The Battle for Access — Health Care in Afghanistan
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《新英格兰医药杂志》
Recent rounds on the infectious disease ward in Mir Wais Hospital, in Kandahar, Afghanistan, found a young farmhand recuperating from meningitis sitting with the two friends who had accompanied him to the hospital. He had survived the disease, but only barely, and the episode had left him blind. In quiet tones, the man discussed with the medical staff whether his condition was permanent. In another room, a family of six was recovering from typhoid fever. The family members were fortunate that they had sought care early, because typhoid has a fatality rate of nearly 10 percent in Kandahar. The most acutely ill patient was in the female wing — a comatose teenage girl with suspected meningitis whose illness was not responding to treatment. Her mother had brought the girl to the hospital three days earlier and had remained at her bedside ever since.
Mir Wais is the referral hospital in Kandahar, and many patients with the severest illnesses in the southern part of Afghanistan — at least those who have the means — eventually find their way here (Figure). Overall, nearly 6 percent of the patients who are admitted to Mir Wais do not recover. More than half of the patients who die on the ward (57.8 percent) are children younger than five years of age, who usually die from diarrheal diseases. Late presentation is an important contributing factor to the risk of death, since most deaths occur within 24 hours after admission to the ward. Many patients, such as the blinded farmhand and the family with typhoid, have traveled considerable distances to reach Mir Wais. Death records reveal that less than a third (28.4 percent) of the patients who died were from the city of Kandahar, whereas more than one in five (21.1 percent) had traveled from another province altogether.
Rounds at Mir Wais Hospital, Kandahar, Afghanistan.
Courtesy of Médecins sans Frontières.
An hour west of Mir Wais Hospital and Kandahar is the community of Zhare Dasht, or "Yellow Desert," which is home to about 40,000 people, most of whom are Pashtuns who have fled either drought in the south or ethnic disputes in the north. The settlement lies in the desert plain, and the last leg of the road is clearly marked with warnings not to stray from the dirt track that has been cleared of land mines. Here, Afghan doctors and other health workers, with the support of Médecins sans Frontières (MSF, or Doctors without Borders), perform about 7500 consultations each month in a setting that tests the limits of clinical skill, where there is a wide range of endemic disease and no laboratory support. Most patients are children with respiratory infections and diarrheal disease, but each year, the clinicians also see cases of malaria, trachoma, and viral hepatitis. Recently, Zhare Dasht was hit by a regional diphtheria epidemic that sickened scores of people and is known to have killed six. Unfortunately, because of violence and instability, including the deliberate targeting of aid workers, MSF was forced to suspend community-based service at the beginning of winter, the peak season for acute respiratory infections.
Conflict and instability are not new to Afghanistan. The country has struggled through decades of war and continues to rank among the worst in the world in basic health indicators such as infant and maternal mortality. Armed conflict and large displacements of the population have made accurate data extremely sparse, but according to the best estimates available, one in four Afghan children dies before his or her fifth birthday. An estimated 85,000 children younger than five years of age die each year from diarrheal disease, and 15,000 die from tuberculosis. Although important progress has been made in measles vaccinations and other projects that have rapid effects, the health care system faces chronic deficiencies, such as a poor infrastructure and a lack of trained medical professionals.
The poor infrastructure is a substantial barrier to access to medical care and one of the main reasons for late presentations by acutely ill patients. Moving between villages or even cities generally requires slow and laborious travel in four-wheel-drive vehicles. For example, to cross Afghanistan (which is approximately the size of Texas) from the provincial capital of Qala-I-Naw, in the west, to Kabul takes at least three days. The recent repaving and reopening of the Kabul–Kandahar road have reduced travel time, but the road is still too unsafe for aid workers to use. With nearly 80 percent of Afghans living in rural areas, the lack of roads, transportation, and a referral system means that medical care, especially in emergencies, is often out of reach. In the Mir Wais surgical ward, for instance, extremely late presentations of women with complications of pregnancy such as hemorrhage, obstructed labor, or retained placenta result in interventions targeted primarily at saving the mother: more than half the time, when such a woman reaches the ward, her fetus has already died.
