Mr. Faez acknowledged the past contributions of LLU and the AMAA and expressed a desire for continued support.

Mr. and Mrs. Faez toured the neonatal intensive care unit of Loma Linda Childrens Hospital and the Distant Learning Center. He was pleased to see the capability of the Distal Learning Center with the feasibility that the center could provide teaching inside Afghanistan via Satellite from LLU.

He was then welcomed by the Board of the Directors of the AMAA during a reception with guests from the LLU.

The Minister of Higher Education participated in a frank discussion with the directors of the AMAA and answered questions.

He asked the president of the AMAA to continue the ongoing effort and the AMAA to get more involved in medical education inside Afghanistan. The Ministry of Higher Education may provide facility for the AMAA center in Kabul, if the AMAA wishes.

The Afghan Medical Association (AMAA) and Loma Linda University (LLU) co-sponsored an all-day symposium on Sunday, August 4, 2002 at the Wong Kerlee international Conference Center of LLU from 9:00 a.m. to 5:00 p.m.

There were more than 200 participant from all over the US and Canada. Most of the members were from the Afghan Medical Association, the Afghan Physician Association, other medical groups, representatives of Afghan Women Association of Southern California, several ex-cabinet ministers and other dignitaries.

Dr. B. Lyn Behrens, President of LLU and Dr Nafisa Abdullah Huf, a member of the AMAA executive committee, welcomed the attendees of the symposium.

Dr. Yousuf Sadiq, a member of the AMAA executive committee briefly described the goals and activities of the AMAA.

Dr. Ibrahim Seraj, a member of the AMAA executive committee and an associate professor of LLU and Dr. Gordon Hadley, Dean Emeritus of LLU, presented the past medical education in Afghanistan.

Dr. Wali M. Aseem, Cardiovascular Surgeon of DuBois, Pennsylvania discussed the past health statistics in Afghanistan.

Mr. Yasin Khosti, a member of the AMAA and Associate Director of Afghan Assistant Coordination Authority in Afghanistan and Ms. Homira Nassery, Health Consultant to the World Bank provided information regarding ongoing foreign aid and the World Bank’s role for Afghanistan.

Dr. Khushal A. Stanisai, president of the AMAA and assistant professor at LLU, presented the recent KMI student survey and the ongoing medical education problems facing Afghanistan.

Dr. Richard Hart, Chancellor of LLU briefly discussed LLU’s role in reconstruction of the health system in Afghanistan.

Professor Sohaila Siddiq, Minister of Public Health and a member of the AMAA, presented the recent health statistic in Afghanistan, the ongoing activity of the ministry and the need for expatriate Afghan physician to return and help in the reconstruction process.

She thanked the AMAA and LLU for their past contributions to the medical education and health systems inside Afghanistan and for the warm welcome she received during her stay.

Later she received a certificate of a donation of wireless equipment totaling $78,000.00 from Cisco Systems, microscopes from LLU and $4000.00 to improve the health system in Afghanistan from the Afghan Women Association of Southern California.

There is also a donation of few hundred wheelchair in the process.

Habib S. Baha, M .D., Secretory AMAA

K. Ali Siddiqui, M.D., Director AMAA

October 2002

Introduction

The US Department of Public Health and Human Services, during the preparation for the recent trip of Secretary Tommy Thompson to Afghanistan, requested the Afghan Medical Association of America(AMAA) and the Afghan Physician Association of America consider a joint effort to help address the current health concerns in Afghanistan.

The Department of HHS informed the AMAA leadership of the commitment of the Bush administration and specifically Secretory Thompson, to assess the health needs of Afghanistan and to be a partner in reconstruction of its health system.

The HHS saw the need for a joint effort of the said department and Afghan-American physicians and invited representatives of the AMAA and the APAA to travel to Afghanistan to be part of the discussions with Afghan officials and secretary Thompson.

In addition, they were asked to be a part of the team to assess the health needs of women and children in Afghanistan and to report on Medical Education in Afghanistan.

