KHOST, Afghanistan — As Afghanistan struggles to create a functioning health care system after 23 years of war, military hospitals and mobile clinics run by coalition forces are the only hope for thousands of Afghans of getting adequate medical care.
The Soviet occupation from 1979 to 1989, the civil war that followed it, and the subsequent medieval rule by Taliban militias destroyed what little health care infrastructure existed in the country before the Soviet invasion, and uprooted most doctors and nurses.
According to the 2004 United Nations Human Development Report, there were only 210 health facilities with beds to hospitalize patients in the entire country last year. There are only 0.32 hospital beds per 1,000 people, compared to 2.7 beds on average in other developing countries.
There is only one doctor per 10,000 people, against an average 11 doctors per 10,000 people in other developing countries.
And while humanitarian agencies like Doctors Without Borders fill some of the void in Kabul, most provinces are still considered too dangerous for them.
Most health care providers are located in large cities like Kabul, Herat, Kandahar, Mazar-e-Sharif and Nangahar, while more than 70 percent of Afghans live in rural areas.
Some provincial capitals like Khost have private and public hospitals run by local doctors — usually small, dilapidated and fly-infested structures with antiquated equipment donated by charities. Very few of these have the facilities to handle life-threatening diseases or traumas.
So when Almarsha, a 10-year-old boy from a small village near the border with Pakistan, set off a land mine while gathering firewood, his relatives took him directly to the U.S. military hospital at Camp Salerno, a two-hour drive from the boy’s village.
“The last thing I remember before the explosion was that I was reaching for a branch of deadwood on the ground,” Almarsha said, standing in line for a follow-up visit at a clinic organized by U.S. medics just outside Camp Salerno. “There was a big flash and then my hand started hurting a lot.”
Col. David Barber, the commander of the 249th General Hospital at Camp Salerno and an orthopedic surgeon who operated on Almarsha, said the land mine mangled the boy’s right wrist.
“I tried to save as much of his wrist as possible,” Col. Barber said. “I went really slow on him.” But eventually only the boy’s thumb and part of the index finger could be saved.
Army treats hundreds
The 249th General Hospital from Fort Gordon, Ga., is the largest and most sophisticated medical facility in eastern Afghanistan, and it attracts patients from Khost and neighboring provinces.
Spc. Stephen Scull, a hospital clerk, said that as of March 4, the 249th General Hospital has seen more than 650 patients in the surgical ward alone. In addition, it treated more than a hundred trauma patients.
The hospital staff also set up regular clinics just outside the camp. At one such clinic Tuesday, Army medics saw 85 patients.
Sgt. 1st Class James Gillen, a medic with C Company, 307th Logistics Task Force, said that often American doctors are the last hope for these patients.
“A lot of times … they come expecting a miracle,” Sgt. Gillen said.
Patients from remote villages, who have never seen a doctor, hitchhike for days on elaborately decorated “jingle trucks” to see a doctor at the hospital. Some in critical condition can be flown in by medevac helicopters.
It is not surprising, then, that providing health care services to the population has become one of the most effective tools in winning the hearts and minds of Afghans, even in areas that were initially hostile to coalition troops, said Lt. Col. Mark McLaughlin, commander of the Provincial Reconstruction Team (PRT) in Asadabad, in Kunar province on the border with Pakistan.
Staff Sgt. Scott Cole, a medic at the PRT, said it has three clinics, two for males and one for females run by a female Afghan doctor. On an average day, the two clinics for men see about 200 patients. The clinic for women has had a much slower start. With women’s literacy rate below 13 percent and strong traditions in most rural areas against women showing their bodies, even to a female doctor, most women shun medical help.
Pregnancy’s hourly toll
According to the 2004 U.N. Human Development Report, on average, two Afghan woman die every hour from pregnancy-related causes.
But even rigid tribal customs are beginning to relax as the PRT at Asadabad gains the confidence of people nearby, Col. McLaughlin said. During the initial village-assessment tour in the Sarkanay district of Kunar province, people hid in their houses, he said.
A few weeks later when a medical team went to visit the same district, they were greeted by friendly throngs of villagers. Army medics saw 380 male patients and more than 400 female patients, Col. McLaughlin said.
“We don’t get yelled at by locals, we don’t get doors shut at us,” Sgt. Cole said. “They’ve become extremely friendly.”
Doctor sells souvenirs
But while coalition forces and nongovernmental-organization-run medical facilities can alleviate the shortage of medical care in Afghanistan in the short run, creation of a viable health care system in the country depends on developing Afghan medical professionals and a local health care infrastructure. This will take years, and is limited by a lack of training opportunities and jobs for new graduates.
Dr. Rahmat Ullah graduated from the Medical Faculty at the University of Khost, but he makes his living as a shop owner at Camp Salerno, selling souvenirs to American soldiers stationed there. At night he works at a free eye clinic in Khost — a dilapidated two-story building with very little equipment, no sanitary facilities and a single water faucet in the operating room.
“I dream of becoming a plastic surgeon,” Dr. Ullah said. “I’ll be the first Afghan plastic surgeon — there are no plastic surgeons in Afghanistan.” This also means there is no one to train him in plastic surgery.
Dr. Bashir Ahmadzai, a Pakistan-trained general surgeon, returned to his native Afghanistan in 2002 after coalition forces drove away the Taliban militia, hoping to establish a practice. But after death threats from Taliban sympathizers, he left his clinic in a small provincial town that had no other doctor and now works as an interpreter in the military hospital at Camp Salerno.
He also screens patients to identify the most urgent cases, but in terms of medical work he gets only to change dressings. Dr. Ahmadzai said, however, that watching American physicians work has been an invaluable training experience.
Driving through the busy streets of downtown Khost lined with open sewage ditches, Dr. Ullah said simple improvements in sanitary conditions, access to clean water and child-inoculation programs could have an enormous effect on health in Afghanistan.
According to the 2004 U.N. report, only 23 percent of Afghans have access to safe water and less than 40 percent of children get life-saving vaccinations.
More than 85,000 Afghan children under age 5 die of diarrhea each year because of dirty drinking water.
Pharmacists are few
One of the biggest dangers facing sick people in Afghanistan is the unregulated pharmaceutical trade.
“There are very few trained pharmacists in Khost,” Dr. Ullah said, driving by a row of pharmacies in the main bazaar. “None of these people are qualified pharmacists — they are shopkeepers, their goal is to sell more drugs, not the right drugs.”
The poor quality of drugs imported from Iran, India and Pakistan and overdosing of medication are big problems, said Dr. Ahmadzai, the Pakistan-trained surgeon.
“Some doctors will prescribe seven or eight drugs to treat a disease that should be treated with one drug,” he said.
Many physicians get kickbacks from pharmacy owners if they prescribe more drugs and send patients to a particular pharmacy, said Dr. Ullah, the physician trained at the University of Khost who now sells souvenirs to American GIs at Camp Salerno.
“This is wrong,” he said. “It’s not what doctors are supposed to do. It’s against our oath. But until there is strong regulation by the government, these practices will continue.”