The contribution of anaesthesia services to reduce the burden of disease in an under-developed and developing countries is always under appreciated. It is always wrongly perceived that anesthesia services are only required in secondary and tertiary care centers. However, if available at the first referral center, anesthesia can significantly reduce death and disability because its role extends beyond the operation theatre in resuscitation, critical care facilities, pain relief as well as appropriate management of coexisting diseases.
Contini et al. (
2), who used the WHO tool for situational analysis to assess emergency and essential surgical care, found severe deficiency in emergency surgical capacities and recommended comprehensive approach to strengthen it with certain urgency. They reported an abysmal low percentage of 27.2% certified anesthesiologists at peripheral health centers. The total number of anesthesiologists practicing in the Mazar civil hospital at the end of the mission was 18, and majority of them who received training went to private hospitals in Kabul or abroad. The ratio of anesthetists to surgeons at any given time was 1:7.5, which is much less compared to UK (1:1.25) and Canada (1:3) ( 3). What is further disturbing is that the basic package of health services released by Afghan Ministry of Public Health does not include the basic and essential surgical care among its seven major elements ( 4).
The number of surgical beds available was so small. Only 45 out of the 400 beds in the hospital were for surgical specialties. This was true for all the regions of Afghanistan (
5). The scarcity of beds was further highlighted by the fact that Afghanistan, as a country, is always at war. Conditions for practice of anesthesiology, as per the laid down standards, were far from achievable. This made the task of conducting surgeries even more difficult.
Abnormal tests results for investigations were more frequent in the ASA III than in groups I and II, as expected, but past medical history did not influence the abnormality of the tests: 72% of the patients with past medical history in ASA II had normal laboratory findings. Although abnormalities were recorded in ASA I and II, which was 13.8% in our study, they have been reported to be much higher in few other studies (
Trauma remained the most common cause of morbidity in anesthesia facilities of IMM. Initially, it was war injuries and mine blast injuries, which used to dominate; however, the spectrum later shifted to road traffic accidents with certain peace returning. The blood bank facilities were primitive, with no availability of component therapy. As time passed and the knowledge of anaesthesia and surgical skills were passed on to the local doctors, the requirement of anesthesia services reduced. This was a good trend and only those cases, which had multiple comorbidities, were referred to the Indian anesthesiologist. We did not have the data of the anaesthesia provided by the local Afghan doctors in the operation theatre year- wise, as our request was not accepted. However, this decreasing trend indicated the reliability of anesthesia services provided by Afghan doctors, which was one of the prime aims of the Indian Medical Mission.
General anesthesia (with ETTO), combined with epidural analgesia, was the commonest technique used. This may be due to the fact the large number of cases were abdominal surgeries. In addition, many cases of trauma and reconstructive surgery received anaesthesia by this technique. We intend to publish the data of techniques of anaesthesia used in each specialty at a later date since presently it is out of the scope of this article. The commonest volatile used was Isoflurane. Halothane was the other volatile agent available and used extensively in the first two years. The availability of most of the narcotics, sedatives, muscle relaxants, inotropic drugs and other drugs used in anaesthesia and critical care were in adequate supply. There was no provision for nitrous oxide for the earlier team, but the supply of nitrous oxide improved from 2005 onwards. Oxygen was a great concern with the initial teams. However, slowly, the procurement and donations built up the 1246- liter cylinder stock to about 100. However, it was strongly recommended that a central oxygen pipeline system be installed for OT and the ICU. Most of the anaesthesia machines were donated by India, European countries, the United States and Japan. The autoclave facility was donated by Japanese government, which was very easy to operate and robust (
Figures 4 - 6).
Figure 4. OT when Indian Medical Mission Arrived
Figure 5. Six Months after the Arrival of Indian Medical Mission
Figure 6. One Year After
An interesting observation was that psychiatrists were treating head injuries prior to the arrival of the surgical team of IMM, despite the presence of the doctors from the Western countries, who had tirelessly tried to explain the importance of head injuries being treated by surgeons. It took many efforts to educate the doctors about the role of resuscitation and critical care support, especially in post-operative period.
The next nearest facility providing higher-grade medical care was in Kabul. Most of the superspecialist surgical facilities like cardio-thoracic surgery, neurosurgery, pediatrics surgery etc. were not available at Mazar, putting an immense pressure on the general surgeons to carry on the management, especially during the winter when the worlds’ highest highway “the Salang Pass” was blocked. This prompted for establishment of an effective evacuation system after stabilizing the patient. Since air was a costly mode of evacuation, seven hospital ambulances were modified by anesthesiologists in 2005 after equipping them sufficiently to carry out evacuation by road.
4.1. What is Further Required in Afghanistan?
4.1.1. Awareness of the Need
Recognition of the need for anaesthesia services at all levels of health care and its potential contribution to reducing mortality and morbidity is an important first step.
4.2. Policies and Legislation
In Afghanistan, the provision of anaesthesia services needs to be supported by policies and legislation that allow delivery of selective services by non-physician anaesthetists and mechanisms to achieve the United Nations Millennium Development Goals.
4.3. Education and Training
A multispectral approach for various levels of care is needed to address the inadequately trained and insufficient numbers of anaesthesia health providers. Short-term strategies should aim at improving the quality and quantity of mid-level providers for equitable access to primary health care in strengthening health systems. Task shifting or delegating anaesthesia services to non-physician anaesthesia providers will require the implementation of dedicated training programmes (
7- 9). Many developing countries have initiated task-shifting programmes to increase their capacity in providing anaesthesia and life-saving services, and this has resulted in an increase in the number of surgeries performed (Nepal), which is completely lacking in Afghanistan ( 7).
Long-term strategies should be targeted towards creating facilities for training physician anaesthetists for teaching and training, as well as providing specialized anaesthesia services for pediatrics, cardiac, neurosurgery, urology, plastic and transplantation surgery (
8- 10). 4.4. Policies for Retention
Appropriate environment should be provided in terms of well resourced, structured training, established posts in health facilities with adequate anaesthesia equipment, continuous professional development and financial remuneration that are consistent and comparable with other medical disciplines to reduce the brain drain of anesthesiologists from Afghanistan (
9, 11). 4.5. Conclusions
The Indian Medical Mission was wrapped up in year 2014 after achieving some success in not only providing anaesthesia services to the population but also instilling a sense of pride and achievement in local anesthesiologists. The mission tried to revive the training and education part of its objectives.
There is not enough recognition of the need for anaesthesia services at all levels of the health system and their potential to reduce mortality and morbidity in Afghanistan. As a result, there is a serious lack of equitable services, especially in rural and remote areas. Creating awareness through better documentation of the burden of disease, appropriate policies, legislation, and the establishment of innovative and effective anaesthesia training programmes that address both the immediate need as well as the long-term needs of the health system (
12) is the need of hour in Afghanistan. The Indian Medical Mission was able to make significant progress and contribution towards the growth of anaesthesia in Afghanistan. 4.6. Availability of Data and Material
Authors had no problem to readily reproduce materials described in the manuscript, including new software, databases and all relevant raw data, freely available to any scientist wishing to use them, without breaching participant confidentiality.