Homyra Behsoodi, M.D. and Qudratullah Mujadiddi, M.D. made their assessment and recommendations on maternity hospitals and women’s clinics. K.A. Siddiqi, M.D. and I (Habib S. Baha, M.D.) visited The Kabul Medical Institute(KMI).

Background

Up until the late 1970’s and the beginning of 1980’s, Afghan Medical Schools were under Kabul University and the Ministry of Education. However, after Russian occupation theKabul Medical Institute (KMI) was created. All Medical Schools became under the jurisdiction of the Ministry of Public Health and later on the Ministry of Higher Education.

MEDICAL SCHOOLS: Currently, more then (17) medical schools are known to exist in Afghanistan but only KMI and Nangarhar Medical schools have any hope of becoming legitimate based upon the experience of the teaching faculty.

Kabul Medical Institute has the following Medical Schools in Kabul:

School of Curative Medicine 440 Females 1552 Males

School of Pediatrics 104 Females 679 Males

School of Stomatology 61 Females 349 Males

School of Military Medicine Unknown Unknown

Total(s) 605 Females 2580 Males  3185

TEACHING HOSPITALS: Ali-Abad Hospital, a training hospital located at the Kabul University campus, has been destroyed and demolished as a result of years of civil war. All of its equipment and surgical tools have vanished. A nearby maternity hospital has been transformed into a teaching hospital and renamed Ali-Abad. The afore mentioned hospital has limited tools for teaching which is why KMI Medical schools are dependent upon the Ministry of Public Health. There is a serious need for building a new teaching hospital on the University Campus.

OBSERVATION:

On October 5^th, all four of the Afghan-American Physicians had a meeting with Afzal Anwar, M.D., President of KMI, and its staff members. After a long conversation, and listening to their urgent needs, they toured all of the medical departments including: KMI Publications Department and library. The library has been supported financially by Loma Linda University (LLUMC California), along with medical books donated to the library by the AMAA. We noticed that the department of Publications operated with limited resources. There is only one Gestetner printing press, and it runs primitively by hand due to the lack of electricity. In the other corner of the same room, we observed a typewriter, which appears to be the only other resource for KMI’s 3,000 students.

In addition, there is also an archaic copy machine within the premises. In this institution’s prime, it was well known for having the most modern and impressive printing equipment in Afghanistan.

On October 6^th, Dr. Baha met with the Dean of the Curative Medical School, Dr.Wahab Noora. He explained to him all of his urgent needs and transportation problems as well as the need for communication/information technologies such as; telephones, fax machines, and personal computing/Internet. This request also includes the obvious, running water and electricity. Then on the same day, he met with the Senior Anatomist, Habib Brahman, M.D. (who was one of his past students and assistants in Nangrahar Medical School, Jilalabad). He had an informative conversation regarding his needs as well as recommendations. After that, he visited the Department of Microbiology. It was fortunate to meet with a group of current (male) students as well as approximately 20 female students in the Microbiology Lab. They were doing a Gram’s stain as a part of the lab assignment. The tools and conditions that they have to work with are very inadequate. The facility is large and capable of housing many more students; however, due to the lack of resources all students have to huddle into one corner of the room. Only one technician was available to assist all students. This is partly due to the inadequate salary of the professors, who must also maintain an outside job in order to survive. Many of them are still awaiting the pay promised them months ago. Ultimately, because of this dire situation, the students suffer. The primary teacher is someone who normally might be an assistant or technician under the doctor.

Even with the harsh realities and suffering of the medical staff and students, the overall interest and desire to excel and to learn is extremely high, which is good news. Students are literally begging for a chance to learn. They show an earnest desire to get the help they need to become good physicians. During conversations with the students, it was discovered that the majority of them felt that the most pressing issues were the acquisition of more textbooks and the importance of learning fundamental English, as the need is evident in the pursuit of a higher education.

To assess teaching material K. Ali Siddiqui, M.D. visited the Department of Pathology and Histology, while Dr. Baha visited the Departments of Anatomy, Physiology and Microbiology. Dr. Said Abdullah Hashemy, Professor of Pathology, was kind enough to show Dr Siddiqui his department. It presently consists of six assistants and two technicians. Needless to say, the findings are disappointing. There are only a few microscopes and not one single textbook of Pathology or Histology. There is no atlas of Pathology in the department other than in the library.

