Access to health care in Afghanistan is among the worst in the world. RFE/RL correspondent J.M. Ledgard traveled to one of the country's most isolated provinces to look at what it means to be sick in Afghanistan.
Chaghcharan, Afghanistan; 8 August 2003 (RFE/RL) -- The mullahs of Afghanistan's remote Ghor Province are in despair. Their people have always been among the poorest in Afghanistan.
"During the 23 years of war we lost everything," says Amanullah Amanullah, a senior cleric.
"Ghor was the poorest and most remote province in Afghanistan before the war. We did not have roads, schools, hospitals. Now it is worse," he says. "Many people have emigrated to Kabul and other places. Some villages no longer exist. There are not enough laborers to bring in the harvest."
Ghor has few public services -- and not much of an economy. Education is limited. There are an estimated 750,000 people living in the province, and only four high schools. Most children in the villages of Ghor have little hope of ever receiving an education.
"They have zero chance," says Amanullah. "The best they can hope for is some winter classes with the local mullah, studying the Koran."
The 3,000 mullahs in the province are partly to blame. Most are illiterate and more interested in selling magic charms and amulets to the needy than assisting with schooling.
The best customers for the mullahs' amulets are the sick. Access to health care is even worse than for education. Ghor has only five doctors and a single 20-bed hospital in Chaghcharan -- a dusty village, nearly 400 kilometers west of Kabul, which serves as the province's capital.
The hospital has improved since the French delegation of the nongovernmental Medecins du Monde undertook to rebuild and supply it in November 2001. But it can still perform only basic surgical procedures. Often that isn't enough. Medical care is the last resort in this devout and superstitious part of Afghanistan. Many of those who make it the hospital are already terminally ill.
Women are especially vulnerable. Some have been bleeding for days from the complications of pregnancy before reaching the hospital. There is little doctors can do for them: the hospital has no blood bank or even the ability to test for blood type. In one case, an Afghan surgeon passed his own blood into the patient. Amazingly, she survived.
The hospital is clean by Afghan standards and the pharmacy well stocked. But space is a problem. There is no special room for tuberculosis patients. They lie, coughing, on cots in the corridor. There is no special section for children, either. A young boy winces and quietly weeps in a bed beside dying elderly men. A vat of boiling water scalded much of the boy's body. Such cases are among the most difficult to deal with, say the doctors. The wounds of burn victims are often badly infected by the time the patients reach the hospital, and changing their dressings is difficult for the male nurses, who have little formal training.
A sense of the medical challenge faced at the Chaghcharan hospital comes with the arrival of Mehman Gul, a 15-year-old girl, carried by her father from a village 30 kilometers away. She is laid down on the floor, porcelain white, skeletal, barely breathing. Then a bed was found for her (see photo)
. She died in it an hour later, wasted away from typhoid and hunger.
Noosh Afarin Shahab Dolati is the hospital's gynecologist. She is working with a Medecins du Monde midwife to reduce the dangers of pregnancy for Ghor's women. Four local women are training as midwives. They will learn clinical procedures and public-health education. Some of them, it is hoped, will make trips to remote villages to urge traditional midwives to adopt medical practices.
According to Dolati, health problems are exacerbated by the ignorance regarding health care and the continued faith in magic spells and religious traditions.
"Mullahs are very powerful in this area. People first go to see them. Only in the last stages will they come to us. And it causes a very big problem for us to help them. By the time they get here it is sometimes too late. For example, we have many women with problems concerning their placenta. The placenta remains inside the woman for three or four days. I have seen with my own eyes a woman whose placenta remained inside her for five, six, even seven days."
"There is no understanding of hygiene in the villages," Dolati continues. "The women know nothing about their own bodies. Tetanus is common among babies because traditional midwives make mothers deliver their babies into bowls of dirt gathered from the farm yard or the village street. The women believe they will be rewarded by Allah for delivering their baby into earth."
Some of Dolati's stories are even more horrific.
"One woman came to the hospital recently. She was in very bad condition. She had come from a distant village." The woman had tried to deliver a breech birth; her baby had shifted into a shoulder-first position. Dolati says, "The traditional midwife told the father she was not strong enough to pull the baby out. So the father came and finding the arm of the baby he pulled as hard as he could. But the arm of the baby came off in his hand."
The rest of the baby, Dolati says, remained in the womb. The woman was brought to the hospital four days later. Her baby was dead, and the woman's uterus had to be removed.
Medecins du Monde is doing what it can. It hopes that its present two-year budget of $1 million will be extended into 2004. But it is a struggle, says Matthieu Tillet, the agency's regional director. "Our mission is only to support the Afghan government in its task of running the hospital," he says. "We don't want to take over."
Sometimes that means taking a back seat in disputes Afghan doctors would prefer foreigners to solve. But Medecins du Monde has to entrust the hospital to its local staff anyway. Security concerns mean the French team must depart in November and return in March with the melting of the snow. "The roads are impassable for most of the winter and the airstrip is snowed over," says Tillet. "It is impossible to guarantee safety in those conditions."
Medecins du Monde is planning an exit strategy. It wants to be out of Chaghcharan by 2005. By then the midwives should be trained. But the fear is that Kabul will simply forget about the hospital. A review of the funding effort for health care already has. The new plan for overhauling health care by the U.S., EU and World Bank -- the major donors -- overlooks Ghor altogether.
"Don't worry," Tillet says wryly. "We're going to remind them."