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Afghanistan Front Page: Loma Linda University revives a decades-long relationship with Kabul.

AFGHANISTAN WAS ONCE A PLACE only a few westerners vaguely knew about. Most people could not locate this intriguing country on a world map. Today, the realities of 9/11 have brought images of this landlocked country into households around the world on an almost daily basis.

Slightly smaller than the state of Texas, Afghanistan is bordered on the south and east by Pakistan, on the west by Iran, and on the north by Turkmenistan, Uzbekistan, and Tajikistan. Afghanistan's recent history is a story of war and civil unrest. The Soviet Union invaded the country in 1979, but was forced to withdraw 10 years later by anti-Communist mujahideen.

Subsequent fighting among the various mujahideen factions gave rise to a state of warlordism that eventually spawned the Taliban, which seized power in 1996. Following the September 11, 2001, terrorist attacks on New York, the United States, assisted by Afghani Northern Alliance forces, toppled the Taliban regime.

A Long Relationship
For most of its 100-year history Loma Linda University (LLU) has been involved in international health-care initiatives,* and the roots of the Adventist health message in Afghanistan began shortly after the turn of the twentieth century. As early as 1920 Pastor J. E. Fulton of India, writing in the September 1920 issue of the Loma Linda Medical Evangelist, reported that one of the leading officials in the Afghani government had urged members of the Seventh-day Adventist Church working in India to come to Kabul to investigate the opening of a limited sanitarium in the Afghani capital. In his article Pastor Fulton noted that "this Afghani delegate is an influential man and has promised to help us in various ways to get our health work started in his country."

In 1962, more than 40 years later, Loma Linda began its official involvement in Afghanistan. Anchored by G. Gordon Hadley, M.D., dean emeritus of LLU School of Medicine, and assisted by Loma Linda physicians (including Bernard Briggs, Roy Jutzy, Benjamin Herndon, and John E. Peterson), this effort (including World Health Organization support) has provided faculty and consultation resources to the leading medical school in the country and other similar facilities throughout Afghanistan. When the Soviet Union invaded Afghanistan in 1979, Loma Linda's involvement temporarily stopped.

In 1996, at the request of national and medical school leaders in Afghanistan, a team from LLU headed by Joan Coggin, M.D., M.P.H. (immediate past vice president for global outreach for LLU Adventist Health Sciences Center); and Michael Ryan, Ph.D. (director of Global Mission for the General Conference); and Dr. Hadley returned to Afghanistan to assess the needs of the medical school curriculum and see what help could be provided.

Maranatha Volunteers International (with funds from the Euro-Africa Division of Seventh-day Adventists, private donors, and Global Mission) constructed a four-bedroom home, and three one-bedroom apartments for Loma Linda in Kabul, about a 15-minute drive across town from the medical school complex. A teaching center, named the Loma Linda Center, was also remodeled by Maranatha. This center, opened on July 4, 2001, consists of teaching laboratories, a tissue laboratory, a medical library, and a student laboratory facility with 45 computers and 30 microscopes donated by LLU for use by faculty and students.

Loma Linda's efforts progressed rapidly. Previously, the medical school's library consisted of books and journals dated prior to 1972. This is now being changed. Books and journals have been donated by various governments and publishers and are vastly improving the holdings in the medical library.

After the Attack
On September 11, 2001, all efforts in-country came to a halt. "Fortunately, no Loma Linda personnel were in Kabul during the time of the terrorist attacks on the United States," says Richard H. Hart, M.D., Dr.P.H. "We had concerns about damage to our housing complex in Kabul with the invasion of Afghanistan by the United States and its coalition forces. But miraculously, largely because of the efforts of the Afghani staff employed by Loma Linda, the property remained intact and unharmed."

After September 11, 2001, and the fall of the Taliban government, the new government of Afghanistan once again asked LLU to return and assist in the redevelopment of the medical education program in the country.

"The entire medical school complex was severely damaged during the struggles within the country," says Hart, LLU chancellor, who is coordinating Loma Linda's efforts in Afghanistan. "A decision was made to rehabilitate this facility in stages as funds became available." Currently, teams of United States military personnel, using local contractors, are restoring the medical school and other structures of Kabul Medical University.

"The primary need of the health-care system is for qualified personnel in multiple disciplines," Dr. Hart says. "This includes a variety of individuals in the 'intermediate' categories such as nursing, midwives, and other allied health support personnel.