Even if a patient manages to travel to a government clinic, there is no guarantee that he or she will find a doctor. With only 8 physicians per 100,000 people, many districts do not have a doctor at all. Especially in rural areas, it is not atypical for the formal training of a medical officer who serves as many as 25 villages to consist of no more than a few months of medical education completed decades ago. Poor salaries (about $32 a month for a physician), sometimes paid months in arrears, push the doctors to pursue private practice and to cater to patients who can afford to pay for service. In practical terms, this means that doctors who subsist solely on a government salary are generally on duty for only about five hours each day, usually from 8 a.m. to 1 p.m., even in major urban hospitals.
Many of the elements necessary for the rehabilitation of the health care system are clear. Additional doctors and nurses need to be trained and allocated, with special emphasis on rural postings and female professionals (cultural norms necessitate that women see female doctors regarding obstetrical and gynecologic matters). The transportation infrastructure needs to be strengthened so that patients can reach health care providers and so that outreach health care services or badly needed programs, such as those for tuberculosis control, can serve their communities. Access to clean water and proper sanitation facilities must be improved in order to reduce the risk of waterborne disease, one of the leading killers of Afghan children. Yet in Zhare Dasht, as in much of the southern and eastern regions of the country, where more than one third of the country's population lives, the long process of reconstruction that is necessary for addressing these problems is severely hindered by ongoing insecurity and armed conflict.
Currently, the majority of health care in Afghanistan is provided through nongovernmental organizations. It is estimated that more than 80 percent of functional health care facilities have some form of support from such organizations, often including the supply of medicines and other basic materials. In the south and east, these groups must operate with extreme caution, if they can work at all, because aid workers are perceived as supporters of the coalition's political agenda and, as such, have become targets of anticoalition forces. Members of a nongovernmental de-mining organization were recently detained by gunmen near Zhare Dasht, although they escaped with only minor wounds. Several other aid workers, both Afghan and foreign, have been murdered in similar ambushes. The inability to deliver aid means that millions of Afghan civilians are beyond the reach of humanitarian assistance, including basic health care services. Indeed, one of the main reasons that the staff of Mir Wais Hospital sees so many patients who come from considerable distances is that the reconstruction and rehabilitation of medical services in the surrounding areas have been severely limited by the ongoing conflict. (Figure)
Patients Waiting to Be Seen in Kandahar, Afghanistan.
Photo by Sebastian Bolesch, Berlin. Reprinted from Akut, ?rzte ohne Grenzen, Berlin, with the permission of the publisher.
In the face of such daunting barriers, some efforts have been made to focus aid on a particular health care problem. Afghanistan remains one of the worst places in the world to give birth: maternal mortality has been estimated at 1600 per 100,000 live births, with the highest rates occurring in the most remote areas. In an effort to improve the odds for mothers and infants, MSF has opened the Dashte Barchi basic emergency maternity clinic in western Kabul, with skilled midwives on call 24 hours a day. Nearly 15 percent of patients require emergency transfer, mainly owing to complications such as preeclampsia and hemorrhage. In six months, the number of patients at the clinic doubled, the number of deliveries reached 220 per month, and additional midwives had to be hired to meet the demand. This increase, which reflects the fact that the medical staff is not only qualified but also culturally acceptable (i.e., female), is indicative of the unmet demand for obstetrical–gynecologic services. But the high rate of obstetrical emergencies remains a sobering indicator of the dire needs and the potentially fatal outcome for Afghan women who have complications during delivery.
