The Atlanta Journal-Constitution
Sunday 18 November 2007
For four years, federal officials have touted a U.S. medical training program in Afghanistan as a model of success that brought "top-notch" care to a major Kabul maternity hospital.
Yet privately, the Rabia Balkhi Hospital project has repeatedly alarmed scientists at the U.S. Centers for Disease Control and Prevention who were responsible for tracking care there, records obtained by The Atlanta Journal-Constitution show.
The rate of normal-sized babies dying in labor and delivery at Rabia Balkhi jumped 67 percent last year, CDC scientists in Atlanta found. Worse, the newspaper's analysis shows these babies were nearly four times more likely to die when delivered by Caesarean section, a potentially lifesaving operation encouraged by U.S. trainers.
Afghan mothers were in danger, too. Eighteen died in childbirth there last year; two-thirds of the deaths involved c-sections, including issues with surgical skill, anesthesia, transfusions and misdiagnoses, records show.
Among them: an Afghan Air Corps pilot who bled to death in July 2006 following a c-section.
So when Afghan President Hamid Karzai's wife chose to give birth at Rabia Balkhi in January, the U.S. military sent an 11-member medical team and critical equipment to "backstop" the delivery, said Col. Donald Thompson, who was then the U.S. command surgeon in Afghanistan. The baby was born safely without a c-section.
CDC scientists have warned Washington for years that the project might be risking lives. Officials at the CDC and the Afghan Ministry of Public Health now question whether the training pushed Afghan doctors to perform more c-sections before they were ready and before the hospital had the necessary anesthesia, sanitation and blood supply.
Until recently, officials at the U.S. Department of Health and Human Services, which runs the project, have deflected criticism. Where others saw a project hobbled by poor design and management, they saw success in a dangerous environment.
Rabia Balkhi has been "an unqualified success," said William Steiger, director of HHS' Office of Global Health Affairs, in an interview. "Hundreds if not thousands of lives have been saved."
Former HHS Secretary Tommy Thompson, who had touted the project during his brief presidential campaign this year, said he was unaware of serious issues raised by the CDC and others. "I'm very surprised and concerned about it," he said in response to the newspaper's findings.
U.S. doctors who worked at Rabia Balkhi have also warned the project lacked the authority and resources to turn the hospital around. They restated their concerns in interviews with the Journal-Constitution.
"Short of saying it was half-baked, I'd say it was not as energetic as it could have been," said Dr. Douglas Laube, who consulted on the project from 2003 to 2005. Laube is past president of the American College of Obstetricians and Gynecologists.
The hospital is cleaner and provides better care since the project began, experts agree.
Even so, Afghan doctors there still lacked basic knowledge of anatomy and physiology, a contractor's assessment found last fall. Most doctors, though improved as critical thinkers, still lacked basic skills to resuscitate mothers and newborns. Doctors consistently failed to make sure newborns were breathing after c-sections.
Training at the hospital, provided by a revolving door of doctors, midwives and others often serving three-month stints, has been piecemeal and at times poorly attended, records show. The project lacked a set curriculum for three and a half years. No U.S. obstetrics trainer has been on site for 12 months.
U.S. officials don't know about 2007 death rates at the hospital because the CDC wasn't there to collect data. Last fall, HHS cut off the Atlanta-based agency's funding to monitor care, saying others could do it.
CDC and other experts have long questioned whether the training could succeed given the severity of Rabia Balkhi's problems and the U.S. refusal to tackle much beyond training.
The hospital initially lacked soap and hot water. It routinely ran out of surgical gloves, antibiotics and other basic medical supplies. Its doctors' medical training was outdated and cursory - the equivalent in some cases of a second-year U.S. medical student's, some experts said.
But in response to inquiries by the Journal-Constitution, HHS has revisited the concerns and formed a technical advisory group to address the rising death rate. Advisers will travel to Kabul in December. Last month, the agency hired RTI International, a North Carolina-based research institute, to evaluate the project at a cost of $1 million.
"I'm very pleased they're taking this seriously," said Dr. Faizullah Kakar, Afghanistan's deputy minister of public health.
Unsanitary Conditions
The project began in 2002, a few months after the overthrow of the repressive Taliban regime. It started with Thompson's desire to do something about Afghanistan's maternal and infant death rates - among the world's worst.
