Experts Talk About Afghanistan's Medical Shortfalls
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03/26/10 Kate Bradshaw
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While the battle rages in the United States over how much access everyone should have to health care, many in Afghanistan are living with few ways of getting the care they need. On the final day of the USF Symposium on Afghanistan and Pakistan, experts tackled the question of how to provide quality care in that country, and it appears there are no easy answers.

Dr. Vincent Berkley says he’s an army of one. The assistant surgeon general is the sole full-time U.S. Department of Health and Human Services staffer in the Afghan capital of Kabul. And he says health care there is a mess.

The national security force, believe it or not, has its own system. The Ministry of Education has its own system and hospitals. The MLTH has its own system and hospitals. In a country with sanitized hospitals and heavily regulated prescription drugs, it may be hard to envision the chaos Berkley says is the reality in hospitals in Afghanistan.

There's no, really, opportunity to look at the standards for pharmaceuticals, and how they get into the country. The borders are porous. When a patient needs a drug, oftentimes they will go the bazaar, and buy that drug and bring it to the hospital. There is no administration. Patients bring their own supplies oftentimes.

As for the question of how Afghan hospitals select their medical staff.

There really is no process for credentialing health care workers. From the technician in the laboratory to the technologist in radiology to the midwife to the physician to the nurse, how do you know what their training is? Does the ministry of public health have a way to do that? The answer is no.

But Berkley says the lack of a centralized system could give the Afghan government an opportunity to build a health care system from the ground up.

Perhaps one of the things that we can look at is to perhaps convince the government to say, “Here's an opportunity because of the devastation, to start at the ground and build the new system.

Dr. Eugene Bonventre is from Center for Strategic and International Studies. He says medical care in a country defined by war depends on coordination between civil and military sectors. He says the United Nations definition of civil-military coordination deems this essential.

And it's essential, in order to promote the humanitarian principles: neutrality, impartiality, humanity, independence, etc. But Bonventre says this is far from reality. It takes energy to do it; it takes political will to do it; it takes money to do it; it takes time to do it; and the default setting is to not do it.

Part of the reason it’s hard to coordinate these efforts, he says, is that nongovernment organizations are often afraid of being targeted by insurgents. He cites a 2004 incident that resulted in the deaths of several Doctors Without Borders workers.

Five of their staff were murdered in Afghanistan in 2004. Not only that, but the government would not investigate. And they suspect that there was some complicity with the Afghan National Police. Nothing has been proven, but nothing also, nothing has been investigated. But this led to the withdrawal of Afghanistan—not because of the murder of the staff, but because the Taliban made an announcement that the reason they killed the staff is because they associated with the U.S. military.

Bonventre notes that the Department of Defense doesn’t dedicate much of its budget toward administering civilian health care in occupied countries, nor does it currently give much direction.

*The Department of Defense has a lot of doctrine policy experience on force health protection. On health assistance, the only thing they have is one sentence in a policy document that came out in 2003, and that sentence says, “Military health personnel will be prepared to meet civilian health needs in conflict.”*

He says that document is unclear on whether the Department of Defense is talking about military contractors or what would in this case be Afghan citizens. Also, the definition of counterinsurgency, or COIN, does not specifically address administering health care to civilians who happen to be in the line of fire. Many say that Afghan women are the biggest victims of these health care shortfalls. Dr. Hamida Ebadi says that prenatal care, especially the gap between routine and hospital care, is a striking example of this.

There is no link between basic passage of health service and essential passage of hospital service. The majority of organizations are interested in community programs, but the quality is not good in the hospitals. And we refer a lot of patients from the community to the hospital, and they cannot receive quality care, how it will happen to these patients.

Panelist Brian McCarthy, of Health and Human Services’ Centers for Disease Control and Prevention, said one can gauge the state of a nation’s health care by how efficiently it carries out emergency caesarian sections.

It's about nine maternal deaths per 1,000 caesarian sections, the nine maternal deaths being associated with failures of the system: getting the wrong blood type, anesthesia, infection control, all of the issues you would expect might happen with a high-risk intervention in a low-resource setting.

But while health care in Afghanistan may be below what most consider acceptable standards, the panelists said they hoped to get the word out about the country’s needs. This may be a challenge in a time when some experts say U.S. chances for victory, something many say has yet to be defined, are growing dim in Afghanistan.

President Obama has said the United States will start scaling back the mission in 2011. The amount of nation building that would subsequently occur is unclear.

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