No tissue processing machines were present other than the ones provided with LLU assistance. It is apparent that students are forced to learn by relying on memory. This brings to mind the Afghan expression, ” anything written in the ice and exposed to the sun will melt away”.

During Dr. Siddequi’s visit to the Department of Surgery at Ali-Abad Hospital he met with his old classmate Dr. Said Hassan Manawi, who is presently Chief of Surgery. The findings at this site are also discouraging. The condition of the scrub room and operating room are desperately below standard. Contamination was everywhere. Dr. Manawi revealed that patients are admitted with infection, as a result of prior inadequate medical care, and discharged with infection due to hospital contamination. There is no reliable data as to patient mortality after discharge. The patient rooms are overcrowded. There are no restrictions for visitors. They sit on patient beds and most of the time one cannot distinguish between patient and visitor since patients wear their own clothing during their hospital stay.

Dr. Manawi, who trained in England and practiced surgery in Ireland for five years, stated that he could not operate because of his allergy to latex. There are no latex-free gloves available in the hospital. Dr. Siddiqui promised that either the Afghan Medical Association or he would send him latex-free gloves.

The team visited with Secretary Thompson on the grounds of the American Embassy in Kabul for a working lunch on Tuesday, October 8^th, 2002. During the meeting, assessments of the KMI and Maternity and Pediatric Clinics of Kabul were presented. Mr. Thompson requested the team’s presence at his meeting with the Afghan Secretary of Public Health, Dr. Sohaila Sidiq. In this meeting, Secretary Thompson presented the following recommendations to the Department of Public Health:

To build a modern pediatric and women’s clinic in Kabul. This clinic would not only deal in pediatrics and woman’s health, but would also be a teaching institution for doctors, nurses and midwives. These trainees would then serve other provinces and communities. This plan was exciting and welcomed by Dr. Sidiq.

Secretary Thompson stated that some American Universities, including Johns-Hopkins, have expressed a desire to affiliate with KMI. Dr. Sidiq however clarified that at the present time KMI is operating under the Department of Higher Education. She is now a part of the process of including KMI as part of the Department of Public Health. Only then could an affiliation with Johns-Hopkins (or any other American medical school) be considered.

The meeting concluded and a press conference was then held in the American Embassy.

Conclusion

Dr Baha and Dr. Siddiqui addressed ways to fulfill the Medical Schools needs with Dr.Anwar, the president of KMI. He indicated that he would welcome foreign professors to teach the students if they would teach for at least one semester and administer a final exam for their course(s). If a Professor could not stay long enough to complete a semester, then he would be welcomed to teach the faculty.

Loma Linda University has been affiliated with KMI for many years. This affiliation however, has basically been limited to the teachings of Dr. Gordon Hadley, Professor of Pathology, a limited rejuvenation of the pathology laboratory, improvement of KMI’s library and the building of the LLU compound for visiting professors. This has been a great effort on the part of LLU, but certainly not even close enough to meet the needs of KMI.

Dr. Nadir Omar, the French-trained physiologist and past professor of Kabul Medical School, came from France and was present at the meetings. He discussed the long and historic affiliation that France’s University of Lyon has had with KMI and the desire to continue it. Although, he admitted the involvement had been somewhat limited in recent years.

Other Universities have expressed interest in affiliating themselves with KMI. But, no significant teaching or material aid has been provided.

RECOMMENDATION:

In all departments that the AMAA members met with, the needs were consistent. It would be trivial to list the departments and their needs individually since they are nearly identical (and lengthy). Below is a list of the most general and urgent needs:

Teaching environment: The most important needs are basic classrooms and the equipment and supplies needed to conduct educational programs including, but not limited to textbooks, lab equipment (basic chemicals, storage/measurement tools, lab stations), audio/visual components like projectors, monitors, charts, writing utensils (pencil/pen, paper, folders, etc,) computers and printers.