While the maternity clinic in Kabul is coping with an influx of new patients, the doctors at Zhare Dasht are discussing how to scale down services with minimal adverse effects. When MSF announced this past November that the security situation made travel to Zhare Dasht impossible, the settlement's council of elders was anxious but understanding. The elders and nongovernmental organizations pragmatically determined how to organize ambulance transportation to Mir Wais Hospital as needed. Members of the medical staff at Mir Wais, for their part, braced for yet another emergency — many of them had started to work here in the midst of an earlier crisis, a cholera outbreak in 1999, and they had provided the support and antitoxin for last year's diphtheria epidemic. The family with typhoid has gone home, opening up needed beds, and the farmhand and his friends have returned to their province and an uncertain future. The nurses at Mir Wais, always at the ready, prepared their vacated beds for the steady stream of incoming patients, double-checked drug stocks, and ensured that all was in order in case they needed to call on the patient overflow tents that had been set up behind the ward.(Brigg Reilley, M.P.H., Gl)
Mir Wais is the referral hospital in Kandahar, and many patients with the severest illnesses in the southern part of Afghanistan — at least those who have the means — eventually find their way here (Figure). Overall, nearly 6 percent of the patients who are admitted to Mir Wais do not recover. More than half of the patients who die on the ward (57.8 percent) are children younger than five years of age, who usually die from diarrheal diseases. Late presentation is an important contributing factor to the risk of death, since most deaths occur within 24 hours after admission to the ward. Many patients, such as the blinded farmhand and the family with typhoid, have traveled considerable distances to reach Mir Wais. Death records reveal that less than a third (28.4 percent) of the patients who died were from the city of Kandahar, whereas more than one in five (21.1 percent) had traveled from another province altogether.
Rounds at Mir Wais Hospital, Kandahar, Afghanistan.
Courtesy of Médecins sans Frontières.
An hour west of Mir Wais Hospital and Kandahar is the community of Zhare Dasht, or "Yellow Desert," which is home to about 40,000 people, most of whom are Pashtuns who have fled either drought in the south or ethnic disputes in the north. The settlement lies in the desert plain, and the last leg of the road is clearly marked with warnings not to stray from the dirt track that has been cleared of land mines. Here, Afghan doctors and other health workers, with the support of Médecins sans Frontières (MSF, or Doctors without Borders), perform about 7500 consultations each month in a setting that tests the limits of clinical skill, where there is a wide range of endemic disease and no laboratory support. Most patients are children with respiratory infections and diarrheal disease, but each year, the clinicians also see cases of malaria, trachoma, and viral hepatitis. Recently, Zhare Dasht was hit by a regional diphtheria epidemic that sickened scores of people and is known to have killed six. Unfortunately, because of violence and instability, including the deliberate targeting of aid workers, MSF was forced to suspend community-based service at the beginning of winter, the peak season for acute respiratory infections.
Conflict and instability are not new to Afghanistan. The country has struggled through decades of war and continues to rank among the worst in the world in basic health indicators such as infant and maternal mortality. Armed conflict and large displacements of the population have made accurate data extremely sparse, but according to the best estimates available, one in four Afghan children dies before his or her fifth birthday. An estimated 85,000 children younger than five years of age die each year from diarrheal disease, and 15,000 die from tuberculosis. Although important progress has been made in measles vaccinations and other projects that have rapid effects, the health care system faces chronic deficiencies, such as a poor infrastructure and a lack of trained medical professionals.
The poor infrastructure is a substantial barrier to access to medical care and one of the main reasons for late presentations by acutely ill patients. Moving between villages or even cities generally requires slow and laborious travel in four-wheel-drive vehicles. For example, to cross Afghanistan (which is approximately the size of Texas) from the provincial capital of Qala-I-Naw, in the west, to Kabul takes at least three days. The recent repaving and reopening of the Kabul–Kandahar road have reduced travel time, but the road is still too unsafe for aid workers to use. With nearly 80 percent of Afghans living in rural areas, the lack of roads, transportation, and a referral system means that medical care, especially in emergencies, is often out of reach. In the Mir Wais surgical ward, for instance, extremely late presentations of women with complications of pregnancy such as hemorrhage, obstructed labor, or retained placenta result in interventions targeted primarily at saving the mother: more than half the time, when such a woman reaches the ward, her fetus has already died.
Even if a patient manages to travel to a government clinic, there is no guarantee that he or she will find a doctor. With only 8 physicians per 100,000 people, many districts do not have a doctor at all. Especially in rural areas, it is not atypical for the formal training of a medical officer who serves as many as 25 villages to consist of no more than a few months of medical education completed decades ago. Poor salaries (about $32 a month for a physician), sometimes paid months in arrears, push the doctors to pursue private practice and to cater to patients who can afford to pay for service. In practical terms, this means that doctors who subsist solely on a government salary are generally on duty for only about five hours each day, usually from 8 a.m. to 1 p.m., even in major urban hospitals.
