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Afghanistan: on the frontline of health care

31-10-2007 Feature

Sharifa Seddiqi is a most unusual woman. Not only is she the sole female surgeon in Afghanistan's war-ravaged southern province of Kandahar, she also runs Mirwais hospital in Kandahar, the main hospital in the region.

   

  ©ICRC/ M. Kokic /af-e-00773    
 
Gunshot wound victim recovers in the intensive care unit. 
     

This is not a job for the faint-hearted. Kandahar's Mirwais hospital serves a population of 3 million in what remains one of the most insecure and violent areas of the country. It is also where women continue to suffer particular repression in a resolutely traditional society.

" Of course a woman in Afghanistan faces great challenges, especially in becoming a professional " , says 38-year -old Dr Seddiqi, wearing a loose black robe and a long white shawl covering her head. " But I was lucky that my family always supported me. I'm proud to now have such an important job. "

Even getting to work in the morning can present a challenge. " With all the suicide bombs and explosions, I do sometimes fear that I will be killed, that I will be in the wrong place at the wrong time " , says the doctor. " But I can't be a prisoner in my own house because of that. "

As hospital director, Dr Seddiqi works closely with the International Committee of the Red Cross (ICRC), which has been supporting Mirwais hospital for the past 11 years. After rehabilitating the surgical department, the ICRC extended its support to the entire 380-bed facility, recently signing a five-year agreement with the Ministry of Public Health to implement a package of reforms.

" Together we are essentially aiming to raise the standard of hospital services to a nationally agreed level, and to ensure that there is both the necessary equipment and expertise to meet patient needs in the future " , says Dr Seddiqi. " We have already achieved a lot, but as you will see, there is still a long way to go. "

After a round of meetings and dealing with administrative matters, Dr Seddiqi's morning typically entails a tour of the wards.

Passing huddles of women shrouded in the traditional full-length burka, waiting anxiously outside an operating theatre, the doctor remonstrates with a group of four armed policemen guarding their wounded colleague. She asks them to leave their weapons outside. They refuse. " This is a problem " , sighs the doctor. " Armed men from all the fighting groups around here tend to wander in and out of the hospital and it makes people nervous. But we are building a new security fence which will help to really demilitarise th e compound. "

At the men's intensive care unit, the doctor checks the new arrivals. These include two men with gunshot wounds, sustained in a burglary, and a six-year-old boy with blast marks over his face and chest, his hands and feet badly injured, after he picked up an explosive device that he found in his yard. " Car accidents usually account for the vast majority of surgical patients " , says Dr Seddiqi. " But at times we get a lot of war-wounded, both military and civilian, including mine injuries. "

In the separate women's intensive care unit, there are a number of burns patients. A teenage girl with gauze bandages covering her legs is wheeled to the dilapidated bathroom to be washed. " Sadly, we still see quite a lot of young women with big burdens in life who try to commit suicide by setting themselves on fire " , says Dr Seddiqi. " In a few cases it's the husbands who do this to the women for punishment, but most often it's the women looking for a means of escape. "

   
  ©ICRC/ M. Kokic /af-e-00774    
 
Ella Scott (ICRC Teaching Nurse) checks on a baby in the paediatrics' ward. 
     

Passing through the crowded paediatric ward, the doctor stops to talk to the mother of a severely malnourished 18-month-old girl. The emaciated child is held by her 10-year-old sister, who stays in the hospital to look after her when the mother goes out. The woman has six children and is pregnant again.

" The problem is that many of these people are uneducated, poor and displaced by the conflict " , says Dr Seddiqi. " The mothers often don't breastfeed for long enough, and then give only sugar and water to the babies. Those born at home are not vaccinated. Then when they fall sick, the insecurity makes it very difficult sometimes to even reach the hospital. "

Moving to the obstetrics department, the doctor arrives just as the expatriate ICRC obstetrician is trying to deliver a breech baby, calmly giving instructions to the throng of midwives, nurses and relatives around the bed.

The situation is critical: the 18-year-old mother is convulsing and semi-comatose; she has high blood pressure and a caesarean section at this stage would almost certainly kill her. An oxygen machine is eventually found and wheeled in. It does not work.

Swatting away flies in the heat and stench, the obstetrician finally manages to deliver the baby, a girl, and immediately rushes with her to the neo-natal room. With a midwife, she clears the baby's nose and mouth, and uses a hand-held device to pump in oxygen. There are no respirators. But their frantic efforts are in vain: after several minutes the baby's heartbeat disappears completely and her lifeless form wrapped in a blanket and given to the grandmother.

" At least in this case the mother will probably recover " , sa ys the obstetrician. " And the fact the baby was a girl will make the loss somehow less tragic for the family. The mother will be expected to produce another child very soon. "

Afghanistan's infant and under-five mortality rates are among the highest in the world, with an average of 1,000 children dying each day, according to UNICEF. This is partly because some 90 per cent of rural women are estimated to deliver babies at home without any medical care.

For those who manage to reach adulthood, the average life expectancy is just 42, according to the World Health Organisation. Diarrhoea, respiratory infections, malaria and malnutrition are the biggest killers. Afghanistan is one of the very few countries in the world where polio is still endemic.

   
  ©ICRC/ M. Kokic /af-e-00772    
 
Sharifa Seddiqi (Mirwais Hospital Director) and Bronwen Markham (ICRC Hospital Administrative Advisor) working together to improve care for patients. 
     

" With the ICRC's long-term investment and support, a lot has already been achieved, from improved hygiene and clinical practice to rehabilitation of the water supply and staff training. However, public expectation is sometimes unrealistically high " , says Dr Siddiqi. " People expect change fast, without understanding the concept of capacity building in order to achieve sustainable results. What is the point of having fancy equipment that can't be maintained? We should strive for realistic standards in the Afghan context – not a western context – and remember that we are starting from zero, from a state of total collapse. "

" Of course there are still big gaps " , says the doctor. " Amongst our priorities for next year are to establish a reliable data collection system, which is still sorely lacking; to improve and expand the gynaecology and paediatric services; to further rehabilitate hospital infrastructure; and, not least, to refurbish the mortuary. "

Back in her office, Dr Seddiqi is besieged by staff and visitors requiring her attention, and demanding immediate solutions to a multitude of problems. The doctor calmly delegates tasks, then firmly closes the door and pours herself tea.

" I love my job, despite the stress " , she smiles. And her biggest wish for the future? " To have a child. But I still wouldn't forsake my work. There's still so much to do. "