After the 10-year the former Soviet Union invasion (from 1979 to 1989), most of the Western support to Afghanistan was withdrawn. Internal conflicts for domination and the latter inefficient Taliban government lead to the destruction of Afghanistan’s infrastructure including the already inadequate health care facilities available, resulting in a poor health care system. After the disposition of the Taliban in 2001 by the United States invasion, NGOs were the main entities delivering health care to the public in Afghanistan including emergency services [1,2].
In 2001, Afghanistan reported one of the poorest health indicators in the world (Table 1) . Infectious diseases, including malaria, measles, acute respiratory infections and diarrheal diseases, in addition to malnutrition, physical and psychological traumas and human right abuses were highly prevalent in the country .
Health Indicators in Afghanistan in 2000 .
Infant mortality (per 1,000 live births)
Under age 5 mortality (per 1,000 live births)
Women with antenatal care
Skilled attendant delivery
In January 2002, the Jordanian military field hospital was established in Mazar-e-Sharif in Afghanistan to provide medical care to many Afghanis. The Jordanian Military represented by the Royal Medical Services (RMS), a leading health authority in Jordan, was responsible for the staffing, operations, and security of the hospital, while the U.S. military offered logistical support, including the delivery of up to 7,500 different medical supplies and training of the Jordanian Special Forces team to maintain security of the field hospital .
Since the grand opening of the 50-bed hospital, over 500,000 Afghans was treated with 807,522 patient visits, 7,572 surgeries performed 4,833 admissions and millions of immunizations. The Jordanian hospital offered medical care for the first time for many Afghans and as stated by a US CENTCOM DJ5 “was truly a cornerstone to winning hearts of Afghans’”. This is not surprising, since RMS was ranked as number 1 supporter for the UN & Humanitarian Missions across Middle East & North Africa. Over the years, the Jordanian Field Hospitals were positioned in 31 different locations including Afghanistan, Palestine, Liberia, Congo Haiti, Cote D’ivoire, and Egypt to name a few (Figure-1), protecting lives, alleviating hardships and safeguarding dignity of persons/nations [5–7].
In this paper a Jordanian surgeon, who is one of the authors (A.E), shares his experience lasting for 100 days in the Jordanian military field hospital in Afghanistan in 2003 and describes the challenges and strengths/ opportunities of such experience in addition to the faced ethical implications and dilemmas.
The field hospital consisted of two inpatient tents, each consisting of 12-13 beds, in addition to outpatients (Figure-2). The inpatient tents had constantly running generators, which kept power for lights, heat and life-saving machines running. Clean water and meals were provided to patients and their families. The tents were well-equipped medical facility. Ultrasounds, X-Rays, routine laboratory tests (such as Complete Blood Count (CBC) and thyroid function tests) were all available at the field hospital. Nonetheless, pathology services and CT-scan were not available. Such request would be sent to the capital Kabul for processing, which took months for the results to return, forcing doctors to improvise and take hard management decisions to provide the best care possible to their knowledge. Medical supplies were always kept in stock including vitamins and other pharmacy supplies.
Although housed in tents, the field hospital was clean with high infection control standards. Zero surgically-related infections rate was reported during this period although major surgeries were performed. The most common surgery was thyroidectomy due to massive goiter secondary to iodine deficiency (Figure-3). Other types of surgery included removal of huge abdominal masses, reconstructive and plastic surgeries (Figure 4 a - d) including cleft left, war injuries and amputation, and burn-related wound debridement, resection of gastrointestinal tumors, and disc surgeries. Security measures were in place to ensure the safety of both the Jordanian medical team and to the patients and their families. All of the above-mentioned factors had provided the Afghans’ the chance to access high quality, safe and essential surgery.
The medical staff was all males and included Jordanian doctors, nurses and some paramedics who had extensive expertise in a variety of fields, including internal medicine, general surgery, primary care, emergency medicine, cardiology, obstetrics and gynecology, pediatrics, dermatology, gastroenterology, rheumatology, orthopedics and urology. In addition to Afghan doctors, community members and paid translators helped facilitate the treatment of patients.
As sad as it is, the field hospital provided a great training opportunity for Afghan doctors and medical staff, as they were guided and trained by Jordanian doctors with extensive medical and surgical expertise. This has successfully contributed to building qualified healthcare workforce in Afghanistan, especially with the witnessed “brain drain” of qualified healthcare workers outside of the country and the lack of reliable local medical training programs at that time.
Religious, Cultural and Ethical Issues
Although paid translators were always present, language barrier between Jordanian doctors and Afghan patients still existed. The all-male medical staff also presented a challenge as according to Afghan cultural norms only women can provide medical care for other women. The Afghans showed an overall trust of the Jordanian doctors; this probably is due to similar religious beliefs and cultural norms. This has contributed to the unique success of the field hospital compared to many other relief groups with religious affiliations who had previously reported facing major obstacles when it comes to working in Afghanistan .
Privacy and confidentiality issues were taken into consideration; nonetheless, the Jordanian surgeon reported that no actual consenting took place before surgeries. There was no medical records for patients or any formal tracking or record-keeping system, which made the surgeon task more challenging from obtaining patients’ medical history to providing postoperative care. This issue resulted in interruption of proper care, especially when surgeons are deployed on short missions resulting in participation of several surgeons in the treatment of a single patient. Challenges such as low literacy and poverty remained. Very poor roads and lack of transportation system forced patients to walk or use livestock to visit the field hospital from surrounding rural areas.