A Teaching Hospital in close proximity to KMI: Immediate help to rebuild and resurrect the Ali-Abad Hospital.

The urgent need to update the current curriculum for medical education.

The availability of foreign or AMAA qualified professors to teach the existing teaching faculty and to establish a program to update the teachers as priority in addition to student education.

Continuing medical education for Medical Staff.

Experienced foreign medical school advisors to set up the administrative structure and to assist with the ongoing administrative needs of the medical schools.

A drastic reduction in the number of medical students to a level proportionate to the needs of the country and the currently available teaching environment.

View Photo Gallery

I returned to the homeland after 34 years. My return was filled with anticipation, fear, and so many emotions that I knew that I’d have to throw myself into it. I went to medical school in Afghanistan , the first woman to come to the United States  for medical training. My medical background in Afghanistan was intense and primal, as my training in the United States was both sophisticated and complete. I had no idea how to reconcile what I had been to what I am today. A one-day trip in Kabul had a world of stories in it. It was an odyssey. The sadness that these people have gone through is not so easy to describe in an ordinary way. I will walk you through it; only if you promise me you will listen. That is all I want from you, just listen, and for the rest you decide what to do.

At  this  point in time since I am a physician and will share with you a tiny corner of a hospital where I worked and shared my knowledge and experience with women physicians. The hospital is called Rabia Balkhi, located in the busy section of downtown Kabul . I spent most of my time in the women’s section in the department of Obstetrics and Gynecology, made rounds in the ward, spent time with obstetricians on duty, shared experiences and gave advice, and performed some gynecological surgery. In this hospital the delivery rate was 55 to 80 infants per day. Yes, giving birth can sometimes be simple and will just happen anywhere in the bed, or on the floor, without the slightest attention from a doctor, nurse or mid-wife. Since a majority of these women have no prenatal care whatsoever, there will be some undiagnosed complications, high-risk pregnancy among them, and sometimes hours and days passed before they were evaluated. There were times that 20 to 30 women were in active labor and gave birth at the same time with very little care, some giving birth on the cool and naked steel of a delivery room table, of which only a few of those tables were available. Some with sad and wizened faces lay on the cement floor; sometimes even 2 to 3 women lay altogether on a flat cushion, wrapped with their shawls. Some women even brought their 1 or 2-year-old children with them to the hospital, since there was no one at home to take care of the children, and the women would go through labor and birth in the same bed with them in the hospital. These were just the lucky ones.

Most deliveries still occur at home as the women were not able to get to the hospital or may not have had permission by a male family member to go out. The vast majority of Afghan women receive no prenatal care. Afghanistan has been reported to have a high maternal mortality rate of 1700 per 100,000 and infant mortality rate of 165 per 10,000. In the hospital that I spent some time in, five women died. In this short period, the causes of these maternal deaths were: post-partum hemorrhage and lack of availability of blood transfusion, ruptured uterus, many cases of cephalic pelvis disproportion and severe preeclampsia. Severe preeclampsia was a relatively common finding. The very sad part to me was that  basic precautions and simple protocols could have prevented some of these catastrophic problems and deaths. But this was (and is) not in place at this time inAfghanistan .

One morning a critically ill patient with severe preeclampsia was presented by a physician on call. The patient was in the hospital for 3 days with this severe illness; no complete physical exam, no lab tests, her blood pressure was checked only 3 to 4 times (during these three days). She was lying on the bed  with a severely puffy face, gazing at the ceiling with a bottle of IV fluid, which was going nowhere, with a terribly swollen arm and a Foley catheter containing about 100 ccs of coffee-colored urine. Worried relatives were sitting around her, deeply concerned about her condition. They kept giving her some apple juice to help her thirst. She was 20 years old and she died two days later. Her 29-week-old infant survived. If this had been handled with care and a simple protocol for the treatment of preeclampsia from the time of her admission, her death would have prevented, as it is for so many other deaths. I can say that pregnancy, giving birth and motherhood is a big risk in Afghanistan  at this time.

