on a particular health care problem. Afghanistan remains
one of the worst places in the world to give birth: maternal
mortality has been estimated at 1600 per 100,000 live births, with
the highest rates occurring in the most remote areas. In an effort to
improve the odds for mothers and infants, MSF has opened the Dashte
Barchi basic emergency maternity clinic in western Kabul, with
skilled midwives on call 24 hours a day. Nearly 15 percent of
patients require emergency transfer, mainly owing to complications
such as preeclampsia and hemorrhage. In six months, the number of
patients at the clinic doubled, the number of deliveries reached 220
per month, and additional midwives had to be hired to meet the
demand. This increase, which reflects the fact that the medical staff
is not only qualified but also culturally acceptable (i.e., female),
is indicative of the unmet demand for obstetrical-gynecologic
services. But the high rate of obstetrical emergencies remains a
sobering indicator of the dire needs and the potentially fatal
outcome for Afghan women who have complications during delivery.
[Photograph]
Patients Waiting to Be Seen in Kandahar, Afghanistan.
Photo by Sebastian Bolesch, Berlin. Reprinted from Akut, Arzte ohne
Grenzen, Berlin, with the permission of the publisher.
While the maternity clinic in Kabul is coping with an influx of new
patients, the doctors at Zhare Dasht are discussing how to scale down
services with minimal adverse effects. When MSF announced this past
November that the security situation made travel to Zhare Dasht
impossible, the settlement's council of elders was anxious but
understanding. The elders and nongovernmental organizations
pragmatically determined how to organize ambulance transportation to
Mir Wais Hospital as needed. Members of the medical staff at Mir
Wais, for their part, braced for yet another emergency many of them
had started to work here in the midst of an earlier crisis, a cholera
outbreak in 1999, and they had provided the support and antitoxin for
last year's diphtheria epidemic. The family with typhoid has gone
home, opening up needed beds, and the farmhand and his friends have
returned to their province and an uncertain future. The nurses at Mir
Wais, always at the ready, prepared their vacated beds for the steady
stream of incoming patients, double-checked drug stocks, and ensured
that all was in order in case they needed to call on the patient
overflow tents that had been set up behind the ward.