Afghanistan Briefing

Dr. Peter VanDyck: Good morning. Well, I have the privilege of talking to you and sharing with you a few thoughts about Afghanistan. Many of you have asked me about it and I do like to talk about it and share with you the challenges that we're feeling. I wonder if I can have the lights down a little bit because there are a few pictures here and they show much better if the lights are dimmed. Rabia Balkhi is the name of the hospital where we're working in Kabul, Afghanistan. Rabia Balkhi was a woman poet, a Sufi poet, from about 1,000 years ago and the name of the hospital, obviously is her name. Secretary Thompson visited Afghanistan a little more than a year ago. He was very moved, extremely moved, by the infant mortality and the maternal mortality and by other things he saw. There are no vital records in Afghanistan, there are no birth certificates, there are no records of births.

So the only way to do an infant mortality study or maternal mortality study is by live interviews of a certain geographic area and just historically querying every family, if the mother died and was it related to pregnancy or if a baby has died in the first year of life. CDC did this and the maternal mortality rate in a couple of the rural areas of Afghanistan were the highest every recorded in the world: 6,500 per 100,000 live births. And for those of you who know the United States' rates, it's around 9 or 10 per 100,000 live births. So 6,500 is clearly very high. And in the Kabul area, the biggest City--Kabul probably has three million people now--the maternal mortality rate was around 500 to 600 per 100,000 live births. The infant mortality in the country is around 160 per 1,000 live births. And again, we know the United States' rate is 7.0, or 6.9 or 6.8.

So clearly there is a need for something related to maternal and child health to improve access to care, the level of care, the content of care, and anything else associated with care. Secretary Thompson then said, "I want to demonstrate the ongoing commitment of the United States to reconstruction efforts for the Afghan government and to help President Karzai reconstruct Afghanistan." He wanted to provide direct high-quality health care to the Afghan maternal and child health population. He wanted to provide opportunities to train local Afghan health care workers in modern maternal and child medicine. And he wanted to provide a situation for EXPAT Expatriate Afghan Health Workers to return to Afghanistan, whether they be in the United States, in England, in Pakistan as many are. Somehow providing a vehicle for them to return and help improve the maternal and child health situation in Afghanistan.

I led a team in December last year to begin exploring what might be possible and clearly this was a partnership. A partnership between the United States are among them, the Department of Health and Human Services, NIH, CDC, HRSA and others, the Department of Defense and Secretaries Thompson and Rumsfeld had many discussions between them about how the Civilian Affairs Units in the Department of Defense could help in this reconstruction effort, and clearly the Ministry of Health in Afghanistan. So this was a partnership, an exploration, to try to help the Secretary fulfill his dream and commitment to President Karzai of trying to improve maternal and child health in that country and what would be an appropriate way to do that. Afghanistan is an interesting place.

When I went in December, I went on a military aircraft, fly from Dubai, United Arab Emirates, or actually I flew from Oman in the United Arab Emirates on a C-130 plane strapped into the side with the marines in full gear. At that time security was a little unsure in Kabul and so every place we traveled we traveled in a bulletproof SUV with a Humvee with machine-gunners in front of us and a Humvee with machine-gunners in back of us, being fairly obvious about where we went, clearly. And you wondered if that wasn't inviting as a target perhaps. We also wore the bulletproof vests that you see soldiers wearing. So that's how we went from appointment to appointment.

And obviously trying to assess what the situation is and how we can help, you're going to visit the ministries, you're going to visit the medical school, you're going to visit the hospitals, you're going to visit AID, and WHO and UNICEF and all these other agencies, and so you're really out most of the time. We stayed on a secure, Department of Defense compound, went out for appointments, came back when the appointments were over and didn't travel out at night and didn't frequent any restaurants or anything else in Afghanistan. So security was fairly tight and our travel, although not limited, was precise and circumscribed. Since then, we've relaxed a little bit.

And since there've been several car bombings and suicide bombings in Kabul over the last six months, there've been two or three against military targets, I've chosen not to travel with the military and to travel in an unmarked car or travel in a car that has a NGO-type label on the side. Kabul seems to be a relatively safe place. I'm going to show you a few pictures here. Rabia Balkhi Hospital, and I'll tell you some statistics in a minute, is an old hospital, sketchy plumbing, sketchy electricity, sketchy equipment, sketchy inventory and it was chosen as the hospital by the Ministry of Health that we should work in as the United States and recognize that there are many other countries helping reconstruct Afghanistan and basically other hospitals were already assigned and so this was the hospital that was chosen for us.

