Troubled Afghan hospital needs Canadian SWAT team ================================================= * Wayne Kondro * © 2007 Canadian Medical Association Canada's doctors should “adopt” the ill-equipped Mirwais Hospital in Khandahar as a contribution to reconstruction of war-torn Afghanistan, a Paris-based international development security policy research group argues. And to that end, the Canadian International Development Agency should fund a physician-led initiative to upgrade all facets of operation at Mirwais, including monies to send a SWAT team of Canadian doctors, medical educators and health care administrators to Khandahar to elevate capabilities and standards at the troubled facility, Senlis Council president and lead field researcher Norine MacDonald said in an interview. ![Figure1](http://www.cmaj.ca/https://www.cmaj.ca/content/cmaj/177/8/837/F1.medium.gif) [Figure1](http://www.cmaj.ca/content/177/8/837/F1) Although the International Committee of the Red Cross has moved to elevate surgical capacity at Khandahar's Mirwais Hospital, it remains what an agency official calls “an Afghan hospital.” That includes rusty, rickety equipment; unhygenic conditions and inadequately trained staff. Among aspects of hospital operations that must be improved are record-keeping, hygiene, housecleaning, laundry, dietary services, the use of medical gases, the coordination of supplies and basic surgical practice. Image by: Senlis Council While the Canadian International Development Agency claims to have spent $5 million to upgrade the hospital and a further $350 000 for a maternity ward on its grounds, an Aug. 6 tour of the facility by Senlis found “no evidence” whatsoever that the monies have actually been spent and led to any significant change in the appalling conditions at the facility (*CMAJ* 2007;177[2]:134). “We weren't able to validate that that money had arrived,” MacDonald added. “We certainly didn't see any evidence of that $5 million in the hospital. So what we were left with was a lot of unanswered questions.” Those findings indicate there's a desperate need for a third party to become involved to oversee refurbishment of the facility, including a program to elevate and update the skills of its physicians, MacDonald said. “We've been talking about our grave concerns about the situation at Mirwais Hospital to the Canadian government for months now and we haven't seen any substantial change in the situation, in the hospital, over that period of time, so clearly something else has to be done.” ![Figure2](http://www.cmaj.ca/https://www.cmaj.ca/content/cmaj/177/8/837/F2.medium.gif) [Figure2](http://www.cmaj.ca/content/177/8/837/F2) Patients in the overcrowded “malnutrition ward” at Mirwais Hospital. Image by: Senlis Council “What we would hope for Mirwais Hospital is that Canadian doctors would adopt that hospital and really use that as an example of Canada's commitment to Khandahar and the Afghan people. What we would like to see is a group of people from the Canadian medical community work on the renovation, the training, the operating, the resourcing of that hospital.” “What do they need? They need training. They do need equipment. They need an understanding of what the basics of modern medical practice are. The doctors and the people who are working in that hospital are incredibly dedicated and we know they are working long hours and far into the night to deal with the victims of the fighting there. But their training is out of date. They don't have any access to any type of continuing education.” “Mirwais needs short-term, medium-term and long-term help. And I think eventually people from the medical community would recommend there be an expansion of the facility. It's the only medical centre in southern Afghanistan. We don't know exactly how many people live there. There hasn't been a census. But there are millions [an estimated 8] in southern Afghanistan and on top of that, it's a war zone hospital that's dealing with the casualties.” “I think this would be an easy job for the Canadian medical community to go in there as a sort of medical SWAT team. It's well within their capacity to do that job and bring it up to even the most basic standard.” Much of the coordination work could be done in Canada, but ideally, a special civilian team should be sent into the hospital to develop and implement a raft of basic programs, including ones on record-keeping, hygiene, housecleaning, laundry, dietary services, the use of medical gases, management of supplies and basic surgical practices, MacDonald said. MacDonald said Senlis' recent tour of Mirwais indicated there have been a few positive developments within the facility, including the establishment of a very basic pharmacy and installation of a new water tank on the roof. There's also some indication the International Committee of the Red Cross has moved to help Mirwais develop its surgical capacity and a triage system. ![Figure3](http://www.cmaj.ca/https://www.cmaj.ca/content/cmaj/177/8/837/F3.medium.gif) [Figure3](http://www.cmaj.ca/content/177/8/837/F3) One of 2 operating theatres at Mirwais Hospital in Khandahar. Image by: Senlis Council But Mirwais remains an unhygienic, inadequately equipped facility, the Council says in an updated report. The pediatric malnutrition ward “remains dangerously overcrowded and under-resourced,” while the 2 operating rooms and intensive care unit are overwhelmed. “The overcrowded ‚open ward' format of the Intensive Care Unit does not allow for the containment of infectious diseases, and there is no monitoring or resuscitation equipment in the ICU. The airway management equipment remains limited, and there are no