Workshop B: Health Care
By Wolfgang Lillge, M.D., Editor, Fusion Magazine, Germany
The development of a modern health care system in Afghanistan through the eyes of Ibn Sina
My name is Dr. Wolfgang Lillge from Berlin, Germany. I am very honored to be part of the discussion about health care. I am a trained physician, but my main activity was and is in the field of science journalism. For many years I have been the editor-in-chief of the German-language science magazine Fusion, which promotes the development of future technologies in all areas of science like fusion power and space research.
I would like to begin by drawing your attention to an important cultural link between us in Europe and Afghanistan. Not only was Ibn Sina, also known as Avicenna in the West, the author of the Canon of Medicine,
the definitive authority among doctors in Europe until the 17th century, but you also have in Afghanistan a legendary figure of female courage – Malalai of Maiwand, a nurse in the Afghan War of Independence against the British colonial power in 1880, also called the French Jeanne d’Arc, about whom the German poet Friedrich Schiller wrote one of his most famous dramas. Back in 1880, when the Afghans had lost all hope in the battle and were fleeing, she took off her veil, made a flag out of it and faced the enemy. The soldiers turned back and finally won the battle.
Let us be inspired by such heroism to win the struggle for Afghan sovereignty and development.
The challenge of providing Afghanistan with public health care and a modern medical system is enormous. After 40 years of war, combined with geopolitical manipulation by outside forces, the nation has been left virtually without a health care system, one of the most important sectors of any society. Infant mortality is high, and there is a lack of doctors, nurses, hospitals, and basic sanitation.
But Afghanistan and the region have a rich history of medical science, culminating in the works of the universal genius Ibn Sina. In the revival of Afghanistan, his work and that of the Islamic Golden Age can be a reference point for building a bright future.
I believe that the top priority for Afghanistan, with the most immediate impact on improving the health of the population, is the establishment of a public health system. Ibn Sina would probably think today that this is the responsibility of the state, as it is in many countries around the world.
Public health stands for
- Providing clean water
- Providing sewage treatment
- Monitoring disease outbreaks
- Immunization campaigns for infants and adults – Prevention programs, dental health monitoring, etc.
Clean water is the key to a healthy population: Wherever clean water has been provided, it has cut urban mortality by nearly half and reduced child mortality by nearly two-thirds. The social return on investment in clean water technologies is more than 23 to 1.
We need only look at the facts in Afghanistan today, as I have them (please correct me if the latest figures are different:
- About 8 out of 10 Afghans drink unsafe water.
- 93% of children in Afghanistan (15.6 million children) live in areas of high or of high or extremely high water
- 5 out of 10 Afghans don’t have access to at least basic sanitation, basic sanitation facilities.
- Approximately 94% of schools across Afghanistan do not have access to basic handwashing facilities.
- Approximately 35% of health facilities lack access to at least basic drinking water.
Addressing these issues would provide the greatest immediate benefit in terms of improved health and fewer deaths.
We therefore propose a crash program to
- Ensure that everyone, everywhere has access to basic water, sanitation and hygiene – a water point within easy reach, and soap and water for washing hands.
- Ensure that everyone has a toilet where waste is safely disposed of. This would immediately reduce health care costs, prevent millions of cases of diarrhea, and increase school and work attendance, among other benefits.
- A major focus should be on building water pipes in cities and in the countryside, combined with sewage systems and treatment facilities.
Let me give just one example from China, where between 1990 and 2020 there was a clear correlation between the proportion of the rural population with access to piped water and the incidence of waterborne infectious diseases. In 1990, the proportion of China’s rural population with access to piped water was only about 30%; by 2020, it had risen to nearly 80%. During the same period, the number of waterborne infectious diseases (caused by enterobacteria and viruses) fell from 90 per 100,000 population to less than 10 per 100,000 population.
Another important function of public health is to monitor disease outbreaks. This could be done through what we would call Ibn Sina Brigades. By this we mean a mix of medical professionals and volunteers who will survey the health situation throughout the country and also provide basic medical care.
Ibn Sina brigades can also be used in rural areas to perform a variety of tasks related to water filtration and decontamination, and the installation of sewage and wastewater treatment systems. They can monitor and detect possible water contamination and identify contacts in the event of an infectious disease outbreak.
Ibn Sina Brigades can be recruited and trained in communities, especially among youth. They can fill the current shortage of medical personnel that will continue for some time. This could be the way for many young people to enter productive and useful careers. Thus, in the Ibn Sina Brigade system, they can serve society in various health care functions while completing their own vocational training.
