MERLIN Afghanistan(Kandahar) Medical Report
JULY and AUGUST 1995.
I: MEDICAL
MERLIN expanded its programme to include theprovision of drugs to Qalat Hospital, in Zabul Province at the end of July. It is hoped tostart physical rehabilitation of one wing of the building and provision of food for the staff and patients inSeptember. WFP has agreed to provide food for work for the rehabilitation work anda daily provision of food for 20 staff and 15 patients. The medical work in Kandahar and Helmand Provincescontinued uninterrupted, despite the increased security precautions and tensions in the area. 1.1 Pharmaceutical Distributions
M mthly pharmaceutical%.1 tributions have now been introduced to all the MERLIN health facilities and the Mirwais Hospital. These have beencalculated on past usage and prescribing habits but with a certain degree of flexibility to allow forchanging patient numbers. Due to the uncertain securty situation September'sallocation for both the district clinics and Lashkargah Hospital were delivered in the second lastweek of August. 1.1.1 Mirwais Hospital:
The package of assistan,e signed by MERLIN andthe MoPH concerning the Mirwais Hospital has + +orked well during these two months. The provision of food to the in- patients has beencarried out to the satisfaction of WFP. MERLIN provides basic equipment andreagents for the laboratory and it is now providinga full range of simple examinations ona daily basis. Theseare free of charge. A minimum fee is being charged foran x -ray examination and the film continues to be supplied by WHO. Three doctors currently work in the male OPD andthey are now filling in their registration books as required and so allowing closer monitoring of drugusage and prescribing habits. Monthly drug quotas have been introduced for boththe out patient pharmacy and theemergency room pharmacy. These have been calculated generously to allow foran increase in consultations or war wounded. Demand for drugs continues to be high and this hasnot always been mirrored in increased patient numbers. On investigation some explanationsappear to be a. Unrecorded prescription of drugs by visiting doctors and other membersof the health care staff. h. Poor prescribing habits in particular prescriptionof unnecessary antibiotics or of two antibiotics simultaneously when only one is required. In an effort to tackle these problems printed prescriptionpads have been provided to the MoPH and MERLIN doctors and the monthly drugquotas are being adhered to more strictly.It is hoped also to do some training with the doctors (seepara 13). The MoPH introducedc,., sultation fees for the patients attending of 200 Afghanis the male OPDon 13/8/95. A fee per consultation is charged and thismoney is used for general running hospital. MERLIN introducedthis fee into its MCH in costs of the taken at the MCH clip tandem with the MoPHand the money e is also returned to the MoPH (seepara 1.2). This appears to have very little effect on the consultationrates. had 1.1.2 DoRahi Clinic:
Dorahi clinic was previouslystaffed by one male and one female doctor v, orking 4 and3 hours respectively. Regretfully thefemale doctor isno longer able to attend the clinic hours of the clinic havetherefore been changed every day. The doctor from Saturday to 5.5 hours a day and it is staffedby the male to Wednesday and by bothdoctors on Thursday.Patients requiring consultation with the femaledoctor are either referredto the Mirwais Hospital Thursday. MERLIN is searchin g for another female doctor. or asked to return on
Consultation feeswere introduced into the DoRahi Clinic on 26/8/95. These feesfollow the MoPH guidelines and themoney collected is given to the MoPH. of the female doctor The introduction of thisfee and the loss seem to have had little effecton the consultation rates which appear stabilised at around 600per v eek. to have
UNICEF introducedan ORT corner into the DoRahi containers of prepared ORS Clinic during July. Thisconsists of two and two cups. These sitnear to the main entrance and the staff been asked to register thenumber of people using this have this slightly and the registrar service. MERLIN hasattempted to regulate now takes the patients with diarrhoeato the ORT corner and explains to them the benefits of ORS.She also gives and it's treatment. Further group health education sessions aboutdehydration health education is given bythe nurses in the MCHroom. 1.1.3 District Clinics:
