Thursday, October 14, 2010

The Great Wall of Kabul

Its not the Great Wall of China, but the tales are just as grand. It was built as protection against the invading Arab armies and later used as shelter against the British (there are three fabled Anglo-Afghan wars, not including the current.) It stands among the newly built mud huts, sprawling the mountainsides. Looking up to the houses from the street, one can’t help but wonder how the slopes are traversed to get to some of these homes—especially in winter, with the snow. We had he best kabob at the foot of the Great Wall of Kabul. It was in fact the best I’ve ever had. Bourdaine has nothing on me.

The kabob was a treat after our visit to Rabia Balkhi—Kabul’s dedicated women’s hospital. It stands in name but in resources each hospital we visit is severely lacking in the basic things one needs to see to call it a hospital. We know that thi has become a running theme in our visits to each public hospital thus far. So how do the country’s hospitals and doctor’s run? With little resources and technology it therefore stands solely on the shoulders of physicians to diagnose based on the very basics that all of us as physicians learn early on in medical school- by physical examination. We have come to know these doctors as some of the most intelligent and clinically astute MD’s we have ever met. Many have told stories of seeing patients in the midst of gun-fire and rocket ships blaring from above the hospital ceilings. All Afghan doctors deserve a salute for their selfless giving, bravery, and humanity. But the place of female physicians is without question very special to us. Though most were still unwilling to be placed on film or have pictures taken mostly for security concerns, they shared with us their lengthy stories. They spoke of previous years where they saw patients secretly in their homes, performed surgeries and deliveries under the burqa, livied in hiding in hospital basements- for fear of being jailed or even killed by Taliban for practicing their beloved profession. Though today they practice freely, their woes are far from over. They do not have enough functional fetal monitors and no uterine contraction monitor at all; the blood product and drug shortage the plagues most public hospitals does not spare them; and they do not have a neonatal ICU.
Homes with a View
Rabia Balkhi, though, is still unique. Staffed by obstetricians, primary care physicians, and Midwives. The hospital is government run with oversight from the Ministry of Health but receives technical support from the International Medical Corps (IMC). It is a major referral center for all obstetrical emergencies and a major training center—including residency training programs and midwife training programs. The Midwife training program is meant to supplement the severe shortage of doctors in the rural setting which contributes to the one of the worst maternal mortality rates anywhere in the world. Because of the security situation, very few doctors are willing to leave the city itself; so the Basic Package of Health Services (discussed in our first, Project Overview) has set aside funding to train Midwives to supplement this shortage. They have an ambulance system, with only a few vehicles that are meant to transfer between hospitals and are generally reserved for transfer FROM outlying hospitals. Since these outlying hospitals are no more than rudimentary clinics and delivery centers as far as obstetrics is concerned, Rabia’s ambulances serves as the initial framework for prehospital care.
The destroyed presidential palace--Darul Aman
The entry to Rabia Balkhi is jammed by human traffic. Women swarm the 2x4 window etched in the main wooden gate to get registered. Wait times of greater than a week are not unheard of. Once they get to registration, the great majority are sent to the general labor and delivery section and a small minority are sent to the emergency section. We visited the emergency section with the deputy chief of obstetrics. It was rather rudimentary: 6 beds, one blood pressure cuff, one ultrasound machine, and one uterine contraction monitor that was out of service. There were 4 patients. One of the patients was a transfer from the south of Kabul: after giving birth she had hemorrhaged. She was brought in a day earlier and because the hospital did not have enough blood, they screened family members and designated a younger sibling as a donor. The patient was receiving her transfusion as her story was being told.

The broader picture of healthcare in Afghanistan has not improved much, but it is getting better. The greatest hope lies in the younger generation of doctors that are eager, willing, and more than able. We visited two newer training hospitals, Cure and Afshar, that were different and inspiring. We will talk about them in our next blog and also touch on the meaning of free healthcare, user fees, and the role of government.