Response to Articles in the Atlanta Journal-Constitution on the HHS Afghanistan Health Initiative

On November 16, 2007, the Atlanta Journal-Constitution published a pair of articles critical of the Afghanistan Health Initiative, a project funded by the U.S. Department of Health and Human Services (HHS) to improve maternal and child health and reduce maternal and child mortality in the Islamic Republic of Afghanistan.

The articles omitted many of the facts, which provide a clearer picture of the successes to date that HHS and its partners have achieved to date in pursuing the goals of this initiative.

Background of Afghanistan Health Initiative

• Afghanistan has one of the highest infant-mortality rates of any nation in the world, and the highest maternal-mortality rate ever recorded. In the past four and a half years, the nationwide infant mortality rate in Afghanistan has fallen from 165 per 1,000 live births to 135 per 1,000 live births.
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• Through the Afghan Freedom Support Act of 2002, HHS has received funding since Fiscal Year (FY) 2003 for its Afghanistan Health Initiative, aimed at supporting the reconstruction of that country by improving maternal and child health, and reducing maternal and child mortality.
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• Specifically, the activities of the HHS Afghanistan Health Initiative have focused on Rabia Balkhi Hospital (RBH), the largest maternity hospital in the Afghan capital, Kabul, in an effort to increase the core knowledge and clinical skills of the physicians and other health-care professionals at RBH, as well as the leadership and management skills of hospital administrators.
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• By strengthening hospital management and leadership, and developing culturally appropriate residency programs for physicians, midwives and other health providers at RBH, we have been able to improve the quality of maternal and neo-natal health care for Afghan mothers and their babies.
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• As part of the Afghanistan Health Initiative, HHS has also worked with the Afghanistan Ministry of Public Health (MoPH) to help the MoPH implement its national health strategy, and to support the MoPH as it builds capacity to sustain these public-health and medical investments in RBH.

Response to the Articles in the Atlanta Journal-Constitution

• In the eleven months Atlanta Journal-Constitution reporter Alison Young has worked intensely on researching and writing these articles, she did not travel to Afghanistan to experience first-hand the extremely difficult environment in which international relief and assistance efforts must operate in that country.
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• Make no mistake, Rabia Balkhi Hospital does not compare to a modern U.S. hospital. However, as Alison Young herself reports in her article since HHS began its involvement with the hospital, it “is cleaner and provides better care since the project began, experts agree.” RBH is considered the best hospital in Kabul. It is clean, and it offers good health care to the people of Afghanistan.
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• RBH experiences a volume of births in one year (13,000-16,500) three to four times the number of births at American hospitals.
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• And because RBH has become one of the best hospitals in Afghanistan, its reputation draws an increasing number of patients, including many with very poor health and nutritional status, which has the unintended impact of stressing an already overburdened facility.
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• All HHS staff who have visited Afghanistan and who have been involved in this project have a heartfelt desire to do something to help the women and children who so desperately need our assistance in gaining access to basic medical care.
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• As we embarked on this project, no one underestimated the incredible challenge, and we fully recognized that much more would be needed from other sources, but doing something to get started was better than standing by and doing nothing.
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• What we have already accomplished at RBH exceeded our initial expectations, and created the hope that, with more investments and time, sustainable improvements can occur. HHS is proud of the work we have done in extremely challenging circumstances in Afghanistan. Everyone agrees there is much more that we can do, and many challenges to meet.
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• The challenges of providing health care in a war zone are enormous. Security restrictions have made it consistently difficult to deploy our personnel to Afghanistan.
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• Furthermore, in the short amount of time since we began the Afghanistan Health Initiative, the Afghan Government has had two different Health Ministers, each with very different approaches to conducting business; multiple Deputy Health Ministers; and two directors of RBH.
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• The newness and fragility of the Afghan Government has not always made decision-making and the flow of financial support for the project a simple matter.
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• But true to our tradition, if HHS is asked to help, we always do our best to contribute.

Funding for the Afghanistan Health Initiative

• Since FY 2004, the U.S. Congress has directly appropriated Federal dollars for this activity in HHS’ departmental budget as follows:

• In FY 2003, we spent approximately $1 million in preliminary costs, mostly in travel and staff time to gain situational awareness on the ground in Afghanistan to help us understand what type of formal project to design. These were discretionary funds identified and reallocated in HHS' existing FY 2003 appropriations, including $200,000 in the budget of the HHS Centers for Disease Control and Prevention (CDC).
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• HHS has dedicated the largest portion of these appropriated dollars to support the activities of the Maternal and Child Health program at RBH, which the Afghanistan Ministry of Public Health authorized in accordance with the Ministry’s policies, procedures and directives. These funds went to three recipients: HHS/CDC and two non-governmental organizations (NGOs): International Medical Corps (IMC) and CURE International. In combination, these recipients have been the cornerstones of the HHS Afghanistan Health Initiative.
  

RBH: Then and Now

• When HHS medical and public-health experts arrived in Kabul in December 2002, and in the following months as our staff made other visits, we found conditions at the newly renovated RBH so chaotic that it was possible for a woman to enter the hospital, give birth, and leave never having received medical assistance, and with no record of the baby’s birth.
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• Initial visits further revealed non-existent or scrambled medical records for mothers in the hospital.
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• HHS quickly recognized this was a daunting environment in which to conduct a project. HHS’ vision was to make a serious, meaningful impact as fast as possible in the areas of surveillance and health monitoring.
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• In May 2003, the four maternity hospitals in Kabul had no counting or accounting for any woman or newborn, and at RBH, less than three percent of the women at RBH had a retrievable medical record three days after discharge.
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• Without quality medical records, a true assessment of the quality of care was close to impossible.
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• As of January 2005, HHS/CDC was able to account for every mother and baby born in the four hospitals in Kabul, and by May 2006, the number of women who had a retrievable medical record had increased to 100 percent.