The work in the 5 districtcliïa.. continues and anaverage of 1100 patients wereseen each week. Around 20 to 25% of thesepatients are seen by the female as women travel longer and longer doctor and this numbercontinues to rise distances to consult witha female medical worker. It was necessary to discontinuethe employment of the for reasons of health worker working inMaywand Clinic gross misconduct. The clinicwas closed for one week whilst found but is now functioningwell. a replacement was
Consultation fees are beingintroduced into the district the MoPH and the Minimum clinics this week. This is inline with both Primary Health Care Planfor Afghanistan. A charge for consultation witha health worker and 200 afghanis of 100 afghanis introduced. for consultation witha doctor is being
1.2MCH
The weekly attendance figures for the MCH clinics forJuly and Augustare shown below. The decrease in the attendanceat the Mirwais clinic in week 3 forbidding all women from was caused by the enforcement ofa rule travelling in rickshawsunescorted and the in week 9 by the MoPH registeringsystem for consultation fee. confusion in Attendance at the MCH clinics
400T 300°s.-` ° Mirwais
200 DoRahi 100 s __--.----_.. Districts
1 0 1 1 1 1 1 1 1 1 1 2 3 4 5 6789 Week N°
The graph below shows the number of malnourished children attending the MCH clinics. The decreases in weeks 3,4 < Malnourished Children Attending the MCH Clinics Mirwais / ` O DoRahi :._.,,,,,i.,...._ ,,;,:: -....2'/ Districts o 1 I 1 1 -r 1 "' ! 1 2 4 5 6 7 8 9 Week N° Discussions were held with all medical, paramedical and nursing staff to improve the system of care for malnourished children and pregnant women. The number of pregnant women attending the clinics stabilised at between 30 and 60 at week and around 25% of these women are attending for their second and third visits. The low number ofre- attendees remains a problem for good ante natal care and appears to be mainly caused by the problems for women moving outside their homes. However it is hoped to discuss with thewomen in more detail the reasons for their reluctance to attend. Consultation fees have been introduced into all the clinics as mentioned above. These apply only to the patients attending the doctors. Patients attending the MCH clinic only and those referred by the nurses to see the doctor are exempt from payment. No severely sick patient will ever be refused consultation for lack of money. Health education continues to be a main feature of the MCH work. Practical training sessions have been held with the clinic staff to improve teaching methods. 1.3 Helmand Province The pha, maceutical distribution to Lashkargah Boost Hospital continues without any problems. Basic reagents and a microscope have been supplied to the laboratory which is working to it's full capacity. . After the original surge in numbers of out patients following MERLIN' provision of drugs the numbers of consultations have stabilised at around 1150 a week. All the staff continue to work 4 hours a day receiving only a minimum daily supply of food. The medical staff substitute their salaries with earnings from there private clinics. This is not, however, possible for the chowkidars and cleaners and for this reason it is difficult to get adequate numbers of people to work in these positions. This leads to problems with hygiene and crowd control within the hospital. In an effort to increase safety in the hospital and relieve some of the pressure on doctors an attempt was made by the MoPH to ban guns from the hospital. This was supported by the Governor of Helmand Province and was successful for some weeks. However with the increased Taliban presence in the town this ruling has again broken down. An MCH clinic has now been set up in the hospital. The clinic has been set up by the staff along the same lines as the previous MCH clinic which closed after the invasion of the Russian forces. The clinic is ; `.erefore concerned purely with preventative medicine, ante -natal care, health education and monitoring of nutritional status in children. The female and child OPD is a seperate clinic. There was much initial confusion over the provision of food to the children by the clinic. The previous policy in the 1970's had been to distribute food to all pregnant and lactating women and all children under six years of age and this was still the expectation of all the staff and mothers. Attempts have been made to emphasise the importance of health education and the mother's understanding of her problems. Unfortunately due to staff abscences and the disturbances due to the presence of work men for physical rehablitation of the building the clinic has not been able to work on a very regular basis and was operating for only 20 days between the 10th of July and the end of August. 