Report from Afghanistan Medical needs are overwhelming

by Donald E. Meier, MD, director of surgical services, Children's Medical Center of Dallas; associate professor, UT Southwestern Medical School

As my flight took off from DFW on Wednesday, Jan 16, I finally had time to catch my breath and ponder a few thoughts as to why I was on this plane. After all, three weeks earlier I had no plans to go to Afghanistan, and now here I was on a plane headed eastward-far eastward!

The momentum for this trip began when I read a Dallas Morning News article chronicling the sorry state of affairs in Afghan hospitals after 23 years of war. I knew that our years working in a mission hospital in Nigeria had given my wife Patsy (an OR nurse) and me the skills needed to help in some little way with the rebuilding of Afghanistan. But as I sat on my back porch sipping a home-dripped cup of Starbucks, I was more interested in last night's results for the Stars and Mavericks than in going to another "developing world" hospital.

So back to the Sports Day section-at least until David Harding came back into my life. David was an agricultural missionary in Nigeria while I was there during the 1980s. When he came to Dallas for a meeting, I offered to treat him to the Queen of Sheba Restaurant, knowing he had grown up in Ethiopia and loved Ethiopian food. Little did I know that his Dallas meeting was with three nongovernmental organizations (NGOs)-Cooperative Baptist Fellowship, Conscience International, and World Vision. These three were trying to formulate an appropriate humanitarian response to the Afghanistan situation. They were specifically looking at ways to revamp the Indira Ghandi Children's Hospital in Kabul. Before the meal was finished, I realized that I had been "selected as a volunteer" to assess this hospital from a physician's standpoint.

Twenty-one flying hours, 33 total hours, and four airports later, I found myself numb in Islamabad, Pakistan. I accompanied David and Jim Jennings, the president of Conscience International. The only way to enter Afghanistan is by way of a United Nations plane that runs three days per week and holds only about 40 passengers, each with a baggage weight limit of 20 kg.

We arrived in Kabul after a 30-minute flight over the beautiful Indo Cush Mountain range. Evidence of bomb damage was visible around the airport, but I was informed that damage had been inflicted several years ago during previous Afghan conflicts. In fact during my whole stay in Kabul, the only evidence of American bomb damage I could see was to a communications center on a hillside surrounding the city.

I stayed in the guest bedroom of a family working for International Assistance Mission, an NGO with work in Kabul for at least 25 years. My two colleagues and I stayed in a spare bedroom with single beds. We had plenty of blankets and a kerosene heater. The temperature each night dropped to 10 to 15 degrees F. I slept in long johns, pajamas, a sweatshirt, and three pairs of wool socks. I had as many blankets as I could find and my coat on top of those. One time when I woke up, I wasn't sure if I had the strength to keep breathing from all the weight on top of me. I was assured by all the Afghans that this was a very mild winter!

I spent the next four days meeting with government officials and medical officials and doctors at two Afghan hospitals-the Indira Ghandi Children's Hospital and the Wazira Akbar Khan Hospital, a government teaching hospital caring for adult patients. My purpose in coming to Afghanistan, and particularly in attending these meetings, was to determine what a limited group of concerned Americans could do to help improve health care here.

I had the privilege of attending an operating room session at the IGCH with Dr Mustafa, the chief of surgery. Chronicled below are my observations as I recorded them in the operating room.

The patient, a 4-year-old boy with a kidney stone, is brought into the operating room by his mother, who also brings a plastic sack full of operating room supplies which she has been required to secure on the open market before a deal could be arranged for the operation. The child, who is fully clothed in several layers except for bare feet, is left in the OR in the care of an Afghan operating room "nanny." The anesthesia person comes into the room, lays the child down on the OR table, and starts an IV with the cannula, which the mother bought. A bottle of IV fluid, which partially has been consumed by many previous operations, is collected from a shelf next to the omnipresent kerosene stove in the middle of the OR.

I am escorted to the next room to scrub my hands. The water is so cold that I feel like I'm immersing my hands in the North Sea in the middle of February. I make it back into the OR and the child is sleeping after his ketamine injection. Inhalational agents are not available and rarely is any child intubated for an operation. I'm not sure there even is an oxygen cylinder for the "anesthesia machine." I'm not concerned with the child's safety, however, because I safely used ketamine as the exclusive anesthetic agent many times in my Nigerian career.

The scrub team consists of myself, Dr Mustafa, and an intern who serves as the scrub tech/nurse. Except for intermittent pauses for repeat ketamine administration, the operation proceeds without difficulty in a left lateral decubitus position. There is not a cautery, so the incision is bloodier than what I am accustomed to at Children's, and it takes a bit longer because each bleeder must be ligated. The child actually receives an intraoperative blood transfusion. A pelvotomy is performed and the stone extracted. Because there are no "store-bought" Penrose drains, the intern must sacrifice a strip from his left glove to serve the same purpose. The wound closure is performed in multiple layers using chromic catgut because this is what the mother found to purchase in the market. The child has received a good operation and goes back to the "more intensive care" of the three surgical wards.

The above recitation gives a realistic overview of the situation in one of the best hospitals in Afghanistan. Even it has glaring needs for building infrastructure, basic equipment, and basic supplies. The needs are overwhelming for any single group to consider filling. Sure, organizations such as Dallas' Medisend generously provide equipment and supplies for developing world hospitals, but these organizations cannot be expected to fill more than a fraction of the tremendous needs of this country. It will take a massive effort by governments to provide the money needed, and a massive accountability effort to make sure that the supplies, which are so graciously given by concerned humanitarians around the world, do not end up for sale on the street for the benefit of private entrepreneurs. Governments around the world have pledged several billion dollars, and unbelievable numbers of NGOs are entering Afghanistan trying to determine how they can help in this crisis. The major problem facing the government of Afghanistan, and in particular, the minister of public health, is how to coordinate all the groups that want to help.

I have decided to concentrate my efforts on medical education for Afghan physicians and nurses. The most recent textbooks I could find in any of the teaching hospitals were 1940s vintage. Each Afghan doctor with whom I spoke was quite interested in medical education programs, which would cover a defined curriculum, use audiovisual tools, and provide printed handouts. The Afghan doctors want American specialists to come prepared to teach, but also be willing to learn. Afghan doctors know they have a lot to learn, but also believe they have a lot to teach American doctors, and that any meaningful educational conference must involve an exchange of ideas.

I plan to return to Afghanistan when commercial airlines resume service and when adequate housing for a group of visitors can be arranged. My initial plan is to take a team of four specialists for the pediatric hospital and four for the adult hospital. The ideal would be for the visiting physicians to have developing world experience so the medical culture shock would not be so overwhelming as to be depressing. The American physicians would not only give lectures, but also would see patients on wards and in clinics. Surgical specialists would operate with the Afghan doctors. Textbooks, a few basic pieces of equipment, and some supplies could be taken as baggage. The total time away from home would be about two weeks, with one full week in Afghanistan and three days on either end for travel and overcoming jet lag.

Physicians interested in volunteering for medical missions work can contact Connie Webster, DCMS director of community service, at 214-948-3622 or connie@dallas-cms.org.