ventilators. The operating room consists of 2 theatres with 2 operating tables in each theatre, and surgical instrument sets are stored wrapped in stained worn cloth.” Senlis inquired about the Canadian maternity ward project and was directed to a tent on hospital grounds. “We did find one large tent on Mirwais Hospital grounds but when we there, it was an empty tent. When we went back the next day to film it, it was gone. So we were not able to validate the presence of a Canadian/CIDA [Canadian International Development Agency] maternity care project at Mirwais Hospital.” MacDonald said a series of emails from the Canadian International Development Agency indicated a $5 million grant (later reduced to $3 million, according to an Aug. 20 email to Senlis from Michel de Salaberry, senior civilian coordinator for the Department of Foreign Affairs) was given to the Red Cross to improve Mirwais. But the Red Cross says Canada did not make a special allocation for the facility. “We received $1.7 million Swiss francs for medical activities in Afghanistan and $1.7 million Swiss francs for general ICRC activities but no money specifically allocated for Mirwais Hospital. ICRC accounts are regularly audited by external companies and are publicly reported,” said spokesman Simon Schorno. ![Figure4](http://www.cmaj.ca/https://www.cmaj.ca/content/cmaj/177/8/837/F4.medium.gif) [Figure4](http://www.cmaj.ca/content/177/8/837/F4) Surgical instruments are stored in rags between use. Image by: Senlis Council Asked if the agency takes issue with Senlis' description of conditions at Mirwais, Schorno replied that while the Red Cross is working to improve surgical capacity, “we're not by any stretch of the imagination saying this is a perfect facility and that we have resolved all the problems there. The fact is, this is an Afghan hospital, where obviously, health services, in general, need support, and need to be upgraded.” A senior Canadian International Development Agency official, speaking on condition of anonymity, said Senlis errantly assumed Canada's contribution was earmarked for Mirwais, rather than to the Red Cross' overall Afghanistan program. “We do a package of things of health. Obviously, there's a lot of work on vaccinations, a lot of work on emergency medical supplies to families and stuff. With respect to Mirwais Hospital, the Red Cross is the lead implementer of the reform agenda and the sort of bringing this hospital to the next level. So the Red Cross is the primary link with us on support for improvements there.” ![Figure5](http://www.cmaj.ca/https://www.cmaj.ca/content/cmaj/177/8/837/F5.medium.gif) [Figure5](http://www.cmaj.ca/content/177/8/837/F5) The Mirwais Hospital morgue, like other sections of the facility, is altogether primitive. Senlis Council officials say they aren't certain whether it is refrigerated. As is evident, it's definitely not attached to any manner of pathology lab. Image by: Senlis Council With regard to the vanishing tent, the official said the $350 000 was similarly a contribution to a maternal health program being conducted by UNICEF, not a specific capital commitment to a maternity ward at Mirwais (as previously stated in Canadian International Development Agency documents). Moreover, the $350 000 is but a prelude to a broader, forthcoming $10 million initiative to reduce maternal and infant mortality, which will be overseen by UNICEF throughout all of Afghanistan, not just the Khandahar region, he stressed. “What we're seeing at Mirwais, with UNICEF is a partnership which we think is going exactly in the right direction. If Senlis knew enough to ask the right people the right questions, they would have had their facts straight.” ![Figure6](http://www.cmaj.ca/https://www.cmaj.ca/content/cmaj/177/8/837/F6.medium.gif) [Figure6](http://www.cmaj.ca/content/177/8/837/F6) Last spring, the Canadian International Development Agency said it invested $350 000 in a UNICEF project to establish a residential obstetrics care facility at Mirwais. When Senlis inquired, they were directed to an empty tent. A day later, it had vanished. Image by: Senlis Council “The $350 000 is making a capital contribution [the tent] as well. It's got some training elements of it, for emergency obstetric training. It's got some local consultations element and that's got very well. And it's got a provision for some of the capital supplies.” The future $10 million outlay “is actually going for larger scale emergency, obstetrics and care services providers training. So we're going to [train] 90 separate professionals [in Khandahar province]. We're also doing supplies and equipment to over 40 emergency obstetric care facilities, including Mirwais,” as well as training 425 other health workers. Within 6 months, the maternity ward “will actually see the light of day.” The official did concede, however, that the videos and pictures taken by Senlis are indicative of a need to significantly improve conditions at the facility. The Red Cross, he added, has “just concluded an agreement with the [Afghanistan] ministry of public health to take on that overall upgrading process. And so, the support that we've given through the consolidated appeal and what they're building up right now is actually going to cover all facets of hospital improvements.” But Mirwais “still has a long way to go,” he added. “We think that the Red Cross is actually the best institution that we could possibly think of, to take on that upgrading task.” To that end, Canada will make additional contributions to the Red Cross. “We're ready and willing to provide support for any of their recommendations to try to deliver on that [Mirwais] upgrading program.”