1.4 'Training MERLIN started training Traditional Birth Attendants (TBA's) in the villages in July. Four groups (thirty seven women) have completed their training in Daman and Dand districts and fourteen women are currently receiving training in Arghandab district. The course covers the WHO TBA teaching material but is adjusted according to the needs of the community. The course concentrates on teaching the older women of the villages who are currently working as TBA's. The trainers have met with a very good reception from all the villages. Although this form of training has not been previously carried out in these areas many of the people are familiar with the idea from Pakistan. The District Clinic Medical Supervisor continued his teaching of the health workers. The subjects covered included diarrhoea) diseases, anaemia, pain, fever, ear infections and gastritis. The four health workers who received this teaching were given a formal assessment at the end of August and were found to be satisfactory, all scoring over 60 %. "Iwo of the health workers attended a 3 day training course on Control of Diarrhoea! Disease run by WHO. This course will be repeated this month and it is hoped that one health worker and a n fn.se from DoRahi and Mirwais MCH clinics will be able to attend. Two of the health workers will attend a refresher course for mid -level health workers at the AHDS /AVICEN training centre starting on 5/9/95. This is a residential course lasting 3 weeks. Locum health workers will be employed during this time. This course will be repeated in the next few months and it is hoped that two more of the MERLIN health workers will be able to attend. Training sessions were held with the MCH staff at regular intervals. Subjects discussed included problems with breast feeding, care of the malnourished child and treatment and advice for the child with diarrhoea/dehydration. Two discussions sessions were held with the MERLIN doctors to discuss care of the malnourished child and the place of antibiotics in the treatment of diarrhoea. Guidelines for the treatment of anaemia were also distributed, During the next few months, it is hoped to work in close co- operation with the AHDS / AVICEN training staff and Kandahar City doctors to compile treatment guidelines for the common diseaes of the area. 1.5Data Collection: The data collection has been slightly altered to a weekly surveillance system of sentinel diseases from the Mirwais OPD / Do Rahi clinic and the 5 District Clinics. Weekly morbidity data and data on diarrhoea) illnesses from all these facilities are supplied to WHO / UNICEF and the MoPH. It was pleasing to note that through the system, MERLIN picked up a ? cholera outbreak even before the overall diarrhoea rates increased (see 1.6). The diarrhoea rates are now decreasing in all facilities. Monthly laboratory data from Mirwais Hospital and Do Rahi Clinic are also being collected and given to WHO / UNICEF and MoPH. Entamoeba histolytica and Giardia lamblia are found frequently. Of the positive MP smears, less than 20% of them are P. falciparum (NB: on very small numbers though, 25 / 146). 1.6 Cholera Outbreaks. In early to mid July, cases of suspected cholera were reported from one of our District clinics (Mundisar). This was noted prior to the more general increase in the number of diarrhoea cases that was reported from the health structures that MERLIN supports. WHO reported other sporadic suspect cases in 1 other District and possibly within the city itself. The number of suspect cases were always small and isolated geographically to one or two areas. One case (a 5 year old child from MERLIN Clinic in Mundisar in mid July) was confirmed to be Vibrio cholerae by swab testing, via the WHO laboratory in Islamabad. As far as MERLIN knows, this was the only confirmed case in the Province but very few swabs were sent for testing.In the last weeks of August, the numbers of diarrhoea cases being reported have fallen. In mid August, .MERLIN was requested to do a follow up evaluation to a prior UNICEF visit, regarding a possible cholera outbreak in Kajaki District in Northern Helmand. 2 MERLIN team members went on a 2 day evaluation to the District. 