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.

1 comment:

Deirdre said...

What you are describing illustrates a huge problem at my medical school. We are getting more and more medical students applying to our university residence program from Afghanistan and Iraq, who aren't qualified. It's tragic because they think a doctor is a doctor (and we are racist for denying that), they want to do the right thing for their families by leaving and they are taking medical resources away from their country.