Bringing health care back to Afghanistan: "They need everything," even food and water

Government agencies, charities and physicians worldwide contemplate ways
to rebuild the medical infrastructure of this war-ravaged country.

By Victoria Stagg Elliott, AMNews staff. Jan. 28, 2002.

In mid-December, Mary Burry, MD, a neuroradiologist from Portland, Ore., arrived in the northern Afghanistan city Mazar-i-Sharif for a three-week volunteer stint at the local hospital.
Once there, she found patients sleeping two to a bed and physicians without medicines or basic equipment. She saw diseases that she'd only read about -- including two children she suspected had polio. She was unable to confirm this because the hospital did not have a lab. Others were severely malnourished. A few people even came without any physical ailments.
With this article Health of Afghanistan Links
"They were very needful for someone to care about them," said Dr. Burry. "They've lived under such a terrible situation for so many years."
But at least in the city, the population has access to these health care workers who do what they can with minimal supplies. Outside the city, hundreds of thousands of Afghans are living in temporary camps with no access to any health services at all.
Years of civil war and instability have destroyed Afghanistan's health system, which was far below Western standards to begin with. Years of drought have made food supplies scarce. The water is unsafe to drink. Child and maternal mortality is among the highest in the world. Vaccination rates are low. There are not enough qualified health personnel. And, even if a person can get a prescription to treat what possibly ails them, there are no pharmacies where it can be filled.
Numerous organizations such as the World Health Organization and Northwest Medical Teams International, the group which sent Dr. Burry, have moved in to address urgent needs. Others are focusing on ways to help the struggling nation's medical system address long-term difficulties. These issues include the high incidence of infectious diseases such as measles and tuberculosis, outbreaks of scurvy and other nutrition-related illnesses, treatment of injuries caused by war and by the millions of landmines still in the ground, and providing mental health care to a traumatized population.
1 in 4 Afghan children die before age 5.
"Indications are that much needs to be done in this country whose long-lasting humanitarian crisis has led to a great accumulation of health needs," said Gro Harlem Brundtland, MD, MPH, director-general of the WHO, in a statement. "Aside from relieving the suffering, rebuilding the health sector is absolutely crucial for the future stability and socioeconomic developing of Afghanistan."
Hospitals and health clinics need to be rebuilt and staffed with trained personnel. Because of the instability over the years, most educated Afghans, including many physicians and other health care workers, left the country, although some are expected to return, at least temporarily, to assist in rebuilding. Education has been very patchy since the Soviet invasion, and during the Taliban regime, many female doctors, who made up 40% of the country's physicians, were forbidden to practice. They faced severe penalties if they tried.
In 1998, for example, John Peters, MD, an emergency physician in Battle Mountain, Nev., and medical director of Refugee Relief International, delivered two tons of medical aid to a group of female physicians. Just a couple months later, the women were all killed by the Taliban.
Doctors who practice medicine in Afghanistan now make little money. Physicians at the hospital where Dr. Burry worked would arrive to do rounds each morning, but were not paid. To address this problem, Dr. Burry's organization is covering their hospital salaries: $125 a month.
Starting from scratch
Loss of legitimately trained personnel either through emigration or death and the lack of any regulatory structures have also created a health industry staffed by people who may not be able to fill the gap.
"There were a whole bunch of private entrepreneurs who created their own dispensaries," said Andre-Jacques Neusy, MD, director of the Center for Global Health at New York University. "How do you incorporate these centers into public health activity and something which can be more structured and supervised? Can they be part of the larger effort of creating a basic primary health care system?"
About 10% of Afghans are vaccinated against polio.
Experts say the general population, which has a high rate of illiteracy, also needs to be educated about basic public health messages such as hand washing. In addition, a system needs to be created to provide safe food and water and control infectious disease outbreaks. Afghanistan remains one of the last hiding places for polio, with just more than 10% of the population vaccinated against the disease.
"The public health system is nonexistent," Dr. Burry said. "Where do you start? They don't chase down contacts for those with infectious diseases so TB is rising. That along with sanitation and immunization would make a huge difference."
But the country also needs the most basic infrastructure and supplies. Save the Children, for example, sent over antibiotics and aspirin last month, but the organization also sent oil to keep the hospitals heated. There is no electricity outside the cities. And, even inside urban areas, power supplies are unreliable, leaving most hospitals to depend on their own generators. Communication technology is almost nonexistent, with most relying on limited access to expensive satellite phones. Some areas of the country are inaccessible either because of insufficient roads or because the roads are just too dangerous.
"A large portion of people who get really sick die before they get to the hospital because they have no ground transport," said Dr. Peters, who has made five trips in the past 20 years to the country and will be returning in the spring.
Afghanistan's rebuilding effort is in the crisis phase, providing for urgent needs. But disaster experts stress that long-term comprehensive planning is vital if the country is to have much of a future. This is not the first time aid agencies have flocked to the area, which has been in some form of humanitarian crisis for decades. However, it may be the first time that the result is viable and lasting. For this to be accomplished, the country's needs must be assessed, and the aid groups involved must collaborate.
"In situations like this there are always zillions of [nongovernmental organizations] so there is a great need for coordination, which is going to be a major feat," said Dr. Neusy, who has not been to Afghanistan yet, although he expects to go this year. He has spent a lot of time in war-torn areas such as Kosovo or Rwanda. "We have to have a really good assessment of the needs, and we have to set some standards. Afghanistan does not have the human resources to deal with the enormity of the needs."
Meanwhile, the WHO has been hosting meetings in Kabul and Islamabad, gathering representatives from United Nations agencies, local and international nongovernmental agencies, and Afghan University.
Experts say while planning for the future infrastructure is extremely important, the health of Afghans could be improved significantly with provision of the most basic services: clean food and water.
One-fourth of Afghanistan children do not live to see their fifth birthday. Many die of vaccine-preventable diseases, but the biggest killers are malnutrition and diarrhea.
"They need everything. They're starting from zero," said Dr. Peters. "But right now, they need food and water."