Next on the public health agenda is immunization of infants, but also of the general population, against diseases such as diphtheria, tetanus, whooping cough, measles, and so on. This could be as important in reducing morbidity and mortality as providing clean water for all. A polio immunization campaign is especially important because Afghanistan and Pakistan are the only countries in the world where polio is still endemic. Vaccination is preventive medicine at its best, and has a long history since Edward Jenner introduced the smallpox vaccine in 1796. In fact, records from China go back as far as the 2nd century BC with attempts to create immunity to smallpox.
Another important pillar of public health emphasized by Ibn Sina is a healthy diet, which makes the human immune system resistant to disease. The current nutritional situation in Afghanistan requires immediate intervention aid from friendly countries, as well as the improvement of agricultural production within the country a topic that will be discussed in our workshop on agriculture and water. Building a functioning health care system is impossible while more than half of the Afghan population is starving – the direct result of the devastation left by U.S. and NATO forces after their withdrawal.
Of course, all of these aspects of public health intersect with many areas of infrastructure and the national economy, such as agriculture, water, electricity, and construction. Therefore, the development of the health system must be closely coordinated with all relevant ministries.
In terms of medical care as such, the long-term goal in Afghanistan is to build a modern health care system with a network of clinics and doctors’ offices, diagnostic and treatment facilities, laboratories, and medical research facilities of all kinds.
This will, of course, start with what is currently available. Afghanistan currently has less than half a hospital bed per thousand people, according to available figures, or 0.39 beds per thousand, according to statistical estimates. By comparison, Uzbekistan has 4.4 beds per thousand people. This means that tens of thousands of modern hospital beds will need to be created in the coming years up from the 16,000 beds in 2020.
Of course, this depends on the industrialization and infrastructure construction of the entire nation. Even if some people say that such a thing is unthinkable in the short term, it must be seen as a goalpost for the future development of the nation.
We must strive for a pyramidal hospital structure:
At the top, there should be one or more university hospitals for specialty care, research, and medical education. At the next level, there should be a central clinic in each province and several smaller health centers in each province for primary care.
Patients’ immediate access to medical care is a network of general practitioners’ offices. Most patients can find appropriate care there. If not, they can be transferred to specialists or the nearest available hospital.
This is the basic structure of Cuba’s health care system, which has been built up since the 1950s under difficult conditions – with little money and under massive U.S. sanctions. Despite the chronic economic crisis, the Cuban health system is one of the best in the Americas.
This is how the Cuban model works:
High-quality, accessible health care for all citizens is one of the main pillars. Today, all health care is regulated and financed by the government (13% of the national budget goes to this sector) and is provided free of charge to Cubans. To overcome limited access to medicines, technology and other material resources, the country has focused on education and a large number of trained doctors to make primary care accessible to all. This allows the focus to be on prevention and reduces the need for costly “cures”. The result is a population in remarkably good health with very low spending: Cuba routinely outperforms all other countries in Latin America and the Caribbean in categories such as infant mortality and life expectancy.
The Cuban health system uses a three-tiered structure to organize primary, secondary, and tertiary care.
The community-based primary care level is characterized by a family physician-assisted nurse system in which each neighborhood is assigned a family physician. These doctors are responsible for keeping track of every patient in the area; determining who is healthy, who is sick, and who is at risk; and making rounds to ensure that everyone receives vaccinations, prenatal care, and other care at the appropriate times.
When patients need a higher level of care or attention, they move to the second level of healthcare, which includes provincially-run hospitals and specialty centers that treat sick patients, manage complications, and promote rehabilitation.
Finally, the third level of health care in Cuba includes nationally administered, specialized hospitals and centers for the treatment and study of specific diseases.
What can be learned from the Cuban model is not only the top-down structure of the system, but also the top priority given to training doctors. In addition to training doctors in Cuba itself, many students from Latin America, Africa and other developing countries can attend medical schools there for free. Even though there is a lot of improvisation in Cuba with old equipment and lack of medicines due to decades of U.S. sanctions, Cuba still has a lower infant mortality rate than the U.S. and Canada and a life expectancy of 76 years.