Maternal and Infant Mortality at RBH

From 2004 to 2006, RBH delivered more than 40,000 babies, or more than 13,000 each year. This figure exceeds by three to four times the average number of births at even the busiest of American hospitals.

For example, the total number of live births at Georgia’s largest hospital, Grady Memorial Hospital in Atlanta, was 3,792, just slightly more than one-fourth of the volume handled by RBH in the same year.

It is important to note that the AJC story focuses on one specific statistic (the increase in the rate of intrapartum death [fetal death during labor or delivery] from 2005 to 2006), while ignoring the broader picture of success in our efforts in Afghanistan that ALL the statistics show.

At Rabia Balkhi Hospital, since the start of the HHS Afghanistan Health Initiative…

• The total number of live births at RBH was 40,456.
  • 2004:   14,797
  • 2005:   12,384
  • 2006:   13,275 
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• The maternal mortality rate decreased 27 percent, from 189/100,000 live births in 2004 to 136.5/100,000 live births in 2006.
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• The number of maternal deaths dropped, from 28 in 2004 to 18 in 2006.
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• The neonatal infant mortality rate[1] decreased 7.5 percent, from 2.7/1,000 live births in 2004 to 2.5/1,000 live births in 2006.
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• The number of neonatal infant deaths dropped, from 40 in 2004 to 33 in 2006.
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• The intrapartum infant mortality rate[2] increased 24 percent, from 7/1,000 live births in 2004 to 8.7/1,000 live births in 2006. However, the rate decreased from 2004 to 2005.
  • 2004 to 2005:  25 percent decrease (7/1,000 to 5.2/1,000);
  • 2005 to 2006:  67 percent increase (5.2/1,000 to 8.7/1,000).
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• The annual number of intrapartum infant deaths increased by 12, from 103 in 2004 to deaths in 2006. However, the rate decreased from 2004 to 2005.
  • 2004 to 2005:  (103 deaths down to 64 deaths);
  • 2005 to 2006:  (64 deaths up to 115 deaths).

Response to Problems Found

• In the spring of 2007, when we became aware of the problems addressed by the AJC article, we took strong steps to address these serious issues.
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• In April, we revived an HHS Technical Advisory Group, comprised of technical and medical experts who have, over the last seven months, conducted a number of reviews regarding the challenges the initiative faces.
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• In September 2007, we contracted with Research Triangle International of Durham, North Carolina, to perform a comprehensive, external evaluation of the initiative.
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• In late August and early September 2007, medical and public-health experts from the HHS Centers for Disease Control and Prevention and the HHS Indian Health Service visited Kabul to provide an initial on-the-ground assessment of the status of work at RBH.
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• In early November 2007, a group of HHS medical and public-health experts met for three days in Washington to chart a course for our work over the coming months and next several years. A second HHS delegation will return to Kabul in early December 2007 to work with the Afghanistan Ministry of Public Health and other partners to continue addressing these issues.

The Afghan Family Health Book

The initiative also has a patient-education component, known as the Afghan Family Health Book, which is an electronic, interactive, health-education tool that uses sound and pictures, developed and distributed to women and families across Afghanistan to improve their knowledge of disease prevention and early-childhood development.

In a partnership with Leap Frog Enterprises, HHS delivered 20,000 Family Health Books, specifically designed to meet the unique needs of Afghan women, to Afghanistan in 2004. The Family Health Books will teach mothers in Afghanistan how to better care for themselves and their children. Given the dismal rates of literacy among Afghan women, books and other written materials have limited use as educational materials.

Out of this project, HHS is now developing a local-language radio show that uses dialogue and text derived from the Talking Book. This will bring to life the Afghan Family Health Book to share salient health messages with Afghan families on a variety of priority health issues via the nationwide satellite radio network Radio Danesh.

Additional Background on HHS’ Afghanistan Health Initiative

HHS formed the following four quality-assurance teams: maternal death, perinatal death, medical records, and hospital infection. In October 2006, through surveillance, Afghanistan staff identified an increase in post-operative infection rates. HHS addressed the problem, and the rates decreased. In 2005, HHS/CDC offered occupational-safety and health training and individual health assessments to the staff at RBH. In 2006, HHS/CDC repeated the training for the other three maternity hospitals in Kabul.

Through professional training and technical assistance, HHS has sought to bolster the administrative and management capacity of RBH, and foster an environment conducive to learning, skill-refinement and the overall provision of quality maternal and infant health care. At RBH, the largest and busiest women’s hospital in the country (with 13,000–15,000 births each year), managerial and clinical capacities have proven integral in establishing a sustainable health-delivery system, as well as improving infection-control procedures, developing a system of medical records, collecting data related to improving health (including morbidity and mortality), and conducting disease surveillance.

HHS adapted a basic U.S. training program for residents in obstetrics and gynecology for use at RBH. Components of the medical residency program are modeled on the system in the United States approved by the Accrediting Council on Graduate Medical Education (ACGME). HHS has taken care to clarify, however, our use of an adaptation of a curriculum endorsed by ACGME does not mean the training program has "imposed" unrealistic or inappropriate standards on the Afghanistan setting, nor set the expectation that the instruction at RBH would actually qualify for ACGME accreditation. Rather, our intent was always to create a residency program that approximated those seen in neighboring countries.

In 2006, the program’s efforts resulted in the development of a new four-year residency program approved by the Afghanistan Ministry of Public Health expert group in Obstetrics and Gynecology.

Last revised: November 28, 2007