3 towns and 4 villages were visited during this time. Although there had been a number of deaths from diarrhoea and vomiting ( 14 over a 15 day period, 6 were under 5 years of age and 8 over 5 years of age. NB: there was no idea of total number of D +V cases over the same time period), in an area with such poor health facilities and during the summer months, many of these deaths would unfortunately be expected. Some sporadic cases of cholera may have occurred but there was nothing to warrant an emergency intervention by MERLIN. In each village visited, a stock of ORS was distributed to an identified individual who would act as the ORS centre for that particular village. Time was splint with the village elders and mullahs passing on basic Health Educationmessages, with requests for the mosques to act as centres for disseminating the same HE messages to the villagers. A stock of ORS / Ringer'slactate solution / tetracycline and cotrim, plus equipment,was left in the AVICEN clinic based in Kajaki town itself. MERLIN's findings were discussed with the local authorities in Kajaki before theteam returned to Kandahar and were then transmitted to the MoPH / WHO and UNICEFonce the team was back in Kandahar. Also in mid- August, MERLIN launched, from Kandahar,an emergency response to a suspected cholera epidemic in Badakhshan. Worryingly high numbers of reported deathsfrom diarrhoea (with average case fatality at 12.1% for the July /August period), combinedwith extremely poor coverage by limited health facilities (suggesting under -reporting), and added to 1 confirmed cholera case tested in Islamabad, prompted MERLIN to send a team of 1 doctor and 1 logistician toset up the initial response. They were then relieved by anew team from London, who continued the active case -finding in remoter regions, setting up ORS points in all affected villages,and equipping central facilities with sufficient supplies and training. The initiative continues untilOctober, funded as a contingency on the Kandahar programme. 1.7: Other Medical Issues: August saw the official opening of an orthopaedic workshop in the grounds of the Mirwais Hospital. The workshop is run by the Afghan Rehabilitation Team (ART) andproduces and fits prostheses. The ICRC First Aid Post is working to it's full capacity and patients requiringmajor surgical intervention are transferred by ambulance to Quetta. ICRC have started the physical rehabilitation of the Mirwais Hospital. They propose toopen a 150 bedded surgical unit and to relocate the services from Quetta to Kandahar. The AHDS /AVICEN run Regional Training Centre is running well and hascompleted two refresher courses for Basic Health Workers and two months ofa three month initial course also to train Basic Health Workers. AVICEN have successfully completed phase 1 of their involvement in the MinimumPrimary Health Care Plan for Afghanistan opening a number of health facilities aroundKandahar, Helmand and Zabul provinces. They are interested in incorporatingsome of the MERLIN health facilities in Phase 2 of this plan. Hazel Simpson MCH Coordinator MERLINAfghanistan(Kandahar) MedicalReport SEPTEMBER1995 Medical Overview: MERLIN continuedits work in Kandahar, three provincial Helmand and Zabul hospitals anda city clinic, all providing provinces where itnow supports general medicalfacilities, and five full -time MCHservices as wellas more district clinics eachproviding a full -time basichealth care. once weekly MCH clinicand 1 PharmaceuticalDistributions The system of providing monthlypharmaceutical distributions MERLIN is workingwell. to all the health facilitiessupplied by 1.1 MirwaisHospital The MoPH changed it's working hoursat the beginning of all the MoPH in the month. Thehours of working the Mirwais Hospitalare now officially Sam for MERLIN has changedthe hours of work - 2pm. In accordance withthis The incentive of the MCH clinicto Sam- 1.30pm. package for the MirwaisHospital basically have been minorproblems with the continues to workwell althoughthere One of the three doctor's attendance. doctors who previouslyworked in the male wards. OPD isnow covering the in- patient The doctors in the Mirwais Hospitalare now seeing an these patientsare seen in the MCH clinic average of 850 patientseach week; 75% of and 25% in the maleOPD. Our drugs continue to go to two pharmacies:one for the MCH and Emergency Room andin- patients. OPD, the other forthe The Mirwais laboratory continues to receivelimited supplies from for more extensivesupport. MERLIN, and WHOhave plans 1.2 DoRahi Clinic Unfortunately, MERLIN has not been unable to find another female doctor towork in DoRahi clinic despite much searching. Most of the women coming to the clinic are happy tobe seen by a male doctor with a chaperone. The female doctor from the Mirwais MCHclinic has been visiting once weekly but due to the increase inthe numbers of gynaecology patients this will now be extended to twice weekly. AHDS are opening a MCH clinic staffed initially by Ifemale doctor near the centre of the city. Thisclinic is much closer to DoRahi than the Mirwais and so will provide women with an easier alternative. MERLIN has employed a secondmale doctor for the clinic to cope with the continued high number of consultations. Despite a steady decrease in the number of patients with diarrhoeal diseaseand the opening by AVICEN of a C2 clinic within one hours walk, attendance at the DoRahi Clinicremains high. Consultation figures average 580 patients/week. Basic rehabilitation work has started to extend the DoRahi Clinic building by one more room.This will allow a vaccination post to be opened inside the clinic. The post will hopefullybe open six days a week providing basic childhood and maternal vaccinations. 