Transcript Slide 1

The Role of Emergency Medicine
in Healthcare Reconstruction in
Afghanistan
Jim Holliman, M.D., F.A.C.E.P.
Program Manager
Afghanistan Health Care Sector Reachback Project
Center for Disaster and Humanitarian Assistance Medicine
(CDHAM)
Professor of Military and Emergency Medicine
Uniformed Services University of the Health Sciences (USUHS)
Bethesda, Maryland, U.S.A.
Clinical Professor of Emergency Medicine
George Washington University
June 2010
The Role of Emergency Medicine (EM) in
Healthcare Reconstruction in Afghanistan :
Lecture Objectives
Review the current status of EM in Afghanistan
Point out difficulties with EM development in
Afghanistan
Present current and planned efforts at EM
development in Afghanistan
Stimulate interest in additional development
assistance for Afghanistan
Afghanistan
History of Emergency Medicine (EM)
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Not yet a recognized or developed specialty
German-Turkish influence prior to 1970’s
Then Russian system 1970’s to 1990’s
Under Taliban rule 1996 to 2001 almost complete
dissolution of the health care system
• Healthcare delivery mainly by Non-Government
Organizations (N.G.O.’s) after 2001
• U.S. system influence since 2001, particularly with
the Afghan National Security Forces (A.N.S.F.)
comprised of the Army National Army (A.N.A.) &
Afghan National Police (A.N.P.)
• No focused EM training programs yet
Health Indicators in 2006 in
Afghanistan
• Some of the worst ever reported :
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Maternal mortality 160 / 1000
Under 5 years mortality 230 / 1000
Under 5 years malnutrition 54 %
Iodine deficiency 51 %
Life expectancy 43 years
Lifetime births per woman 6.8
Access to safe water
• 80 % urban (?)
• 10 % rural (?)
Note that in rural Badakhshan province a
woman has a one in three lifetime chance of
dying from pregnancy
Disease Burdens in Afghanistan
• 60 % of deaths in children are from diarrhea,
respiratory infections, and vaccine-preventable
conditions
• Tuberculosis
– 15,000 deaths per year
– 70 % of cases are women
• Malaria
• Narcotic abuse
• HIV (incidence uncertain due to lack of testing)
Trauma in Afghanistan
• No centralized tracking of cases
• Over the past year:
– > 2500 civilian deaths from the war
– > 1500 ANP deaths
– > 500 ANA deaths
• U.S. military deaths now > 1000 since 2001
• Increasing highway accidents due to increased
traffic and road expansions
• Recent 200 deaths from snow avalanches
Child with burns in Indira Ghandi
Hospital
Challenges / Obstacles to Afghan
Healthcare Reconstruction :
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Security :
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Education :
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The ongoing dangerous security situation :
large areas of the country affected by suicide bombers, improvised explosive devices, direct attacks by
heavily armed paramilitary units, landmines, and criminal activities including the extensive trade in opiate
narcotics and kidnappings for ransom.
direct targeting of healthcare facilities and personnel, teachers, and other aid workers by the Taliban, with a
number of facilities bombed and a number of personnel murdered simply for attempting to provide
healthcare or for teaching.
The almost complete lack of education for females (particularly nurses) for the 5 years of the Taliban’s reign.
The lack of educational standards and accountability at Kabul Medical University and the other medical
schools in Afghanistan during the Taliban reign.
The complete lack of training programs in many of the Allied Health fields.
The “brain drain” of numerous professionals emigrating to other countries (and not returning to
Afghanistan) to escape the warfare or the repressive regime of the Taliban.
Infrastructure :
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The major damage or outright destruction of almost every healthcare facility and most of the education
facilities in the country as of late 2001 due to the preceding many years of indiscriminate warfare.
The Russian / Communist dominance of the healthcare and education systems in the 1970’s and 1980’s, with
resultant limitations in business and banking systems.
Poor road network and complete absence of railways.
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Unreliable electric power supply in most parts of the country.
The prevalence of corruption in the government and police.
The lack of an effective judiciary.
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Challenges (cont.) :
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Environment :
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Culture / Demographics :
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Tribal and ethnic rivalries exacerbated by the practice of carrying on “blood feuds”.
Tribal practices which greatly limit the activities of females.
The large numbers of internally displaced refugees and returning refugees from Iran and Pakistan.
Vital statistics (births, deaths, etc.) are still not uniformly reliable across the country.
Communications / Technology :
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The extensive deforestation and destruction of agricultural systems during the years of warfare.
“Difficult” geography, with an arid south and a mountainous northeast, with limited sources of fresh water in
large areas.
“Difficult” weather, with a prolonged multiyear drought in the last decade, and severe cold and heavy snowfall
the past several winters.
Lack of widespread skills in using computers.
Lack of telephone landlines. Fax capability virtually non-existent.
Lack of widespread knowledge of English.
Use of two languages (Dari and Pashto) throughout the country, requiring many courses and educational
materials to be translated into both languages.
Money / Economy :
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The poor state of the economy and the lack of economically productive industries.
Most of the surrounding countries also have relatively poor economies.
