- © 2007 Canadian Medical Association
Assume, for a moment, that you felt compelled to help equip something along the lines of a 10-bed intensive care unit at a hospital located in a war zone, in which your counter-insurgency measures are causing some of the casualties.
Forget things like a dialysis machine, a high-tech suction pump and patient monitors. Luxuries, one and all. But assume that, as a hospital, it at least has the trained personnel and some basic supplies such as dressings, bedpans, intravenous lines and other forms of tubing, albeit not disposable.
Assume also that you are on a tight budget like the Canadian International Development Agency (CIDA) and must shop second-hand.
A few mechanical ventilators would have to be considered essential. Listed prices from various vendors of used medical equipment? Between US$875 and US$2500.
An anesthesia machine? $1725–$3445.
A medium chamber steam sterilizer? In the neighbourhood of $5000.
A 500 kW/625 kVA back-up generator? $30 000–$62 000.
If you bought at the upper end of the second-hand market, and splurged for say 4 ventilators, the bill would come to about $80 000. Heck, throw in a few bucks for some endotracheal tubes or maybe even some diesel for the generator. Make it an even $100 000. Make it $200 000.
In fact, go wild. As a contribution to the reconstruction of Afghanistan and in the interest of generating good will, while demonstrating the merits of Western approaches, splurge for a couple of million dollars to establish the capacity to conduct basic laboratory work and provide a modicum of sedatives, antibiotics and analgesics for patients in the unit, even though that's currently outside the hospital's existing standard of care.
Arguably, Canada's mere presence in the arena justifies such investment in Afghanistan's health care system, if only to bolster its capacity to handle pressures caused by our participation. After all, Canadian soldiers do fire guns and anyone would be hard pressed to argue that our bullets have not contributed to an increase in the number of penetrating trauma injuries. There is, moreover, the tiny matter of the Geneva conventions, whether provisions for civilian casualties or measures to address the UN Convention for the Amelioration of the Condition of Wounded and Sick in Armed Forces in the Field, in particular, article 3, clause 2, to wit: “the wounded and sick shall be collected and cared for.”
Arguably, Canada thus has a responsibility to ensure that what passes for Khandahar's tertiary care facility, the 450-bed Mirwais Hospital, is at least minimally equipped to handle the increased load. Instead, according to a report by Senlis Council, the Paris-based international development and security policy think-tank, Mirwais is totally unequipped and little more than a “vector for infection.”1
And instead, Canadian military physicians and their counterparts from other nations providing care at a multinational medical unit outside Khandahar find themselves caught in untenable ethical quandaries between their duty to provide emergency treatment for Afghani soldiers and police — who are part of Coalition forces — and their obligation to “move them along” to Mirwais, knowing that they are all but issuing death sentences.2
It could be argued that reconstruction efforts, and particularly health investments agreed to under the January 2006 Afghanistan Compact between the Afghan government and the international community, must necessarily be made at a more basic level than equipping intensive care units.
Health is 1 of 6 targeted sectors of the Compact's economic and social development component, which establishes 2010 benchmarks to extend a basic package of health services to 90% of the population; reduce maternal mortality by 15%; and to provide full immunization coverage for infants under 5 for vaccine-preventable diseases, while reducing their mortality rates by 20%.
One might expect, then, that somewhere within the 50 projects, valued at Can$139 million, that CIDA now has underway in Afghanistan, there might be several initiatives aimed at enhancing the capacity to provide basic health care, even at a level well below the modest equipping of an ICU.
Yet, only 2 are directly tagged as health initiatives, and only 1 is aimed at improving Afghanistan's capacity to actually provide health care. Some $5 million has been allocated for vaccinations under the Global Polio Eradication Initiative, while $350 000 has issued toward a UNICEF project to establish a residential obstetric care facility near Mirwais.
There are, to be sure, public health components within several other projects, including efforts to sanitize water and eliminate vitamin and mineral deficiencies in the Afghani diet. And doubtless all 50 are worthy, however sorely tempted one might be to wonder whether there really is a need to spend millions on “administrative reform-coaches,” governance advisors, planners and, seemingly, all other manner of mandarin.
Health infrastructure is surely of no less value in the reconstruction of Afghanistan. If the European Union, the United States and others are for some reason reluctant to make such investments, Canada and CIDA should not hesitate to step into the breach.