Amid Death, A Model for Hope

In Afghanistan, a general can look like an angel of mercy

Christopher Scott

Acumen, Volume II, Number I

In Afghanistan's cities, it might as well be the 19th century; in the countryside, even earlier-at least, in terms of medical care. Hundreds of thousands of Afghan women, children, and infants will die unnecessarily this year. The death of so many seems anachronistic because, while epidemic and starvation are quite possible in this country, they will not, in fact, be the principal cause. The real culprit will be the lack of modern medicine, and that is perhaps the greatest tragedy. A sick infant dies of exposure in a mountain province with no electricity and no clinic; a woman bleeds to death in the back of a pushcart, 70 kilometers from the nearest hospital. The youngest Afghans die from cholera, diarrhea, dysentery, malaria, pneumonia, polio, and tuberculosis-opportunistic diseases that often follow chronic undernourishment. Thousands die at birth. Political instability is the handmaiden to the crisis.

Yet in the midst of what many call the worst health crisis for women and children in recent memory, a hero has emerged in the form of a former Afghan general. And in this country where men rule absolutely, the surprise is that this general is a woman and a former army surgeon. Sohaila Sediq, a Pashtun, is one of two female ministers in President Hamid Karzai's cabinet, and the only female general ever to serve in the Afghan army. She earned a reputation as chief of surgery for Kabul's Wazir Akbar Khan military hospital for saving the lives of soldiers and civilians during the rocket attacks of the '90s. When the Taliban took over the city in 1996, they prohibited all women from working, and ordered Dr. Sediq to leave the hospital. Within months, the regime realized it had lost the country's best surgeon and asked her to return to the 400-bed hospital, where she treated soldiers on both sides of the conflict, earning the respect of Taliban and tribal leaders alike.

General Sohaila, as she is known, began her work for President Karzai in early 2002, and her appointment as minister of public health has, by many measures, been providential for the women and children of Afghanistan. Dr. Sediq's ministry is small and streamlined, and contains only eight deputies and general directors, most with no government training.

The department's second in charge, Deputy Minister Ferozuddin Feroz, was also a military surgeon, but unlike his boss, he fought the war as part of the mujahideen resistance. Dr. Feroz is matter-of-fact when he relates his experience in the field: "I learned medicine from doing." He describes Dr. Sediq in respectful terms. "Her Excellency the Minister is a very decisive person because, after all, she is a military general," he says. "But she also seeks out advice. There is a lot of give-and-take between her and her senior staff-she is not afraid to make a decision."

Accolades have also come from such independent sources as Ron O'Connor, who has been working in Afghanistan for 30 years and is now ceo of Management Sciences for Health (MSH), one of the largest U.S.-backed nongovernmental organizations, or NGOs, assisting Afghanistan's reconstruction. The minister, he says, is "a forceful woman, deeply committed to improving public health."

That is vital, because the true dimensions of Afghanistan's crisis, as revealed through epidemiology, are enormous. The Lancet has tracked child survival in the developing world for many years. According to a study published last year, 250,000 Afghan children under five years old died in 2000. Afghanistan ranked fourth in child mortality. It is no surprise that among the top ten countries listed in the study, nearly all are currently or have recently been at war.

Afghan women suffer almost as much as Afghan children. Seventy thousand new cases of tuberculosis are expected next year, and of those, about 70% will be in women, double the worldwide incidence. Overcrowding and malnutrition contribute to markedly low body weight in women of childbearing age in Kabul. Tradition compounds the health problems-Afghan women are often confined to small, poorly ventilated sections of the house that are filled with smoke. The country's socioreligious underpinnings discourage adequate health care for most women, and prenatal and neonatal care is nearly absent; as a consequence, the death rate for women is among the highest in the world. The life expectancy for Afghan women is 44, but if present conditions prevail, a female born today will live to only 36.

Childbirth is riskier than many deadly diseases. In the northeastern province of Badakshan, one mother will die for every 15 Afghan babies born. Social pressures on women to bear children means there is little family planning. The World Bank estimates that the average rural family has seven children, not including miscarriage or infant death. The true number of pregnancies over an Afghan woman's short lifetime will number in the double digits. The United Nations estimates that more than 1.1 million Afghan children will be born this year, a staggering birth rate for a population of just 23 million.