"I thought the deaths of the babies were so deplorable, I had to do something about it," Thompson said.
Thompson chose Rabia Balkhi for a U.S. project to train newly graduated Afghan doctors in obstetrics and gynecology. Donald Rumsfeld, then defense secretary, agreed his department would renovate the building.
Named after a famed poet, Rabia Balkhi had grown over the decades from a clinic to a 250-bed, two-story hospital in a congested bazaar. When the Taliban barred women from general hospitals in 1997, it became Kabul's only women's hospital. Last year Rabia Balkhi's largely female staff delivered 13,906 babies, down from 15,509 in 2004. No statistics were kept in earlier years..
Thompson boasted at the hospital's gala reopening in April 2003 that "we now have a new hospital for women to receive top-notch health care and a new training program that will provide the best of medical instruction."
Many visiting U.S. doctors and health experts saw it much differently. "Things are horrible there. Worse than imaginable," wrote Michael Gerber, visiting in May 2003 from CDC's refugee health branch, in an e-mail a month later to CDC headquarters.
Gerber's e-mail described "feces all over the halls, blood everywhere ... no drugs, no record keeping, no signs of the refurbishment save new paint in a few spots."
International relief experts in Kabul believed the U.S. presence at the hospital was attracting more expectant mothers and resulting in more deaths, he warned.
The U.S. program was "just totally unrealistic," said Dr. Pamela Hyde, an Oklahoma obstetrician who was there in 2003. She said the United States needed to bring in a whole team of doctors, midwives and administrators to run the hospital and teach the Afghan staff by example.
The Afghan health ministry had wanted HHS to take over Rabia Balkhi and stock it with scarce supplies, according to U.S. embassy cables.
HHS refused, saying the Afghans wouldn't become self-sufficient that way. Internal documents note that a top priority of the project was to support the newly installed Karzai government.
As a result, nobody had full authority to reform hospital practices, U.S. trainers and contractors said. The Afghan staff lacked critical management and care skills, yet many resisted change. U.S. trainers couldn't even require attendance at classes.
"I knew what should be done but for one reason or another it wasn't done. That is extremely frustrating," said Rick DeFoore, a management consultant assigned to Rabia Balkhi throughout 2006. "Putting a consultant in there to give advice is ... a Band-Aid and Neosporin on a major wound infection."
The project also struggled with structural problems for two years until, Thompson said, he "raised hell" and the Defense Department did more renovation. Sewage flowed in hallways. Often there was no heat or hot water.
"We would have been better off building a new facility," said Dr. Walter "Jerry" Saunders, who taught at Rabia Balkhi in 2004.
Today, the Afghan government wants to build a major hospital in Kabul for about $14 million - far less than the $23 million spent so far on the training project.
At times, HHS' narrow focus on training and what it would not pay for was ridiculous, said Dr. Qudrat Mojadidi, an Afghan-American who advised Thompson on the project in 2002 and 2003. HHS refused, for example, to buy fuel for the hospital's medical waste incinerator, he said.
"They were having 60 babies every 24 hours and all those placentas were rotting out there in the hot sun of Kabul," said Mojadidi, who paid $200 from his own pocket to buy fuel in 2003.
"Every week I'd send two or three e-mails with pictures attached" to HHS officials, Mojadidi said. "Finally [Thompson] sent me a letter saying what a wonderful job I was doing and how many lives I was saving. I wrote back and said: We're not doing anything."
In emails and meetings, CDC officials urged HHS to either suspend the training or make the hospital functional so training could be effective.
"We are extremely concerned about the grim situation," wrote Dr. Stephen Blount, CDC's global health director, in a May 2003 email to Steiger, the HHS official in charge in Washington.
But Steiger was not swayed, writing back that "serious miscommunication" threatened the project.
Nearly a year later, even Rumsfeld was exasperated. "I am terribly disappointed that apparently the midwife hospital in Kabul has not been followed up well. It is not doing a good job," Rumsfeld wrote Thompson in 2004. "We have to do better than that."
Thompson responded by citing successes - training, a new emergency room, fewer deaths. He wrote that "conditions at RBH are improving, and the care being provided to mothers and their infants there is better now than it has been in many years."
