It has been said that it is better for the Afghans to do it “good enough” to an Afghan standard than for us to do it for them. Some Afghans seem very happy to have us buy them their fish, clean it, cook it, and even take care of the dishes. We are here to teach them to fish. And teach them we will. In fact, the best way for us to teach them to fish is for us to teach them to teach others to fish. That is the point behind what may be our most gratifying efforts. On the Coalition and ISAF medical mentor/advisor side, we recently published a 150-page medical mentor handbook, containing everything we wish someone had taught us in predeployment training. It is a living document that will be translated from English into French for distribution to any one of the other 40-plus NATO nations who may participate in the NTM-A medical mission in the future. On the ANSF side, we have now trained over 100 Afghan medical personnel in faculty development, teaching Afghans how to teach medicine to other Afghans. That will be the key to sustainability. In the coming year, in cooperation with USUHS, University of Nebraska Medical School, and the Nebraska National Guard, we will be starting true Graduate Medical Education, focusing first on warfighter services like trauma surgery, intensive care medicine and nursing, preventive medicine, and rehabilitative medicine.
The Afghans have already shown a remarkable ability to practice to their own standards. The crown jewel of our efforts has been the creation of a real ICU at the National Military Hospital with a series of US Navy medical ETTs showing the way. In a little over a year since starting the ICU, the Afghan-US partnership has equipped and staffed ten ICU beds and decreased initial ICU mortality from 30% to now 5% while the number of occupied ICU beds has more than doubled. Not bad, but how are we doing outside the Afghan capital and the flagship hospital of the ANA? A recent blog by a news network not necessarily friendly to our efforts made a comment that being sent to the ANA’s Kandahar Regional Military Hospital (KRMH) was tantamount to a death sentence. That followed several comments made by some of our Coalition medical partners in southern Afghanistan that the mortality of patients transferred from those coalition MTFs to KRMH was 98%. That seemed a bit high, so I asked the ETT on the ground. Maj (Dr) Herman Ellemberger, Emergency Medicine advisor at KRMH, summarized the data he had so wisely already been collecting: From July to December 2009, the overall KRMH mortality was only 4%! That is hardly a death sentence. In fact, many a developing nation in an asymmetric insurgent war would be quite proud to perform to such a level.
What else are we doing to develop ANSF healthcare? Several months ago, CSTC-A initiated a medical special pays program that significantly increases the pays of physicians, nurses, and even Combat Medics. But as we started looking very closely at actual hospital staffing to increase capability in hottest combat areas (Kandahar), we realized that we could not easily confirm that the physicians in the physician slots really were physicians. There are many medical personnel who may have been working years in physician slots who have never actually been to medical school. In January 2010, we will start a formal credentialing process. Pending ANA and ANP SGs approval, we will interview each person in a hospital physician slot to document their training history. We fully expect that a few individuals in physician slots will say “The Taliban ate my medical school diploma.” For some physicians, that may be true. Then all physicians will be required to take a knowledge assessment test, probably the same test required on graduation from Kabul Medical University. If they “pass” to the Afghan standard, we will continue to endorse their physician special pay. If they do not pass but want to continue to receive physician special pay, we will require they take extensive CME and retake the test 6-12 months later. We expect resistance to this program, especially from older personnel. The end product should be medical personnel who are motivated to improve their medical knowledge and practice.
