Intended for healthcare professionals

Education And Debate

Kabul diary

BMJ 1998; 317 doi: https://doi.org/10.1136/bmj.317.7155.401 (Published 08 August 1998) Cite this as: BMJ 1998;317:401
  1. Kamran Abbasi
  1. BMJ.

    News p 369

    When the charity Child Advocacy International invited the BMJ to experience aid work in war torn Kabul, I took the plunge.

    Tuesday 3 March: Manchester, England

    Aid work needs complex logistic support, and I'm greeted by workers from the children's charity Child Advocacy International pushing trolleys crammed with medical supplies. In two weeks the charity has accumulated $60 000 (£37 000) of donated medical equipment. The aim is to renovate the paediatric intensive care ward of the Indira Gandhi Children's Hospital in Kabul, the main paediatric hospital in Afghanistan, thus providing the impetus for the refurbishment of the whole hospital.

    Marshalling the charity workers is David Southall, professor of paediatrics and founder of Child Advocacy International. We are accompanied by three aid workers from the Duchess of York's children's charity, Children in Crisis, which is working with Child Advocacy International in Afghanistan. David Sogan, projects manager for Children in Crisis, feels that the trip should go well, as the team has negotiated carefully with the British representative of the Taliban, the much criticised rulers of Afghanistan.

    I wonder why these people risk their lives in war torn countries. As the plane takes off, I also wonder why I am risking mine too.

    Wednesday 4 March: Islamabad, Pakistan

    As many internal Pakistani flights are on small jets, with little room for our equipment, we hire a minibus—known locally as a flying coach—and head for Peshawar along the Great Trunk Road. We crawl rather than soar—heavy rains and a bald tyre—enduring five cramped hours on a muddy road. Arriving in Peshawar, Sogan takes his wife Judit, a barrister interested in international children's rights, and Linda Burbridge, a marketing manager whose bank has made donations to Children in Crisis, to the bazaar to attire them for Kabul. The Taliban have ordered that Afghan men must grow their beards and that Afghan women must wear full length body covering. Rules are laxer for foreigners, but it is prudent to wear loose fitting, flesh concealing clothing.

    The Taliban were educated in the religious schools of Peshawar. As divisions widened within the mujahedin—who gained power after the Russian withdrawal—the Taliban swept through southern Afghanistan. Northern Afghanistan still remains outside the control of the Taliban and is divided up by various Afghan factions. The Taliban, who are notorious for their treatment of women, have received less foreign aid than necessary to provide basic sanitation, food supplies, health care, and education. Meanwhile, the supply of arms continues, and the war goes on.

    Thursday 5 March: Peshawar, Pakistan

    We are flying on a jet of the International Committee of the Red Cross. The only other flights to Afghanistan, apart from clandestine night flights, are with the United Nations and Ariana Afghan Airlines. Kabul airport has no radar, and the city nestles on a plateau in the Hindu Kush mountains. Bad weather and regular shelling by opposition forces make flying hazardous. We head west to Afghanistan, and beyond a break in the mountains lies a large plateau and the historic city of Kabul, a once great mountain kingdom. On this clear, cold day we are greeted by the sight of dead MiG fighter planes and bomb damaged buildings. Snow capped mountains ring the city, and the airport terminal is dark and deserted. We are the only visitors to arrive today. As we leave the airport, a sign warns us that there are 10 million land mines buried in Kabul.

    Time is short, so we hurry to the nearby Indira Gandhi Children's Hospital. It is in a pitiful state, unclean and with blocked toilets so that waste seeps into the corridors and wards. Most of the windows have been smashed, making it bitterly cold inside. The only heating is from old, wood burning stoves that spew as much smoke into the wards as they do outside. Children are crowded into barren wards, usually two to a bed. Medical equipment is in short supply, and the medicine cabinets are almost empty. Needles and syringes are reused, and, with no sharps boxes, even walking around is hazardous. Children are paying the price for the war inflicted on this poor country, and their hardship is being perpetuated by the impasse between the Taliban and foreign agencies, namely Unicef and the European Community, over issues of sexual equality and illegal drugs.

    Figure2

    The only ambulance is ready for service at the Indira Gandhi Children's Hospital

    We manage to track down the chief surgeon, who suggests that, in the absence of the hospital president and vice president, we seek final permission for the project from the minister for public health. We rush to the ministry of public health, but the minister, Mullah Abbas, has left and we will have to wait a day to see him.