1.3 District Clinics The Health workers from Shawalicoot and Mundisar Health Centres attended a threeweek refresher course at the Regional Training Centre this month. Locum health workers were employed in these two clinics. The five district clinics continue to see an average of 1100 patients a week and25% of these patients are seen by the female doctor. 1.4 Helmand Province This month saw a new Minister of Public Health in Helmand. Mullah Barrie wasmoved to the Department of Education and replaced by Mullah Mohammed S harf. It was discovered at the beginning of the month that drugs had been transferredfrom Lashkargah to Girishk Hospital during the recent hostilities. This wasdiscussed with the MoPH and MERLIN's position on the subject was reiterated. The new MoPH stated that cleaners working in the hospital would receive a salary fromthe last week of September. The MCH clinic ran most days this month despite the absence of some of the staff. Theclinic is attracting many malnourished children and poorly nourished pregnant women from the surrounding area. There is still little understanding amongst the staff about the role of health education and how to pass on information to the women. It is hoped that the staff of theclinic will be able to visit the clinics in Kandahar to gain a better understanding of their potential role. 1.5 Zabul Province September saw some problems with the drug provision to Qalat Hospital as it appeared that the drug register was not being completed. This led to delays in starting the physical rehabilitationof the building, the dispatch of the monthly drug quota, and the provision of food to staff and patients. However after much discussion with Mullah Hakim (MoPH) and other staff membersit seemed that there had been a certain amount of misunderstanding over the system of drug registration suggested by MERLIN. This has now been clarified and monitoring will continue. MERLIN has also agreed to help establish the laboratory at the hospital and will be providingbasic supplies. 2 MCII The number of children attending the city MCH clinics seems to have stabilised out at an average of 300 children per week in each clinic. The staff are now concentrating more effort on teaching the mothers of vulnerable children and this has sometimes left them too busy to weigh all the children. When this happens the general appearance of each child is checked and the thinner children are weighed and registered. For this reason they do not have such accurate figures for the total number of children attending the clinic this month. The number of pregnant women attending the clinic remains between 30 and 50 a week as shown below. Week 1 Week 2 Week 3 . Week 4 N° of 1st Visits 25 28 29 32 Re- attendees 10 12 8 15 Total N° of Pregnant Women 3 5 4 0 3 7 4 7 The graph below shows the total number of malnourished children attending the clinics each week since the beginning of July. This includes both children on their first visit and re- attendees. Malnourished children Attending the MCH Clinics 80 60f . A Mirwais 4 0 .--./1 . ',...... 20 DoRahi ..-.¡..-f.-+/,--..._...n ..-._.---- 0' i r t t I Districts 1 2 3 4 5 67 89 10 11 12 13 Week N° N.B Since week 10 children between the ages of 1 and 5 years have been monitored for malnutrition using the weight for height measurement. Previous to this the weight for age measurement was being used. On changing from wt/age to wt/ht some of the children previously judged as malnourished no longer qualify. More accurate statistics have been collected on the malnourished children attending the clinics and the results are shown in data collection. ( para 1.5 ) 3 Training The TBA training continued this month with the successful completion of thecourse by all fourteen women from Arghandab. Three new courses were started in Maywand district. The Health Workers from Mundisar and Shawalicoot Health Centres attendeda 3 week refresher course for mid -level Health Workers. The course was taught