Rumsfeld declined to be interviewed.
Thompson said Wednesday he believes the hospital "is a hell of a lot better than it was when we started." He said he doesn't remember hearing concerns from officials at CDC or others.
"I thought the program was well-received by everybody," he said. "All I wanted to do was make sure women were taken care of."
Insufficient Training
International Medical Corps, a California-based nonprofit hired by HHS in 2004 to run the training, rarely met its contract goals, records show.
Ideally, six U.S. or Western-trained health professionals were supposed to teach year-round. IMC met that goal in only six months.
At least two ob/gyns were supposed to be at Rabia Balkhi throughout the year. But the nonprofit met that goal in only 11 months since 2005. IMC in 2005 even brought in an ob/gyn who gave up his Florida medical license in 1998 after a series of disciplinary actions.
IMC officials, who blamed the incident on a lapse in procedures, said the man was dismissed after three weeks and did not treat patients.
IMC officials told HHS that difficulties in recruiting forced them to largely rely on Afghan trainers who might offer "lower-quality courses."
The years of disjointed training was evident in the care observed by Dr. Catrina Funk, an ob/gyn, and Dr. Jeff Whittall, a pediatrician, who worked there in 2006.
"Twice myself or Jeff walked into the OR and realized the patient didn't have a heartbeat on the table, but nobody else realized it because the patient didn't have a monitor," Funk said. Anesthesia doctors had new equipment kits, she said, "but they didn't necessarily know how to use them."
IMC Vice President Rabih Torbay said his group's work was hampered because HHS failed to make sure hospital staff, consultants and contractors - each working for a different employer - worked toward the same goals.
"What was lacking was someone who would bring all those pieces together," Torbay said.
Last year HHS hired another contractor - CURE International - to help the hospital run its staff and order supplies better.
But CURE officials told HHS last month they want out of the project. In a letter to the Afghan health ministry, CURE cited problems with hospital leadership: "Under the existing circumstances, CURE ... does not expect any further long-term or sustainable outcomes from this project."
C-sections, Mortality
When the Journal-Constitution first asked about c-section deaths at Rabia Balkhi, HHS officials said they were unaware of CDC's concerns. "I don't know what they're referring to," Jeannine Greenfield, an HHS nurse assigned to run the project, said in April. "There hasn't been that dramatic a rise in c-sections."
IMC also initially disputed a c-section problem, saying collection methods skewed CDC's data. CDC disagreed.
Earlier this year, the HHS Web site claimed the project had reduced maternal and infant mortality at Rabia Balkhi by 80 percent to 90 percent. But after the Journal-Constitution questioned the statistics, HHS officials admitted they could not substantiate the claim and removed it.
"We had intended that statement merely to be an indication of the extent of improvements at the hospital, and not a precise measure," agency officials said in a written statement.
The hospital's labor and delivery death rate for normal-sized babies actually rose 67 percent in 2006, CDC data show, while the c-section rate for them climbed 45 percent. The hospital's post-operative infection rate increased 66 percent.
"The mortality rate is going up, the Caesarean rate is going up," said Dr. Brian McCarthy, CDC's point person on the project. "That raises a flag."
Another serious concern: Even successful c-sections put the women at risk of uterine ruptures in future pregnancies. In Afghanistan, the average woman bears seven children, rarely with a doctor present.
Project officials found many c-section deliveries were unnecessary.
"It was a big concern. From the very beginning we were talking about it," said Dr. Anna Thurairatnam, an obstetrician who served as IMC's program manager at Rabia Balkhi in 2006.
IMC alerted HHS to the emerging issue. A March 2006 report devoted a page with charts to a rise in maternal and neonatal deaths at Rabia Balkhi. IMC also reported an uptick in deaths and concerns about c-sections in September 2005.
Help on the Way
Since last spring, HHS has recognized a need to investigate c-section deaths at Rabia Balkhi. The agency is sending teams to Kabul to help create a quality assurance program to improve care, and it plans to restore funds for CDC's help.
"Sometimes we think the wrong women are getting c-sections," said Dr. Peter van Dyck, the HHS official leading the advisory team. "Sometimes women who need a c-section aren't getting it. And some who are getting it aren't getting appropriate [post-operative] care."