Cuba used to have 5 doctors per 1,000 people, while Afghanistan statistically has less than 0.3 doctors per 1,000 people. To catch up, large training centers – Ibn Sina faculties in major cities – will have to be built to train thousands of new doctors over the next decade. Perhaps Cuba will be willing to step in, or even send a large group of doctors to Afghanistan, as it regularly does in African countries. Trained doctors in the Afghan diaspora should also be motivated to return home. The same training applies to all other specialties, from nurses to medical technicians, laboratory experts, and so on. Of course, close cooperation with the Ibn Sina Brigades at the lowest level is essential.
As in the Cuban model, it will be necessary to have basic clinics in every Afghan district and at least one second-level hospital in every province. This would avoid excessive travel or transport time for patients to receive adequate care. University hospitals will then serve as a link between teaching and practice, where the best doctors and scientists and their students will work.
Building a network of hospitals in Afghanistan requires input from virtually every sector of the economy:
Construction materials such as cement and steel, water supply and sanitation, electricity, medical technology such as X-rays, CAT scans, ultrasound machines, surgical instruments, etc., as well as the supply of pharmaceuticals and sterile supplies. Trained technicians must support all functions in the clinics.
In response to the COVID-19 pandemic, China has shown that large hospital structures can be built in a matter of weeks using prefabricated units. In Wuhan, two new temporary hospitals were built in record time to help fight the fast-spreading virus in February 2020. The Xiaotangshan Hospital was built in seven days, reportedly breaking the world record for the fastest hospital construction.
I think China is very willing to share its experience with Afghanistan. In the near future, we also need to create other new industries for vital medical supplies, especially a pharmaceutical industry to produce medicines in Afghanistan.
Currently, a major problem in Afghanistan is the treatment of heroin addicts and the general presence of drugs, a relic of the long occupation by American and NATO troops. Up to 10 percent of the Afghan population is addicted to drugs, with methamphetamines and other drugs playing an increasing role. All drug addicts must be cured and reintegrated into society. The government has already taken the first step by almost completely eradicating opium poppy cultivation for heroin production. This is very important and has irritated certain financial circles in the West who need the proceeds from the drug trade to stabilize their rotten financial system.
In our November 2022 report, we gave some examples of additional health care options available in the age of space and the Internet. One of them is “teleconsultation” between medical centers and local doctors or directly with paptients. Of course, this requires a functioning communications system with Internet and satellite access.
Where there are not enough doctors in rural areas, medical vehicles can be sent with important medical instruments on board, especially imaging equipment, which can be connected to specialists in medical centers via Internet technology.
Another spin-off of space travel is the use of drones for medical purposes. For example, blood supplies or essential medicines can be quickly transported to remote areas where they are needed. This is already being tested in Africa, and Afghanistan will soon be able to find out how it works for them.
Finally, a word from the world of popular education, because we want to motivate the population to support and actively participate in the health program. The historical figure of Ibn Sina could be used as a popular TV or radio personality in regular nationwide broadcasts. A famous actor dressed as Ibn Sina could remind
the population of their great heritage in the science of medicine and stimulate curiosity to learn more. This could be combined with relevant health information about basic hygiene and how Ibn Sina discovered many new treatments in his time. He could demonstrate how to treat water with clorine tablets to make it safe for human consumption. He could explain his knowledge of treating eye diseases and other surgeries, or describe his method of anesthesia, which was still being used by doctors in the 17th century. All of this could be presented in an appealing narrative manner to capture the attention of all ages. My colleague Tobias Faku will tell you more about such a project.
I think Ibn Sina would be happy to see your efforts to build up the nation, if he were alive today. Thank you
Given that the Afghan government currently controls only 3.3% of total health spending (according to Dr. Mirwais Ahmadzai), there are almost limitless opportunities to improve the health of the population.
The first priority is to improve general public health (clean drinking water, sanitation, immunization, etc.). This should be financed primarily with funds from the increased tax revenues that will be available after the successful fight against corruption, as well as with investments from abroad (China) for integrated water and sanitation projects.
There was general agreement at the conference that the Afghan health system must become independent of “donors” of any kind.
A different approach is needed to improve the hospital situation. Investments must be made to build new hospital capacity so that medical services currently available only abroad can be provided in the country as soon as possible, thus eliminating the need for patients to pay for costly treatment abroad.
Private clinics must be opened to the public.
Investments in the construction of pharmaceutical plants will increase the availability of medicines and other medical supplies.
Based on the results of the SMART analysis process initiated by Mr. Raufi (which was discussed in detail in the health workshop), other investment priorities will be defined.