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High-risk operation: The rebuilding of Afghanistan's medical system

After physicians who fled the country years ago returned last fall, they urged U.S. assistance to focus on women's and children's health.

By Amy Snow Landa, amednews correspondent. Jan. 6, 2003.

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The night their daughter was born, Habib Baha, MD, and his wife were afraid they would not make it to the hospital. Armored tanks patrolled the city enforcing a strict nighttime curfew.

Driving to the hospital meant risking arrest. Dr. Baha's name was already on the Communist government's list of anti-Marxist troublemakers. A few days earlier, he had been released from a prison camp after serving a six-month sentence for expressing his political views. Returning home, he found he had lost his position at the medical school where he taught anatomy for 13 years. He then went to the bank and found that it had been nationalized, his account liquidated.

Now it was just after midnight. His wife was in labor with their fifth child. They had to risk it. Dr. Baha helped his wife into the car and drove.

The year was 1979. The place: Jalalabad, Afghanistan. Soon after the birth of their daughter, Soviet troops invaded. Dr. Baha and his wife and children fled to Pakistan with the little money they had. They would move to Germany and later to Texas before settling in San Diego. Dr. Baha would once again teach anatomy, this time at a training center for medical technicians.

No family member went back to Afghanistan, even for a visit. Then last fall, Dr. Baha got a call from the U.S. Dept. of Health and Human Services asking him to travel to his homeland to help assess the country's health infrastructure.

Having rebuilt his life in the United States, Dr. Baha saw the offer as a chance to help rebuild the shattered medical system of the country he escaped. "I felt it was time," he said.

He joined three other Afghan-American physicians who spent two weeks in Kabul on the HHS mission. The physician team visited hospitals, clinics and Kabul University's medical school. They presented their findings to HHS Secretary Tommy Thompson when he visited the Afghan capital in October 2002 and pledged U.S. assistance in reconstructing the country's medical infrastructure.

A health care system in ruins

The physicians' report to Thompson was grim. More than two decades of Soviet occupation, war and Taliban rule had reduced most of country -- including its medical system -- to rubble. "It seemed like a house that had been burned to the ground and only the ashes are left behind," Dr. Baha said. In fact, he went to see the house where his parents had once lived in Kabul and found only its skeleton still standing.

"Everything was incredibly broken and bad," said Qudratullah Mojadidi, MD, an obstetrician-gynecologist in Jacksonville, Fla., and clinical professor at the University of Florida College of Medicine.

Kabul's hospitals were in awful condition, with crumbling walls and rickety plumbing. The physicians found that one women's hospital, Rabia Balkhi, was delivering about 200 babies a week without anesthesia or oxygen for performing cesarean-section deliveries. "If you judge a hospital from zero to 10, that hospital is somewhere from zero to one," said Dr. Mojadidi, who led the physician team in Kabul.

The physicians suggested to Thompson that HHS should pursue a project that would have an immediate impact on the health of women and children, rather than trying to fix the country's entire health care system.

Within weeks of his visit to Afghanistan, Thompson announced that HHS would focus assistance on improving the health of women and newborns, and would start by building a maternal and child health clinic in Kabul early this year.

"Life is too short and too awful for too many Afghan women," Thompson said when he announced the clinic in November 2002. "We're taking a critical first step toward making the lives of Afghan women better and more humane."

More than a year after the Taliban's collapse, Afghanistan is still one of the worst places in the world to be pregnant. According to a report released in November 2002 by the Centers for Disease Control and Prevention and the United Nations Children's Fund, there are an estimated 1,600 maternal deaths for every 100,000 live births in Afghanistan -- a maternal mortality ratio second only to that of Sierra Leone.

The country also has one of the highest infant mortality rates in the world, with one in four children dying before age 5.

Medical training in shambles

The effort to improve medical care for women and children in Afghanistan is complicated by a dearth of trained physicians and other health care personnel. The visiting Afghan-American physicians found that it will be many years before Afghanistan's own medical schools can produce the well-qualified physicians that the country desperately needs.

The doctors toured Kabul University's medical school, where they had studied 20 to 30 years before. The physicians were appalled by its condition. Once the country's leading medical school, Kabul Medical Institute now struggles to train 3,000 impoverished students without a teaching hospital, knowledgeable faculty or basic equipment.

"There is absolutely no medical education there by any standards," Dr. Mojadidi said. Bombing has destroyed the hospital that once stood on campus. Most Afghans qualified to teach medicine have long since fled the country, were executed or were forced off the faculty.