Dr. Margaret Kitt of the CDC, who visited the hospital on the team's behalf in September, said it has improved significantly since 2003 and even since last year. Still, she said, "a lot more progress ... needs to be made."
"Things are very difficult and very fragile in Afghanistan," Kitt said. "I think this is a really important opportunity for everything to continue to move forward. We don't want to lose this opportunity."
US Buys Teaching Gadgets Instead of Medical Supplies
By Alison Young
The Atlanta Journal-Constitution
Sunday 18 November 2007
Instead of helping Rabia Balkhi Hospital buy medical supplies needed to deliver 14,000 babies a year, the United States spent $1.3 million on computerized LeapFrog talking books.
The idea was to teach illiterate Afghan women about hygiene, prenatal care, immunizations and nutrition from talking picture books popular with U.S. children.
Never mind that rural Afghan people have never seen touch-screen technology. The U.S. Department of Health and Human Services gave LeapFrog a no-bid contract after an offhand comment by the daughter of a supporter of then-HHS Secretary Tommy Thompson, according to interviews and records obtained by The Atlanta Journal-Constitution.
It was more than a quarter of the money Congress gave HHS in 2004 to tackle maternal and child health issues in Afghanistan.
At the same time Rabia Balkhi in Kabul routinely lacked soap, hot water, proper operating room equipment and working incubators. HHS made a policy decision to focus only on training at Rabia Balkhi and refused to buy medical supplies.
In the past, the Afghan health ministry could only afford to supply its hospitals for about one week each month.
"After one week, we cannot buy gloves" or other supplies, Dr. Faizullah Kakar, the deputy health minister, said in February. Patients were being asked to bring their own.
In December 2004 Thompson announced the delivery of 20,000 LeapFrog books to Kabul. Then they sat in a warehouse for nearly two years until the Afghan government started distributing them. HHS officials said it took that long to field-test the books.
Meanwhile the devices' AAA batteries died; HHS spent another $9,800 to replace them last fall.
Thompson, in an interview last week, said he didn't think the books were purchased with funds from the congressional appropriation for Rabia Balkhi. "I still think it's a tremendous tool," he said.
HHS officials and Thompson defend the LeapFrog purchase and call the project innovative. But a $95,000 study commissioned by HHS found the books had dubious value.
Afghans who used the book learned from it, but fewer than 10 percent were willing to use it during a 2005 pilot project. Most found the device too complicated and preferred being taught by people.
"From a cultural perspective, it is not surprising," the report by the nonprofit group International Medical Corps concluded. "They have little or no experience with learning from books or electronic forms of media."
The study suggested the book might be most effective if used in conjunction with a live health educator.
How did HHS decide to buy LeapFrog books?
Kimberly Weiner Greene said she made an "off-the-cuff" comment to her dad, Jerry Weiner, a friend and supporter of Thompson's.
Weiner was attending an Afghanistan brainstorming meeting with Thompson. During a break, Greene said, her dad called to chat.
"Without thinking about what I was saying, I said: 'What a no-brainer. We should make LeapFrog books,' " said Greene, noting HHS was looking for a way to get information to women in rural areas without doctors.
Users could just tap a pen on pictures in the book, she noted, and hear an Afghan speaking in their language.
Greene said she never expected HHS would actually do it. Thompson called a few days later to say he loved the idea, she said.
Thompson's former HHS spokesman, Tony Jewell, said: "If there's a good idea, it doesn't matter where it came from. It was certainly vetted."
William Steiger, director of HHS' Office of Global Health Affairs, called the books' educational potential "extraordinary." He said they'll now be used alongside a live health educator.
Dr. Najiba Zamani, an Afghan-American consultant for LeapFrog, said she was shocked that the field study questioned the books' effectiveness. "In my opinion, those women, they need this book," she said.
Zamani said she's seen Afghan women cry when they learn what depression is from the book and that help is available.
And she said the book's ability to raise awareness about "birth spacing," by talking about how carrots planted too closely together become scrawny and weak, provides a culturally appropriate way of addressing a sensitive sexual issue.
Was the book the best use of limited U.S. funds?
Kakar said the books will be useful.
"But when it comes to priorities, we have donors. They do things according to what they think is right," he said. "Our priorities might be a little different."
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