Friday, January 29, 2010

My Afghan Introduction to Medicine

Najiba is ill with weeping infected blistering lesions around her mouth which should be easily managed with an antibiotic. I can only hope that the Afghan medic knows what to do. Her child looks even more ill. They have been waiting with forlorn patience for hours sitting on the ground outside the clinic in Laskar Gah in the desert heat of the Helmand Valley . As a medical student in 1962 working for the summer in Afghanistan, this is my introduction to medical deprivation.

The Afghan medic briefly looks at her and the child, writes a prescription on a piece of paper in Farsi and says, "next." As an observer collecting research data on infant mortality (continues at 30% within the first year of life), I feel so helpless.

Another mother on the way out begs me to look at her child's ear. An otoscope is produced, and I see a protruding black object from the child's left ear canal. Somehow with a hemostat I manage to remove a wriggling cockroach. One small thing accomplished but such a feeling of overwhelming impotence.

The child drinks water is from an open ditch. She has round worm (Ascaris) infestation in her bowels, a nearly universal finding in Afghan children who have no access to clean water. Immunizations are rare with smallpox common. In the late 1960's Peace Corps female health workers travel from village to village with an eradication campaign. Small pox disappears from Afghanistan but water born diseases remain.

Infant diarrhea and dehydration leading to death is all too common. Two ex-US Army nurses enlist as Peace Corps pediatric nurses in a Kabul Hospital. I watch them with disbelief. The child arrives sick, dehydrated and with a weak cry. He needs intravenous hydration but no IV fluids are available. Also not available are sterile needles, saline, or gloves. The nurses boil up a saline IV formula along with some reusable needles and 50 cc syringes. Bare handed they place their finger over the end of the syringe, pour in saline, attach a needle, and inject the saline into the infants left flank. They then repeat the procedure with the same needle, into the right flank. The infant is gently handed back to the mother who left with a glint of hope in her eyes, saying "Tashakor." (thank you).

A woman from a village 50 miles away is pregnant for the 8th time, having lost four of children to illness. But this time she is very ill, at term pregnancy, in labor yet having severe abdominal pain. The Afghan doctor says, "It's likely a ruptured uterus." The visiting American OB-GYN says, "No one could walk in with a ruptured uterus, it must be an ectopic pregnancy." At surgery, the uterus has indeed ruptured and the child amazingly survived. They explain to me that Afghan women lack Vitamin D, have no sun exposure, and lose calcium from breast feeding and multiple pregnancies. The bones soften and the birth canal narrows, leading to the obstetrical emergency and uterine rupture.

The young man lies on a charpoi bed in a remote village near Maimana in the north. His father pleads with me to come to his house and examine him. The young man is thin, a teenager, embarrassed and uncomfortable - possibly in pain. The father gently lowers the bed cover and I'm shocked. The left testicle is hugely swollen about five times the normal size. It is rock hard with similar hard enlarged lymph nodes in the groin. The cancer is obvious, even treatable. Again I'm helpless as a medical student. I write out the name of an excellent surgeon at Kabul's Avicenna Hospital and advise the father that some help may be available there. I told him I hope that his son does well. The father nods, and adds accepting his fate, "Enshallah." (Allah willing).

Comment: I returned to Afghanistan in 1965, a relatively peaceful time under King Zahir Shah. In the US Public Health Service assigned to the Peace Corps, I provided health care for the volunteers and did programming work for the volunteer health care workers. The Afghans were eager to learn English and improve their skills in many fields. Yet they were proud and naturally mistrustful of foreigners given their history. We were "non-believers". The stories of the British invasion and occupation in the mid 1800's were passed from generation to generation. They are a proud people, tribal, and independent. Yet we found them respectful and friendly with a quick smile.

I have great respect for the young Americans serving in the Peace Corps. These were the early days of the Peace Corps when Sargent Shriver was still the director. I still remember my interview with him and the huge picture of the Kennedy family hanging on his office wall - quite daunting.

Dysentery was a way of life for the Peace Corps there and bowels became the frequent subject of complaint and humor. There were amoeba, giardia, salmonella and, of course, worms.

An urgent call comes from a volunteer, "I've got worms, I've got worms."

"OK, it's OK. We've got really good medication to get rid of them. Come on in."

She replies, "But you don't understand!"

"What don't I understand?"

"It's only half way out!"

These round worms are often not a major issue and pretty easily treated. But they can enter the appendix or bile duct and cause acute obstruction - or even at times bowel obstruction.

We hear a lot about war injuries, but lack of basic medical care continues to be a huge problem. An Afghan doctor is trying to open a large outpatient urgent care center in Kabul, built with funds from the US military. But the local university medical graduates have very marginal training. 80% of them failed a very basic skills test and none of them had ever sewn up a laceration. There's a long road ahead, even after the violence ends.

1 comment:

  1. The desperation of life in Afghanistan and the obstacles facing medical personnel are probably as true today as in the 60's. Although there have been concerted efforts by various American and international agencies, the need remains great. Your experiences are written as though they remain vivid in your mind. They must have evoked strong emotional reactions in you.