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In Afghanistan, health care is competing with chaos

From the March ACP-ASIM Observer, copyright © 2002 by the American College of Physicians-American Society of Internal Medicine.

By William Hoffman

Two physicians discuss the daunting health crises faced by a people recovering from decades of war

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As Afghanistan tries to recover from decades of war, physicians from around the world are preparing to lend a hand.

Boston-based Physicians for Human Rights (PHR), a human rights advocacy group, has been sending physicians to Afghanistan to assess the state of health care there. Fresh off a two-day flight from the other side of the world, two physicians from the group talked to ACP-ASIM Observer about their travels in Afghanistan early this year.

Lynn Amowitz, MD, an internist and instructor at the Brigham and Women's Hospital in Boston, who works with the organization, said that because the country's hospitals are in complete shambles, an extraordinary effort will be needed to rebuild. She also noted that mental health and women's services are practically nonexistent.

In some areas, however, organizations are beginning to provide primary health care services to at least some of the population. Jennifer Leaning, MD, professor of public health at Harvard School of Public Health and attending emergency physician at Brigham, said some nongovernmental organizations are providing care at government clinics and mobile clinics.

Despite these signs of hope, the country urgently needs help. Afghanistan has an average of only four hospital beds for every 10,000 people. Worse yet, many of the country's facilities are in Kabul, forcing Afghans to walk miles through areas littered with land mines.

Here is the doctors' assessment of the state of health care in one of the world's most ravaged nations—and their suggestions for how American physicians can help.

ACP-ASIM Observer: What kinds of nongovernmental organizations are currently helping rebuild Afghanistan's health care system?

Dr. Leaning: A thin but engaged cadre of medical personnel, primarily from the international community, is providing health care. A few military field hospitals have been set up as a result of the U.S.-led coalition war. Some medical facilities supported by the Red Cross are operating in various parts of the country.

ACP-ASIM Observer: What types of physicians does Afghanistan most need now: general practitioners, surgeons or other specialists?

Dr. Amowitz: In rural areas, the supply of trained health personnel is nonexistent. In 24 of 31 provinces, for example, there are no hospitals or medical staff. For every 10,000 people in the country, there is an average of 1.8 physicians. Because three-quarters of the physician population is in or near Kabul, most provinces have less than one physician for every 10,000 people. The greatest need is for primary care physicians in pediatrics, women's health, internal medicine and ob-gyn. Afghanistan has one of the highest mortality rates for mothers, infants and children, so better care for women and children is an urgent need.

ACP-ASIM Observer: What is Afghanistan's biggest health challenge?

Dr. Amowitz: The lack of basic needs, such as food, shelter, clean water, health care access, education and work opportunities. Education, for example, determines whether a mother knows how to feed her child or make sure that water is boiled so it is clean. Sadly, 80,000 children a year die of diarrheal disease.

Dr. Leaning: Afghan physicians need training, retraining, continuing education and upgrading of their skills and knowledge base. They've been so cut off from the rest of the world.

ACP-ASIM Observer: What does the Afghan government say it needs most from foreign physicians?

Dr. Leaning: It most needs physicians to train others in the hospitals and clinics, doing bedside teaching and consultation.

ACP-ASIM Observer: How can American physicians who want to help get involved?

Dr. Leaning: If they want to travel to Afghanistan, they should join a coordinated or group effort. Two or three should go at a time, in part to maximize their effectiveness.

Keep in mind, however, that there are few places where you can stay with any degree of support. There's very little running water and only intermittent electricity in the cities. A Westerner can safely eat in very few restaurants in Kabul without fear of food poisoning. Mazar-e-Sharif has one, at best.

The physical capacity to support extra people is really limited. You need to stay in guest houses, and those are packed with staff from nongovernmental organizations and journalists.

You also need to be physically hardy because the cities are at high altitudes and the facilities are primitive. You need to be prepared to rough it-to sleep in sleeping bags, drink only boiled water and not bathe every day.

ACP-ASIM Observer: How can physicians help if they cannot make the trip? Can they give money?

Dr. Leaning: Money that doesn't go through the right channels is only going to contribute to the corruption that already exists in the Afghan medical system. I don't think that contributions will help build the primary health care system, because the administrative structures are not yet in place.

William Hoffman is a freelance writer in Fairfax, Va.

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Need more information?

Physicians for Human Rights needs volunteers to support its advocacy campaigns. For more information, call 617-695-0041 or go online to www.phrusa.org.

The following organizations are looking for physician volunteers to help improve health care around the world:

  • Health Volunteers Overseas is dedicated to improving global health through educational efforts. The group does not currently have programs in Afghanistan but is active in other countries. Call 202-296-0928 or go online to www.hvousa.org.

  • Medicines Sans Frontiers, also known as Doctors without Borders, is looking for volunteers to serve in Afghanistan and other parts of the world. Call 212-679-6800 or visit its Web site at www.doctorswithoutborders.org.

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