It's the only comprehensive women's health hospital in Afghanistan. Comprehensive because it does deliveries, but it also has ENT, general surgery, internal medicine, dermatology, and other services for women only. It's a women's-only hospital. The only other hospital comparable to it in Afghanistan is a delivery hospital, only for women's deliveries. It does not offer other services for women. So the Department of Defense remodeled Rabia Balkhi Hospital, stripped it, put in new plumbing, cleaned the pipes, made it serviceable to a point within an old structure. And that was finished in April and in order to reopen there needed to be a ribbon cutting. And so Secretary Thompson traveled again to Afghanistan for a day to rededicate this hospital after the remodeling.

And you can see Secretary Thompson in the middle of the picture, the United States Ambassador Finn, is on the left and the woman is General Sediq, who happens to be the Minister of Health. She's a surgeon. The other people are typical nurses or people that would work at the hospital. One of the things that was built into the remodeling is a daycare center and it's a daycare center for the employees' kids. And a whole top floor of a building was remodeled to take these kids, because this is looked at as a help in getting people to the hospital. I have to tell you that the pay for a physician in Afghanistan is about $30 a month, for a government physician, someone employed by the government, which all workers are who work in hospitals because all hospitals are run by the Ministry of Health. The pay for the nurses at the hospital is $30 a month.

The pay of the physical therapists at the hospital is $30. The pay of the cleaning lady at the hospital is $30 a month. Well, you can quickly see that there's a fairly unique payment structure here and that everybody in every hospital gets $30 a month. The Chief of Nursing gets $30. The Director of the Hospital gets $30 a month. So providing daycare for the kids is clearly a benefit that helps people go into government service and want to serve people because of the low pay. We had a meeting with President Karzai and he was very supportive of the project, very interested in it and a very nice exchange. This is in President Karzai's palace and in his meeting room.

Let me tell you a couple things about Rabia Balkhi Hospital. Women's Hospital in Kabul, I talked about its comprehensiveness, 36,000 patients per year, about 13,000 deliveries per year, maybe a few more. It was about 40 per day. This was before the remodeling. Shortly after the remodeling the other hospital closed for remodeling and we were delivering up to 100 to 110 babies a day for a period of a couple of months. And if you think conditions were poor before doing 40 deliveries a day, that really stretched things to the extreme. Now we're back down to about 40 to 50 deliveries a day and while that's a lot, it's a relatively comfortable amount for the staff and the facilities at the hospital. There are about five C-sections a day and about 88 other general-type surgeries a day, non-pregnancy related.

And from the best of the numbers we can collect, there are about 500 each of complications of pregnancy related to preeclampsia, placenta previa, abruptio placentae, and fetal deaths each year. With 600 maternal deaths per 100,000 deliveries, and if there are, say, 15,000 deliveries here a year, that's about one-seventh of 100,000. So that's one-seventh of 600 or even 700. So that means in this hospital alone, you may have 80 to 90 maternal deaths a year. That's like a maternal death every three or four days. That's like two maternal deaths a week. I mean this is serious. I mean these numbers add up very, very quickly. And, of course, the complications are on top of that. About 400 patients screened each day in the outpatient department, and I'll show you what that looks like in a minute. There are about 140 physicians on staff. About 60 are obstetricians, and of those 60 who are obstetricians, 13 are attendings and about 50 are in training somewhere in the residency training, which I'll talk about in a minute. Twenty-three nurse midwives and here's some of the hospital.

Because it's a women's hospital, a women's hospital only, men drop off their women, sisters, mothers, partners, wives, at an entrance to the hospital. This is before remodeling and you can see this is an alleyway leading into the courtyard in the middle of the hospital. It comes off a very busy street. And this is the waiting area for entrance into the Outpatient Department and you can see the tarp over the top. After remodeling, this became a corrugated iron roof, which was much more solid. But the men here drop the women, who then go through a gate that's guarded into the entrance of the hospital and they wait for however long it takes for the women to be seen. If it's for a delivery, they wait for the delivery; the woman stays usually three to five hours and then goes home.

