Team in Afghanistan Looks to Double Health Care Access

By Fred W. Baker III
American Forces Press Service

Feb. 19, 2009 - The walls of the Paktia provincial hospital are a bleak, dirty, two-tone, painted gray along the lower half and lime-green to the ceiling. Charred electrical wires poke from the plastered walls, hot-wired with no caps, covers or even electrical tape binding them. Its halls reek of a mix of disinfectant and an odor that comes from having too many patients and too few rooms.

There is no light, save for that spilling in from the windows and doors. The hospital runs its lights and its lifesaving equipment using a high-powered generator. But it has only enough fuel to operate six hours a day. The fuel is saved for when critical care must be provided.

This 30-bed hospital in Gardez City is the largest and provides the best care in the province, said Air Force Capt. James E. Parris, who visited there this week to meet with its director and survey its needs.

Parris is a physician's assistant with the Paktia Provincial Reconstruction Team, and he's charged with assessing the health care needs of the province and making recommendations for projects and purchases.

Much of the hospital's equipment is old and needs to be replaced. Parts are not even available for the leaking, 15-year-old anesthesia machine.

"I think it gives the people in the operating room more gas than it does the patient," Parris joked.

But while the equipment may be outdated, and the facilities unembellished, the hospital offers a range of specialty care such as ear, nose and throat, orthopedic, ophthalmology and obstetrics and gynecological care.

"In a way it's like we've gone back in time. It's very archaic. But the doctors and the medical providers they have are very good," Parris said. "They do a phenomenal job for the facilities that they have."

The same could be said for health care throughout this eastern Afghanistan province. What they have is good, but there is simply not enough to go around -- not enough facilities, not enough doctors and nurses, and not enough medicine, Parris said.

The somber premises did not stop an enthusiastic female doctor from showing off the babies born in the past few hours. Four babies were lying in a dark room with their mothers who, for the visit, were fully covered in the traditional burkas or blankets.

The hospital delivers about 300 babies a month. It has only four delivery beds and eight post-natal care beds. At times, Parris said, babies have been delivered in the hall on mats on the floor. Because of the lack of space, mother and child are sent home within six hours of delivery, providing there are no complications.

In the outlying regions of this rural province, most babies are delivered at home by family members. Because of a lack of access to medical care and malnutrition and disease, the infant mortality rate here is 16 percent, and 20 percent of mothers die during childbirth. Of those children who survive, one out of five will not live to see their fifth birthday, Parris said.

A 6-year-old boy recently was brought to the local hospital with a bowel obstruction. The child weighed only 18 pounds when admitted. After surgery and regular feedings, the child was up to 24 pounds. But he had to leave the hospital. Luckily, Parris was able to find him follow-on care at a clinic in the northern part of the province.

Malnutrition, diarrheal diseases due to parasites and poor water supplies, and respiratory illnesses are common, especially among small children. Also, there are many burn injuries, because the villagers use wood and fuel stoves for heating.

"Things that in the states you wouldn't even think of are killing people here," Parris said. "And that's frustrating, but you really can't do much about it."

Health care is free here for those who can get to it. About 200 small health care centers or sub-centers are scattered across a province that is roughly the size of Rhode Island and is home to a half-million residents. These are rural facilities normally operated out of a home. Those working them have limited medical training and can treat only colds and coughs and the like.

Fifteen basic health care centers are scattered among the province's 14 districts, offering the bottom rung of basic health care. These are typically staffed by a doctor and one nurse or two midwives. They offer exams, vaccinations and can deliver babies.

Basic health care centers see as many as 1,000 patients a day, serving multiple villages. In the more rural areas, some patients walk as far as 15 miles for care. Because of the distances, many simply do not seek health care until it is too late.

"A lot of times, it's not going to happen because they have to work that day. If they don't work that day, they may not eat that night. So health care kind of goes by the wayside," Parris said.

There are eight comprehensive health care centers, each with two doctors and typically three midwives. And two district hospitals are staffed with a handful of doctors and a mix of a half-dozen nurses and midwives.

Parris has projects in the works that will double the number of health care facilities in the province. But even that, he said, is not enough.

Ground was broken for a new U.S. Agency for International Development-funded, $7 million, 100-bed provincial hospital last summer. It is expected to be finished in two years.

Also, the PRT is working to fund a $4 million midwife training facility with classrooms, dorms and a 50-bed maternity hospital all on the same campus. Midwives are a staple within the community medical centers. They currently attend a free, two-year training program with the agreement they will return to their districts to work.

Midwives help with family planning in the villages. They train pregnant women on the foods they should eat and monitor their health. Many pregnant women here are anemic because of a poor diet. They lack iron-rich foods, such as greens, broccoli and spinach, and suffer from protein deficiency because they don't eat enough nuts, milk and cheese.

To provide much-needed power to the medical facilities, the PRT is proposing a solar system for each. At up to $50,000 for each facility, the systems would provide basic power, leaving their existing generators as backups and all but eliminating high fuel costs.

There also are plans to buy 10 ambulances for the province for about $300,000. Three will stay in the provincial capital of Gardez City, and the rest will be pushed to outlying districts.

There is an extreme shortage of basic medicines, Parris said. The Afghanistan government doles out medicines to clinics based on population data gathered in a 2003 census. Parris said that census drastically understates the actual population, and he estimates that the clinics see as many as three times the patients for which the government allots medicines.

Every clinic in every village needs basic medicines, Parris said, from pain relievers to decongestants to blood pressure medicine.

The medicines are delivered quarterly and most clinics run out within a month of receiving its supplies. They can offer a prescription, but the high poverty rate makes it improbable that they will be filled.

A process is supposed to be in place for emergency resupply by the government, but Parris has spent the past few months here trying to work through the bureaucratic system.

"It doesn't seem to be working," he said.

Corruption within the system also is a problem with medicine delivery. Because a license isn't needed to sell them locally, medicines are an easy target for thieves.

Parris said it easily could be another decade before there is adequate medical care in the province.

He compared his efforts within the province to running a marathon, as opposed to a sprint. Rather than trying to complete projects during his nine-month deployment here, he instead is laying the groundwork for many that will not be finished, and the results realized, for years to come.

Parris is quick to point out, though with some prejudice, that while millions of dollars are going into local infrastructure, the province would be ill-served to ignore its most valuable asset.

"It's great to build roads. It's great to builds schools. But if you don't have people healthy enough to take advantage of those things, it's all for naught," Parris said. "By building the health care capacity and taking care of the people, the people can take advantage of all the things that we're doing for them."