Many women that I had the opportunity to talk to seemed to live in the constant stages of pregnancy, giving birth from age 15 to almost 44. In personal conversations with the women, I found it is not so unusual for them to have 10 to 14 children, with no knowledge of contraception. Even after talking to physicians, the women were not well aware of the many methods of contraception. I believe there is an emergent need for family planning in Afghanistan for many reasons.

In the operating room it is not unusual that during a major operation, your scrub nurse will tell you “I ‘m sorry there are no more sutures.” In this hospital, patients had to bring sutures, blood and antibiotics for their surgeries. If there were no more sutures in the middle of surgery the patient’s relatives would be sent to buy more sutures. In another case involving a hysterectomy for a ruptured uterus on a full-term pregnancy, the operating room suddenly became dark. “It is a black out.” Losing electricity in Kabul for several hours is not so unusual; with no generator in the hospital, surgery was performed under candlelight. This is not a story told from some far away time, I witnessed the experience and it happened when I was in this hospital. There were many unusual cases, perhaps unusual for you and I, that were a routine way of living for these courageous and hard-working physicians. I found these physicians capable people, but unfortunately their medical knowledge and academic information were quite substandard due to the continued disturbance of education. I found them eager to learn; their personal and professional lives full of so many tragedies. They were very hard working people. 

As you can see, I did not go to some dozen hospitals located in Kabul , I mainly wanted to spend time in this women’s hospital and in my area of specialty. I was told this was the only maternal hospital in Kabul , that the other maternal hospital was under construction.

I would like to mention that this hospital, Rabia Balkhi, was visited six months ago by the U.S. Department of Health and Human Services, and was promised to become one of the most modern women and children’s hospital, to receive assistance with modern technology and medical personnel, after six months. April 21st was an exciting and big day for Rabia Balkhi hospital and it’s physicians. Officials from Afghanistan’s Department Public Health and the U.S. embassy in Kabul , the U.S. Department of Health and Human Services and many other dignitaries arrived for the opening ceremony, ribbon-cutting and tour of the hospital. I attended  the opening ceremony. It was a very nice day. Two days later I worked in the same exact hospital my observations and experiences were already discussed. I only wish that we all had attended on April 21st in Rabia Balkhi hospital to keep our obligations and promises, since we all know that only cutting a ribbon and being visited by dignitaries is not the solution for the health problems of the Afghan people.

The other area of my visit was the medical school from which I was graduated in 1968. I visited my old classes, spent a great deal of time with medical students, male and female. I was greeted warmly, even with the harsh realities and suffering of the medical staff and students for all these years. I found them with the strong desire to excel and learn. They wanted me to stay with them and continuously asked me when I would be back. Some offered that I could stay with them and visit their homes and families. I also spent several hours with the Dean of the medical school, visited some of the classes and laboratories, which were under construction, the old Ali Abad hospital, the “teaching hospital”, which was completely destroyed during the war. I was very happy to see the medical library, which was originally supported financially by Loma   Linda   University along with medical books donated to the library by the AMAA. I also had a lengthy conversation with the Minister of Higher Education. He expressed strong feelings about elevating the standard of education of the medical school and was very supportive of continuing medical education and improving the clinical skills and knowledge of practicing physicians. My visit with the Minister of Public Health was quite brief due to her travel schedule, but I had many formal and informal meetings with the General Director of Planning and Policy of the Ministry of Public Health, who listened to my concerns in regard to the present situation of Rabia Balkhi hospital and general health care systems in various categories, such as nursing, midwives, with particular emphasis on the needs of women and children in rural areas.

I was also fortunate to have the opportunity to attend a meeting of a group of Afghan physicians that came from all over the world and gathered in Kabul , who were trying to coordinate with a particular department of Public Health and be of assistance to the health system…

Also, I participated in the signing agreement between Loma Linda University , the Afghan Medical Association of America, the Ministry of Higher Education, the Ministry of Public Health, and the Kabul Medical School for the improvement of health care, training of physicians and improvement of medical school education. The details of this agreement can be found on the home page of AMAA.This was a profoundly fulfilling and memorable trip. You and I together, from here or there can make a significant difference in the lives, health, and education of these people and the time is now.

Nafisa Abdullah , MD