This is then entered under that tarp with the men in the back of the picture here and these are the women waiting then to get into the Outpatient Department. And if you look on your right there's a door where women can enter into the Outpatient Department from this exterior alleyway waiting area. Women, when they come to the hospital, there may be some men inside this hospital. There are some men physicians, although not many, there are other men who do other tasks in the hospital, usually cover their face with a burka. The burka usually is blue, like you see in most of these women, and covers the head and face completely. There are women, as you see on your lower right, who use the burka as a scarf, and there are other women, as you can see dressed. On the street now in Kabul, probably 75 to 80 percent of the women wear the full burka and the other 20 or 25 percent don't.

You'll see the employees of the hospital here shortly and how they dress. This is inside the waiting area for the Outpatient Department. This was remodeled by the Japanese. This is a very small room, 400 patients a day. It's very crowded and needs much improvement in patient flow, level of triage and other equipment, level of people who are giving care in the Outpatient Department, but this gives you feeling for what it looks like. There are six examination beds in two separate rooms for this Outpatient Department. This is the leadership of the hospital. The woman in brown next to me is Dr. Nazarene, she is an Obstetrician. She is the Director of the hospital. In pink next to her is Dr. Marion.

She's an Obstetrician and she's the Assistant Director of the Hospital. You can see me in my flack jacket and Dr. Samay on the right is the Chief of Obstetrics and is the Dean of Obstetrics and has taught almost everybody who's an Obstetrician in the hospital and in Afghanistan for that matter. This is typically how they would dress during a hospital day. This is a c-section suite. This is before remodeling. It looks about the same after remodeling, except that blank place in the wall now has an air-conditioning unit, there are new lights, there's a new table, but this gives you a feeling for how that looks. This is one of the OR Nurses. And this is an isolate in the nursery from a picture from our first visit. You probably can see three babies there in this isolate.

The two small ones back-to-back are a set of twins from one mother, and the other baby is another baby from another mother. And they had two working isolates when we started and with 40 deliveries a day, or 50 deliveries a day, had enough small babies that they needed two or three in each isolate. That's now improved and the nursery looks much better and there are more isolates and it doesn’t happen too often that we get babies from multiple families in the same isolates. Mothers breastfeed. All mothers breastfeed. The nursery takes care of small babies, but not to park babies. Babies who are sick get moved to a tertiary level hospital, and I'll show you that in a minute. These babies are here staying warm. The twins who were delivered are a little small, but will go home with the mother probably in a day.

Most mothers, as I say, stay three to five hours and then go home. Well, this gives you some of the pictures. Now, what were the unmet needs that we discovered? What are we going to eventually do here? Training obstetricians and gynecologists is a primary unmet need. The attending physicians, the attending OB's at this hospital have not had a refresher course since the Russians were there. And the Russians invaded I think first in 1979 and 1980. So for 20 years, the obstetricians and gynecologists have not had any refresher courses. As we tried to find the residency curriculum, the postgraduate residency curriculum that all those residents were being trained with, we couldn't find it.

There is no postgraduate residency curriculum for any specialty, let alone Obstetricians, in the country. And so if we think we're going to go train Obstetricians and gynecologists, it's not a matter of taking something that's already there and teaching it, it's creating something from the very beginning. The residents' training came from these obstetricians who were attendings who had never had postgraduate training in obstetrics. So it was clear that we needed to upgrade the knowledge and skills of the existing attending staff at this hospital, as well as other hospitals, but this hospital was our primary concern, and we needed to create a postgraduate residency training program and obstetrics is an unmet need, or creating one certainly was an unmet need. But training were not the only needs. You can't train in modern medicine in a facility that isn't equipped and doesn't have much lab, and doesn't have much infrastructure, and doesn't have much inventory.

There are no medical records in the hospital. Medical records because there's no paper. This is for real. When they open a pair of gloves, they pull out the paper insert, turn it over to the blank side and use that as a medical record for a patient because there's so little paper. So basics. No medical records, the labor and delivery log, sketchy. Every baby weighed 2,500 grams. You know why? That's about 2,500 grams. And when the baby was small, they all weighed 1,500 grams. That's about 1,500 grams. So people are concerned and care, but they're just the basic things that you expect to see, to build upon, aren't there. So clearly remodeling and upgrading the hospital is important.

