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.

No comments: