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.

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