One of the things that's happened the hospital is remodeled, it looked fairly good, but with the crunch of deliveries and I think with the quality of materials used, some of the remodeling is beginning to fail and some of the sinks are not working well, some of the plumbing is not working well, and we're back to the point of having to put major effort into keeping the hospital maintained and keeping it clean. Upgrading of c-section suites, equipment, laboratory, pharmacy, x-ray, teaching supplies, library. People reuse gloves and wash them because they were afraid if they changed gloves between every patient, that there wouldn't be enough gloves tomorrow.

How do you teach people to use gloves every day? Well, first you have to have a supply. Upgrading laboratory. All the laboratory is reagent based, there are no machinery in the laboratory. Hand blood counts, hand gram stains, bilirubin, total blood counts, blood sugar, creatinine, those are some of the basic tests that are done. Pharmacy, fairly well, stocked pharmacy. X-ray, two portable machines. Teaching supplies, there were no modern books in the library of this hospital of any kind. There were no computers, there are now, and nobody knew how to use a laptop computer, basically. So we're really working with no infrastructure.

Teaching, training on and maintenance of equipment and supplies, some equipment is being donated, sonogram, new x-ray, laboratory equipment, but there is no biomedical engineer in Afghanistan and so how do you get it fixed? How do you maintain it? So out of all this, and after several visits, we arrived at specific goals to meet the Secretary's need. One was to develop a postgraduate residency training curriculum in obstetrics and gynecology for the country of Afghanistan. And then, secondly, to take on teaching this postgraduate residency program for one full cycle, four years, at Rabia Balkhi Hospital to about those 50 residents that are there.

And hopefully, it would be incorporated into the training at the two other major hospitals that train obstetrical residents. So this became then the specific goals of the project after two or three months of assessing. So this is what we are beginning to undertake. So how do we begin? Well, in May we began. We said we need to refresh the obstetric attendings' knowledge and skills in OB by, originally it was a three month refresher course, we quickly realized after two months that we couldn't do it in three months and the knowledge was so basic it would take us a year to bring the practice of the attending anywhere near able to teach even first-year Residents, and anywhere near the practice of modern medicine. And so we've committed now to doing refresher training for a year for the attendings.

Long-term postgraduate training and English language training. They quickly determined they wanted teaching in English, they wanted the textbooks in English, and in order to do that, they needed English classes, particularly medical English classes. The attending Physicians speak English fairly well, some obviously better than others. The Residents speak less well. They read fairly well, but they speak it less. And then to recruit United States faculty to do this, or expatriate faculty from the United States or Pakistan or wherever, but people who are teachers, who've been professors, who are Board Certified in these different areas. And we felt the team needed to include a couple obstetricians, a pediatrician or a pediatric nurse, a family practice physician, an anesthesiologist, a nurse midwife and a hospital administrator, or certainly some combination of four or five of these people as a team.

And that we would try to rotate them every two to three months in Afghanistan practicing, teaching, modeling, demonstrating and upgrading the practice of the hospital. You might add, why a hospital administrator? Maintenance, inventory, supplies, medical records, everything that makes a hospital run needs help. This is teaching at the hospital. During the remodeling a teaching room was created. These are the nurses and physicians now learning from PowerPoint. And this is what the nurses and physicians look like. You can't tell a nurse from a physician, they look the same, they dress the same, they now have nametags so you can tell, so we can tell, who's who. But in these sessions, there are 50 to 60 who come for these teaching sessions. Time lines.

We began the project in May 2003; we're doing ongoing teaching of the attending until summer 2004. In October 2003, this year, and I just came back a week ago, we are beginning to teach Residents not the major postgraduate curriculum, but a couple of times a week to begin to upgrade their practice. Between October this year and June next year, we will be writing a postgraduate curriculum for obstetrics for a four-year training program and get the appropriate approvals through the Ministry of Health and we hope in September 2004, to have the attending physicians' knowledge and skills upgraded enough that they could at least teach first and second-year residents and our United States faculty would begin teaching the existing third- and fourth-year residents the new curriculum and we've committed to Rabia Balkhi Hospital.

I'm going to show you a few more pictures, give you a few more things about the challenges, and then we'll have some time for questions. We need to clear this room by 11:45 for lunch. This is a street scene now in Kabul. There are cars everywhere, there are old taxi's everywhere, there are donkey carts and there are bicycles everywhere. You can see men and women mixing. You can see the women with burkas; you can see some women without burkas. There's hustle and bustle everywhere. People have wonderful spirit, wonderful energy. There is reconstruction going on all over.