"The Ministry of Higher Education of Afghanistan and Kabul Medical University are committed to producing quality physicians with adequate medical knowledge and skills to serve the needs of the country," Dr. Hart says. "However, to achieve this will require strengthening the educational system at its various levels--allied health teaching, clinical activities, classroom instruction, and continuing education of practicing physicians.

"As peace is returning to Afghanistan, medical students are returning to school," Dr. Hart states. "Because a number of Afghani medical students fled to their villages during the various conflicts, they have not returned in force--nearly 6,000 (many more than the school could properly handle in the perspective of teaching exercises)."

The medical curriculum is a seven-year program. Students may be admitted to the medical program following completion of a12-grade equivalent education in the United States.

Previously, any student admitted to Kabul Medical University could choose to enroll in the new medical curriculum. The medical branch of the university was one of the most popular areas of learning because every graduate of the medical school is guaranteed a job with the Afghani government at $40 per month. Efforts are currently under way to institute a more selective process in the selection of students and place an emphasis on quality rather than quantity.

A New Agreement
During Dr. Hart's visit to Kabul in 2003, a new agreement was worked out with the Ministry of Higher Education, representing Kabul Medical University, and the Ministry of Health.

"Our effort now will place greater emphasis on providing faculty support," Dr. Hart says. "Some faculty from Afghanistan will come to Loma Linda for one- to three-month periods to enhance their educational skills. In return, some of Loma Linda's faculty will travel to Afghanistan to help the faculty at Kabul Medical University to develop better educational materials and implement new teaching methods in the classroom. Our computer facility has been upgraded and is in constant use by faculty and students."

Overseeing and implementing the computer laboratory and also teaching English as a second language to students and faculty at Kabul Medical University is Geoff Jutzy. Mr. Jutzy, a graduate of Walla Walla College, College Place, Washington, has been on-site in Afghanistan for approximately 18 months.

"One of our biggest challenges in maintaining the facility will be the 'dust' factor," Mr. Jutzy says. During the dry period frequent dust storms are seen in the area. Special precautions are being taken to protect the computers from being damaged by dust.

The hope is that an Internet system will soon be implemented at the school. The Internet will help the students and faculty to have access to current medical literature. In addition to providing assistance to the basic science teachers at Kabul Medical University, Loma Linda, in cooperation with the Afghan Medical Association of America, will provide four- to six-week clinical fellowships (observation only) at Loma Linda for Afghani physicians to improve their clinical teaching skills.

"Loma Linda is also working with the Afghani Ministry of Health to develop continuing medical education programs for the entire country," Dr. Hart says. "The Ministry of Health will identify appropriate topics along with local specialists willing to participate in the continuing education programs. Course work will focus on the development of clinical skills, using interactive teaching methodologies. To date, three physician teams, headed by Roy V. Jutzy, M.D., retired chair of the Department of Medicine, have traveled to Kabul to hold continuing education programs.

"The Ministry of Health is extremely interested in developing continuing medical education programs for the entire country that will help to upgrade the quality of physicians who are now practicing in Afghanistan," Dr. Jutzy says. "Approximately 2,000 physicians currently are in Kabul alone, but their level of training varies widely. Hopefully, this continuing education program will help to bring the skills of physicians up to speed."

"Tremendous challenges lie ahead," Dr. Hart says. "We are delighted that Loma Linda can be part of this educational effort."

In March 2004 a team of five health-care professionals, headed by Dr. Hart, traveled to Kabul in response to a request made by the Afghani ministry of health to explore the possibility of operating the major teaching hospital located in Kabul, the capital, a city with about 3.5 million inhabitants.

The Wazir Akbar Kahn Hospital, operated by the ministry of health, was built approximately 35 years ago. Today the hospital is located among a cluster of medical facilities, including the Indira Ghandi Children's Hospital, a physical therapy clinic operated by the International Committee of the Red Cross, and an allied health educational complex. Located on an adjacent piece of property is a military hospital operated by the Afghani ministry of defense. Currently, the hospital is undergoing a complete renovation, according to Dr. Hart. All patients have been referred to other medical facilities in Kabul.

"The Norwegian Red Cross, operating under the auspices of the International Committee of the Red Cross, is completely rehabilitating the hospital," Dr. Hart says. "When completed later this year, the 200-bed facility will once again be ready for occupancy."

