Mutilation and death are daily occurrences in the lives of many Afghans. The police are especially vulnerable. They will often be the first to arrive at the incident site after an enemy attack, and they are frequently exposed to violence themselves. As part of the Norwegian Police Advisory Team (NOR PAT) – the Norwegian Armed Forces’ police advisory contribution to Afghanistan – I developed a model for reinforcing medical preparedness in the police in Mazar-e Sharif in Afghanistan in the autumn of 2013.
Norway’s military engagement in Afghanistan has been controversial, and in this article I will not discuss the background for the Norwegian engagement. I wish instead to provide an example of the opportunities for international health work that the Norwegian Armed Forces provide.
High mortality in the police
Police activities in Afghanistan tend to have a more pro-active character than what we know from police work in Norway. The police function largely as a paramilitary security force in addition to performing police work in the more traditional sense. In large and small military operations, the police fight shoulder to shoulder with army personnel against rebels and criminal networks.
In the last decade, the police in Afghanistan have suffered considerable losses in combat action and terrorist attacks. The mortality rate among police officers who have been injured in combat (the case fatality rate) is currently high, exceeding the level of the Afghan army (36 % as against 22 %) (Afghan National Security Forces (ANSF) casualty data, January – July 2013, International Security Assistance Force (ISAF). Figures published with permission from Captain Stephen Olsen, the Norwegian Armed Forces’ press officer in Afghanistan in the autumn of 2013). In comparison, the corresponding figure for American soldiers during the Second World War was 30 %. In the current conflict in Afghanistan, the rate for the coalition forces has decreased to somewhat less than 10 % (1).
In Afghanistan, provision of medical services during police operations and evacuation and hospitalisation of wounded officers is the responsibility of the police themselves. These tasks are mainly undertaken through the police’s own health infrastructure. In Mazar-e Sharif, the police have a separate police clinic, equivalent to a large GP’s office with an ambulance service. In Kabul, the police have their own hospital. The police in Mazar-e Sharif have no hospital of their own, but use partly the army hospital and partly the public hospital in the city.
Supporting medical development
Through the Anaesthesia Project (2), implemented in the period 2006 – 12, Norway helped develop the anaesthesiology department of the public hospital in Mazar-e Sharif. Despite the Norwegian efforts in the field of anaesthetics, the hospital currently has limited capacity to support the police in case of traumas, because of a shortage of competence in the field of trauma surgery (personal communication, Dr Seddiqi, senior consultant in anaesthesiology, Balkh public hospital).
For many years, ISAF has placed major emphasis on developing the medical capacity of the Afghan army (personal communication, Colonel Dr Fazekas of the Hungarian Defence Force and head of ANSF Medical Development Branch of ISAF Regional Command North). Today, the army hospital in Mazar-e Sharif has well developed services for treatment of traumas, even in comparison with Western standards. The hospital is committed to maintain a «uniform-blind environment», meaning that the army and the police are entitled to equal medical treatment services at the institution.
The members of the police health advisory team. From left: vehicle commander/Second Lieutenant Erik, vehicle operator/Enlisted Soldier Eirik, doctor/Commander Jon Magnus and nurse/Lieutenant Arne. Photo: Norwegian Armed Forces.
Into battle with no medical services
Based on the fact that the police have direct access to the advanced trauma capacities of the army, I regard their relative excess mortality after injury as a result of challenges inherent in the police’s own pre-hospital practice.
The time immediately after a trauma, «the golden hour», is crucial for the patient’s survival (3). In Afghanistan, the police operate in an environment where external medical support/reinforcement cannot be counted on. Pre-hospital medical preparedness in the police force thus depends on solid medical competence and the availability of basic medical equipment among all police officers.
Police training in Afghanistan encompasses eight weeks at a «basic patrolman course», including half a day of first-aid training (personal communication, Colonel Dr Fazekasof the Hungarian Defence Force and head of ANSF Medical Development Branch of ISAF Regional Command North). In addition, according to Afghan guidelines, each police officer should be issued with personal medical equipment/first-aid kit (tourniquet, pressure bandage and nasopharyngeal tube). However, actual first-aid skills and access to medical equipment in the Afghan army have not been systematically investigated.
My observations of the medical training provided during the «basic patrolman course» made me doubt whether this course was suitable for providing the police students with necessary basic first-aid skills. Moreover, a considerable proportion of the police officers with whom I later spoke in Mazar-e Sharif stated that they had never undergone any kind of first-aid training, despite the fact that they had recently completed the «basic patrolman course», and none of those whom I spoke to reported having access to personal first-aid equipment. During ISAF’s half-yearly public health conference in Kandahar in the autumn of 2013, I heard of similar experiences from the other regions of Afghanistan.
The Afghan police operate in a very violent environment. There is reason to assume that a large number of Afghan police officers are exposed to a risk of violence on a daily basis, without having real access to basic medical preparedness. Such absence of medical services carries an unacceptably high human cost, and also serves to render the police force less robust.
