Friday, October 31, 2008

Critically Ill: Afghanistan's Healthcare System (Part Three)

This is the third and final article illustrating several of the challenges encountered in building a functioning healthcare system in Afghanistan.

Hopefully your village has a medical clinic, and hopefully the clinic is more than just a white building

When you visit a medical clinic in the United States, you direct yourself to a building in which various medical services are provided. In Afghanistan, the local medical clinic might be a physical structure devoted to healthcare, but within its walls very few services are likely provided. Your local “clinic” might even be the home of the government-appointed healthcare agent for your village. Your clinic might have a physician on duty, but most times you will only see there a poorly trained nurse or, even more likely, a local citizen with very minimal medical education who nonetheless is contracted by the Ministry of Public Health to provide the little healthcare he or she is able to offer the community.

I’m not implying the services always are poor, but they are certainly scarce. In fact, the Basic Package of Health Services for Afghans promoted by the Ministry of Public Health calls for little more than comprehensive vaccinations, pre- and post-natal care, treatment and control of malaria and tuberculosis, and nutritional supplementation. The ministry has not yet been able to provide for the entire population even this rudimentary package as resources – both human and financial – are lacking. The providers available often are not well-educated or trained, but they are committed. When you look at the scant stock of pharmaceuticals, vaccines and essential supplies available to these workers, you realize that even a US-trained physician would have trouble addressing the medical needs of the Afghan communities.

The construction of a proper clinic building is a source of great pride and hope for Afghan communities. It serves both practical and symbolic purposes. Practically, a clinic building serves as node where community medical treatment can be consolidated and then enhanced. In many remote places, providers dispense government-funded medical care in their personal residences as no dedicated local clinic structure exists. A clinic building also symbolizes that a community not only possesses cache and prestige, but that improved medical services might soon be available. The building itself therefore becomes a sign of hope, prosperity and advancement.

You must be cautious when constructing medical clinics (in addition to other government facilities such as schools and police stations) in Afghanistan as well-meaning donors and development personnel often have made the mistake of raising a building only to learn that the Afghan government lacks the resources to staff, equip and administer the facility. Then, your medical clinic becomes simply an empty white building with a red crescent painted on its wall.

How much is that pacemaker in the window?

Consider this scenario: You are a patient in an Afghan hospital, and your physician presents you with a prescription for an intravenous pharmaceutical he feels necessary for you to recover from your illness. He doesn’t write an order for the drug to be given by the nursing staff, because the hospital pharmacy doesn’t have the drug in stock. In fact, he probably doesn’t even give the prescription to you, as you are ill and bed-ridden. He probably gives the prescription to a relative of yours in the hospital with you who is there to attend to your needs such as food, laundry and bathing, as the hospital provides none of those services.

If the relative is able to afford the pharmaceutical, he or she proceeds to a local bazaar where a wide array of drugs can be bought with or without a prescription, even though the quality of the drugs is often suspect, especially those manufactured in Pakistan, China and India. (Afghanistan has made considerable advances in medical care the past several years, but the country is still far from developing a drug enforcement agency.) Medical devices are usually available at these markets as well.

The situation in Afghanistan is similar to that of many developing countries. The American surgeon Atul Gawande writes of the shortage of medical supplies in public Indian hospitals that has created such a demand for the goods that the hospitals are now surrounded by “rows of ramshackle stands with vendors selling everything from medications to pacemakers.” * In Kenya, I witnessed family members returning from local pharmacies with morphine, hypodermic needles and an assortment of IV fluids.

If you or your family cannot afford the required drug or device, you simply hope for the best. In these cases, the hospital wards merely serve as holding facilities or inhospitable hospice rooms.

Because Afghan physicians make very little money working in public hospitals, they do not always give their patients in those facilities proper attention. In fact, sometimes patients languish in those hospitals with no physician care whatsoever. Recently a colleague recounted for me how he found a surgical patient, recently transferred from another hospital with drainage tubes still protruding from his abdomen, wandering the halls of a Kabul hospital with his medications in hand, looking for someone to care for him. The patient claimed he had been in the hospital three days since his transfer, but had not yet spoken to anyone – physician, nurse or technician – on the medical staff.

Until some sort of plan for proper hospital services is drafted and funded, most of the Afghan medical centers will offer very little to the population. And until then, most hospitalized Afghans will, unfortunately, be wondering the same thing as much of the ambulatory patient population: “Is there any treatment available for me?”

*Atul Gawande, Better: A Surgeon’s Notes on Performance, p. 241.

Thursday, October 23, 2008

Critically Ill: Afghanistan's Healthcare System (Part Two)

This is the second article illustrating the challenges encountered in building a functioning Afghan healthcare system.