There are stalls, open shops along both sides of the road on almost any road you go on. And if you're in a convoy or a small convoy or moving in a military vehicle, you can see you don't move very fast. And so it's concerning for the people who so security. A typical street vendor. He's got a cup of tea; he has his pedaling shoes. You can see the shops in back pedaling fresh beans, legumes, peas, potatoes, and there's really a hustle and a bustle and an energetic approach to things. This is the tertiary level Children's Hospital where sick babies go from our hospital. And I'm just going to show you a few pictures, because we're a clinical group or a health-related group, a few pictures like this.

There is a tension between trying to keep the babies at the hospital where we are and referring them to the Children's Hospital because the tertiary Children's Hospital's facilities are no better than the hospital where we are. You have to recognize there's no infrastructure, there's not enough money to equip the hospitals appropriately. Although they're well-trained pediatricians and neonatalogists at the Children's Hospital, they lack supplies, they lack freshness in supplies, they lack some drugs and they lack equipment. So they do the best they can and there are countries that are helping and things are improving, but it's very difficult. It's also very difficult to know what your infection rates are.

Women go home very early, babies go home with the women and if they come into the other hospital and there are no records, how do you know what your post-delivery infection rate is and if babies are really surviving when they go home. So these are all issues we're trying to deal with, but it's tough. This is a baby, it's a newborn that came back after a day, after being sent home. You can see, I think, from the baby's face that she's dehydrated, she's off-and-on on an IV, she has sepsis, she's not doing very well. This room is the size of a regular small office and there are six to nine babies in this room. The mothers tend to care for the babies and hold the babies, even if they have IV's and the medical personnel come and care for the baby in the mother's lap. Another baby in the same room. This baby had the same thing, sepsis, following a delivery for a day or two.

These mothers both have infections, as well, postpartum infections and are being treated. There are two babies in this picture and they're both receiving oxygen from the big tank. We have one baby in the mother's lap and another baby under the oxygen hood. And there's actually a third baby being held by the mother in the purple scarf and purple shawl to the right of the screen. There is no oxygen concentrator at this hospital, there wasn't when we began. This is the Children's Hospital again, the oxygen is coming straight from the oxygen tank and into the cannulas for these babies. These babies also had neonatal conditions, which necessitated them being in this newborn neonatal nursery. This is the tertiary level neonatal nursery for Afghanistan and for Kabul.

These babies are just a little older and, again, you can see the multiuse of the bed. There are three babies on this bed, three mothers lined up caring for their three babies. Mothers are very concerned. The staff is very concerned. And it's really kind of disheartening to see for lack of equipment, and for lack of coordination, and lack of facilitation, and lack of infrastructure that babies clearly don't do as well, as they could with the implementation of some very simple things.

This is a brand new outpatient clinic. And this is a bright spot. This is a brand new clinic. It's built by one of the NGO's that we're working with. It's just on the outskirts of Kabul and this is where mothers go if they may have delivered at our hospital or another hospital in Kabul and then they move to the outpatient MCH clinic for their follow-up care. Here they're lined up outside, waiting to go in. It's a nice day; this was in May. They're lined up with their babies to either have a postpartum visit or a well-baby visit in a fairly well, built and fairly well, equipped clinic. They also get health education.

These two babies are very healthy and bright and alert and are coming in for immunizations. You can get a nice picture here of how the burkas look and how the mothers dress. I have to say the people are extremely attractive, despite terrible conditions they're relatively clean. The babies have great spirit, the kids are wonderful to work with, they have great spirit. There's a toughness and a resilience in the people that make it very comforting to work there. But the conditions are an extreme challenge. Again, the brightness of the eyes, the resilience of the people, the spirit in the people I think comes through in a picture like this. And again here, boys that are curious, just always want to come up and talk to you and shake your hand and they're very glad we're there.

So what are the challenges? We have American faculty four or five of them, CDC has two or three staff, we have eight staff hired from a local NGO. We are flooding this hospital with 10 to 12 people every day to model behavior in the postpartum room, in the nursery, in the labor and delivery room, in the outpatient clinic, to try to model what appropriate behavior is. CDC is trying to improve surveillance, medical records, labor and delivery log, triage, patient flow from the outpatient into the other areas. We're trying to model hospital administration by a Hospital Administrator who's there now who happens to be from the VA system.