During a recent visit to Loma Linda University, Afghani deputy minister of health Abdullah Sherzai, M.D., asked Dr. Hart if Loma Linda would consider running the Wazir Akbar Khan Hospital and upgrading the facility to the equivalent of an American community hospital.

"If Loma Linda University is able and willing to take on this task, this collaborative effort could play a significant role in changing the way the Islamic world sees the United States," Dr. Sherzai notes. "What better way to change the worldview and the world direction than to give life to a country that has nothing but its will?"

Prior to the closing of the hospital for renovation, Wazir Akbar Khan Hospital could accept only the most needy patients. "Only those in immediate need could be helped," says Mahammed Njib Haleem, M.D., vice president of the hospital and an internist. Saleem Tawana, M.D., chief of surgery, noted that they could schedule only elective surgeries one or two days a week because of a lack of medicines.

The Challenge Ahead
Hospitals in Afghanistan have limited resources, according to Dr. Sherzai. Many of those in regions outside Kabul do not have electricity or running water in the facility. Although Wazir Akbar Khan Hospital has those amenities, the facility lacks even basic medical equipment, such as stethoscopes, blood pressure cuffs, and modern medications.

"We estimate that it will take approximately $2 million worth of equipment and supplies to bring the state of the hospital up to an acceptable level," Dr. Hart says. "We will need an additional $3 or $4 million for staffing, construction of an outpatient clinic, and housing for expatriate medical staff.

"We are gratified that the United States government has now agreed to fund this ambitious project [to the tune of $3 million for the first year]. Without external funding," Dr. Hart says, "this project would not have been possible."

"This will be an opportune time for LLU to collaborate with the ministry of health in operating the hospital," says Dr. Jutzy, who with Jan Zumwalt, M.S., M.B.A., R.N., executive director for case management at LLU Medical Center, evaluated the current medical staff needs for the hospital. "We have been assured by the ministry of health that Loma Linda will retain only those physicians, nurses, and other medical staff that can make a positive impact on the hospital." Currently, most hospitals throughout Kabul and in the rest of Afghanistan are staffed by physicians who work only part-time at the facility.

"The pay for an Afghani physician is approximately $40 a month," Dr. Jutzy notes. "Consequently, physicians will work in the hospital for a few hours in the morning and then operate their own private practice in the afternoon to supplement their hospital income." The additional income increases a physician's pay to approximately $300 to $400 monthly.

"We know that we will have to pay more to retain a qualified medical staff," Dr. Jutzy says. "We expect to be able to increase the pay of hospital physicians to equal what they would make in private and public practice together."

With the increase in pay, the Loma Linda group, with the concurrence of the ministry of health, expects that finding a qualified staff will not be difficult.

"We will still need from seven to 10 overseas personnel to play key administrative and medical roles in the foreseeable future," Dr. Hart says. "Tentatively, we are looking at supplying a hospital administrator, a business manager, three or four physicians, one or two nurse managers, and a physical plant operations manager."

The Wazir Akbar Khan Hospital is situated in an ideal location, according to Dr. Hart. The facility is located in the center of extensive grounds that can be transformed into a parklike setting for patients and visitors. In addition, there is enough vacant land surrounding the hospital to build housing for the expatriate staff.

"We are very interested in helping Afghanistan with this facility," Dr. Hart says. "We have been working with Kabul Medical University, Afghanistan's primary medical education facility, on upgrading medical education, and recognize the additional value of establishing a solid teaching hospital. We expect to have local medical students and residents, as well as nursing students and other students in the allied health professions working and learning in the facility."

Currently, many patients who can afford medical care are seeking treatment in nearby countries such as India and Pakistan. "We hope that many of these patients will choose to remain in Afghanistan and seek treatment at the new facility when it is opened," Dr. Hart says. "This will be good for the patient and good for the country.

"Tremendous challenges lie ahead," Dr. Hart says. "We are pleased that Loma Linda can be a part of this effort to rebuild the health-care and medical education systems of Afghanistan."

*Loma Linda University and Medical Center, along with their alumni, have been instrumental in developing nearly 500 health-care facilities of varying sizes--including many Seventh-day Adventist hospitals--around the world.

Richard Weismeyer is the director of university relations at Loma Linda University, Loma Linda, California.

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© 2005, Adventist Review.