There is No System Here: The Example of Medical Waste Disposal

A few months ago my office began getting regular emails from American engineering teams scattered around Afghanistan who were alarmed that they were encountering medical waste improperly disposed in fields, ditches and trash dumps. The emails included photographs of used syringes and hypodermic needles, empty IV bags and soiled gauze sheets strewn on open ground. The engineers were shocked, and the subtext of their messages was “What are you medical folks going to do about this?” The answer, which for diplomatic purposes wasn’t included so bluntly in our replies, was “We aren’t going to do anything about it right now.”

Just as Afghanistan has no sound system for providing medical care, it has no infrastructure or service for disposing of medical waste. If you practice medicine in the United States, you take for granted that red plastic boxes designed for safe needle disposal are available in the clinic, and that when they are halfway filled they will be carted, along with larger red bags of other assorted medical waste, to a container where they will wait until the medical waste disposal truck comes to collect the garbage. Later, in places that I hope I never see, community-sized piles of medical will wait for incineration, with non-burning waste subsequently carted away for another type of disposal such as burial in land or disposal at sea.

The only concern I have with this system is the behavior of mob-infiltrated waste disposal companies that often cut corners, and thus increase profit, in their treatment of the waste, as evidenced on the New Jersey shoreline in the 80s when used needles, dumped from a trash freighter not yet far enough out to sea, washed ashore.

Afghanistan has no system yet to dispose of human waste, let alone medical waste. Kabul, the largest and most metropolitan of Afghan cities, has no public sewer system. The minority of the homes that have plumbing rely on trucks to empty their individual septic tanks, and the waste is then spread onto nearby fields, one of which is located just a few minutes drive from the center of the city. Outhouses are the most common lavatory in Kabul.

If an Afghan medical clinic has proper needle disposal containers and designated medical waste garbage bags, an unlikely proposition, then the personnel have no avenue to properly dispose of those receptacles once they are full. The Afghans have two choices: Let the waste sit in the clinic, or heave it onto the closest patch of barren earth or into the nearest open ditch.

At a few of the major Kabul clinics and hospitals, American development personnel have installed incinerators to ensure more hygienic medical waste disposal. The incinerators have solved some waste problems for hospitals, such as the question of how to dispose of flesh surgically removed from patients. Before, at a major Kabul medical center, amputated limbs and other choice bits of the human body that were not going home with the patients simply were buried on the hospital grounds. The only challenge was to inter the pieces deep enough so that local dogs couldn’t smell and unearth them.

But the incinerators brought new problems as well. Electricity often is unreliable in Kabul, and the incinerators don’t burn much without power. The incinerators are imported, rather exotic machines here. If one malfunctions, you cannot simply thumb through the Kabul Yellow Pages and pick the medical equipment repair specialist of your choice. The companies who sell the incinerators and other medical equipment typically have, at most, only a few service representatives for the entire country; and Afghanistan is about the size of Texas, with a transporation infrastructure that rivals that within countries such Mali and Papua New Guinea.

The hierarchical, bureacratic nature of Afghan medical facilities has also worked to subvert the use of what incinerators are in place. In one hospital, a specific employee is charged with collecting the building’s waste and the depositing it in a storage room. However, that employee does not possess the key to the storage room. The key to the storage room door is the possession of another hospital employee, who must coordinate with the waste collection agent to ensure that needle boxes and red garbage bags can pass through an open disposal room door to await incineration. The employee responsible for transporting the waste from the storage room to the incinerator, another actor in this tableau, also depends on the availability and good will of the waste disposal room keymaster so that the waste can transit from the hospital building to the incinerator itself. Thankfully, the door to the incinerator has no lock, so the transportation agent, if motivated, can deposit waste directly into the unit. However, the transportation agent has not trained to actually fire up the incinerator. The process of burning medical waste is the responsibility of another employee, qualified and facile in incinerator operation. Of course, the incinerator mechanic is helpless unless the machine has electrical power, which comes from a nearby outlet through an extension cord. The keeper of the extension cord is yet another hospital employee, hopefully collegial with the incinerator mechanic and willing to produce the cord so that the medical waste can burn.

Even if medical waste is burned properly in the incinerators, the Afghans have nowhere to dispose of the (hopefully sterilized) metal needles and ash. I don’t know where they deposit this stuff. My guess is that it somehow makes its way to field or ditch where American engineers, aghast at the sight of it, avidly photograph the scene and rush the images to us medical personnel. I contend that improperly disposed waste is an encouraging symbol as it represents the fact that Afghans somewhere were actually receiving some sort of medical care. I’m more concerned that most Afghan medical clinics still lack the supplies to even generate medical garbage.