For Dr. Nazarene, the woman OB who is the Hospital Administrator, who has no formal hospital administration experience, so we have a Hospital Administrator helping her set up department head meetings, inventory control, we have new equipment on the way, how do you make sure it doesn't walk away after it's installed in the hospital. All these kinds of issues. We're working on a maintenance contract to improve the general overall stability of the hospital and the equipment and the sinks and the toilets and the fans and the heaters and all of these things. In this hospital, there were no heaters when we were there in December and the ground was frozen all the time I was there and we're delivering 50 babies in a day in a hospital with no heat.

There is no infrastructure for teaching, so there are no books, there are no computers, there are no medical records from, so you have to create a milieu where medical records are valued and where the teaching system is valued. So what have we done, we have created a schedule, besides the modeling, besides the elbow-to-elbow work, we have created a schedule where we have an administrative meeting from 8:00 to 9:00 every morning with all the staff, they decide what they're going to do that day, what they did yesterday, what posters they're going to make, what educational sessions they're going to have.

At 9:00 there are rounds. Rounds by the residents who are on-call the night before and they present all the residents and attendings the difficult patients who came in the night before, in English, they do relatively well, they write it down and they make their presentations in our American faculty question, answer, help understand the difficult patients for everybody. Then from 10:00 to 12:00, the residents from the night before on-call, and the attending from the night before on-call. By the way when I say attending on-call, that's new. There was never any attendings on-call. There was no on-call schedule at the hospital when we arrived. So very basic things we've had to create. Make rounds on the patients that were difficult from the night before and our American faculty make bedside teaching rounds. At 1:00 then we have a didactic session where we teach the attending, usually with PowerPoint, or with models, basic obstetrical knowledge skills and techniques.

One of those days a week we go into surgery with the attending and one of those days a week are grand rounds. The attending and the residents both leave the hospital about 2:00 in the afternoon. Where do they go? They go to a private practice. Why do they go to a private practice? Because they can't make any money at the hospital. What do they make? Thirty dollars a month. In a private practice from 2:00 to 5:00, or 2:30 to 6:00 in the afternoon, they can make about $250 a month. That enables them to pay their rent and pay for food and have a basic subsistence to care for their family. So when do you teach? When do you do postgraduate education for the residents in this milieu of coming to the hospital and having to do 50 deliveries and day and do c-sections and all the rest where we're busy, and leaving the hospital at 2:00 in the afternoon.

And so we've tried to create a structure where we contain the teaching and do it (inaudible) with patient care between 9:00 and 2:00 in the day and then the Residents will go on their way, and the attending too. Residents have private clinics, as do physicians, because there's no postgraduate training that's formal. Anybody who's graduated from medical school can hang up a shingle which says, "I'm an Obstetrician" or else "I do mothers and kids," or "I do kids," or "I do pregnancy care," or "I do internal medicine," nobody can challenge it because there's really no postgraduate education. So that's the formal structure during the day.

We are getting equipment donated, we have faculty scheduled through February or March. Faculty stays in a safe house behind security, they have a cook, they have 24-hour transportation if they need to, to and from the hospital, they have 24-hour translation, they have email capabilities. It's a relatively safe and a relatively comfortable existence giving the situation in the City. If any of you know faculty, pediatricians, pediatric nurses, nurse midwives, OB's, a hospital administrator, who would like to build two or three months in Afghanistan on this project, there's a small stipend, but it is a very fulfilling and I think self-satisfying term of work in a foreign country. I'm going to stop there and take a few questions before we have to vacate the room. So that's our challenge in Afghanistan.

It's been very challenging for me. I appreciate our staff and the bureau allowing me to go for periods of time. I've been there five times now in the last eight months and will continue to go and be a part of the team including CDC, NIH, and others in the department. This is not a one-person or a three-person effort. This is an effort by multiple agencies in the department to make a difference in Afghanistan and to be committed to help at the hospital for a period of time, three to four years. Thank you very much. And I'd be happy to take some questions. It's hard to see hands with the lights; you'll probably have to stand up.

Unidentified Speaker: What do they use for families planning after they deliver?

Dr. Peter VanDyck: The question is, "What do they use for families planning after they deliver?" They use pills mostly, birth control pills. They do use family planning; there is a family planning clinic at this hospital. There is one IUD in use, but it's mostly pills. Depo-Provera is also used some. Paul, did you have a question?

