Jim Holliman, M.D., F.A.C.E.P. Program Manager Afghanistan Health Care Sector Reachback Project

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

2. 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

3. AfghanistanHistory of Emergency Medicine (EM) • 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

4. Health Indicators in 2006 in Afghanistan • Some of the worst ever reported : • 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

5. 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)

6. 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

7. Child with burns in Indira Ghandi Hospital

8. Challenges / Obstacles to Afghan Healthcare Reconstruction : • Security : • 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. • Education : • 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 : • 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. • 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.

9. Challenges (cont.) : • Environment : • 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. • Culture / Demographics : • 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 : • 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 : • 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.

10. Health System Challenges in Afghanistan • Basic infrastructure not in place • Lack of depth in management and technical expertise at the Ministry of Public Health, and dependency on Non-Government Organizations (NGO’s) • Lack of data describing health status, knowledge, attitudes and practices

11. 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

12. Leftover reminder of prior conflict

13. Provincial Security Ratings

14. Many have been victims of land mines

15. 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

16. 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 %) !!

17. MoPH Healthcare Plans

18. Types of MoPH Basic Health Facilities Health Post Basic Health Center (Clinic) Comprehensive Health Center District Hospital

19. Capacity, staffing, equipment, medications available are each rigidly specified for each “level” by the “Essential Package of Hospital Services”

20. 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-e-Sharif, Heart, Gardez, and Kandahar • Many clinics allegedly built by U.S. A.I.D. do not exist or are nonfunctional or unstaffed

21. Entrance to the Gardez Hospital ER

22. Emergency room in Gardez Hospital

23. 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

24. 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.

25. 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

26. ANA National Military Hospital (NMH) in Kabul

27. Summary of Current Challenges for Emergency Medicine in Afghanistan • 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

28. 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

29. 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

30. QUESTIONS ? Thank You for Your Attention