By Radha Lewis, MD

While making plans to travel to Afghanistan, I vacillated between excitement and fear. According to US newspapers, this country is a war zone filled with suicide bombings and rockets colliding randomly into businesses and homes. Why would I put myself in front of harm's way? 

The capital city of Kabul, I have discovered, is a city like any other - filled with children going to school, women shopping for groceries, and men joking on street corners. Although there are some basic security precautions, I never felt unsafe. The enormous need for basic services - paved roads, clean water, electrical power, and basic health care - is what's frightening about Kabul.

It was a surprising and exciting few weeks volunteering in the CURE International Hospital in Kabul. I've drawn heavily upon my education in family medicine. I regularly search for remotely learned facts and treatment algorithms that might help in the care of patients. There are virtually no specialists for consultation; almost all skilled physicians have long since left the country, which was at war from 1980 until only a few years ago. The new generation of physicians is usually poorly trained to practice medicine in an organized and thoughtful manner.

One day, I participated in the care of a woman with TB meningitis and a Gohn complex on CXR, diagnosed a spinal compression fracture, a case of idiopathic recurrent bigeminy in a dizzy 19-year-old, and two early pregnancy losses. I taught a resident to suture a hand wound, admitted a baby with severe dehydration and an adult with new seizures. I placed two IUDs and performed three mid-pregnancy ultrasounds. I heard from a resident about a woman who came into the clinic at dawn carrying her newborn baby who died from sepsis during the night. From the dispassionate telling, I realized that death of a newborn is a sadly regular occurrence here.

There is an endless supply of sick patients suffering from a wide range of both acute and chronic illnesses. Diarrhea, pneumonia, malaria and tuberculosis are too often fatal.  Among Afghans who live to adulthood, the disease processes are similar to those affecting Americans including cardiovascular disease, congestive heart failure, cancers and diabetes. Their prevalence is difficult to determine because most patients never access care. 

Statistics regarding the health of women and children are sobering. The national maternal mortality is 1,600 per 100,000 live births.  Afghan women, who marry at ages 15-17 years and bear, on average, six to seven children each, frequently die during childbirth. Most women never see a physician or midwife. In many provinces, the risk of dying from pregnancy-related complications is as high as one-in-six mothers.  In large part, this is due to an enormous lack of capable providers. This impacts heavily upon the children, who die regularly from preventable causes for lack of medical attention. Every year, 86,500 newborns die in Afghanistan, and the mortality rate for children under the age of five surpasses 20 percent throughout the country.

This environment is ideal for family physicians, but this specialty was unknown here until three years ago when a US-trained family doctor founded the first-and-only program in Afghanistan training physicians to meet the needs of rural underserved communities at CURE Hospital. On my first day, I was invited to the graduation ceremony for the second class of six family medicine residents. The local community and representatives from the Afghanistan Ministry of Public Health attended the ceremony. A national television crew came with battery-operated equipment to document this monumental event.  Although the lights flickered out on multiple occasions throughout the ceremony, not a single person was distracted from honoring what these new physicians have accomplished and the enormity of the task before them.

Like residents who join the US National Health Service, these graduates are committed to practicing in rural provinces for two years. They will offer clinical services in all areas of adult and pediatric medicine including major surgeries and operative obstetrics. After three years at CURE, with its rotating supply of international physician teachers, relatively abundant laboratory resources, well-equipped pathology lab, and access to a variety of treatments, they are as well-prepared to take on this challenge as any Western-style physician. Like US residents, they regularly consult their PDAs and UpToDate, perform literature searches, and consult with distant colleagues via email. Their history-taking, physical examination and clinical decision-making skills are excellent. They are remarkably resourceful with limited supplies. 

The hospital is bright and airy, with a large carefully planted rose garden in front to welcome the patients (one thing nearly all Afghans have in common is their love of flowers, particularly roses). Afghan and international providers work together to manage this 100-bed facility that includes a moderately large NICU that cares for premature infants down to 27 weeks gestational age. Interestingly, the monitoring equipment used in both L+D and the NICU was donated and installed by a Rotary Club in Fremont, Ca. Nearly 100,000 patients are seen yearly; although some die, many lives are saved.

The resident clinic is far from typical. The place is packed with men in colorful turbans, and women in long blue burqas shepherding large-eyed children. There is a wing for residents' continuity patient visits, plus areas for labor and delivery, tuberculosis management, childhood de-worming treatments, an ultrasound clinic, and a busy 24/7 emergency room.  The family medicine residents provide all of these clinical services, diagnosing and manage diseases from fetal hydrocephalus to end stage liver disease.  In the process, they are learning necessary essentials for practice in the most remote areas.

In a short time, I have learned immensely about the diagnosis and treatment of illnesses that I rarely (if ever) see in the US My intention was to teach, but I am so grateful to have learned so much about practicing medicine in an environment like this. For interested physicians, this is an extraordinary place not only to contribute to the knowledge and skills of the local physicians in training, but also to learn in an exceptional environment.