Unidentified Speaker: (Inaudible)?

Dr. Peter VanDyck: The question is: we're doing a lot for them; we could be doing a lot more. Do we learn anything when we're there? I'll tell you it's a greater learning experience being there and trying to set priorities when everything's a need. How do you influence people to be concerned about the things they've never been concerned about? How do you get people to be concerned about education for postpartum women? How do you get people concerned about sending a small baby home with a mother breastfeeding and realizing that may not work very well? How do you get people concerned about getting prenatal care?

How do you get people concerned about 6,500 deaths per 100,000 deliveries? It's way too many. How do you get people concerned about going somewhere? How do you get people concerned about getting trained? So these are really issues that we're now dealing with. How do you get people to be interested in getting postgraduate education? And, by the way, they are. They're extremely interested in being better trained and realize what they're missing. More so now that we've been there a short time than before. So we are learning. We are learning to get a plan, to get approval, to try, to regroup after a month or two, reassess, reevaluate, re-plan, reassess, it's a very humbling experience.

And if you ever though you knew what it was you wanted to do, you quickly learn that what you think will work, doesn't work for some reason and you have to move on. Why are the sinks all being pulled off the wall? Well, because people have to wash their feet before prayer and they have the prayer two or three times a day so they lift their feet into the sink to wash. And the pressure of lifting your feet up into the sink pulls it off the wall in two or three weeks. Well, who would have thought that? What's the solution? You put in sinks with pedestals that have a pedestal to the floor that won't pull off the wall. I mean, just one example of a cultural thing that makes the hospital look terrible and unfunctional, which can be easily solved.

Unidentified Speaker: I think my point was more (inaudible) and obviously a governed and free-market system has (inaudible). You mentioned there's a spirit thing among most of the staff and even among the resiliency of the children (inaudible). As those dynamics play out separate from kind of the free market vision at our health care system (inaudible) I was trying to get at. How bad experience is a plus for (inaudible)?

Dr. Peter VanDyck: I don't think we can relate the systems very well. In Afghanistan, all health care is free. It's free in the face of no infrastructure. It's free in the case of the Ministry of Health responsible for all the hospitals and having no money to provide gloves, drugs, equipment, upkeep, maintenance. So how do we help the Ministry of Health understand that a totally free health care system is probably not going to be solvent for any period of time in this country? They are working on thinking about creating a small charge, looking at having a bigger budget in some way. But with no infrastructure it's very difficult. So these are issues the Ministry of Health is dealing with and has consultants about and talking about and influence what we do. But it's a very difficult thing.

Unidentified Speaker: (Inaudible). So do you see any difference with this new education (inaudible)?

Dr. Peter VanDyck: That's a good question and the question was it's very difficult and not very culturally acceptable, generally speaking, for a female to be seen by a male physician, or a male nurse, or a male anybody for that matter. Of the 80 or so obstetricians at this hospital mixed between attending and residents, there's only one male and he's the Dean of OB, he's the Chief of OB who's taught all these people. He actually can move fairly freely into the delivery room and out of the delivery room because basically everybody knows him and he's old and as he says, "my gray beard," not mine, his, "helps and I'm looked up on as an older, past my prime male, I guess, and the females accept that." We have tried to find female providers. We don't always and we sometimes have male Obstetricians there. We are very sensitive to the issue. It's not a problem in surgery.

It has not been a problem in rounding in the wards. It can be a problem in the labor and delivery suite and we just have to be very sensitive to that. Most of the women are not bothered for themselves, although some are. That's not the issue, they're more worried about leaving the hospital and having it get out that they may have been seen by a male physician and having the family having a problem with it. So we're very sensitive to this issue. It is an issue, but it's not one that we can't overcome. Any other questions? Well, thank you very much. That was fun sharing with you. It does add to my experience and my view of the world. And it also is interesting being able to split my job between attention to Afghanistan and attention to MCH issues here and I really do thank the staff for taking up some of the slack when I'm gone.

My understanding is we need to take all of your information, all your folders and things, from the room because they're going to sweep in here, set the tables and then we're going to have lunch back in this room. And it's going to take about 30 minutes. So lunch is about 12:15 here in this room. Take your folders and your personal effects with you and then you can bring them back them. Thanks.