Wednesday, October 15, 2008

Critically Ill: Afghanistan's Healthcare System (Part One)

Most medical professionals, when they first arrive in Afghanistan, are pretty shocked when they recognize the poor quality of medical care available in this country. The average Afghan probably has little to no access to healthcare at all, but what is available publically might be less than what an American can supply at home from the family medicine cabinet. Decades of war, corruption, destructive cultural biases and international indifference have devastated Afghan society, including the education system and national medical institutions. The healthcare system in Afghanistan today, where the government’s per capita expenditure is less than $3, is a dissheveled, ailing patient on its back and in need of resuscitation. I’m not able to dissect the entire system, examine its components, and then propose a plan to improve its functioning; but I can produce several vignettes which I hope illustrate the problems. Consider it a short primer, in two parts, on the state of Afghan healthcare today.

“Physician” is More a Title Than an Academic Degree

Until very recently, you didn’t have to do much to graduate from medical school in Afghanistan. Admission standards were extrememly lax, with several hundred students matriculating each year to the most prestigious medical school, Kabul Medical University (KMU). Once enrolled as a student at KMU, you didn’t have to attend class to graduate. Attention to the seven-year medical school curriculum was optional: No student failed, and students did not know the nuisance of medical competency and licensing exams. At the end of the seven year program, which essentially was a protracted lecture series, all students graduated with an M.D. degree and simply chose what field of medicine best suited them. Although some students entered residency programs at Afghan hospitals, such advanced training certainly was not required. You want to be a surgeon? Go ahead and cut. You’re a medical doctor.

Many US medical school mercifully utilize the pass-fail grading system, but students must then pass a series of national licensing exams before continuing on to further medical training and autonomous practice. The Afghan system was, unfortunately, pass-pass.

The system is slowly changing. Selection for a seat in a medical school class is now much more competitive, a fact that angers many influential Afghans who have grown accustomed to easily “enrolling” their kin in medical school. Tuition at the schools is free, so wealthy and connected Afghans often considered the academic excursion as nothing more than a seven-year shopping sojourn for their children. Additional rigor has evolved as at the end of the medical school curriculum as well, as graduating students must pass an exam in either medicine or surgery in order to practice.

These changes in medical education should produce more competent physicians in the years to come, but unfortunately the quality of physicians already practicing in Afghanstan varies tremendously. Many physicians possess an understanding of human biology not quite as extensive as that of a bright American high school student. Some physicians who have received advanced training in medicine or surgery nevertheless still lack a basic understanding of the fundamentals of medical intervention. An American orthopedic surgeon here recently considered it a victory that he persuaded the Afghan surgeons to stop sharing one set of operative instruments for the two surgical cases taking place in the same operating room.

Afghanistan does boast some very good and talented physicans and surgeons. Often these people have trained in the former Soviet Union, Pakistan or Turkey. Others are simply very dedicated, intelligent, and driven to provide the best possible care under the circumstances. Unfortunately, there are too few of these folks around, and it will be years before medical education reforms and training initiatives serve to stock the Afghan healthcare system with a preponderance of competent physicians.

If You Paid Me Like an Interpreter, I Would Practice as a Doctor

The monthly salary for a physician working at a public hospital for the Ministry of Public Health is about $50. Physicians working for the Afghan Army earn more, but still only $200-300 per month. An Afghan interpreter working in Afghanistan for the United States, another government, a foreign business, or one of the numerous non-governmental organizations (NGOs) here averages $600-800 as a monthly salary. Medical students in Afghanistan, as a population, have much better facility in English than most other groups of people. The quality medical texts available here are often written only in English, and the medical school curriculum (that is a seven-year program modeled on the British system) includes English language instruction. Therefore, a shocking number of medical school graduates in Afghanistan have no intention of using their degress to provide medical care to their countrymen. Instead, they graduate from medical school and immediately find employment as interpreters.

Many physicians who do work at the public and military hospitals are strictly morning employees. They cannot afford to support their families on their government salaries, so they practice at the government institution until about 13:00, then they depart to their private clinics where they attend to patients who are able to pay cash for their services. Some brazen physicians even utilize the government clinic buildings and equipment to conduct private clinics. Security at the military hospitals is often compromised as some physicians instruct their private patients to see them at the military installation, even though entry to those facilities is supposed to be restricted. At another government hospital, an advising American intensivist was shocked to find the Afghan ICU attending physician absent from the critical care ward every afternoon, but using internationally donated equipment and supplies on the ground floor of the hospital to conduct his profitable private practice.

The consequence of the pitiful salaries and short working hours of Afghan physicians charged to provide medical care to the overwhelming majority of Afghans is that the wealthy have the opportunity to pay for decent care, while the poor often have trouble even finding a physician they can afford to visit. The physicians themselves are stuck in a system that offers no financial security if you treat the needy. Moreover, many Afghan physicians who might look forward to a relatively lucrative private medical practice simply look to emigrate from Afghanistan. I know personally several well-trained doctors who chose to forfeit any opportunity to practice medicine as they secured visas and moved to the United States, where they will be lucky to live a middle-class existence after their arrival. No institution in the US will recognize their Afghan medical credentials, and they will more likely be driving a taxi cab than ever seeing clinic patients in any capacity. Their country misses them.