Health for development
NOR PAT is Norway’s advisory unit for the Afghan police, subject to ISAF command. The unit’s mandate is to contribute to a sustainable development of the police in Mazar-e Sharif in Northern Afghanistan. NOR PAT’s development strategy has previously placed little emphasis on medical services. In my opinion, health is a key element in the development of sustainability. As doctor in NOR PAT I therefore saw a considerable potential in upgrading medical services at the pre-hospital level in the police force in Mazar-e Sharif.
A diploma is awarded to a participant. Photo: Norwegian Armed Forces.
In line with NOR PAT’s general advisory assignment and in close collaboration with ISAF’s medical command, NOR PAT, under the leadership of Colonel Halvor Johansen, established the first police health advisory team in Northern Afghanistan in the autumn of 2013. The team consisted of nurse/Lieutenant Arne, vehicle commander/Second Lieutenant Erik and vehicle operator/Enlisted Soldier Eirik, in addition to the author.
The key to better police health
We were quickly able to collect detailed information on the situation with regard to medical services in all police districts in Mazar-e Sharif on the basis of the close collaboration between the advisory teams of NOR PAT and the heads of police in the city. Major-General Ehsas, head of the police in the Balkh province, also contacted us early on with an invitation to undertake a detailed review of the capacity of the police clinic in Mazar-e Sharif.
The results of our mapping of the medical services in the police districts were disheartening. We were unable to identify a single police officer charged with any particular tasks or responsibilities related to medical services in any of the city districts, and there appeared to be little updated competence in the medical field on which to build.
The police clinic in the city, on the other hand, appeared to be professionally solid. On the basis of the medical competence among the clinic’s staff and their access to medical equipment, consumables and drugs, I assessed the clinic as largely able to provide adequate, general health services to the city’s police force.
In my opinion, the key to better police health was found in making use of the resources and skills linked to the police clinic in Mazar-e Sharif for purposes of upgrading the medical skills of individual police officers.
Medical upgrading of the police districts
In cooperation with the doctors at the police clinic in Mazar-e Sharif, we established a programme in first-aid training for the local police (4). The first-aid training courses were held at local police stations by the doctors from the police clinic. The training courses encompassed two hours of practical exercises in the use of a tourniquet, pressure bandage and nasopharyngeal tube and in the transport of the sick and wounded. The courses had a dual purpose – we wished to raise the general medical competence in the police districts in Mazar-e Sharif, and also to establish contact with staff members who had an interest in medical training. In this way we aimed to facilitate future first-aid training courses in Mazar-e Sharif on a semi-annual basis.
The course participants were provided with medical supplies in accordance with Afghan standards for personal medical equipment (tourniquet, pressure bandage and nasopharyngeal tube), ordered through the Afghan medical logistics system at the police clinic.
On the basis of a standardised questionnaire, all course participants were interviewed by NOR PAT on their previous experience with first aid and the equipment used, and their familiarity/experience with the police clinic in Mazar-e Sharif.
It was a fundamental precondition for this project that the activities should be able to continue after the Norwegian forces had left Afghanistan. All activities were therefore organised by the Afghans themselves, the trainers were Afghans and the project was funded exclusively with the aid of Afghan resources. NOR PAT supported the project with assistance for planning of the courses and advisory services associated with their implementation.
Great interest in training in the police force
As it turned out, there was a great interest in first-aid training at the local police stations. Attendance at the courses amounted to 30 – 60 % of the staff at the various stations. I consider this to be an extremely large number, when taking into account that the police work in shifts and are responsible for a number of sentry points and patrols around the city. Six months after the start of the project, a total of 170 police officers from all of the city’s eleven police districts had undertaken a refresher course in first aid (approximately 40 % of the police force), and altogether 163 police officers had been provided with personal first-aid equipment.
The training course included participants from all the major ethnic groups in Mazar-e-Sharif, women and men alike. We encountered no problems in facilitating the participation of women, despite the fact that all the Afghan course instructors were men. We did observe, however, major variations in first-aid competence among the different police districts of Mazar-e Sharif. These observations will enable a more targeted emphasis on police health in the future.
In the spring of 2014, NOR PAT supported the police clinic in Mazar-e Sharif in planning an upcoming round of training courses in the city’s police districts and an expansion of the project to include the remaining police districts in the Balkh province. Our goal is that the Afghans will implement this round of training courses independently, without any direct participation by NOR PAT. In this way, we wish to test the extent to which the initiative now is able to proceed unaided.
The Norwegian Armed Forces in international health work
NOR PAT’s initiative for improving police health is based on a simple model, and in my opinion it has a potential for becoming sustainable. In cooperation with the advisory team to the ISAF command, I have now initiated a process with a view to preparation of recommendations for equivalent courses in other regions of Afghanistan.
We hope that our initiative will help establish a more robust police force as well as increase stability and development for the population of Afghanistan.