    Friday 6 March 1998: Kabul, Afghanistan

    Friday (“Jummah”) is the holy day of the week. The Taliban have made Friday prayers mandatory for Muslims, and a register of attendance is kept. I'm surprised to learn that Kabul has a church, and intrigued that the priest has moved Sunday service to Fridays. Kabul also has a large Hindu community, and in the 1970s the Indian government had close links with Afghanistan, and a hand in the development of the children's hospital, subsequently renamed the Indira Gandhi. Those links have long since been severed.

    Saturday 7 March: Kabul

    I return to the ministry of health with the two Davids and our translator, Afzal, who also works for the ministry of education. The Taliban authorities' restriction on girls'education has made foreign agencies reluctant to provide the ministry of education with financial support. By limiting access to education for girls and restricting work opportunities for women teachers, the Taliban have alienated themselves from major funding bodies such as Unicef and the European Community. Afghan society is another example of a culture that absorbed Islam and fashioned it to its own ends. But, although rulers regularly distort religion to suppress women and minorities, the true tradition of Islam is one of equality.

    On our arrival at the ministry of public health, we are immediately ushered in to meet Mullah Abbas, the minister of public health and a member of the Afghan Shura, the chief law making council of the country. The mullah, who seems to have softened his attitude towards foreign agencies according to David Sogan, is enthusiastic about our proposal, and, according to protocol, gives us a letter authorising our work. He also agrees to help release our equipment, soon to arrive at Kabul airport. Mullah Abbas highlights the lack of a cancer hospital, no pathology service, and a dearth of educational material as major deficiencies. All pathological samples are sent to Peshawar. At the back of his room is a short row of outdated medical books. “These are all we have in the entire ministry of public health,” he sighs. Even the BMJ, we are told, has not arrived for six months. A lack of aid is making basic healthcare provision an impossibility. He adds, “Unicef say a lot but they are doing very little. They have not even given us a stethoscope.”

    Authorisation letter in hand, we return to the hospital, and park beside a bullet ridden green van—the only ambulance. Dr Hussain, the hospital vice president, has returned from Peshawar. Pleased that our work can go ahead, he takes us on a tour of the hospital. At the neonatal unit, a filthy blanket is draped over the entrance, hiding a small room with smashed windows and broken incubators. The incubators are unusable. A head box is linked to an ageing oxygen concentrator and is used by the six newborn babies in rotation. The babies are laid on benches and warmed by an electric heater. They look close to death. Shorn of our usual array of high tech medical gadgetry, we feel desperate and impotent and leave to arrange the labourers for the renovation work. Afzal is a trained engineer and is in charge of organising them.

    By late afternoon, we are back in our residence, trying once again to set up an email link to the outside world. Suddenly, a loud explosion shakes the building. The windows shake but remain undamaged. Outside, we see the terrified faces of four small girls who had been playing across the road, smiling and waving at us. They are now frozen with fear. We learn later that a rocket with a 60 km range landed within a quarter of a mile of us.

    Figure4

    Blocked toilets at the Indira Gandhi Children's Hospital

    Sunday 8 March: Kabul

    International Women's Day. The only women in employment are working in hospitals as doctors, nurses, or cleaners, and some who are employed by foreign agencies. Only men work in the government ministries, shops, and schools.

    We visit Tahia Maskan, the main orphanage in Kabul, which was built by the Russians. All the children huddle in the warmth of the renovated wing of the orphanage, which, for Kabul, is a comfortable and pleasant place to live. The World Food Programme, a UN organisation, supplies beans, lentils, and rice. Children in Crisis supplements that diet with fruit and vegetables. None the less, the diet is meagre, and many children have vitamin deficiencies. The neglected part of the orphanage is unclean, cold, and damp. The dining room is dark, with a wet floor and dirty tables. Water seeps in from the kitchen, where the tap drips continuously. The renovated section is in marked contrast. The children sleep here and have classes that are mixed sex for those aged under 5. Some of the teachers are women, and there are two women social workers. The girls are confined to the second floor, which has no toilet, so they either use the roof or sneak outside to the overflowing latrines.

