Problems with Procurement

Many practitioners of modern medicine are quick to describe physicians and other healthcare “providers” as much more than simply skilled technicians able to manipulate human physiology with interventions that bring cure to maladies and injury. Some of us wish to retain the appellation of “healer,” signifying a more holistic approach to medicine that considers the patient’s entire state of good health, and not merely the absence of disease, as the therapeutic target. I agree that the ultimate goal of health is truly wellness, but I also know that I and most other physicians I know are really trained manipulators; and unless we consider ourselves faith healers, we aren’t very good at our jobs if we don’t have a considerable arsenal of pharmaceuticals, prosthetics, surgical screws and laboratory tests available for diagnosis and treatment. (I have yet to meet an internist able to reduce blood pressure significantly with conversation and meditation; or a surgeon successful in staunching internal bleeding with prayer and hypnosis.)

Few physicians in Afghanistan have access to even a fraction of the array of goods that an American physician relies upon for practicing medicine, a dearth that severely limits the care that competent Afghan physicians are able to offer. Even the influx of US government dollars does not solve the problem of scarce material resources for care here. Almost every component of Afghan society decayed and fell apart over the last forty years, including the commercial sector. You might have the money to buy laboratory reagents from the United Arab Emirates or a European supplier, but there is no reliable refrigerated transportation service in Afghanistan. In fact, those supplies, necessary for any modern hospital to support clinical diagnoses and treatment, might not ever make it through Afghan customs, even if they reach the border of the country. For a few weeks a colleague has been trying to determine if a cache of laboratory reagents is sitting unaccounted for – and likely spoiling – in a customs’ warehouse in Kabul or at a border station with Pakistan. Or if the supplies simply disappeared somewhere between the manufacturer’s warehouse and the designated Afghan hospitals.

The shipment might have been high jacked coming through Pakistan. The AP reported today that gunmen along the Khyber Pass attacked a convoy of trucks carrying “military vehicles and other supplies” (lab reagents?) destined for US forces in Afghanistan. I’m sure the bandits who pulled the heist are thrilled with the Humvees and trucks they captured; but if they took the time to examine the rest of the booty on the convoy and discovered vials of chemicals used to determine blood cholesterol levels and hundreds of urine pregnancy kits, they likely chucked these items into a Tora Bora ditch.

If the supplies you order do make it into the country, you have to be careful about how you distribute them. Highway banditry is the rule in Afghanistan, even moreso than in Pakistan. Local truck drivers typically consider every major roadway in Afghanistan a toll road, with the fare calculated and extracted from whatever goods comprise their loads. It’s a system similar to what the Mob ran at JFK Airport for years, and highlighted in the movie Goodfellas. So you should assume a rather high percentage of cargo loss if you send out a convoy of supplies to traverse Afghanistan.

Sometimes you can arrange direct delivery of supplies to a district hospital or clinic through a nearby airport, but you then risk incomplete accounting from the hospital personnel in the regions far from Kabul, as those folks just might pilfer a pallet or two of goods from the delivery and then report to the central accounting agency in Kabul that certain supplies never arrived.

The Recurrent Problem with Local Vendors

The United States government has a policy that American military personnel utilize local vendors when possible to secure the supplies we need in order to operate hospitals and clinics. The rule is reasonable, with the rationale that bolstering local Afghan businesses will boost the overall Afghan economy. Considering the prices many of these local vendors, who are cognizant of the US government rule favoring them as procurement agents, the American taxpayer is boosting certain sectors of the Afghan economy quite nicely. I have seen medical products of such low-quality and high-price that they would make even the most unscrupulous US military contractor blush with shame: flimsy nasopharyngeal airway tubes for $30, plastic catheters for $20, malleable arm splints for $60. And that’s the cheap stuff. I’m not sure how much x-ray film and surgical screws cost here, but the price tags would surely rival the infamous $400 hammer and $600 toilet seat that the Pentagon purchased in the 80s.

We may not be exporting stellar business ethics to the Afghans, but we are certainly developing an entrepreneurial spirit among the commercially aggressive men angling for whatever US business exists wherever they can find it. Builders, suppliers and vendors here often will promise that they can construct or deliver anything you require, regardless if they have ever contracted for the service or material before. I have seen business cards that read “Provider of medical equipment, and building foundation construction experts,” and “Shipping all your business supplies, with pharmaceuticals, and superior auto service.” Think that a US agency needs another service that you might be able to provide? Simply add that “specialty” to your business card, bid for the contract, and worry about delivering what you promised after you are chosen for the job.

Many of the Afghan businesses are experienced and honest with respect to their abilities, but contracting and quality problems arise far too frequently with local businesses. A medical technician’s school, funded by the US military, ordered through a local vendor a mannequin to teach resuscitation techniques, and a few different skeletons for anatomy instruction. The Afghan vendor assured the school that he could produce quality goods. The resuscitation mannequin delivered was simply a doll’s head. One of the instructional skeletons was similar to the paper decorations that litter most elementary schools before Halloween. Another skeleton was a poster with detailed anatomical references such as “upper leg bone.” A few of us joked that, for surgical instruction, we should order the game “Operation.”

Last month an order of more than $1 million in desperately needed pharmaceuticals finally reached a Kabul hospital. When the US agent responsible for the purchase went to inspect the shipment, he found that the local vendor had substituted cheaper drugs of dubious quality from China and Pakistan for the order, even though the contract specified pharmaceuticals only from reputable manufacturers in the United States and Europe. The Afghan quality assurance agent at the hospital happens to be a friend of the vendor, and appeared willing to stock the pharmacy with the inferior goods, almost certainly after a nice bribe from his buddy. If the US agent hadn’t caught the fraud, patients would have been exposed to poor quality therapeutics and the vendor would have made a profit considerably higher than the windfall he already was assured had he adhered to the contract.

An Afghan proverb translates into something like “If you wait 100 years for your revenge, you have moved too quickly to exact your just retribution.” The Afghan mind still puzzles me; and I don’t fully understand the adage as the average life expectancy in Afghanistan falls somewhere in the mid-40s. I only hope that the average Afghan, who would be happy with a modicum of modern medical intervention, doesn’t have to wait much longer for a little bit of healthcare and a national business ethic that isn’t grounded in thievery.