Injuries caused by gunshots, explosions and traffic accidents account for a considerable proportion of the clinical picture in Afghan emergency units. Competence in anaesthesiology is essential to reduce morbidity and mortality in the population of this war-torn country. For many years, Norway has helped develop the anaesthesiology department at the public hospital in Mazar-e Sharif through the so-called Anaesthesia Project.
In the context of my work related to police health in Mazar-e Sharif (1) and in close dialogue with the Norwegian Defence Medical Service (FSAN), I took the initiative to evaluate the anaesthetics department at Balkh hospital in Mazar-e Sharif one year after the completion of the project (2).
The evaluation was based on interviews with key project actors, including anaesthesiologist and Afghan project partner, Dr Hamidullah Seddiqi (3), and the Norwegian Armed Forces’ senior consultant in anaesthesiology, Colonel Dr Knut Ole Sundnes, as well as on visits to the anaesthetics department at Balkh hospital in Mazar-e Sharif.
Civilian-military cooperation on anaesthesiology
The Anaesthesia Project was a medical civilian-military cooperation project (4) undertaken in the period 2006 – 12 with a view to developing sustainable competence in anaesthesiology in Afghanistan. The partners included the Afghan health authorities, the World Health Organization (WHO) and the Norwegian Armed Forces.
The project was led by the Norwegian Armed Forces’ senior consultant in anaesthesiology, Colonel Dr Sundnes, and was based on WHO’s guidelines for «training programs for essential surgical skills in rural hospitals» (5). In parallel with the project, relevant medical literature was translated into Dari, and provisions were made for the donation of Norwegian anaesthetics material adapted to Afghanistan’s resource situation (personal communication, Colonel Dr Sundnes). The Anaesthesia Project was established in the Faryab and Balkh provinces, based on the competence in anaesthesiology in connection with the Norwegian military presence in these regions, including the former Norwegian military field hospital in Faryab.
At the start of the project there was no formal competence in anaesthesiology available in Afghanistan, nor were there any positions or authorised salary payments for anaesthetists or nurse anaesthetists. With few exceptions, anaesthetics were administered by technicians with no professional health training. The public hospitals in Faryab and Balkh each served a population of somewhat more than one million. In addition, Balkh hospital was responsible for the northern Afghan regions, with approximately nine million inhabitants.
Under the leadership of Major Dr Kjetil Ness, the project soon yielded very favourable results and was regarded as a pioneering project for development of health competence in Afghanistan (6). However, following attacks on Norwegian medical personnel affiliated with the project in Faryab in May 2007 (2) and a deteriorating security situation in the region, the project could not be continued there.
Afghanistan’s first anaesthetist
Despite the adverse events in Faryab, the Anaesthetics Project was successfully continued at Balkh hospital until its completion in the summer of 2012 as planned. After six years of Norwegian-led supervision in anaesthesiology, including a total of one year of internship in Norway at Bærum Hospital, Ullevål University Hospital, Vestfold Hospital, Haukeland University Hospital and St. Olavs Hospital, and as the first Afghan doctor since the 1970s, Dr Seddiqi could apply to the national authorities for approval as a specialist in anaesthesiology.
In the summer of 2012, the anaesthesiology department at Balkh Hospital consisted of six assistant anaesthetists in addition to Dr Seddiqi. At their disposal they had the equipment necessary to administer general anaesthetics in an appropriate manner (personal communication, Colonel Dr Sundnes). Colonel Dr Sundnes concluded that the project had achieved its objectives and that a potentially sustainable basis for a well-functioning anaesthesiology department had been established at the hospital.
In the wake of the Anaesthesia Project, there were great expectations to the further development of the anaesthesiology department in Balkh and the extent to which the competence established with Dr Seddiqi could provide a platform for further competence enhancement at the hospital, so-called sustainable learning (7).
My investigations at Balkh Hospital in the autumn of 2013 indicated that a positive development had taken place at the anaesthesiology department over the previous twelve months in terms of material, routines and access to drugs.
Today, the department is operating at full capacity, and it has sufficient experience and routines to support six parallel surgical operations with general anaesthetics. The staff has access to the necessary consumables and drugs. The anaesthesia provided is based on Western guidelines and is documented according to Western standards. All the Norwegian equipment that was donated to the anaesthesiology department at Balkh hospital through the Anaesthesia Project, including six anaesthesia machines, is in use and functions as intended. Over the last year, written guidelines for maintenance of the equipment have been prepared. It is reported that these are being complied with.
Moreover, Dr Seddiqi has succeeded in obtaining additional anaesthetics equipment for his department through the hospital’s own logistics system and external funding. In many ways, the anaesthesiology department thus appears to be in a more robust shape than when the project was completed a little more than a year ago.
The personnel situation at the department, however, remains challenging. An increase in workload without an equivalent increase in staffing has put great pressure on the personnel. Dr Seddiqi has therefore prepared a plan for trainee positions in anaesthesiology at the department, and he is currently waiting for a response from the authorities regarding allocation of the necessary authorised posts.
In my opinion, the Anaesthesia Project has played a decisive role in the development of the present anaesthesiology department at Balkh Hospital, and the department appears to have undergone a positive development over the last year. Assuming that the efforts to establish trainee positions in anaesthesiology at Balkh Hospital succeed, there are good indications that the Anaesthesia Project has been able to establish a sustainable Afghan competence in anaesthesiology in Balkh.