I am including a well-written email to friends and family from Dr. Pat O'Connor. He is a pediatrician who has served in the Indian Health Service for a number of years. He is working in Kabul as part of a team that is teaching and developing improved levels of obstetric and newborn health care at one of Kabul's largest maternity hospitals. Resident physicians, their supervisors and a host of midwives performed 72 deliveries there one day this past week. Many of the women have little or no prenatal care available, and only come to the hospital if suffering complications.
Pat and Dr. David Gahn (OB-Gyn and director of this program) have been sharing my apartment with me this past month as housing gets tighter in the ever-expanding Embassy mission in Afghanistan. Both have become great colleagues and friends.
Dear Friends,
I apologize for my lack of writing so far this trip. It's been a trip that has been far more meeting-heavy, and less clinical work, than usual. Unexpectedly, that has made it more busy for me, and I just haven't gotten around to writing ya'll. The "meeting work day" can run the gamut of times, but often involves writing reports on each of the meetings that I attend. The clinical work day is usually 8:30 am to 3:30 pm, as the on call staff at the hospital take over about 3 pm, because the daytime docs (attendings as well as residents) head off to their private clinics. And the "clinical work day" doesn't require near so many written reports...hence my longer working days....
The private clinics are the places that allow Afghan doctors the ability to provide for their families. The salary for a doctor working at a government hospital like Rabia Balkhi used to be $30 per month (when we started in 2003), though now this has been increased to about $250 per month. By comparison, an NGO (non-governmental organization; e.g. CARE International) may offer $1000/month to an Afghan to serve as an interpreter. Indeed, many of the doctors in this country, by virtue of their needing to learn English as the language of medicine, are far better off interpreting, rather than practicing. And it is surprisingly expensive to live here (rents for a family are commonly $400 to $800 per month). A figure that has also been inflated by the presence of foreigners who need a place to stay. This demand really drives up the rent, since the housing is quite limited. There are thousands of civilian foreigners here, many doing great work, but the economic impact for the locals can be surprisingly negative.
And this subject of the economy brings me to my first story. Recently a mother and grandmother brought a very little baby to the nursery at RBH to see my pediatric colleague, Dr. Anis Azizi. He is the "true" pediatrician that I work with, who I've bragged about before. He is now working for our project to follow-up every baby and mother who is delivered by C-section at Rabia Balkhi. This amounts to about 1200 C-sections per year. He contacts each family by mobile phone, and gets information on the mother and baby for up to two years after the c-section. One unexpected bonus of this follow-up is that the people are incredibly appreciative (and surprised) that anyone would care to see how they were doing. And Dr. Anis has been able to give a lot of great pediatric telephone advice to families, when they have a concern about their baby or the mother. This family felt that the baby seemed fussy a lot of the time. So he suggested they bring the baby to see him in the nursery. Turns out that the baby was born very small--1500 grams, or 3 lbs. 5 oz. We have learned from this project that almost every baby born at 1500 gr. and below will die: this is just reality in a resource poor country. Babies under that weight require the kind of high tech care that is routinely delivered in American neonatal intensive care units, but there are none of those in Afghanistan.
Anyway, somehow this baby survived, and is now just over 2 months old. But his weight upon arrival in the nursery was 1.71 kg or a whopping 3 lbs 12 oz. No wonder the infant was fussy--he was starving! And he looked it: all his bones were showing, and he had this "worried" and hyper-alert expression that is typical of starving babies. The mother simply didn't have enough breast milk, possibly partly because the baby was so small and weak, that it just couldn't nurse very well. The baby otherwise looked healthy, and probably just needed to be fed to be able to survive. The family reported that they couldn't afford formula. Dr. Anis found out that the father worked as a cook, and was supporting 5 people besides the baby. He was paid $150/month. The cost of formula (a seldom used thing among the general population in Afghanistan) was about $50/month. There did not seem to be any source of "charity" milk, and so I gave the family $40, which will feed the baby for almost a month. If the mother continues to try to breast feed, and supplements with the formula, this may be enough to allow the child to grow larger and stronger that he may be able to breast feed well on his own and grow into a normal child. Dr. Anis will have the baby return to our nursery in one week so that we can see if he is taking to the formula, and if he has gained weight.
Now to the other extreme: three days ago, I was called by the Director of Rabia Balkhi Hospital, Dr. Najia Tareq. She said that she was speaking with her good friend (and former med school classmate), the First Lady of Afghanistan, about the First Baby. Dr. Najia told Mrs/Dr Karzai that her son was "too fatty," and that she barely recognized him. The First Lady asked if Dr. Najia knew of a good pediatrician, and she suggested the American pediatrician (me!). I was asked to come to the Presidential Palace to examine the child, to see if there was a medical problem with the child. So, after my day of work at Rabia Balkhi, I met Dr. Najia at the entrance to the Presidential Palace and we were escorted on to the grounds. It is a huge complex with a 16 foot stone wall around it, and includes several important Ministry Buildings (like the Ministry of Defense), as well as the living quarters of the First Family. The actual palace is occupied by the relatives of the former king, Zahir Shah, who returned to Afghanistan in 2002 and died here in 2007. He had ruled for 40 years, until 1973 when he went on a trip to Italy. While he was out of the country, his cousin, Daoud, overthrew the monarchy, and started a communist regime, with the assistance of the Soviet Union. This was the beginning of the wars, civil and otherwise, that ravaged the country for the next 30 years.
The relatives of Zahir Shah are allowed to live in the real Palace, out of national "respect" for the family. The Karzai's live in one of the nearby houses, that were originally designed for the relatives of the king, and that is where Dr. Najia and I met the First Lady and Mirwais, her son. The house was very nice, of course, though I only made it to the large sitting room. Mirwais had just turned three, and was playing around in the room with his toy attack helicopter. I thought that was a little sad at first, thinking that he was a child of war, but then quickly thought what every 3 year old boy in the USA wanted to play with--probably an attack helicopter. He was very verbal, and playful, and active, and seemed like a pretty normal 3 year old. I talked to the First Lady about his developmental history, and medical history, and about his diet. She wanted to make sure that he didn't have some kind of "glandular" problem as the cause for his weight. We then weighed him (24.0 kg) and took his height (99cm), and calculated his BMI (24.5). I then gave him a good exam, and delivered my diagnosis: the first "baby" of Afghanistan is FAT!! Everything else on his exam was just fine. And he didn't come close to the heftiest of the American fatties that I've seen. So, we just talked about the usual things: limit television/video time (he doesn't watch TV or play video games), keep him active, and eat a lot more vegetables and fruits. Turns out that his three main food groups were rice, meat and whole milk; a certain recipe for largeness.
I was very nervous going in for the examination, but during my visit, I just felt like I was talking to any other concerned mother about her child. Mrs. Karzai was very pleasant to talk with and asked good questions and was very receptive to advice. I got to play tickle games and peekaboo with the First Baby, while she and her friend, Dr. Najia, took some time to catch up. The First Lady thanked me for coming over to the Palace, and seemed quite relieved that I didn't believe that there was any medical problem with her only son.
As I near my retirement from the US Public Health Service, I am now considering limiting my practice to those children of Royal, or at least, Presidential, birth. Please feel free to forward any referrals who meet that criteria.
I hope all is well back home for you all. I leave for Tucson in one week, on 3 March, and hear that the desert Southwest should have a GORGEOUS Spring because of all the recent rain. I can't wait.
Salaam,
Pat