by AVICEN trainers in the AVICEN /AHDS Regional Training Centre. The work of the two HealthCentres continued throughout this time, staffed by locum Health Workers. Two of the nursing staff attended a 3 day trainingcourse on the Control of Diarrhoeal Disease. This was a repeat of the course. held in August whichwas attended by two of the MERLIN Health Workers. Two of the nursing staff and three of the Medical staff attendeda 5 day workshop on Control and Treatment of Malaria run by WHO. It is hoped that the staff attending boththese courses will be able to pass on their newly acquired knowledge to the other nursing and medicalstaff through a series of informal teaching sessions held during the next month in the MERLINoffices. One of the nursing assistants and one of the female registrars attendeda 6 day training course on mother and child heahh care including subjects suchas pre- and postnatal care, childhood and maternal vaccinations and nutrition. The coursewas run by AHDS and included one of the MERLIN doctors and the expat nurse as guest speakers for four of the teachingsessions. The attendees were all female and included nurses, vaccinators, health educators andnursing assistants working for NGO's or MoPH. Fourteenwomen attended fromKandahar and Helmand Provinces. The course took place in the Mirwais Hospital with fullsupport from the Minister of Public health. The MERLIN doctors are now meeting once weekly for informal discussionson current medical issues and practices. Plans to support the resources of the Training Centre include the provision ofsupplements on specific topics for the pre -existing health worker curricula and thepurchase of text books for the Iibrary. 4 Data Collection: Due to the increase in the number of malnourished children attending the city clinicsand the decreased food security expected during the winter months MERLIN hasstarted to collect more accurate statistics on the malnourished children attending both the city and district clinics. Some of the results for September were as follows: For children under 1 year of age: Week 1 Week 2 Week 3 Week 4 Mildly malnourished 6 6 1 6 Severely malnourished 7 9 8 3 Total 13 1 5 9 13 For children between 1 and 5 years of age: > 80% weight for height 8 8 14 11 < 80% weight for height 12 12 11 11 Total 20 20 15 22 Re- attendees 19 20 24 [ 18 N.B. The judgement of 'severely' or 'mildly' malnourished for children < 1 year is made purely on subjective grounds from the nurses general impression of the child's condition. On further investigation it would appear that the reason for the proportionately high numbers of severely malnourished children is that mothers do not bring their otherwise healthy children to the clinic unless they appear "very thin and unwell ". Further information is being collected in PoRahi Clinic where all the malnourished children are being sent to the laboratory for the following examinations: Haemoglobin and stool microscopy for worms and /or giardial cysts or trophozoites. The numbers of malnourished children attending DoRahi Clinic are lower than the Mirwais Hospital but unfortunately it is difficult to collect similar information from the Mirwais as this is not a MERLIN laboratory and is already very busy. Currently only selected/high risk malnourished children undergo these tests in the Mirwais. Between July and September all pregnant women attending the two city MCH clinics for their first visit were asked questions relating to childhood mortality in their families.Questions asked included the number of children who had died, their sex, their age and the cause of death if known. The data was adjusted to exclude death due to injury and a comparison between deaths in male and female children was made. The results were as follows: Children died between the aces of O and 14 days: Clinic Attended 1Iale Female , Mirwais 8 7 DoRahi 18 16 Children died between the ages of 15 days and lvear: Clinic Attended Male Female Mirwais 88 76 DoRahi 125 124 Children died between the ales 1' ear and 5 years: Clinic Attended Male Female Mirwais 7 33 DoRahi 34 30 Total number of childhood deaths from both clinics: Male Female Total excluding Neonatal Deaths 253 266 Total of All Ages 279 289 The result shows no significant difference in the number of deaths in each gender group. Cholera Outbreaks. There have been no more reported cases of cholera from any of the MERLIN health facilities. HUMAN RESOURCES: At the end of September, the expats in the field are: Nick Weatherill - Coordinator James Foote - Logistician Hazel Simpson - MCH Coordinator Michael Roe - Doctor Hazel Simpson MCH Co- ordinator.