    On our way home, we manage to lay our hands on the Kabul Times, the official Taliban newspaper. An editorial is devoted to women's rights, and I am surprised to read: “The right to knowledge is a mutual right for males and females…. We are truly in need today of women doctors, teachers, and nurses…. Men and women are equal and no one has the right to discriminate between the two sexes, since God Almighty equalled between men and women in all forms of activity and all aspects of work, responsibility, and reward.”

    Monday 9 March: Kabul

    While work continues at the Indira Gandhi Children's Hospital, we visit Malalai hospital, the only tertiary referral obstetric hospital in Afghanistan. We are greeted by Dr Mahmood Nawabi, the only male doctor who works on site here. Eighty usable beds cater for 35-40 deliveries a day. Few of the doctors can perform caesareans, and three male doctors who can, work from home. They operate, but do not see patients before or after procedures. With no on site paediatricians, all neonatal complications are sent to the Indira Gandhi hospital. Dr Nawabi laments: “We tried to get a female paediatrician but no one has been willing to help us. We will be happy to have a qualified paediatric doctor.”

    The state of the hospital is a testament to the dedication of Dr Nawabi and his team. He is paid 150 000 Afghanis a month ($5) and works a 1 in 4 on call rota. “You must help the staff as well,” he pleads. “If there is no help for the doctors, then many more will leave the country.” We leave Malalai hospital impressed, thinking that this is a well organised unit where modern equipment and incentives for doctors will have a huge impact.

    I arrange a meeting with Unicef's project manager, Robert Biakcin, as I have been surprised by the level of criticism of the organisation's work in Kabul. An initially cordial meeting turns frosty when I ask Mr Biakcin why government ministers, hospital physicians, and aid workers feel that Unicef could be doing more for the health care of children in Afghanistan. “We do a lot but don't say very much. NGOs say a lot but don't do very much,” he fumes.

    Night flights are becoming more frequent, making it difficult to sleep, or it may just be that I'm more jittery since the rocket blast two days ago.

    Tuesday 10 March: Kabul

    Work at the hospital is going well, and Afzal's team of carpenters and painters will probably have finished before we leave. All that remains is the medical equipment we sent as freight on Ariana Afghan Airlines, which is arriving today. Brandishing our letter from Mullah Abbas, we try to persuade the customs staff to release our goods. Our hopes are dashed when we learn that we need authorisation from the ministry of finance and an official pharmacist to inspect our medical supplies.

    At the ministry of finance we put our case to two ministers with matching beards and turbans—the younger in black, the more senior in white. A local squats behind me on a window ledge as we discuss the release of our equipment. The ministers readily sign our form. Laughter breaks out as we leave, and I'm relieved when it is explained that the man perched behind me has been ticked off by Black Turban: “Don't sit like a donkey, what sort of impression does that give? These people are doctors.”

    Wednesday 11 March: Kabul

    I'm woken by anti-aircraft fire, which seems near to me, but David Sogan reckons it's at least 10 km away. Rumours suggest that a massive spring offensive is around the corner, as both sides try to inch forward. For now, however, the Taliban are secure in Kabul, and I'm reasonably secure in the knowledge that our flight out of Afghanistan is booked for tomorrow.

    Afzal's team should complete the paediatric intensive care ward today. First, I have a meeting with the WHO representative in Kabul, Dr Abdi Momin Ahmed. Arriving at the WHO's new headquarters, I'm amazed by the opulence of the building, a shining marble palace in a city of dilapidated structures. Even as I enter, more marble is being unloaded from trucks. I ask him about the WHO's justification for such plush accommodation in this poor city. Dr Ahmed looks flabbergasted, telling me that the marble is being imported by the owner of the property and that the WHO is renting the house for $1000 a month, which he considers reasonable.

    By midday, we gather at the hospital to see the fruition of our project. The paediatric intensive care ward has been washed, sterilised, and painted. A wall has been knocked through to increase space, the toilets have been unblocked, and windows have been repaired. All the beds have been painted and fitted with lights, new mattresses, and blankets. Our medical equipment has finally reached its destination and covers the doctors' area in the centre of the room. A new medicine cabinet stands by the door, brim full of drugs. Afzal's beard can't hide a self satisfied grin.