Decades of conflict have destroyed the public health system in Afghanistan and scattered physicians and other health professionals to neighboring Iran and Pakistan. Many made their way to the West to practice medicine on safer shores, and today Afghanistan counts only 1 physician for every 50,000 people. Measuring the traumatic stress of war and disease in the country, a unicef study found that 72% of children have lost one family member, and two-thirds have seen a dead body; worse, there are only eight psychiatrists in the entire country. The International Monetary Fund reported in September that opium accounts for half of Afghanistan's gross domestic product, and while most of the opium is exported, the incidence of drug abuse is growing. To compound the malaise, hiv infections are on the rise.

No-nonsense management

By all accounts, Dr. Sediq's bureau has made significant headway in its first year. In September, a Lancet editorial reported that the ministry of health had vaccinated 11 million children against measles in 2002, stopping a disease that killed 30,000 children under the Taliban. One of the biggest challenges to any postwar reconstruction is managing the welter of agencies and resources sent to aid the country. Amid the great confusion about who should be doing what, and where, the ministry developed a no-nonsense strategy for dealing with the relief efforts. One year ago, it asked the msh to survey every community health facility in the country. Results revealed that of the 1,100 locally supported facilities extant, many were run by international aid agencies that had stepped in during the long years of conflict. Once the inventory was done, the government was better able to distribute resources at the central, provincial, and state levels. The government now requires every agency to submit a contract describing in detail the services needed and the commitments required. Dr. Feroz says the contracts have added a much-needed level of discipline to the effort. "During the war years, these agencies operated quite freely and had little government oversight," he says. "Now we are readjusting their services to make sure that we get the maximum benefit from minimum resources."

Vaccinations and tough management are necessary and straightforward steps to mitigate Afghanistan's crisis. Difficult challenges remain for Dr. Sediq and Dr. Feroz, and solutions probably won't emerge anytime soon. Like unicef and the World Health Organization, the ngos have used their substantial budgets to lure trained physicians to Afghanistan. But the new workers command salaries that, in some cases, are 20 times higher than that of the local professionals, causing all sorts of tensions. While Dr. Feroz maintains that his staff has standardized the salary scale and promised hardship pay to doctors in remote areas of the country, some physicians on the ground have yet to see the effects.

Everyone agrees that training new health care professionals must take priority. There is no central system of medical training or education, and in much of Afghanistan, tradition dictates that women can be seen only by female doctors. Dr. Feroz believes this is the biggest challenge he faces. "The Taliban forbade women from working and going to school," he says. "It has left a huge number of uneducated young women. We must address the shortage of midwives and community health workers with fundamental training in health care."

Awaiting a renaissance

The uncomfortable reality is that window dressing is sometimes required to raise international awareness. To great fanfare, Secretary of Health and Human Services Tommy Thompson and Secretary of Defense Donald Rumsfeld reopened the Rabia Balkhi women's hospital in Kabul with President Karzai in April 2003 after a six-month renovation. Nafisa Abdullah, an Afghan expatriate, women's physician, and member of the executive committee of the Afghan Medical Association of America, went to the opening and stayed for a month to help train local doctors. Once the ribbon cutting was over, she was stunned by what she saw. Rabia Balkhi delivers between 60 and 80 babies per day, and many women presented with complications, including postpartum hemorrhages and ruptured uteri. The obstetrics unit had only three birthing tables, so many mothers delivered on the floor. According to Dr. Abdullah, even Kabul's public health infrastructure was under water. "To say that Rabia Balkhi is a model of postwar reconstruction is wrong-in fact it's the worst model imaginable," she says, her frustration apparent. "The local physicians are burned out, inured to dying, lacking compassion after so many years of war. Days would pass before I would see a female physician. There were no sutures, no bulbs to suction the newborns, not even a rubber band to start an iv!"

Dr. O'Connor sighs impatiently when he hears stories from expatriates confronting the harsh realities of a health care system ravaged by decades of war. "Short-term solutions address short-term problems," he says. "Expatriates can't solve this problem. Doctors can't solve this problem. Only hard, patient work will get this done."

In the meantime, Dr. Feroz is taking the long view, too-setting his sights on 2006. Health care, such as it is, is free in Afghanistan, and most international aid will run out in three years. That's a very short time in which to rebuild a nation's health care system. "After we develop basic services with lower-cost interventions, such as maternal, newborn, and child health, immunizations, public nutrition, disability, and a reliable supply of basic drugs," he says, "we will have the greatest opportunity to make our health system sustainable. Introducing fiscal responsibility through a revolving fund or cost recovery is the best way to do that."

There is a clear-eyed pragmatism at work in Afghanistan that is hard to miss. Dr. Sediq and Dr. Feroz just might manage to get the job done.