Many of the elements necessary for the rehabilitation of the health care system are clear. Additional doctors and nurses need to be trained and allocated, with special emphasis on rural postings and female professionals (cultural norms necessitate that women see female doctors regarding obstetrical and gynecologic matters). The transportation infrastructure needs to be strengthened so that patients can reach health care providers and so that outreach health care services or badly needed programs, such as those for tuberculosis control, can serve their communities. Access to clean water and proper sanitation facilities must be improved in order to reduce the risk of waterborne disease, one of the leading killers of Afghan children. Yet in Zhare Dasht, as in much of the southern and eastern regions of the country, where more than one third of the country's population lives, the long process of reconstruction that is necessary for addressing these problems is severely hindered by ongoing insecurity and armed conflict.
Currently, the majority of health care in Afghanistan is provided through nongovernmental organizations. It is estimated that more than 80 percent of functional health care facilities have some form of support from such organizations, often including the supply of medicines and other basic materials. In the south and east, these groups must operate with extreme caution, if they can work at all, because aid workers are perceived as supporters of the coalition's political agenda and, as such, have become targets of anticoalition forces. Members of a nongovernmental de-mining organization were recently detained by gunmen near Zhare Dasht, although they escaped with only minor wounds. Several other aid workers, both Afghan and foreign, have been murdered in similar ambushes. The inability to deliver aid means that millions of Afghan civilians are beyond the reach of humanitarian assistance, including basic health care services. Indeed, one of the main reasons that the staff of Mir Wais Hospital sees so many patients who come from considerable distances is that the reconstruction and rehabilitation of medical services in the surrounding areas have been severely limited by the ongoing conflict. (Figure)
Patients Waiting to Be Seen in Kandahar, Afghanistan.
Photo by Sebastian Bolesch, Berlin. Reprinted from Akut, ?rzte ohne Grenzen, Berlin, with the permission of the publisher.
In the face of such daunting barriers, some efforts have been made to focus aid on a particular health care problem. Afghanistan remains one of the worst places in the world to give birth: maternal mortality has been estimated at 1600 per 100,000 live births, with the highest rates occurring in the most remote areas. In an effort to improve the odds for mothers and infants, MSF has opened the Dashte Barchi basic emergency maternity clinic in western Kabul, with skilled midwives on call 24 hours a day. Nearly 15 percent of patients require emergency transfer, mainly owing to complications such as preeclampsia and hemorrhage. In six months, the number of patients at the clinic doubled, the number of deliveries reached 220 per month, and additional midwives had to be hired to meet the demand. This increase, which reflects the fact that the medical staff is not only qualified but also culturally acceptable (i.e., female), is indicative of the unmet demand for obstetrical–gynecologic services. But the high rate of obstetrical emergencies remains a sobering indicator of the dire needs and the potentially fatal outcome for Afghan women who have complications during delivery.
While the maternity clinic in Kabul is coping with an influx of new patients, the doctors at Zhare Dasht are discussing how to scale down services with minimal adverse effects. When MSF announced this past November that the security situation made travel to Zhare Dasht impossible, the settlement's council of elders was anxious but understanding. The elders and nongovernmental organizations pragmatically determined how to organize ambulance transportation to Mir Wais Hospital as needed. Members of the medical staff at Mir Wais, for their part, braced for yet another emergency — many of them had started to work here in the midst of an earlier crisis, a cholera outbreak in 1999, and they had provided the support and antitoxin for last year's diphtheria epidemic. The family with typhoid has gone home, opening up needed beds, and the farmhand and his friends have returned to their province and an uncertain future. The nurses at Mir Wais, always at the ready, prepared their vacated beds for the steady stream of incoming patients, double-checked drug stocks, and ensured that all was in order in case they needed to call on the patient overflow tents that had been set up behind the ward.(Brigg Reilley, M.P.H., Gl)