    The medical staff of the hospital are stunned by the transformation. The doctors, mostly women, assemble for training on how to use the new equipment, which we manage to complete before the official opening of the revitalised ward by Dr Abdul Bashir Hassan, deputy minister for public health. Naturally, leaving such expensive equipment is a risk—it may be misused or confiscated by the government for use elsewhere. But medical appliances donated on previous visits are still being used as intended, and, as we leave, Dr Hussain locks the door to the intensive care ward and, reassuringly, begins itemising the equipment.

    Thursday 12 March: Kabul

    Mission accomplished, we're ready for home. We've set up a modern paediatric intensive care ward that can be used as an example to obtain more funding for the hospital. We cram into three Land Cruisers, and a jostle for the better seats leaves Southall and myself on the bench seats at the back of the smallest vehicle. Our UN convoy heads east out of Kabul, rushing through Taliban checkpoints, where less privileged travellers are being frisked. Soon we are racing down the Kabul gorge, sandwiched between sheer, barren rocks and hurtling white waters. The gentle undulations of the road become a rollercoaster, and, as our trade-off for leg room against head room misfires, we are left holding on for dear life.

    The UN drivers don't bother with convoy rules, and, with our colleagues out of sight, we are marooned by a puncture. While we wait for the tyre to be repaired, a crowd quickly gathers, and a slight young man with a pointy moustache picks up a weighty rock and walks towards us. We are perturbed when he raises the rock above his head, but his next move is to throw it away from our vehicle and then draw a line in the ground with his toe. In the absence of Geoff Capes, Southall takes up the challenge of a shot putting contest, which delights the crowd. We are warmly waved off to resume our rollercoaster ride.

    Approaching Jalalabad, we see palm trees and camels, and the environment is more typical of a South Asian city, much hotter and more dusty. A Danish crew fly us straight to Islamabad. A good night's sleep lies between us and our flight home to a different world.

    On reflection

    Afghanistan is a complex country, comprising many poor but fiercely independent races, who tend to distrust each other rather than cooperate. The delivery of health care is similarly blighted: numerous underfunded agencies with differing goals are striving to maintain one of the most basic healthcare systems on the planet. The breakdown in dialogue between the Taliban and leading foreign donors, namely the European Community and Unicef, continues to cripple healthcare provision.

    Although recent months have seen the Taliban further restrict women's movements—foreign agencies were banned from employing local women—it is difficult not to feel that the donor community's heavy handed approach to the issue of women's rights has provoked further repression of women rather than liberating them. The Taliban's reluctance to deal firmly with poppy farmers, whose wares eventually supply drug addicts in the West, has raised another barrier. The Taliban can no longer be wished away: after a brief, but ultimately doomed, attempt at a negotiated peace, divisions within the Northern Alliance have allowed the Taliban to secure their hold on the southern two thirds of Afghanistan and bolstered their ambitions for the rest of the country.

    In Kabul, the Indira Gandhi Children's Hospital is struggling on, desperately short of funds. The renovation of the intensive care ward was intended to encourage a grant from the Department for International Development, Unicef, or the European Community Humanitarian Office, to upgrade the rest of the hospital. Instead, the charities' proposal was not supported. To make matters worse, Jack Bell, field worker in Kabul for Children in Crisis, was left to handle the fury of other non-governmental organisations, which felt that our intervention was inappropriate. “Just a lot of envy, I believe,” he said. “ICU is going fine. We're still doing the hallway and the other rooms, but the one room is full—two babies per bed.” It's nice to know that some traditions don't change. But, reassuringly, on a return visit to Kabul in June, David Southall noted that other non-governmental organisations were refurbishing other wards.

    In July, the situation for aid agencies in Kabul took a turn for the worse when the Taliban ordered all non-governmental organisations to move to the old polytechnic building in Kabul by 19 July. Aside from the potential security risk of being confined in the same area, the polytechnic building has no electricity or running water and is within firing range of the front line. UN organisations like the WHO and Unicef were exempt from this edict, as was the International Committee of the Red Cross. Not surprisingly, all but one of the non-governmental organisations decided to leave Kabul rather than face the consequences of not complying with the Taliban's order. Child Advocacy International and Children in Crisis are currently negotiating with the Taliban for a fairer arrangement, so that their aid work can resume.

    While the political power struggle grinds on, we can only hope that a few of the countless disadvantaged children in Afghanistan will benefit from the changes that were initiated at its main paediatric hospital.

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