The school building had no running water or functioning toilets. There was one Petri dish left in the microbiology department and a few broken microscopes.

"They're graduating physicians who have no clue about practicing medicine," Dr. Mojadidi said. "The chair of the ob-gyn department can't do a basic C-section."

Given the health personnel shortage, HHS officials are proposing to staff the Kabul clinic with Afghan-American volunteers. The plan is to have about five physicians rotating on three- to six-month cycles. The department would pay for volunteers' travel expenses and accommodations. HHS is also looking for Afghan-American nurses, midwives and other health care professionals.

The clinic, to be built by the U.S. Dept. of Defense, will also function as a training center. The goal is to teach Afghan health workers basic skills as quickly as possible, so that they can go back to their villages and teach others how to care for pregnant women and newborns.

Help wanted

Despite high hopes, the clinic's future is unclear. The project is not actually in HHS' fiscal 2003 budget. Agency officials said they were determined to find the funding and send over physicians and nurses. But it remains uncertain whether enough Afghan-American physicians will volunteer.

"That's the two-million-dollar question," Dr. Mojadidi said.

HHS has partnered with the Afghan-American Physicians Assn. and the Afghan Medical Assn. of America to recruit physicians. But the doctors who made the trip to Kabul are skeptical.

"In reality, how much of this will happen is very uncertain," said Hamaira Behsudi, MD, a family physician in Arlington, Va. "I don't think we can guarantee it."

It is not easy for physicians to leave their practices for two or three months to work without pay, said Dr. Mojadidi, who speaks from experience. Despite the cost to his practice, Dr. Mojadidi has been going back to Afghanistan once or twice a year for the last 20 years to run a women's health clinic and teaching hospital in Jalalabad and to establish clinics at refugee camps along the Pakistan border.

He has tried to interest other Afghan-American physicians in helping him but has never found a single volunteer. "I'm hearing there is more interest now, but I'm not very optimistic."

Dr. Mojadidi believes that physicians who staff the clinic in Kabul "need to be fully paid." HHS officials said they were still working through the details of the project, but they emphasized that it is a volunteer effort. "This is about giving back to Afghanistan," said a department spokesman.

Another obstacle is security. Afghanistan remains unstable. Al-Qaeda fugitives, Taliban holdouts and feuding warlords still pose a threat, despite the presence of 7,000 American troops and 5,000 international peacekeepers.

"Last time I was in Jalalabad, they were offering $100,000 for a live American and $50,000 for a dead one," Dr. Mojadidi said.

But Dr. Baha said he was surprised by the sense of safety he felt during his visit to Kabul. "I was in fear the first two days, but I found the people in Kabul so friendly, there was no fear. Morale was so high. People were so happy to be free of the Taliban." There was such a feeling of goodwill toward the United States that cab drivers would not charge him a fare.

Still, safety is a worry, even in Kabul, where most peacekeepers are stationed. A car bomb explosion rocked the city last fall, killing 30 people, and rockets have hit the city's eastern edge.

Nor is the medical school immune from violence. Kabul police shot and killed a second-year medical student at the university during a November 2002 riot protesting the lack of food and electricity in the dormitories.

A spokesman for HHS said the department was continuing to assess the security issue.

Finally, there is the question of how much the HHS-funded clinic and training center will be able to accomplish, given the vast need for health care services in Afghanistan. The physicians who went to Kabul said they were glad the agency was planning to build a clinic and training center there, but that much more needed to be done.

"It's like a drop of water on a hot plate," Dr. Baha said. "It just evaporates."

Still, Dr. Baha, who is secretary of the Afghan Medical Assn. of America, said he knows there are Afghan-American physicians who are interested in returning to Kabul once security improves. "There are a lot of doctors who would like to go for two or three months," he said.

The Afghan-American Physicians Assn. also has begun gathering names of potential volunteers and has found "a few candidates who are definitely interested in going," Dr. Behsudi said. Much interest comes from young physicians who are not yet licensed and probably would need crash-course training before they could go over, she said. Retired physicians are also interested in volunteer efforts in Afghanistan.

Dr. Mojadidi is one such physician. The 64-year-old plans to retire from his Florida practice in June and is looking forward to devoting himself full time to international volunteer work. He plans to reopen his Jalalabad women's clinic and teaching hospital, which the Taliban shut down in the 1990s. He is working to gather financial support for the hospital, which he hopes to open by the end of the year.

"Once you help people who have been miserable for so long and you see them smile, you feel so good you become addicted to it," he said.

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