The Afghan national government is largely dependent on outside funding from Non-government organizations,
the United Nations, other international organizations, and other countries.
• There is poor coordination of efforts between all these outside organizations.
Salaries of most government workers (including physicians) are too low for a reasonable standard of living.
Health System Challenges in Afghanistan
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Basic infrastructure not in
place
Lack of depth in management
and technical expertise at the
Ministry of Public Health, and
dependency on NonGovernment Organizations
(NGO’s)
Lack of data describing health
status, knowledge, attitudes
and practices
More Challenges for Development in
Afghanistan
• Inaccessibility
(geography, climate)
• Security
• Ethnic and culture
diversity
• Balancing tertiary care
and primary services
• Donor / partner
coordination and
collaboration
Leftover reminder of prior conflict
Provincial Security Ratings
Many have been victims of land mines
Administration of Emergency
Medicine in Afghanistan
• Full service E.D. for U.S. military at Bagram and
several other NATO (ISAF) military hospitals
• Emergency departments in regional hospitals and
several hospitals in Kabul
• District hospitals and community health centers
have emergency rooms
• Staffing by G.P. or other specialty physicians
• No trained administrators
• Medical logistics systems just starting for A.N.S.F.
and essentially absent for other facilities
Funding of Emergency Medicine
in Afghanistan
• Afghan constitution guarantees free “Basic Package of Health
Services” to all citizens
• The “Essential Package of Hospital Services “ (EPHS) specifies
hospital staffing & equipment
• Virtually all current E.D. funding is from U.S. military (for
A.N.S.F. facilities) and from N.G.O.’s, the U.N., World Bank, and
European Commission for civilian facilities
• Afghan Ministry of Public Health (MoPH) has almost no sources
of direct income
• CURE Hospital in Kabul is fee for service (sliding scale $) with
some charity care
• Unfortunately the country’s major source of income at present
is opium (the world’s largest producer, > 90 %) !!
MoPH Healthcare Plans
Types of MoPH Basic Health Facilities
Health Post
Basic Health Center (Clinic)
Comprehensive Health Center
District Hospital
Capacity,
staffing,
equipment,
medications
available are
each rigidly
specified for
each “level” by
the “Essential
Package of
Hospital
Services”
Patient Access to Emergency
Care in Afghanistan
• Not good for most Afghans
• Kabul has 10 hospitals providing emergency
care, but civilians do not have access to the
National Military Hospital
• New regional military hospitals in Mazar-eSharif, Heart, Gardez, and Kandahar
• Many clinics allegedly built by U.S. A.I.D. do
not exist or are nonfunctional or unstaffed
Entrance to the Gardez Hospital ER
Emergency room in Gardez Hospital
The Emergency Medical
Transportation System in Afghanistan
• U.S. and the International Security Assistance Force
(I.S.A.F.) have ground & air ambulances, but just for
I.S.A.F. troops
• Kabul has 13 ambulances run by Norway N.G.O.
• 700 ambulances & 2 helicopters purchased by U.S.
military in March 2007 for A.N.S.F. combat casualty
evacuation and are starting to be distributed
• Very poor roads in much of the country make
ambulance access and transfers difficult
• Concept of referral system is nonexistent
• As per the E.P.H.S., defibrillators will only be available
at the regional hospitals
Afghan Physician Training
Challenges
• 8 medical schools, most without
hospitals.
• 7 years after high school (includes
“college”).
• Variable entrance requirements.
• Variable objectives and
requirements for graduation.
• Limited exposure to patients.
• Standardized curriculum but
lacking in qualified professors.
• Seventh year clinical rotations.
• Rotating Internship of 1 to 2 years.
• Can wait years for selection to
specialty training.
Current EM Training in
Afghanistan
• No EM residency
– Proposed for the National Military Hospital (NMH)
but no faculty yet
• Emergency Trauma Care Course presented in
2008 and translated into Dari
• Inconsistent assignment of military EM
mentors to the NMH and the 4 regional
hospitals
ANA National
Military Hospital
(NMH) in Kabul
Summary of Current Challenges for
Emergency Medicine in Afghanistan
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Everything !!!!
Lack of supplies and equipment
Lack of trained physicians and nurses
Lack of integration of healthcare for
A.N.S.F. and MoPH beneficiaries
• Gender care issues
• Poverty and illiteracy
• Security
Future Development of Emergency
Medicine in Afghanistan
• The CDHAM Reachback Project will hopefully help the
U.S. Command Surgeon’s office to coordinate broad
healthcare system reconstruction efforts
• Some Afghans can train in other countries’ EM
residency programs (? Iran, Turkey, etc.)
• Focused short term courses in EM for the current
practitioners
• Mentoring by military medical personnel
• Exchange programs for trained personnel
• Longer term : national society and certification
EM in Afghanistan :
Lecture Summary
EM is still at a very rudimentary development stage in
Afghanistan
EM is certainly needed and applicable to
Afghanistan’s epidemiology
Despite the current security situation, the future for
EM development in Afghanistan appears bright,
although development will be slower than in other
countries
QUESTIONS ?
Thank You for Your Attention